Shared Flashcard Set


Critical Care
Final Critical Care
Undergraduate 4

Additional Nursing Flashcards




symptom management and psychosocial aspects of end-of-life/hospice patients. (restlessness, confusion, pain management)
Hospice-support/care for patients in last phases of incurable diseases with less than 6 months to live. 24/7 symptom management, advanced care planning, spiritual care, and family support, respite care, pain control. Moderate opioids do not hasten death. Restlessness occurs when cerebral metabolism slows. Assess for spiritual distress, do no restrain, use soft and soothing music and soft touch, limit number of visitors. Confusion can be caused by opioids, corticosteroids, or underlying disease. Assess pain, constipation, urinary retention. Provide a quiet and well-lit room. Reorient to P/P/T. Administer benzos/sedatives PRN. Stay close, stay calm, reassuring voice. Provide family with support and allow them to help with cares.
Pain management (most feared symptom of death): regularly assess quality, location, intensity, and contributing factors. Limit skin irritants (wetness, hot/cold, pressure). Administer routine medications around the clock on a regular basis, complementary/alternative therapies may be used (guided imagery, massage, acupressure, heat/cold, therapeutic touch, and relaxation techniques). 
anthrax/smallpox, emergency room assessment and care, education
Anthrax: Inhalation-high mortality, abrupt onset, diaphoretic with fever and cough, chest pain, septicemia, shock, respiratory failure (common cold symptoms) spread by direct contact with the bacteria, treated with Ciprofloxacin, pencillin, and doxycycline
Cutaneous-most common, small papules that resemble insect bites, which will advance to block ulcers, swollen lymph nodes, and destruction of the surrounding tissue. 
GI-ingestion of contaminated uncooked meat, s/s nausea or vomiting, hematemesis, diarrhea, abdominal pain, ascites, sepsis (causes inflammation and lesions)
Treatment: ATB to prevent systemic manifestations-Ciprofloxacin, Penicillin, Doxycycline (postexposure prophylaxis for 30 days if the vaccine is available, 60 days when no vaccine is available)

Smallpox: highly contagious, moves person to person via bodily fluids, transmitted in air droplets, and handling of contaminated material.
S/S smallpox: high fever, malaise, rash on tongue that spreads to face and extremities

Treatment: no cure, Cidofovir (vistide), vaccine given to those exposed, vaccine immune globulin VIG  
communication ICU patient 
Inability to communicate can be distressing for the patient who may unable to speak because of the use of sedatives and paralyzing drugs, or an endotracheal tube. As part of any procedure, the nurse should explain what will happen or what is happening to the patient. When the patient cannot speak, explore alternative methods of communication, including devices such as picture boards, ntoepads, magic slates, or computer keyboards. When speaking with the patient, look directly at the patient and use hand gestures when appropriate. If the patient does not speak English, use an interpretor. Nonverbal communication is important. High levels of procedure-related touch and decreased levels of affection-related or comfort-related touch characterize the ICU. Patients have different levels of tolerance for being touched-usually related to cultural background or personal history. It may be appropriate to provide comforting touch with ongoing evaluation of the patient's response. Often the ICU nurse encourages the family to touch and talk with the patient even when they are unresponsive or comatose
elder abuse-nursing management
Elders who have been mistreated are have 3x higher risk of death than those who have not. The majority of those abused are women, and the cases are underreported. Lack of reporting can come from older adult's isolation, impaired cognitive or physical function, feelings of shame, embarassment, guilt, or blame. Lack of reporting by the HCP may be due to lack of confidence in identifying or reporting victims of elder mistreatment. 9/10 the family is the perpetrator, usually adult children dependent on the elder for housing and finances. Nurses should always assess for dehydration, malnutrition, pressure ulcers, poor personal hygiene, and lack of compliance with the medical regimen. Interview the victim alone. Key assessment findings are explanations that are not consistent with what is observed or contradictory explanations between the patient and caregiver. Be alert for vague excuses for missing activities. Assess for recurrent problems despite treatment. Assess for new onset of psychiatric problems. Mandatory reporting to an appropriate agency. Include thorough assessment with precise documentation, collecting and preserving any evidence, social service consultation, and if in immediate danger-consider a safety plan.  
adult learning principles 
Independent learners-they need direction to resources, they will make their own decisions for their lives and take responsibility for those decisions, and you must respect their independence
Readiness to learn arises from life's changes-to them, each life process is a problem to be solved, dependent on readiness and motivation, crisis is a "teaching moment". 
Past experiences are resources for learning-engaged in informal learning, increased motivation based on past experiences, identify past knowledge and experiences to help with this one. 
Immediate value-they want to apply their learning immediately, there is little appeal in long-term goals, provide them with short-term realistic goals
Approach learning as problem solving-they seek resources to deal with the problem, so avoid irrelevant information but provide explanations, target teaching on specific problem/circumstance.
Self as doers-learn better by doing via demonstrations, computer activities, and proactive skills. 
Resistant to learning when incongruent with self concepts-do not learn when treated as a child and told what to do, need control and self-direction to maintain self-worth. 
patient safety in the ICU (fall safety, fire safety) 
RACE-rescue, alarm, contain, extinguish

