Acute complex conditions exam 1

Subjective pain assessment

N-normal O-onset P-precipitating/aggravating/relieving factors Q-quality R-region/radiation S-severity/other symptoms T-timing U-patient understanding/perception

Observable pain assessment

behavioral indicators

pain assessment tools

FLACC (infants) CPOT (clinical care plan observation tool) Wong Baker faces tool

pain assessment importance

self reporting, alternate communication methods, observable behavioral, physiological indicators

5 components of pain

sensory, affective, cognitive, behavioral, physiological

Types of pain

acute chronic nociceptive: somatic,visceral neuropathic: peripheral, central

nociception of pain

transduction, transmission, perception, modulation

pain assessment limitations

inability to respond, language barrier, altered loc, delirium, neonates, cultural influences, lack of knowledge, beliefs and attitudes about pain, addiction and tolerance, respiratory depression

Pain Pharmacology

opioid agonists: morphine, fentanyl nonopioids: acetaminophen, nsaids, ketorolac

pain prevention measures

•Physical techniques -Heat or Cold -Massage •Cognitive-behavioral techniques -Relaxation -Distraction -Music therapy •Movement therapy -Yoga •Biologically based therapies Aromatherapy

Subjective Renal Assessment

•Renal-focused health history •Urinary output and symptoms (FHP: elimination) •Medications •Nephrotoxic (NSAIDS, diuretics, etc.) •Surgeries •Functional Health Patterns •Elimination •Sleep-Rest •Reproductive/sexuality

Objective Renal Assessment

Inspection •Weight, general appearance Palpation •Costovertebral Angle Tenderness •Bladder Documentation •Normal physical assessment •Assessment abnormalities

Acute kidney injury

-Ranges from slight deterioration to severe impairment -Rapid loss of kidney function with: •Rise in serum creatinine and/or reduction in urine output •Elevated BUN and K+ •Azotemia—accumulation of nitrogenous waste products -High mortality rate; other life-threatening conditions

types of acute kidney injury

Prerenal Intrarenal Postrenal

Pre-renal kidney injury

-Interruption of blood flow to the kidneys -Hypotension, shock

Pre-renal Pathophysiology

•factors that reduce systemic circulation causing reduction in renal blood flow which leads to oliguria •Severe dehydration, heart failure, decreased CO •Autoregulatory mechanisms attempt to preserve blood flow •Prerenal azotemia results in i urine output

intrarenal Acute kidney injury

Occurs as a result of direct damage to the kidney from lack of oxygen (acute tubular necrosis). ■ Causes ☐ Physical injury - trauma ☐ Hypoxic injury - renal artery or vein stenosis or thrombosis ☐ Chemical injury - acute nephrotoxins (e.g. antibiotics, NSAIDs, contrast dye, heavy metal, blood transfusion reaction) ☐ Immunologic injury - infection, vasculitis, acute glomerulonephritis ■ Nursing Care ☐ Assess for oliguria or anuria. ☐ Assess for edema and manifestations of heart failure or pulmonary edema. ☐ Restrict fluid intake as prescribed. ☐ Review laboratory values for elevated potassium, low calcium levels. ☐ Monitor for ECG dysrhythmias and changes (tall T waves). ☐ Assess for flank pain, nausea, and vomiting. ☐ Assess for lethargy, tremors, and confusion. ☐ Monitor daily weights.

Postrenal acute kidney injury

occurs with urinary tract obstructions that affect the kidneys bilaterally •Caused by mechanical obstruction of outflow which results reflux into renal pelvis, impairing kidney function

Acute kidney injury phases

Initiation - initial cause leading to oliguria Oliguria - metabolic waste products build up due to lack of excretion Diuresis - beginning recovery, lab values stabilize Recovery - renal function recovers, may take several

RIFLE classification

•Risk (R) - elevated creatinine 1.5 x baseline or GFR dec 25%; 0.5ml/kg/hr x6h •Injury (I) - serum creatinine 2 x baseline or GFR dec 50%; 0.5ml/kg/hr x12h •Failure (F) - creatinine 3 x baseline or GFR dec 75%; <0.3ml/kg/hr x 24h •Loss (L) - persistent kidney injury >4 weeks •ESRD/ESKD(E) - outcome >3 months

