Nursing 170 Course Review Fall 2024 PDF

Course Review Nursing 170 Recorded Lectures Review Readings Vocabulary Pharmacology Class Activities Case Studies HESI Remediation Values: Electrolytes, H & H, WBCs, Platelets, Osmolality, Glucose ranges, Diabetes diagnostics, ABGs, Temp ranges, Cholesterol, Troponin, ACC/AHA Blood pressur...

Course Review Nursing 170 Recorded Lectures Review Readings Vocabulary Pharmacology Class Activities Case Studies HESI Remediation Values: Electrolytes, H & H, WBCs, Platelets, Osmolality, Glucose ranges, Diabetes diagnostics, ABGs, Temp ranges, Cholesterol, Troponin, ACC/AHA Blood pressure stages, Preeclampsia lab & BP diagnostics.  Define & Describe Risk factors Clinical Manifestations Treatments Nursing Considerations FLUID & ELECTROLYTES Fluid Imbalances FVE & FVD Electrolyte Imbalances 2/3 1/3 Vital to cell Transport system to function and from cells Osmolality = Concentration of solutes “WATER FLOWS WHERE SODIUM GOES” Types of fluids: Isotonic normal saline (0.9% sodium) No Cellular Shifts Hypertonic solution higher osmolality (3% sodium) Pulls fluid into vascular (increases extracellular) Hypotonic solution lower osmolality (0.45%, 0.33%) Pushes fluid into cells (increases intracellular) Osmotic pressure = Power of a solution to draw water across a semi-perm membrane. Osmosis: Movement of water across a semipermeable membrane to achieve equilibrium. Diffusion: Movement of particles across a permeable membrane from area of higher particle concentration to an area of lower particle concentration. Filtration: Movement of water through a cell or blood vessel membrane because of hydrostatic pressure differences.  Fluid Volume Deficit (FVD) Fluid Volume Excess (FVE) Hematocrit, Specific Gravity, Hematocrit, Specific Gravity, M Blood Osmolality, BUN Blood Osmolality, BUN Decrease A Increase N C Oliguria Polyuria I L Altered Level of Altered Level of Consciousness F Consciousness (ALOC) (ALOC) I Decreased skin turgor/Tenting Pitting E N Edema/Anasarca/Ascites/Third S I Spacing T Dry Skin & mucus membranes Thin, Shiny Skin C A Orthostatic Hypotension Hypertension A T Flat Neck Veins Distended Neck Veins L I Weight loss Weight gain Thirst Loss of appetite O Sunken Fontanel (infants) Bulging Fontanel (infants) N S  FVD Treatments FVE Oral or IV Hydration (Monitor for Diuretics: Loop, Thiazide, K sparing overuse) Electrolyte replacement (if Low sodium diet needed) Give blood products Restricted fluid intake Daily Weight and I & O’s Daily Weights and I & O’s Maintain Safety: Fall risk: Maintain safety: Fall risk: Orthostatic, Skin breakdown, bathroom assist, Skin breakdown, Reposition Reposition (High Fowlers for ** CLASSairway)  FVD FVE Low blood volume, Low blood pressure, Low blood sodium or Low blood oxygen = ADH & Renin release. Renin-Angiotension- Aldosterone system = (Vasoconstriction) = volume retention. ANP & BNP (peptide hormones) from heart in response to excess blood volume and stretching cardiac walls. Promotes sodium wasting and acts as a potent diuretic = volume wasting Hematocrit % of whole blood comprised of RBC’s in relation to plasma M 42 – 52% F 37 – 47% Specific Gravity 1.005 – 1.030 Osmolality (serum & urine), Hematocrit, Specific Gravity: FVD = Increases FVE = Decreases  SODIUM “Where sodium goes, water follows” (ECF) 136 – 145 mEq/L Often enters the body through foods and fluids (e.g., smoked or pickled foods, snack foods, condiments) Hypernatremia Hyponatremia Actual NA excess vs Relative NA excess Actual NA deficit vs Relative NA deficit (Conc) (Dilution) Hyperaldosteronism NPO Excessive diaphoresis Kidney failure (dec excretion) Fever Hyperglycemia Corticosteroids Infection Diuretics (overuse) Excessive Cushing syndrome hypoNA fluid Excessive sweating Wound drainage SIADH Excessive ingestion of NA