Fall safety-keep room well lit, call light within reach, frequently ask if bathroom use is needed, ensure patient gets adequate sleep, keep interventions grouped together so as not to constantly disturb the patient  
Role of the nurse educator 
Be confident in subject matter. Make sure you know what you are about to teach. If you don't know the subject matter and patient asks a question, make sure you find them the correct answer. Don't make something up. Teach health risks, disease, appropriate self-care. Explain what the disease is, why it is important to control it, and what the patient will need to know about diet, exercise, and expected/unexpected outcomes of medications. Teach the patient how to use equipment and identify what findings should be reported to their HCP. Provide the patient with additional information and resources. Do not use medical jargon. Define any medical words/terms. Nonverbal communication-sit relaxed, face patient, with eyes level. Open body gestures communicate interest and willingness to share. Active listening with open-ended questions. Nod, rephrase, reflect, clarify. Allow time for listening. Empathy-do not judge, sympathize, or correct. Understand-put aside one's own self for a moment and put yourself in their shoes. 
delirium in older adults 
Repeatedly reorient patients. If cause is drug induced, discontinue medications. Delirium can also accompany drug and alcohol withdrawal. Fluid and electrolyte imbalances and nutritional deficiencies are corrected if appropriate. If problem is related to environmental conditions-make changes to reduce stimulation or increase stimulation. If secondary to infection, appropriate ATB. Protect the patient from harm. Priority is given to creating a calm and safe environment. Keep family at bedside, provide familiar objects, transfer patient to a private room or one closer to the nurse's station. Plan consistency of nursing staff if possible. Reassure and reorient to Place, time, and procedures. Clocks, calendars and listings help. Environmental stimuli-noise and light need to be reduced. Make eyeglassess or hearing aids readily available. Personal contact through touch and verbal communication can help reorient. Sensory deprivation can precipitate delirium. Avoid restraints. Use music therapy, massage, relaxation techniques. Timely removal of catheters and physical restraints. Early mobilization and ROM exercises to maintain skin integrity. Support family and caregivers during episodes of delirium. Teach them precipitating factors. 
Treat underlying causes.
Delirium goals"
Improve patient's cognitive status. Reduce risk of adverse outcomes like aspiration, prolonged immobility, increased length of acute care, institutionalization, and death
psychosocial aspects of mass casualty event 
Determine support systems. Define current degree of personal control, decision making, and independence. Identify presence of hope. Identify specific areas and depth of anxiety and fears. Identify expectations of surgery, changes in health status, and effects on daily living. Identify current roles or relationships. Preview previous experiences, hospitalizations, or treatments. Determine responses to those experiences. Identify current perceptions of surgical procedures. Identify amount and type of information the patient requires. Assess understanding of procedure. Identify accuracy of information patient has received from others. 
sleep deprivation in the ICU, assessment
Difficulty falling asleep or having disrupted sleep due to noise, anxiety, pain, frequent monitoring, or procedures. Contributing factor to delirium and impaired recovery. Structure the environment to promote the patient's sleep/wake cycle
Cluster activities, schedule rest periods, dim the lights at bedtime, open the curtains during the day, observe psychological measurements without disrupting the patient, limit noise, provide comfort measures
Use benzodiazepines, benzodiazepine-like (Ambien) to induce and maintain sleep.  
Sleep deprivation can cause delirium.  
nutritional considerations for the ICU patient 
Goal-to prevent or correct nutritional deficiencies from hypermetabolic states (burns, trauma, sepsis) or catabolic states (acute renal failure). Early provision of enternal nutrition (via GI) or parenteral nutrition (via IV) 
Enteral-preserves the structure and mucosa of the GI mucosa and helps prevent the translocation of GI bacteria
Parenteral-used only when enteral route is unsuccessful in providing adequate nutrition. (Paralytic ileus, diffuse peritonitis, intestinal obstruction, pancreatitis, GI ischemia, intractable vomiting, severe diarrhea)  
ESI triage 
Level 1-unstable, obvious threat to life, should be seen immediately, high resource intensity, staff at bedside continuously and often mobilized response team. (Ex: cardiac arrest, intubated trauma pt. severe overdose, SIDS, anaphylaxis, shock, respiratory distress) 
Level 2-threatened VS, life or organ threat is likely but not always obvious, should be seen within minutes, high resource intensity, multiple/complex diagnostic tests, frequent consultations, continuous monitoring (ex: chest pain-ischmemia, multiple traumas, child with fever and lethargy, disruptive psychiatric pt) 
Level 3-stable VS, unlikely/possible threat to organ or life, should be seen within the hour, medium/high resource intensity, multiple diagnostic procedures or brief observation or complex procedure. (Ex: gynecologic disorder unless severe distress, hip fracture in the elderly, flu, food poisoning, broken bones)
 Level 4: stable VS, no threat to life/organs, can be delayed being seen, low resource intensity, one simple diagnostic study or simple procedure (Ex: closed extremity trauma, simple laceration, cystitis, typical migraine, UTI, closed ulnar fracture)
Level 5: stable, no threat, can be seen later, needs one or two resources, check-up. (Common cold)  
Poisoning/overdose nursing and medical management 
First priority is always ABCs. Continuous monitoring of neurologic status, LOC, and respiratory/cardiovascular function. VS & I&O. Pharmacological interventions to interact toxic effects-Narcan/Romazicon when depressant is present but the ingested drug is unknown. Narcan will rapidly reverse the effects of opioids. Romazicon reverses the effects of benzodiazepines. Dialysis to prevent irreversible CNS depressant effects and death. Gastric lavage/activated charcoal used when the drug has been ingested within the last 4-6 hours. CNS stimulants are NOT used to treat CNS depressant overdose. After the patient is stable, obtain history-including recent drug use type, amount, time of use, and presence of any chronic illness. If intentional overdose, must see psychiatric professional before discharge. 
thermal injury assessment 
Etiology-hot liquids/solids, flash flame, open flame, steam, UV light, hot surface. 
Partial thickness (superficial): redness, pain, moderate to severe tenderness, minimal edema with pressure
Partial thickness (deep): moist beds, blisters, mottled (pink to cherry red, white) hypersensitive to touch or air, moderate to severe pain, blanching with pressure
Full thickness: dry, leathery eschar, white waxy, dark brown, or charred appearance. Strong burn odor, impaired sensation when touched, absence of pain with severe pain in the surrounding tissues, lack of blanching with pressure.  