AKI findings

•Oliguria or anuria •Tachycardia •Hypertension or hypotension •Bibasilar crackles •Irritability, drowsiness, or confusion •Altered level of consciousness •Bleeding abnormalities, ecchymoses, and purpura •Dry, pruritic skin; maculopapular rash •Dry mucous membranes •Uremic breath odor •Seizures •Myoclonus •Retinopathy •Keratitis, iritis, and uveitis •Cardiac arrhythmias such as atrial fibrillation or a peaked T-wave from hyperkalemia •Limb ischemia or edema

AKi diagnostics

•Serum creatinine, BUN, electrolytes •Urinalysis •Renal ultrasound •Renal scan •CT scan •Renal biopsy

contrindications for contrast medium

•MRI or MRA with gadolinium contrast medium—may be fatal •Contrast-induced nephropathy (CIN) •Diabetics taking metformin: hold 48 hours before and after use of contrast medium; risk of lactic acidosis If contrast is needed for high-risk patients—use low-dose and o

renal replacement therapy

term used to encompass life-supporting treatments for renal failure. It includes: hemodialysis, peritoneal dialysis, hemofiltration and renal transplantation.

acute kidney injury nutrition

•Maintain adequate caloric intake •Primarily carbohydrates and # fat •Adequate protein to prevent breakdown •Restrict sodium, K+, phosphate •Calcium supplements or phosphate-binding agents •Enteral/parenteral nutrition if needed

acute kidney injury nursing process

Nursing diagnoses: •Electrolyte imbalance •Fluid imbalance •Risk for infection •Anxiety

acute care interventions

Acute care: •Strict intake and output •Daily weights •Assess for hypervolemia or hypovolemia •Assess for potassium and sodium disturbances •Meticulous aseptic technique •Careful use of nephrotoxic drugs

acute care evaluations

Evaluation outcomes are that the patient with AKI will: •Regain and maintain normal fluid and electrolyte balance •Adhere to the treatment regimen •Have no complications •Have complete recovery

kidney transplant

•Assess for rejection •Oliguria, edema, fever, inc. BP, weight gain, swelling/tenderness at site •Patient receiving cyclosporine may only show increased creatinine •Prevent infection •Monitor CBC and assess for s/s of infection •Patients receiving immunosuppressant drugs •Monitor urinary function •Living donor kidney functions immediately Deceased donor kidney may not function for 2-3 weeks

diffusion

Movement of molecules from an area of higher concentration to an area of lower concentration.

active transport

the movement of materials through a cell membrane using energy

Osmosis

Diffusion of water through a selectively permeable membrane

hydrostatic pressure

the pressure within a blood vessel that tends to push water out of the vessel

osmotic pressure

pressure that must be applied to prevent osmotic movement across a selectively permeable membrane

Hypovolemia

decreased blood volume

Dehydration

An abnormally low amount of water in the body.

Hypervolemia

abnormal increase in the volume of blood plasma in the body

Interprofessional Care

Many different professionals working together for the good of the patient

Hypotonic IV fluids

Treats intracellular dehydration Lower osmolarity than ECF 0.45% NS D2.545%NS

Isotonic IV fluids

• Normal Saline (0.9% NaCl) • Lactated Ringer (LR) • IV fluids are used to replace or maintain fluid

Hypertonic IV fluids

Used only when serum osmolarity is critically low Osmolarity higher than ECF D50W D10W D5NS D5W in 0.45% NaCl d5LR

Ph

7.35-7.45

Acid-Base Regulation

buffer systems respiratory mechanisms renal mechanisms

buffer system

A mixture of an acid and a base which resists changes in pH •Act chemically to change strong acids to weak acids or bind acids to neutralize them •Respiratory and renal systems need to be functioning adequately

respiratory system regulation

Respiratory center in medulla controls breathing Increased respirations lead to increased CO2 elimination and decreased CO2 in blood Decreased respirations lead to CO2 retention