Watery Decreased Aldosterone Excess diarrhea water intake Excessive admin of NA fluid Diabetes Kidney disease Burns Insipidus NPO or Low salt diet Severe vomiting Manifestations/Nursing Manifestations/Nursing considerations considerations “Big & Bloated” Excitable membranes are less excitable Seizure precautions (if severe) Confusion, cognition, seizure precautions Edema Cerebral changes due to cerebral edema Decreased urine, thirst, dry mucus & inc ICP membranes, restless Weakness, dec DTR, limp, nausea Orthostatic hypotension, weak thready pulse (unless dilutional) COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 11 Treatment (#1 Determine cause) Treatment (#1 Determine cause)  POTASSIUM Major cation of intracellular fluid (ICF) 3.5 – 5 mEq/L Highest in meat, fish, vegetables & fruits. Skeletal, cardiac & smooth muscle, Cell metabolism, Nerve Impulses. Hyperkalemia Hypokalemia Excessive potassium foods or medications Diuretics or corticosteroids or salt substitutes Increased secretion of aldosterone Rapid IV infusion with potassium solutions Vomiting/Diarrhea Blood transfusions of whole or packed Prolonged NG suctioning/ Wound drainage cells Kidney disease impairing absorption Kidney failure/Adrenal insufficiency Heat stroke Potassium sparing diuretics NPO or too little potassium rich foods ACE’s & ARB’s Total parenteral nutrition Acidosis (DKA) or infection Manifestations/Nursing Manifestations/Nursing considerations considerations Dysrhythmias (tall peaked T waves, wide Reduced cellular excitability (Age QRS) increases loss) Muscle twitching/Parathesias/Inc DTRs Dysrhythmias (ST depression, flat or Prolonged = muscle weakness to flaccid inverted T waves) paralysis Weakness, orthostatic hypotension, dec Diarrhea/hyperactive bowels DTR Decreased bowel sounds, ileus Treatment (#1 Determine cause) Treatment (#1 Determine cause) Restrict K intake (diet or meds) Give potassium (amt and route depends Calcium Gluconate (protect heart) on severity) COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 12  CALCIUM Enters the body by dietary intake/absorption thru the intestinal tract. 9 – 10.5 mg/dl Absorption requires active form Vit D. Primarily stored in bone. When more calcium needed in blood, the parathyroid hormone (PTH) released. When excess calcium in blood, the thyroid gland secretes calcitonin. Hypercalcemia Hypocalcemia Excessive intake of calcium and/or Vit D Inadequate intake or inadequate Vit D Kidney failure level Thiazide Diuretics Malabsorption issues: Celiac, Crohn’s Hyperparathyroidism End stage renal disease Diarrhea, Wound drainage, Immobility h/o Parathyroid gland removal Manifestations/Nursing Manifestations/Nursing considerations considerations Decreased neuroexcitability Increased neuroexcitability/ Hyperactive Fatigue/weakness/dec DTRs reflexes Calcifications (eyes, kidney stones) Parasthesias initially that can lead to Confused/lethargic muscle spasms Severe/prolonged causes slowed cardiac Brittle bones/Osteoporosis impulses Hyperactive bowels/diarrhea Hypoactive bowels/constipation Seizure precautions Positive Trousseau’s or Chvostek’s signs Treatment (#1 Determine cause) Treatment (#1 Determine cause) Vit D supplements/Low calcium diet Replacement depending on severity Parathyroidectomy (PO/IV) NS fluids which cause calcium excretion Increase calcium rich foods/Ca or Vit D COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 13 by kidneys supplements  MAGNESIUM Stored mostly in bones and cartilage. Some ICF. 1.8 – 2.6 mEq/L Assists with skeletal muscle contraction, carbohydrate metabolism, generation of energy stores, vitamin activation & blood coagulation. Hypermagnesemia (RARE) Hypomagnesemia Excessive intake of magnesium Inadequate intake magnesium (TUMS, Laxatives, IV infusions) (Malnutrition) Results in = Hypocalcemia Loop or Thiazide diuretics IV mag replacement Chronic alcohol use Kidney disease reducing excretion Malabsorption (Celiac, Chron’s) Manifestations/Nursing Manifestations/Nursing considerations considerations Reduced membrane excitability Increased membrane excitability & Flaccid muscles/dec or absent DTRs nerve impulses Drowsy/lethargic Parasthesias & muscle spasms & inc Cardiac monitoring (low BP and DTRs bradycardia) Cardiac monitoring (due to dec K when Mg low) Seizure precautions Positive Trousseau’s or Chvostek’s signs Treatment (#1 Determine cause) Treatment (#1 Determine cause) COPYRIGHT © 2017, ELSEVIER INC. ALL RIGHTS RESERVED. 14 d/c meds or oral intake Increase Mg intake or if severe  Type 1 Diabetes METABOLISM Type 2 Diabetes Gestational Diabetes Diabetes mellitus disorder of hyperglycemia resulting from defects in insulin secretion, insulin action, or both leading to Type 1 diabetes mellitus (T1D) “Insulin abnormalities in deficiency” carbohydrate, protein, and fat Type 2 diabetes mellitus (T2D) “Insulin metabolism resistance” Gestational diabetes  HYPERGLYCEMIA COMPLICATIONS MACROVASCULAR MICROVASCULAR **Hypertension, Hyperlipidemia, Diabetic retinopathy changes in retina Cigarette smoking and obesity increase Prevalence strongly related to duration of risk of complications. Smoking diabetes. Recommend annual eye accelerates atherosclerotic changes. exams. Cardiovascular disease Coronary Diabetic nephropathy disease of kidneys artery disease risk factor for characterized by presence of albumin in development of myocardial infarction urine, hypertension, edema, progressive (MI). renal insufficiency. First indication microalbuminuria Stroke older adults with T2D 2–6 times more likely to have a stroke Diabetic neuropathy disorder in peripheral nerves and autonomic nervous Reduced Immunity vascular changes system and hyperglycemia reduces white **Foot Care and Safety Importance blood cell activity, inhibiting gas exchange and promoting growth of Sexual Dysfunction microorganisms. Cognitive Dysfunction Peripheral vascular disease both types of diabetes, greater with T2D  ** CLASS ACTIVITY Treatment: IV fluids, IV Regular Insulin, Electrolyte Mgmt  DIAGNOSTIC CRITERIA Prediabetes: Glycosuria 180 mg/dl  AIC 5.7% - 6.4%  Fasting blood glucose 100 – 125  2 hour OGTT >140 - 200 Diabetes ADA Diagnostic Criteria (Confirmed on subsequent day):  AIC >6.5%  Symptoms of diabetes plus casual glucose >200  Fasting plasma glucose >126  2 hour OGTT >200 Gestational Diabetes: Glucose Challenge Test: Non fasting. 50 gm oral glucose at 24 – 28 wks. >140 one hour after must do 2 step testing. Oral Glucose Tolerance Test (OGTT): Fasting. 100 gm oral glucose given. Diagnosis if fasting glucose is abnormal or if 2 or more of: Fasting greater than 95 1 hour greater than 180 2 hours greater than 155 3 hours greater than 140  Asthma GAS EXCHANGE COPD Anemia  Asthma Clinical Manifestati ons & Treatments COMMON TRIGGERS: Pollens, Weeds, Dust mites, Animal dander Exposure to aspirin, other (NSAIDs) Stress Exercise Exposure to hot or cold air Viral infection Smoke & Second hand Exposure to respiratory irritants in workplace  COPD PLAN OFCARE Repeated exposure to respiratory irritants that begin to damage structure of lungs air trapping hyperinflation of lungs bronchitis Pathophysiology Chronic bronchitis disorder of excessive bronchial mucus secretion **Asthma often exists 1. Smoking major factor in development as co-morbidity 2. Recurrent infection common Emphysema characterized by destruction of walls of alveoli, with resulting enlargement of abnormal air spaces Risk Factors Smoking is greatest Frequent exposure to smoke Long term exposure to chemical irritants (workplace or hobbies) Short term exposure to highly irritating substances Genetic: Alpha