Frostbite-ice crystals form in tissues and cells. Results from ambient temperature, length of exposure, type and condition (wet or dry) of clothing, and contact with meal surfaces. Other factors-dark-skinned people more prone, lack of acclimization, previous episodes, exhaustion, and poor peripheral vascular status. 
Superficial frostbite involves skin and SUBQ tissue, usually the ears, nose, fingers, and toes. The skin will range from waxy pale yellow to blue to mottled, and the skin will feel crunchy and frozen. The pt may complain of tingling, numbness, or burning sensation. Carefully handle the area and do not squeeze. Immerse the effected area in water bath-102 to 108 degrees. Blisters will form within hours, debride these and sterile dressing applied. Rewarming is very painful. Analgesia and tetanus prophylaxis should be given
Deep frostbite involves the muscle, bone, and tendon. Skin is white, hard, and insensitive to touch. The area has the appearance of deep thermal injury with mottling gradually progressing to gangrene. The affected extremity is immersed in a circulating bath water until distal flush occurs, then elevated to reduce edema. 3 hours-edema, 6 hours-days-blisters. IV analgesia always required due to thawing tissue pain. Tetanus prophylaxis given. Evaluate for systemic hypothermia. Amputation for injured area if untreated or treatment unsuccessful. 24-48 hours in hospital with bed rest, elevation, and prophylactic ATBs if at risk for infection
abnormal auscultation assessment-cardiac 
Pulse deficit. Where the apical HR exceeds the peripheral pulse rate (cardiac dysrhythmias) 
Arterial bruit-turbulent blood flow sound in peripheral artery (arterial obstruction or aneurysm)
S3-extra heart sound that is low pitched, heard in early diastole, gallop (left ventricular failure, volume overload, mitral/aortic/tricuspid regurgitation, hypotension)
S4: extra heart sound, low pitched, heart in late diastole, gallop (forceful arterial contraction with resistance to ventricular filling, left ventricular hypertrophy, aortic stenosis, HTN, CAD)  
age considerations in cardiac assessment 
Kyphosis: altered chest landmarks for palpation, percussion, and auscultation 
myocardial hypertrophy/increase collagen scarring/decreased elastin-decreased cardiac reserve, heart failure
Downware displacement-difficult to obtain apical pulse
Decreased CO/HR/SV-in response to exercise/stress, slowed, decreased response to exercise and stress, slowed recovery from activity 
Cellular aging changes and fibrosis of conduction system: decreased amplitude of QRS complex and slight lengthening of PR/QRS/QT intervals, irregular cardiac rhythms, decreased maximal HR, decreased HR variability 
Valvular rigidity from calcifications, sclerosis, fibrosis, impeding complete closure of valve, systolic murmur (aortic or mitral) possible 
arterial stiffening caused by loss of elastin in arterial walls/thickening intima of arteries, progressive fibrosis of media, increased systolic and increased or decreased diastolic BP 
Venous tortuosity increased-inflamed, painful, or cord-like variscosities 
cardiac assessment 
PMH-history of chest pain, SOB, alcoholism/tobacco use, anemia, renal failure, streptococcal sore throat, congenital heart disease, stroke, syncope, HTN, thrombophlebitis, intermittent claudication, variscosities, and edema
Medications-current past use, OTC, herbal, Rx (note name, dose, pt understanding and side effects)
*Aspirin-prolongs blood clotting time and is included in many cold drugs
Surgery/treatment/hospitalizations-diagnostic workups or cardivascular symptoms, previous CXR, EKG as baseline. 
Health management/promotion-risk factors (elevated serum lipids, HTN, tobacco use, sedentary lifestyle, obesity) stressful lifestyle, DM, recreational drug use, allergies (shellfish)
nutrition/metabolic pattern-underweight/overweight, typical diet, weight management attitude/plan
elimination pattern-diuretics (increased elimination) constipation, straining during bowel movement, incontinence
Activity/exercise-type of exercise, duration, frequency of each, unwanted side effects like light-headedness, chest pain, palpations, SOB, claudication, limits in ADLs, leisure and recreation
Sleep-rest-paroxysmal noctural dyspnea, number of pillows needed for orthopnea in HF, sleep apnea, nocturia
cognitive-perceptual pattern-ask patient and significant others, assess chest pain and claudication. Dysrhythmia, HTN, and stroke can cause syncope, language, and memory problems.  
Self-perception/self-concept pattern-acute origin may affect self-perception, body image issue with invasive diagnostics and palliative procedures, chronic in nature leads to inability to "keep up" previous levels or activities (evaluate effect of illness on patients) 
Role-relationship pattern-gender, age, marital status, role in household, employment, number of children, living environment, significant others, and level of satisfaction/dissatisfaction with roles
Sexual-reproductive-erectile dsfunction, fatigue, hormone replacement therapy 
Coping-stress tolerance pattern-identify areas that cause stress or anxiety (marital relationships, family, occupation, church, friends, finances, and housing) 
Values-Belief pattern-affected by culture and play a role in level of real or potential conflict, assess value-system 
Normal Cardiac assessment 
inspection-normal skin color with cap refill less than 3 seconds, symmetric thoracic movement, PMI not visible, and no jugular vein distention at 45 degrees
Palpation-PMI palpable in the 5th intercostal at left mid-clavivular line, no thrills or heaves, slight palpable pulsations in abdominal aorta in epigastric area, carotid and extremity pulses 2+ and equal bilaterally, no pedal edema
Auscultation-S1 and S2, apical-radial equal and regular, no murmurs, no extra heart sounds.  
Hemodynamic monitoring (RAP/CVP/arterial line)-nursing implications, assessment 

CVP-measures right ventricular preload. It can be measured with a PA catheter using proximal lumens or with a central venous catheter placed in the internal jugular or subclavian vein. CVP is measured as a mean pressure at the end of expiration. CVP reflects fluid volume problems. Elevated-overload, low-hypovolemia. Normal CVP is 2-6mmHg.

arterial blood pressure-acute HTN/hypotension, respiratory failure, shock, neurologic injury, continuous infusion of vasoactive drugs (Nipride) and frequent ABG samplings. Use 20-gauge, 2-inch Teflon catheter in the radial or femoral artery. Sutured in place. Insertion site is immobilized. Measurements obtained at end expiration. Arterial lines can hemorrhage, infection, thrombus formation, neurovascular impairment, loss of limb. This is why the Allen test should be performed, the line is sutured in, assess for inflammation, continuous flush irrigation every 1-4 hours, assure bag is inflated 300mmHg, and system delivers at 3-6mL/hr. Observe limb for compromised flow-lengthened cap refill, cool, pale, tingling, pain, paresthesia with neurologic impairment. 


pericarditis, basic care management
ID cause, direct Tx. ATBs for bacterial pericarditis. Corticosteroids for pts with pericarditis secondary to SLE, pts already on corticosteroids, or pts who do not respond to NSAIDs. Prednisone given when necessary on tapering schedule. Use cautiously due to numerous side effects. NSAIDs normally control pain and inflammation associated with acute pericarditis. High dose salicylates or NSAIDs are commonly used. Recurrent pericarditis may need Colchicine-an anti-inflammatory used for gout
 Periocardiocentesis is usually performed for pericardial effusion with acute cardiac tamponade, purulent pericarditis, and high suspicion of neoplasm. Hemodynamic support includes volume expanders, inotropic agents like dopamine, and d/c anticoagulants. Percutaneous approach guided by ECG/echo. 16-18 gauge needle for surgical drainage. Inserted into pericardial space to remove fluid for analysis and to relieve cardiac pressure, which can cause dysrhythmias, cardiac tamponade, pneumothorax, myocardial laceration, and coronary artery laceration.
acute pericarditis nursing care prioritization 
Pain and anxiety. Determine amount, quality, location to distinguish from myocardial ischemia. Pericarditic pain is normally located in the precordium or left trapezius, sharp pleuritic pain that increases with inspiration. Relieved by leaning forward, worsened when lying down. ECG monitoring distinguishes between types of pain because ischemia is accompanied by ST segment changes. Pain relief-pt on bed rest, HOB elevated >45degrees, overbed table for support. Antiinflammatory meds to alleviate pain. Upper GI bleed possible, so give antiinflammatories with food, milk, avoid alcohol, give Cytotec to protect the mucosa. 
Anxiety-reduce by providing simple, compete instructions of procedures and possible causes of pain. Especially for pts who have previously had angina/acute MI. CO may be decreased due to cardiac tamponade. Monitor for S&S of cardiac tamponade. (Increased intrapericardial pressure that compresses the heart. S&S include chest pain, confusion, anxious, restless, heart sounds become muffled, pulse pressure narrowed, pt develops tachypnea, tachycardia, and decreased CO.)  Prepare for pericardiocentesis. 
hypertensive crisis, assessment
severe and abrupt elevation in BP (diastolic >140mmHg) What is most important is the rise in BP. Occurs most commonly in patients who have failed to comply with their prescriptions and who are undermedicated. Assessment: monitor for signs of neurologic dysfunction, retinal damage, heart failure, pulmonary edema, and renal failure. Neurologic manifestations are similar to that of stroke. Observe for chest pain and edema. The extreme rise in BP can cause endothelial damage and release vasoconstrictor substances. This can lead to life-threatening damage to target organs. 
Decrease MAP by no more than 25% in the first hour. If stable, goal is 160/100-110 in the next 24-48 hours. Less than 100mmHg is goal for those with aortic dissection. Assess hourly urine output and vital signs.
Frequent neurologic checks-LOC, pupil size and reaction, extremity movement, reactions to stimuli. Help detect any changes in the pt's condition. Monitor cardiac, pulmonary, and renal systems for compensation.

pulmonary HTN, medical management
There is no cure. Tx relieves symptoms, improves QOL, and prolongs life. Diuretics relieve dyspnea and peripheral edema, and may be helpful in reducing right ventricular volume overload. Anticoagulation therapy is recommeneded to prevent thrombus formation and venous thrombosis. Warfarin used to keep INR between 2-3. Hypoxia relieved by low-flow oxygen. Keep 02 >90%. Vasodilator therapy reduces right ventricular overload by dilating pulmonary vessels and reversing remodeling. Calcium channel blockers help manage pulmonary HTN. (Cardiazem and Procardia) Flolan is a prostacyclin that promotes pulmonary vasodilation and reduces pulmonary vascular resistance. Continuously used, it has been shown to improve clinical symptoms and long-term survival. Treatment of choice for those who are unresponsive to calcium channel blockers. Flolan is given via indwelling central line continuously. Short half-life, less than 6 minutes, serious deterioration if disrupted. These patients have symptoms of right-sided heart failure-dyspnea, cyanosis, cough, syncope, and weakness. Dosage depends on weight. Overdose symptoms-flushing, hypotension, and tachycardia. Broken central lines/vascular access can result in infection. Remodulin, a prostacyclin given via SUBQ injection causes vasodilation of the pulmonary arterial system and inhibits platalet aggregation. Longer half life than Flolan. Tracleer-oral prostacyclin blocks endothelin and blood vessel constriction. Can cause hepatotoxicity-monthly LFT. Revatio-oral phosphodiesterase that prolongs vasodilatory effect of nitric oxide and appears to be as effective in decreasing pulmonary vascular resistance. Not used in pts using nitrates because it can cause severe hypotension. Ventavis-inhaled prostacyclin-do not give to pts with BP <85. 
Surgical-atrial septostomy, pulmonary thromboendarectomy, lung transplant.
AS-create intraatrial right-to-left shunt to decompress the right ventricle. Used for pts awaiting lung transplant. PTE is a potential cure for pts suffering from chronic thromboembolic pulmonary HTN. Used in pts with operable sites where emboli can be surgically removed. Lung transplant is the mainstay of treatment for pts who do not respond to drug therapy and progress to severe right-sided heart failure.  Recurrence does not occur in pts with lung transplant. 
mitral valve prolapse, patient teaching
ATB prophylaxis for endocarditis before undergoing dental/surgical procedures if the patient has mitral valve prolapse with regurgitation. Take medications as prescribed. Adopt health eating patterns and avoid caffeine because it is a stimulant and may exacerbate symptoms. Counsel patients who use diet pills or OTC drugs to check for common ingredients that are stimulants that will exacerbate symptoms. Develop and implement exercise program to maintain optimal health. Contact ED or HCP if symptoms develop or worsen. (Palpitations, fatigue, SOB, anxiety) 
ATB for invasive procedures. Meds as prescribed. Avoid stimulants. (Caffeine, ephedrine) Health eating patterns and exercise. Contact HCP with symptoms.  
Peripheral artery disease-patient teaching
Risk factors: cigarette smoking, hyperlipidemia, HTN, DM, obesity, family HX, lifestyle, hypertriglyceredmia, hyperuricemia 
Caused by atherosclerosis (gradual thickening of intima and media of arteries, leading to progressive narrowing of the vessel lumen)
Collaborative Care:
Smoking cessation, treat hyperlipidemia with statins, treat HTN, DM
Drugs-antiplatelets (aspirin, Plavix, Ticlid) ACE inhibitors (prils) decrease in cardiovascular morbidity and mortality, increase peripheral blood flow, and walking distance. Cilostazol increases maximal walking distance and quality of life. Can cause palpitations, headache, and diarrhea. 
Most important nonpharmacological treatment is a formal exercise training program. Improves oxygen extraction in legs, skeletal muscle metabolism, and vascular endothelial function. Walking-most effective for patients with claudication. Exercise 30-60 minutes/day, 3-5times/week, for up to 3-6 months. Slow, progressive physical activity with a warm up period. Walk to discomfort, stop and rest, then resume walking until discomfort returns. 30-40 minutes day/3-5x day.
Sodium <2g/day.  
Gingko bilboa is effective in increasing walking distance for pts. But can cause headache, nausea, gastric symptoms, diarrhea, and allergic skin reactions. Bleeding risks-beware with NSAIDs, aspirin, and warfarin.
Critical limb ischemia-ischemic rest pain, arterial leg ulcers, gangrene of leg in advanced PAD. Protect the extremity from trauma, decrease vasospasm, prevent/control infection, maximize perfusion. Carefully inspect, cleanse, and lubricate both feet. Do no soak. Cover ulcers with dry, sterile dressing. 
Percutaneous transluminal balloon angioplasty-balloon in artery inflated in narrowed atria and dilates artery. Stents can be placed.
Surgery-synthetic graft, endarectomy, patch graft angioplasty. Prevent graft failure with aspirin and heparin. Amputation may be needed.  
peripheral artery disease-nursing management
Screen at clinics-reduce intake of cholesterol, saturated fats, sugars, proper foot care, avoid injury to extremities. Operative extremity should be checked every 15 minutes for skin color, temperature, cap refill, peripheral pulses and movement after surgery. Knee-flexed positions should be avoided except for exercise. Turn frequently. First day after surgery the patient should get out of bed several times. Discourage sitting for long periods of time. Reclined position for swelling. Elastic bandages. NO SMOKING. Learn to inspect feet/legs every day. Clean, all cotton socks. Gradual increase physical activity
abdominal aortic aneurysm, teaching, pain management
reduce cardiovascular risk by controlling BP, smoking cessation, increasing physical activity, and maintaining normal body weight/serum lipid levels. Gradually increase activity. Fatigue, poor appetite, and irregular bowel habits are expected. Heavy lifting should be avoided for 4-6 weeks. Observe for color changes or warmth in extremities, palpate peripheral pulses. Report to HCP if any redness, swelling, increased pain, drainage from incisions, or fever greater than 100F. Prophylactic ATBs for grafts. Sexual dysfunction in males may occur. Urologist referral. Pt should be taught how to palpate peripheral pulses
Preop-disease process, planned surgery, preop routines, what to expect after surgery, and timelines. Bowel prep, preop shower, NPO, preop ATB. An abdominal aneurysm can impair flow to the lower extremities and cause what are known as the five Ps of ischemia: pain, pallor, pulselessness, paresthesias, and paralysis. Splint the incision with pillows, provide adequate pain relief prior to coughing sessions, and position the patient with the head of the bed elevated to facilitate coughing.
heart failure-psychosocial aspects, teaching, nursing care 
Focus on slowing the disease. Follow medication, diet, and exercise regimens. 
Psychosocial-anxiety and depression (Live productively with chronic health problems)
Medication-rest of life to control s/s
Assess pulse rate-<50bpm withhold digitalis or beta blockers.
Monitor BP (especially with HTN) teach about the symptoms of hypokalemia or hyperkalemia if using diuretics that spare or deplete potassium.
PT/OT for energy conserving and energy efficient behaviors for ADLs.
Administer 02 to improve saturation and assist meeting tissue oxygen needs and relieve dyspnea and fatigue.

 Nursing care-physical/emotional rest allows pts to conserve energy and decrease need for additional 02. 

Nonpharmacologic-NYHF III of IV, widened QRS, max medical therapy-Cardiac resynchronization therapy or biventricular pacing. Pace both the right and left ventricles to achieve coordination of these and contractility.
Cardiac transplantation
IABP-in hemodynamically unstable. Used to decrease SVR, PAWP, and PAP as much as 25%, improving CO. Risks: bed rest, infection, vascular complications
VADs-bridge to transplantation (up to 2 years)
 Destination therapy-permanent VAD when not a heart transplant vandidate 
General therapeutic objectives for chronic HF-ID type of HF/underlying causes, correct sodium/water retention and volume overload, reduce cardiac workload, improve myocardial contractility, control precipitating and complicating factors.
Diuretics used in HF to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload.
Thiazide diuretics-first choice in chronic HF because safe, low cost, effective. Treat edema and control HTN. 
Loop diuretics-potent diuretics, promote sodium, water, and chloride excretion. Problems-increase serum potassium, ototoxicity, possible allergic reaction
Spironolactone (Aldactone) potassium sparing diuretic that promotes sodium and water excretion. Adds benefits of ACE inhibitors, and is appropriate when renal function is adequate. It can be used in combo with other diuretics like Furosemide

Vasodilators improve survival. Increases venous capacity, improve EF by improving ventricular contraction, slow process of ventricular dysfunction, decrease heart size, avoid stimulation of compensatory mechanisms, enhance neurohormal blockade. 

ACE inhibitors (prils) useful in systolic and diastolic HF. 
Angiotension II receptor blockers (sartans) for those intolerance of ACE inhibitors. 
Nitrates work on smooth muscle wall to decrease preload and vasodilate coronary arteries. 
Beta blockers-lol-improve survival 

Positive inotropic agents improve cardiac contractility and CO, decrease LV diastolic pressure, and decrease SVR. 
Digitalis glycosides 
Calcium sensitizers

Diet education/weight management critical to control chronic HF
Diet and weight management individualized/culturally sensitive  
Detailed diet history should be obtained and include sociocultural value of food to patient.
DASH diet. Dietary restriction of sodium.
Fluid restrictions prescribed for pts with severe HF and renal insufficiency. 
Pts should weigh themselves daily. If they experience a gain of 3lb over 2 days or 3-5lb over a week, call HCP.  
myocardial infarction 

result of sustained ischemia causing irreversible myocardial cell death
S&S pain not relieved by rest, position change, or nitrate administration (heavy, pressure, tight, burning, constricting, crushing) SNS stimulation and cardivascular changes (BP/HR increase then drop as CO decreases)
Post acute myocardial infarction physical therapy: cardiac rehab, restore person to optimal state of 6 functions-physiological, pschological, mental, spiritual, economic, vocational. Involve basic changes in lifestyle to promote recovery and health.
Activity-warm up and cool down. Do not start/stop abruptly. Frequent-5+ times a week. Intensity based on HR. Do not exceed 20bpm over resting HR. Type-regular, rhythmic, repetitive. Use large muscle groups to build up endurance. Time-30-60 minutes, start at personal tolerance. 


hypertrophic cardiomyopathy-pt teaching
Take all meds as prescribed, follow up with HCP. Encourage low-sodium diet, read all product labels for sodium content. Drink 6-8 glasses of water unless fluids are restricted. Achieve reasonable weight. Avoid large meals. Avoid: alcohol, caffeine, diet pills, and OTC cold medications that contain stimulants. Balance periods of activity with rest. Avoid heavy lifting. Use stress reduction exercises. Report S&S HF to PCP like weight gain, edema, SOB, increased fatigue. ATB given prophylactically before dental work, because this patient is at risk for endocarditis. 
infective endocarditis complications
Pericardial effusion-accumulation of excess fluid in the pericardium. S/S will include muffled heart sounds, BP maintained, cough, dyspnea, and tachypnea

Cardiac tamponade is compression of the heart-chest pain, confusion, anxiety, restlessness, muffled heart sounds, pulse pressure narrowed, tachypnea, tachycardia, decreased CO. JVD, pulsus paradoxus-increase in systolic BP with inspiration that is exaggerated  
aortic stenosis-management of symptoms 
Avoid nitroglycerin because it reduces the preload necessary to help the stiffened aortic valve. 
If HF develops, treat with diuretics, dignoxin, beta blockers, low sodium, and vasodilators. Use Percutaneous Transluminal Balloon Valvuloplasty to open up vessels. Surgery: valvulotomy, valvuloplasty, and prosthetic valves. 
Percutaneous transluminal coronary angioplasty (PTCA) - complications (PTCA is the same category as PCI-percutaneous coronary intervention) 
most common is dissection of newly dilated coronary artery. If damage extensive, the artery could rupture. This could cause cardiac tamponade, ischemia, and infarction, decreased CO, and possible death. There is also danger from infarction should the lesion calcify, the plaque dislodge and occlude distal vessels. Coronary spasm from mechanical irritation of the catheter or balloon can occur as well as chemical irritation from contrast medium. Abrupt closure can occur within 24 hours after PCI. Restenosis can also occur in the first 30 days. 
CABG (complications, pt education, chest tubes) 
Teaching: Surgery-consists of constructing new vessels to transport blood between the aorta and the myocardium distal to the obstructed coronary artery. Grafts take from saphenous vein, radial artery, gastroepiploic artery, or inferior epigastric artery. Post-op-antiplatelet therapy and statins to improve vein graft patency. Give calcium channel blockers and long-term nitrates pre-op to control spasm of radial artery when mechanically stimulated. Gastroepiploic artery and inferior epigastric artery dissection requires extensive surgery and risks for wound complications. 
Goal: palliative tx for CAD, not a cure, but does improve outcomes, quality of life, and surival after CABG  
implantable cardioverter-defribillator (ICD) complications
Hematoma formation at site of insertion
Perforation of the atrial or ventricular septum by the pacing lead  
PEEP positive end expiratory pressure-positive pressure is applied to the airway during exhalation
Normally at exhalation, pressure falls to zero. With PEEP, it remains above zero, usually 3-20cm H20. Lung volume during expiration/between breaths is greater than normal. Increases functional residual capacity improving oxygenation. Increases aeration of patent alveoli, aeration of previously collapsed alveoli, and prevents alveolar collapse throughout the respiratory cycle. 
Best or optimal PEEP is titrated so oxygen improves without compromising hemodynamics. It is used prophylactically to replace the glottic mechanism, to maintain functional residual capacity, and prevent alveolar collapse. PEEP 5 cm H20 is used for pts with a hx of alveolar collapse during weaning.
Auto-PEEP is a result of inadequate exhalation time. Additional PEEP over what is set by the clinician and can be measured at the end-expiratory hold button located on most ventilators. Additional Peep may result in increased barotrauma and hemodynamic instability. Interventions to limit auto-PEEP-sedation, analgesia, large diameter ET tube, bronchodilators, short inspiratory times, decreased respiratory rates, reducing water accumulation in ventilator by frequent emptying/use of heat.
Major purpose of PEEP is to maintain or improve oxygenation while limiting the risk of oxygen toxicity. PEEP helps provide counterpressure opposing fluid extravasation-useful in pulmonary edema. PEEP is indicated in lungs with diffuse disease, severe hypoxemia unresponsive to 02 >50%, and loss of compliance or stiffness. ARDS are a classic indication for PEEP therapy.  
ventilator-associated pneumonia 

occurs within 48 or more hours after endotracheal intubation and occurs in 9-27% of intubated patients, 50% occuring within first 4 days of mechanical ventilation
S&S-fever, elevated WBCs, purulent sputum, odorous sputum, crackles or rhonci on auscultation, and pulmonary infiltrates noted on x-ray
Evidenced-based guidelines on VAP include

  • elevate HOB at least 30-45 degrees
  • no routine changes of the patient's ventilator circuit tubing
  • use of an ET with dorsal lumen above the cuff to allow continuous suctioning of secretions in the subglottic area

    Condensation that collects in the ventilator tubing should be drained away from the patient as it collects.  
Complications mechanical ventilation 
Cardiovascular system-PPV can affect circulation because the transmission of increased mean airway pressure to the thoracic cavity. With increased intrathoracic pressure, thoracic vessels are compressed. Decreased venous return to the heart, decreased preload, decreased CO, and hypotension. 
Pulmonary-lung inflation pressures increase-barotrauma risk increases. Patients with compliant lungs are at greater risk because of increased airway pressure that readily distends the lungs and may rupture alveoli/ephysematous blebs. Also susceptible-pts with stiff lungs/high levels of PEEP, suppurative lung abcesses from necrotizing organisms. 
Pneumothorax-air escapes into pleural space. Cannot expel it. Respiratory bronchioles trap air on expiration. Chest tubes may need to be placed prophylactically. 
Pneumomediastinum-begins with rupture alveoli into interstitium. Progressive air movement occurs into mediastinum and SUBQ neck tissue. Followed by pneumothorax.
Volutrauma-lung injury that occurs when large tidal volumes are used to ventilate noncompliant lungs, resulting in alveolar fractures and movement of fluids and proteins into alveolar spaces.
Hypoventilation-inappropriate settings, leaking air, lung secretions/obstructions, low V/Q ratio. Interventions: turn q1-2 hours, provide chest physical therapy to increase secretions, cough deep breathing and suction. 
Respiratory alkalosis with respiratory rate set too high (mechanical overventilation) or if pt is hyperventilating. Determine cause and treat it. (hypoxemia, pain, fear, anxiety, metabolic acidosis)
 Fluid balance changes due to decreased CO. Results from diminished renal perfusion, release of renin resulting in sodium and water tention. Pressure changes in thorax result in decreased atrial natriuretic peptide, causing sodium retention. ADH and cortisol-increase sodium and water retention. 
Neurological system-head injury, plus PPV especially PEEP can impair cerebral blood flow. Elevate HOB and keep pt's head in alignment. 
GI system-stress ulcers, GI bleed. Reduced CO by PPV can cause ischemia of mucosa and translocation of GI bacteria. Prophylactic H2 blockers, PPIS, and tube feedings to decrease gastric acidity and dimish the risks of stress ulcers and hemorrhage. Gastric and bowel dilation may occur as a result of gas accumulation from swallowed air. Decompress with NG tube. Immobility, sedation, circulatory impairment, decreased intake, opioids, and stress decrease peristalsis. Defecation difficult. 
Muskuloskeletal-maintenance of muscle strength and prevent problems of immobility. Progressively ambulate patients with long-term PPV can be done without interruption. Passive and active exercises, consisting of movements to maintain muscle tone in the upper and lower extremities, should be done in bed. Prevent contractures, pressure ulcers, foot drop, and external hip rotation by properly positioning legs. 
lung cancer, NSCLC medical management
surgical resection for stage I and II
pneumonectomy-remove an entire lung, lobectomy-remove one or more lobes, lung conserving resection/segmental wedge resection.
Radiation/chemotherapy and surgical resection for later stages 
pneumonia nursing care
Prevent aspiration pneumonia in pts receiveing tube feedings caused by interruption of lower esophageal sphincter integrity (oral preferred to nasal) 
turn/deep breathe frequently
assess for return of gag reflex prior to food/fluid following anesthesia to throat
monitor physical assessment parameters-facilitate lab and dx tests, provide tx, monitor response to tx
Initiate ATBs within 4 hours
oxygen therapy, bronchodilators, hydration, nutrition, therapeutic positioning for stable oxygenation (good lung down!)  
pulmonary embolism -nursing management/teaching
Collaborative care-prevent further growth/multiplication in extremities and prevent embolization, provide cardiopulmonary support
Administer 02 by mask/cannula-determined by ABGs
Turn, cough, deep breathe
If shock symptoms, give vasopressor. If HF-diuretics. Pain-morphine.
Anticoagulants-Warfarin (Coumadin) INR 2-3, and LMWH-aPTT 1.5-2.0
Warfarin within first 24 hours, given 3-6 months.  
Fibrinolytic tPA-dissolves embolus and source of thrombus in pelvis of deep leg vein.
Surgery-50% mortality rate-if no response to conservative therapy
Preoperative pulmonary angiography to find embolus
Place vena cava filter to prevent further embolization/migration of clots

Nursing management-bed rest, semi-Fowler's maintain IV lines. 02-monitor VS, cardiac dysrhythmias, pulse oximetry, ABGs, and lung sounds. Monitor PTT and INR. Interventions for immobility and fall precautions. Explain situation, provide emotional support, reassure to relieve anxiety. Anticoagulants 3-6 months. Warfarin drawn monthly. Reinforce need for follow-up

Renal failure complications and medical management/teaching/psychosocial implications 
Complications-damaged tubules cannot conserve sodium resulting in low levels. Avoid excessive sodium intake. Uncontrolled hyponatremia/water excess can lead to cerebral edema. Closely monitor fluid intake. 
Hyperkalemia-kidneys unable to excrete-acidosis worsens hyperkalemia as hydrogen enter cells and pushes potassium out. Dysrhythmias identified/K+ greater than 6, need tx. Tall, peaked T waves, widened at QRS complex, and ST depression. Hematologic disorders-anemia-impaired erythropoeitin, platelet abnormalities leading to bleeding from multiple sources. WBCs altered-immunodeficient. Low serum calcium-kidneys cannot activate vitamin D. Hypocalcemia-PTH released, which stimulates bone demineralization. Phosphate elevated as it is released too. Infection and cardiorespiratory complications are the most common causes of death. Neurologic changes as nitrogenous waste products increase. Symptoms: fatigue, difficulty concentrating, later escalating to seizures, stupor, and coma. 

Collaborative management-primary goal of tx is to eliminate cause, manage symptoms, and prevent complications. First step-make sure adequate volume and CO. Diuretic therapy to prevent overload. Do not force fluids/diuretics when ARF exists. Early dialysis. Fluid intake closely monitored during oliguric phase-adall losses for previous 24 hours plus 600mL for insensible losses. Hyperkalemia-regular insulin, sodium bicarbonate, calcium gluconate, dialysis, sodium polystyrene sulfonate (kayexelate) dietary restriction. 

Common indications for dialysis are volume overload, elevated K+ with ECG changes, metabolic acidosis, significant change in mental status, pericarditis, pericardial effusion, cardiac tamponade. 

HD-rapid changes, short period of time. More complex, specialized equip/staff. Anticoagulant therapy, risk hypotension. 

PD-simpler, risk peritonitis, less effective on catabolic pt, requires longer tx times. Used for intracranial bleeding/cardiovascular instability. 

CCRT-hemodynamically unstable. Gradual removal fluid/solutes. Requires extracorporeal blood circulation, runs continuously and requires 12-24 hours.

Challenge-nutrition-prevent catabolism, which increases urea, phosphate, and potassium. Restrict sodium, fat, increase protein, calories.
Overall goals-recover without loss of function, maintain fluid/electrolytes, decrease anxiety, follow-up care. Prevent ARF by identifying high-risk populations, controlling nephrotoxic drug exposure, industrial chemicals, preventing prolonged hypotension/hypovolemia. Factors that increase pts risk-age, massive trauma, major surgery, extensive burns, cardiac failure, sepsis, obstetric complications, vaseline renal insufficiency by HTN or DM.
Carefully monitor I/Os, extrarenal losses like diarrhea/hemorrhage. ATB for streptococcal infections. Watch elderly/DM pt-contrast is nephrotoxic. Give with acetylcystein/sodium bicarb to reduce risk. Nephrotoxic-smallest, shortest amount/time. Caution with NSAIDs. ACE inhibitors decrease perfusion pressure and cause hyperkalemia. ARF-critically ill, suffers from this and comorbid diseases. 
Nurse-manage fluid/electrolytes during oliguric and diuretic phases. Observe/record I&Os and body weight. Know signs hypovolemia/hypotension. 
Hyperkalemia-major cause death in oliguric phase, dysrhythmias impair neuromuscular function-muscle weakness, abdominal cramps, flaccid paralysis, and absence of deep tendon reflexes. Infection leading cause death-meticulous aseptic technique. Note signs infection both local and systemic. 
Protect pt from others with disease, renal failure may blunt febrile response, ATB-monitor tx type frequency and dose. 
Respiratory complications-pneumonitis can be prevented-humidified oxygen, incentive spirometry, coughing, turning, deep breathing, ambulation. Skin care/pressure ulcer prevention. Stomatitis prevention. Recovery depends on general health, length of oliguric phase, severity of nephron damage. Need good nutrition, rest, and activity. Diet high in calories. Protein and potassium regulated. Long-term convalescence of 3-12 months can cause financial and family burden. Refer to appropriate help. Pt requires transplant or dialysis if does not recover. Hope to regain normal fluid/electrolytes, comply with tx, experience no infection complications, complete recovery. 

peritoneal dialysis-nursing care
simpler than HD, risk peritonitis, less efficient in catabolic pt, requires longer tx times. Used for intracranial bleeding, cardiovascular instability, pt needs instruction on how to keep the dressing dry, avoiding pulling out catheter, follow-up care. 

Complications-infection-s. aureus or s. epidermis-ATB. SUBQ infections can result in abcess formation causing peritonitis, needing catheter removal. 
Peritonitis-contaminated diasylate/tubing. Cloudy effluent with WBC count >100cells/microliter,diffuse abdominal pain, diarrhea, vomiting, abdominal distention, hyperactive bowel sounds, fever, ATB
 Pain-change position, decrease infusion rate
Outflow less than 80% of inflow, may be caused by kink/migration of catheter, frequently resolvex by bowel evacuation
hernias, lower back pain, protein loss, encapsulating sclerosing peritonitis, and bleeding. Atelectasis, pneumonia, and bronchitis may occur from repeated upward displacement of the diaphragm. Hernia-repair-due to increased intraabdominal pressure, also causes lower back pain-regular exercise. Bleeding-effluent first few exchanges, pink/slightly blood, but may be intraperitoneal if continues to be bloody effluent over several days. Check BP and hematocrit. Pulmonary-atelectasis, bronchitis, pneumonia-frequent repositioning, cough, deep breath, elevate HOB. Adequate protein intake as diasylate causes protein, carb, and lipid abnormalities. Thick fibrous membrane-encapsulating sclerosing peritonisis surrounds and compresses bowel, change pt HD because of loss of ultrafiltration. 
acute glomerulonephritis, nursing management
Focus on symptom relief, rest is indicated until signs of glomerular inflammation (protein/hematuria) and HTN subside. Edema is treated by restricting sodium and water. Administering diuretics. Severe HTN is treated with antihypertensives. Restrict protein if increase in nitrogenous waste. (elevated BUN) restriction varies with degree of proteinuria. ATB given if streptococcal infection is still present. Encourage early dx/tx of sore throats and skin lesions. If streptococci are found in culture, tx with appropriate ATB (usually penicillin). Instruct patients to take full course of ATB to be sure that bacteria have been eradicated. Good personal hygiene is important factor in preventing the spread of cutaneous streptococcal infections. 
hemodialysis complications
hypotension that occurs during HD results from rapid removal of vascular volume, decreased CO, and decreased systemic intravascular resistance. Lightheadedness, N/V, seizures, vision changes, chest pain with cardiac ischemia. Treatment includes decreasing the volume of fluid being removed and infusing 0.9% saline solution 100-300mL. Hold BP medications. 

Painful muscle cramps due to rapid removal of sodium and water are a common problem. Tx-reduce ultrafiltration rate adn infuse hypertonic saline/normal saline bolus.

Causes of Hep B and C in dialysis pts include blood transfusions/lack of adherence to precautions used to prevent the spread of infection. 

Sepsis can occur-signs are fever, hypotension, and elevated WBC.  

Disequilibrium syndrome develops as a result of very rapid changes in the composition of extracellular fluid. Manifestations: nausea, vomiting, confusion, restlessness, headaches, twitching and jerking, and seizures. May cause muscle cramps or worsen hypotension. Tx-slowing/stopping dialysis and infusion of hypertonic saline, albumin, or mannitol to draw fluid from the brain cells. 
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