Renal System Regulation

Conserves bicarbonate and excretes acid Three mechanisms for acid elimination Secrete free hydrogen Combine H+ with ammonia (NH3) Excrete weak acids

Acid-base alterations

•Imbalances occur when compensatory mechanisms fail •Classification of imbalances •Respiratory (CO2) or metabolic (HCO3) •Acidosis or alkalosis •Acute or chronic

arterial blood gases

clinical test on arterial blood to identify the levels of oxygen and carbon dioxide

Diabetes Ketoacidosis

•Caused by profound deficiency of insulin •Characterized by: Hyperglycemia, Ketosis, Acidosis, Dehydration •Precipitating factors: Illness, Infection, Improper insulin dosage, Unknown dx •Insulin deficiency: (Fig. 48-12 in the textbook) •Without treatment: •Severe depletion of sodium, potassium, chloride, magnesium, and phosphate •Acidosis à vomiting and further fluid and electrolyte losses •Hypovolemia followed by shock may cause renal failure, causing retention of ketones and glucose and further acidosis •Dehydration, electrolyte imbalance, and acidosis causes coma and if not treated, death

Hyperosmolar Hyperglycemic Syndrome (HHS)

A metabolic complication of uncontrolled type 2 diabetes, similar in severity to diabetic ketoacidosis but without ketosis and acidosis.

subjective respiratory data

•Respiratory history •Smoking/vaping history •Environmental exposures •Allergens •Chemicals Smoke

Objective Respiratory Assessment

•VS with pulse oximetry (consider perfusion) •Work of breathing •Adventitious lung sounds (Upper/lower) •Stridor •Wheeze •Crackles •Rhonchi Audible aeration

Respiratory Diagnostic Tests

•Radiology •X-ray •CT •MRI •V/Q Scan •Capnography •Bronchoscopy A/C/V Blood Gas

pnemonia

an inflammation in the lung caused by infection from bacteria, viruses, fungi, or parasites, or resulting from aspiration of chemicals

Pneumonia types

•Viral—most common •May be mild or life-threatening •Bacterial •May require hospitalization •Mycoplasma—atypical •Aspiration •Necrotizing •Opportunistic

pneumonia manifestations

•Cough: productive or nonproductive •Green, yellow, or rust-colored sputum •Fever, chills •Dyspnea, tachypnea •Pleuritic chest pain •Fine or coarse crackles •With consolidation: •Bronchial breath sounds •Egophony •Increased fremitus •With pleural effusion •Dullness to percussion

pneumonia complications

•Atelectasis •Pleurisy •Pleural effusion •Bacteremia •Pneumothorax •Acute respiratory failure •Sepsis/septic shock •Lung abscess •Empyema

Respiratory Nursing Diagnoses

•Impaired gas exchange •Impaired breathing •Fluid imbalance •Hyperthermia •Activity intolerance

Respiratory nursing implementation

•Monitor assessment parameters, provide treatment, and monitor response •Collaborate with respiratory therapy, PT •Collect specimens •Administer antibiotics •Oxygen, hydration, nutrition, breathing exercises, early ambulation, and positioning •Elevate head-of-bed 30 degrees and have sit up for all meals •Assist with eating, drinking, taking meds as needed •Assess for gag reflex •Monitor reflux and gastric residuals (NG tube) •Early mobilization •Cough and deep breathe, incentive spirometry •Twice-daily oral hygiene

Respiratory nursing care

•Effective respiratory rate, rhythm, and depth of respirations •Lungs clear to auscultation •Absence of infection

pneumothorax

air in the pleural cavity caused by a puncture of the lung or chest wall

spontaneous pneumothorax

A pneumothorax that occurs when a weak area on the lung ruptures in the absence of major injury, allowing air to leak into the pleural space. •Risk factors: Tall, thin, male, family history, or previous spontaneous pneumothorax

latrogenic pneumothorax

caused by medical treatments, especially transthoracic needle aspiration

tension pneumothorax

a type of pneumothorax in which air that enters the chest cavity is prevented from escaping

hemothorax

blood in the pleural cavity

Chylothorax

a condition marked by lymphatic fluid in the pleural space caused by a leak in the thoracic duct.

chest tubes

hollow drainage tubes that are inserted into the chest to drain air, blood, pus, or fluid that has collected inside the pleural space/cavity

pulmonary embolism

clot or other material lodges in vessels of the lung

pulmonary embolism manifestations

•Depend on type, size, and extent of emboli: •Dyspnea most common (85%); mild-moderate hypoxemia •Other: tachypnea, cough, chest pain, hemoptysis, crackles, wheezing, fever, tachycardia, syncope, pulmonic heart sound •Massive PE: change in mental status, hypotension, impending doom, death

pulmonary embolism complications

•Pulmonary infarction •Occlusion of medium or large-sized vessel, inadequate collateral blood flow, and preexisting lung disease results in alveolar necrosis and hemorrhage which may results in abscess and pleural effusion •Pulmonary hypertension •Results from hypoxemia associated with massive (greater than 50%) or recurrent emboli •Right ventricular hypertrophy

pulmonary embolism diagnostics

D-dimer, spiral CT scan, ventilation perfusion scan

Normal Sinus Rythym (NSR)

ECG of a healthy heart shows an organized, uniform rhythm called normal sinus rhythm (NSR)

Sinus Bradycardia

<60 normal sinus rhythm

Sinus Tachycardia

>100 bpm

Paroxysmal SVT

Intermittent SVT. Due to rapid atrial depolarization that overrides SA node (stress, over exertion, caffeine)

Atrial Flutter

irregular beating of the atria; often described as "a-flutter with 2 to 1 block or 3 to 1 block"

atrial fibrillation

occurs when the normal rhythmic contractions of the atria are replaced by rapid irregular twitching of the muscular heart wall

Junctional Rhythm

the SA node is nonfunctional, P waves are absent, and heart is paced by the AV node at 40-60 beats/min

Bundle Branch Blocks

- QRS is *prolonged/wide*

PVCs

premature ventricular contractions

Ventricular Tachycardia

a very rapid heartbeat that begins within the ventricles

Ventricular Fibrillation

the rapid, irregular, and useless contractions of the ventricles

Asystole

absence of contractions of the heart

potassium and the heart

in charge of myocardial contraction. affects rate of ventricular depolarization normal level: 3.5-4.5 mEq/L

How to calculate HR on an EKG

▪Number of QRS complexes in 6 seconds and multiply by 10

cardioversion

Restoration of normal heart rhythm by electrical shock

defibrillation

application of an electric shock to the myocardium through the chest wall to restore normal cardiac rhythm

Dysrhythmia assessment findings

-irregular rate/rhythm, tachy, brady -decreased or increased BP -decreased O2 sat -pain: chest, neck, shoulder, back, jaw, arm -dizziness, syncope -dyspnea -extreme restlessness, anxiety -decreased level of consciousness, confusion -feeling of impending doom -numbness/tingling of arms -weakness and fatigue -cold, clammy skin -diminished peripheral pulses -diaphoresis -pallor -palpitations -n/v

Dysrhythmia Nursing process

ASSESSMENT -Health history -Medications (medications that may affect the heart) -Lab values (INR, PTT, aPTT, assess for anemia,) -Look for physical signs of diminished CO (especially changes in LOC), fluid retention (e.g., JVD [jugular vein distention, crackles, and wheezes], rate and rhythm of apical AND peripheral pulses, extra or abnormal heart sounds DIAGNOSIS -Decreased CO related to inadequate ventricular filling or altered heart rate -Anxiety related to fear of the unknown outcome of altered health state -Deficient knowledge about the dysrhythmias and its treatment POTENTIAL COMPLICATIONS -Cardiac arrest -HF -Thromboembolic event, especially with atrial fibrillation

EKG placement

white= on right snow over grass = White over green smoke over fire = black over red chocolate good for heart = brown by heart

which is the most common lead

2 and v4

subjective cardiac assessment

•Sxs: sob, fatigue, dizziness, syncope, edema, palpitations, weakness, malaise, nausea •Hx: cardiac disease, diabetes, htn, strep infection, tobacco/drug use •Medications •Functional health pattern changes

Objective cardiac assessment

•Vital signs •Inspection: edema, cyanosis, jvd •Palpation: pulses, cap refill, edema •Auscultation: bruits, murmurs, heart sounds

Cardiac Diagnostic Tests

ECG Echocardiography Coronary angiography Cardiac Catheterization -Hemodynamic Monitoring Radionuclide tests -MUGA scan -Thallium imaging -PET scan

Non-modifiable risk factors for CAD

Age Gender Ethnicity Family history Genetic predisposition

Modifiable risk factors for CAD

Smoking, HTN, DM, obesity, diet, activity level, hyperlipidemia

Stable angina

chest pain that occurs when a person is active or under severe stress

care for stable angina

•increase O2 supply •To optimize myocardial perfusion: •oxygen •Nitrates •b-blockers •Calcium channel blockers

Acute coranary syndrome (ACS)

•Prolonged ischemia; not immediately reversible; includes: •Non-ST elevation acute coronary syndrome •Unstable angina and non-ST segment elevation myocardial infarction (NSTEMI) ST-segment-elevation myocardial infarction (STEMI)

MI signs and symptoms

PULSE: Persistent chest pains Upset stomach Lightheadedness Shortness of breath Excessive sweating

MI sequelae

•Dysrhythmias •Heart failure •Cardiogenic shock •Muscle dysfunction/rupture •pericarditis

cardiac catheterization

thin, flexible tube is guided into the heart via a vein or an artery

CABG (Coronary Artery Bypass Graft)

Open heart surgery involving arterial bypass using a transplanted vein

high WBC means

infection

low Hgb means..

anemia This could be indicative of a GI bleed

High Hgb indicates

polycythemia

low WBC count

may indicate viral infections, pneumonia, autoimmune diseases, or cancers

High Hct indicates..

dehydration

Low Hct indicates

anemia, blood loss

high plt count indicates

blood clots can form in your blood vessels.

Low plt count indicates

less than 150,000 platelets per microliter is lower than normal. When you have a low platelet count, you may have trouble stopping bleeding. Bleeding can happen inside your body, underneath your skin, or from the surface of your skin.

BMP tests for

Na, K, BUN, Creat, Gluc, HCO3-, Cl-

BMP indications

may be used to check the health of your kidneys, the status of your electrolyte and acid/base balance, as well as your blood glucose level - all of which are related to your body's metabolism.

high BNP indicates

congestive heart failure

urinalysis

the examination of urine to determine the presence of abnormal elements

Tropinin I and t

Cardiac troponin I appears to be a more specific marker of risk of composite cardiovascular disease and coronary heart disease, whereas cardiac troponin T is more strongly associated with risk of non-cardiovascular disease death

CK-MB

Creatine Kinase-Muscle Breakdown. High --> heart damage

D-dimer test

high--> must rule out PE If a D-Dimer is ordered it means the physician is considering a Pulmonary Embolism as one of their Differential Diagnoses (DDx). D-Dimer is a protein that is excreted by clots of blood. The amount of D-Dimer circulating in the body can be measured. If the D-Dimer is negative, a PE can be excluded from the DDx: Negative D-Dimer = No PE If the D-Dimer is positive it does not necessarily mean there is a PE. It only means the pt must be ruled out for a PE: they must receive a CTA Chest or VQ scan.

ABGs

Arterial Blood Gases pH 7.35- 7.45 HCO3 (Bicarbonate) normal values 22-26 mEq/L PaCO2 ( CO2 or carbon dioxide content) 35-45 mm Hg PaO2 (oxygen saturation in arteria blood)- 80-100 mm Hg

X-rays

electromagnetic waves with wavelengths shorter than ultraviolet rays, but longer than gamma rays

CT scan

a series of x-ray photographs taken from different angles and combined by computer into a composite representation of a slice through the body

echocardiography

an ultrasonic diagnostic procedure used to evaluate the structures and motion of the heart

ecocardiography

ultrasound of the heart

V/Q scan

ventilation-perfusion scan - radioactive test of lung ventilation and blood perfusion throughout the lung capillaries (lung scan)