Antitrypsin Deficiency Initially dyspnea only on exertion Chronic bronchitis cough that produces copious amounts of thick tenacious Clinical sputum, cyanosis, evidence of right-sided heart failure, adventitious lung sounds Manifestations Emphysema insidious dyspnea with exertion, minimal cough, barrel chest due to air trapping and hyperinflation, breath sounds diminished, pursed-lip breathing Patient often thin, tachypneic, uses accessory muscles, assumes tripod position Caloric demand increases as effort to breathe increases Anxiety Clubbing of nails and barrel chest  Pulmonary function testing (FVC, FEV1, PEFR)  Serum 1-antitrypsin levels (Genetic testing) Labs &  Arterial blood gas (Hypercapnia) Diagnostics  Pulse oximetry (88-92%)  CBC with WBC differential  Chest x-ray Oxygen Therapy (88% and 92%) & positioning (Venturi mask or NC) Monitor ABGs Nursing Provide rest periods with ADL’s Interventions Pursed Lip Breathing Cough and deep breathing at least every 2 hours while awake Suctioning Percussion, Vibration, and Postural Drainage Daily weights Smoking cessation Promote balanced nutrition; Hydration/Humidification Promote family coping & education; Reduce anxiety Avoid exposure to other airway irritants, allergens Vaccinations to help prevent respiratory illnesses Antibiotics if infection suspected & Antipyretic if febrile Anticholinergics – Tiotropium (Spiriva), Atrovent/Atropine Pharmacology Bronchodilators metered-dose inhaler (MDI), DPI, nebulizer, orally Albuterol (SABA) and (LABA) may be used in combo therapy (Formoterol) Corticosteroid therapy Pulmicort, Flovent, Qvar, Prednisone Expectorants as needed to clear airway Mucolytics to thin secretions (Guaifensin)  Nasal cannula Simple face mask 24-45% FIO2 40-60% FIO2 Partial rebreather 1 – 6 liters Minimum 5 liters CPAP: 60% - 75% FIO2 Continuous 6 -11 liters Venturi Mask Positive 24-50% FIO2 Airway 12 – 15 liters Pressure Adaptor located between bottom of mask and O2 sources Good for COPD Oxyg High Flow Nasal Cannula 30L/min to 60L/min Non-rebreather Greater than 90% en Combination of heat and humidity minimizes damage to mucous membranes FIO2 10 -15 liters Deliv Not long term use Pneumothorax vs Atelectasis? Tension Pneumothorax: What is the difference?  ABG’s pH Hydrogen Ions 7.35 – 7.45 PaCO2 Carbon Dioxide 35 – 45 PaO2 Dissolved oxygen in blood 80 – 100 Is pt on oxygen? HCO3 Bicarb 22 - 26 PCO2: Hypercarbia (capnia), Hypocarbia (capnia) SaO2: Pulse ox (percentage of hemoglobin carrying oxygen) Kidneys help absorb or excrete acids and bases to balance. Increase in PH (alkalotic) kidneys excrete bicarb. PHARMACOLOGIC THERAPY BRONCHODILATORS Relax smooth muscles of airway Beta Agonists (anxiety, tremors, tachy) (Neb or MDI)  SABA’s: (Rescue Med) Albuterol/Proair/Ventolin, Xopenex  LABAs: (Onset slow/long duration) Salmeterol/Serevent, Foradil, Oral albuterol Anticholinergics (Dry up mucus) (Neb or MDI)  Ipratropium/Atrovent  Tiotropium/Spiriva (60-90 mins) Ice chips, fluids or hard candy for dry mouth PHARMACOLOGIC THERAPY CONT’D ANTI-INFLAMMATORIES Reduce airway inflammation Corticosteroids (MDI, DPI, PO or IV for severe)  Prednisone/Solumedrol  Budesonide/Pulmicort  Fluticasone/Flovent No abrupt removal. Can cause adrenal suppression. Combos: Symbicort, Dulera, Advair, Combivent Leukotriene modifiers (PO)  Montelukast (singulair)  Zafirlukast (accolate)  Zileuton (zyflo) Cromolyn Sodium/Nedocromil (Inhaled or PO) ***NOT RESCUE MEDS/MAINTENANCE  ANEMIA S Decreased RBC production, Increased RBC Loss Or RBC destruction Blood loss (Acute or Chronic blood loss) Nutritional (Iron, Folic Acid, Vitamin B12, Pernicious Anemia Hemolytic Aplastic Common symptoms for all: Fatigue, 30  Hypertension PERFUSION Hypertensive Disorders in Pregnancy PVD  Rhythm  Rhythm is classified as  Regular- The interval between waves is Regular  Irregular- The interval between waves is Irregular Measure P to P or R to R Laboratory assessment Diagnostic Assessment  Serum cardiac enzymes Troponin T 200 mmHg systolic and > 150 mmHg 700 diastolic  Perfusion Concept Exemplar Hypertension During Pregnancy Gestational hypertension Preeclampsia Eclampsia Chronic hypertension (preexisting)  Interventions for Seizures  Left side lying position to promote circulation thru placenta  Provide oxygen  Prevent seizure-related injury by padding side rails  Fetal monitoring  Support the family  Initiate magnesium sulfate for treatment. (monitor for signs of magnesium toxicity) Elsevier items and derived items © 2009, 2005 by Saunders, an imprint of Elsevier Inc. 37  Arteriosclerosis and Atherosclerosis  Pathophysiology Overview  Arteriosclerosis Thickening or hardening of arterial wall Often associated with aging  Atherosclerosis Type of arteriosclerosis involving formation of plaque within arterial wall Blood vessel damage that causes inflammation. Leading risk factor for cardiovascular disease Copyright © 2021, Elsevier Inc. All Rights Reserved.  Peripheral Venous Disease Treatment Goals: Decrease edema and promote venous return  Compression stockings  Compression pumps  Elevate legs  20 minutes……4-5 times/day  Wound therapy for ulcers  Lifestyle changes  Don’t cross legs  Avoid prolonged sitting/standing  Drug therapy (see separate slide)  Peripheral Arterial Disease (PAD) Staging Stage I: Stage II: Stage III: Stage IV: Asymptomatic Claudication Rest Pain Necrosis/Gangrene  No claudication  Muscle pain,  Pain while resting.  Ulcers and is present cramping, or Awakens at night. blackened  Numbness,  Bruit or burning occurs tissue occur on aneurysm may with exercise burning the toes,  Distal part of the be present and is relieved forefoot and  Pedal pulses with rest. extremity (toes, heel. are decreased  Symptoms are arch, heel)  Distinctive  Relieved by or absent reproducible gangrenous with exercise. placing extremity odor is present.  Most common in dependent stage at position. diagnosis. Copyright © 2021, Elsevier Inc. All Rights Reserved.  Peripheral Arterial Disease (PAD)  Exercise Treatment  Increases collateral circulation.  Contraindicated in severe rest pain, venous ulcers or gangrene.  Positioning  Avoid raising legs above heart level  Avoid crossing legs  Avoid restrictive clothing  Foot care  Inspect feet daily for color or other changes.  Avoid injury, wear comfortable shoes, no barefeet  Keep toenails clean and filed  Promote vasodilation  Provide warmth, avoid cold  No electric warming devices to prevent damage due to decreased sensitivity.  Avoid emotional stress, caffeine & smoking  Drug therapy (see separate slide) Copyright © 2021, Elsevier Inc. All Rights Reserved.  Pulses: Normal Pain: Usually mild or Pain: Severe, IC, Rest aching pain Pulses: Decreased or Absent Copyright © 2021, Elsevier Inc. All rights reserved. 43  Medications Peripheral Vascular Disease Anticoagulants (suppress production of fibrin. Antiplatelets (inhibit platelet aggregation. Most effective for venous) Most effective for arterial)  Heparin (IV,SQ)  Aspirin (PO)  enoxaparin (Lovenox) (SQ)  clopidogrel (Plavix) (PO)  warfarin (Coumadin) (PO) Drug of choice for PAD Drug of choice for DVT Monitor for bleeding: Monitor aPTT, Anti-Xa, PT, INR, H&H, platelets  Discolored Urine Monitor for bleeding:  Red/Black Stool  Discolored Urine  Bruising/Petechiae  Red/Black Stool  Bruising/Petechiae  Gums  Gums  Change in vital signs  Change in vital signs THERMOREGULATION Hyperthermia Hypothermia Normothermia Normal body temperature (ranges between 36.2-37.6C or 97 – 100F) Mild: 34–36C (93.2 – Hypothermia 96.8F) Body temperature below 36.2 C Moderate: 30–34C (86 – 93F) Hyperthermia OTHER KEY Severe: