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Nur265 Advanced medsurg Exam 2
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Nur 265 Advanced medsur Exam 2
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Galen College of NursingNur265 Advanced Medsurg
Exam 2 (unit 4, CH 29, 27, 24, 37 Unit 5/6 Ch 57, 58, 59) please see page numbers (will be on exam)
Medical Surgical Nursing: Ignatavicius, Workman, Rebar, Heimgarterner 10th edition
Prof Angoma
Labs to know
Galen College of Nursing
Nur265 Advanced Medsurg
D-Dimer- 68-494
Warfarin INR 2-3; antidote Vitamin K (5 days full effect); teach consistant vit K
Heparin PTT 46-70; antidote Protamine Sulfate (fast onset)
-Most important teaching Keep Dr appointment
Platelets 150-400,000 Aspirin, clopidorel, enoxaparin
Thrombocytopenia platelets 50,000 or less
Bleeding precautions- CHANT= Cirrhosis; Hepatitis; alcohol; Nsaids, Tylenol overuse; liver damage
Signs of bleeding- black tarry stools. Hematuria, epistaxis, petechiae, bruising
Avoid- Vit E, Ginseng, Gingko Balboa, Garlic, Omega 3, St. Johns wort
Ventilation (mechanical) movement of air o2 & co2
perfusion (chemical )- movement of o2 and co2 in blood throughout body
VQ mismatch – issues between ventilation and perfusion ( clot ar, emboli; ) low oxygen ; gas exchange is not occurring
KNOW ABGs’
PH- 7.35-7.45= Less than 7.35 acidosis; More than 7.45- alkalosis
PCO2=35-45 (respiratory)= less than 35 is alkalosis; more than 45 acidosis
HCO3= 22-28 (metabolic)= Less than 22 acidosis; more than 26 alkalosis
If PH is low ; potassium is high****
-Hypervenitation- alkosis ph above 7.45
Hypoventilation – acidosis- ph below 7.35; potassium goes up
All electrolyte imbalances are risk for Seizure
Pulmonary emboli-EMERGENCY blockage of pulmonary artery causing hypoxemia (impaired gas exchange) V/Q mismatch
Patho- blood clot interferes w/ perfusion to lungs
-Causes-DVT, air embolism, fat embolism (long bone broken, petechiae), amniotic fluid, (inherited thrombophilia V Leiden
test)
-Risk factors – Estrogen therapy; PO contraceptives, smoking, obesity, immobility, afib,
Page 588 S/S- hypoxia, sudden onset of dyspnea; sharp, stabbing chest pain, Pleuritic pain apprehension, restlessness, feeling of
impending doom, cough, hemoptysis (pink frothy sputum), diaphoresis, increased RR, crackles, pleural friction rub,
tachycardia, S3, S4 heart sound, low grade fever, petechia on chest (only fat embolism), decreased SaO2;
Heart S/S- tachycardia, distended neck veins, syncope, cyanosis, hypotension (hyper respiration alkalosis ph) more
than 7.45)
-DX- CT, High D-dimer, chest xray, MRA, (assess oxygenation ABG)
-Treatment- embolectomy; vena cava filter, meds anticoags, THROMBOLYTIC
-Meds- anticoagulants=heparin (quick onset; doesn’t last long), warfarin( longer onset; last longer prevent new clots PT &INR
(2-3) consistent leavy veggies ; Thrombolytics= ase, atlepase, if clot is large TPA only thru peripheral line (give 3-4.5hrs onset of
symptoms; bleeding risk; no IM, SubQ, injections, no abgs); no invasive procedure for 24hours
Contraindications for clot bluster”ASE”= active bleeding peptic ulcer; uncontrolled HTN 180/110, 2w recent surg, CVA
-If petechiae on chest priority give O2
1
, Complication- HIT
Page 589 nursing management of PE 1st apply o2 8L-10L via nasal cannula or face mask, reassure patient, high fowler position,
telemetry monitoring, venous access; continuous pulse ox, assess RR every 30mins (auscultate lung sounds; Rate, rhythm, ease of
RR; skin color, cap refill; check position of trachea); Assess cardiac status (compare BP in left & right arm; check pulse quality; pulse;
EKG dysrhythmias; check for JVD) RX imaging and labs (CBC, platelets, PT,PTT, D-dimer, ABG) assess for petechia; give anticoags,
assess bleeding, bleeding precaution, handle patient gently
Page 587 Prevention of PE – start active & passive ROM; early ambulation; compression devices (SCD); anticoagulant therapy;
prophy anticoag, antiplatelet; Avoid tight garters, girdles, constricting clothing; DO NOT PLACE PILLOW below KNEES; alternate
pressure mattress; peripheral circulation assessment every 8hrs; elevate affected limb 20 degrees or above level of heart; monitor
output , reposition every 2hrs, refrain from massing leg; do not cross legs, encourage smoking cessation, teach family and patient
about precautions
Page 724 Pt receiving anticoagulant therapy =Check dose of anticoags even if prepared by pharm; monitor for S/S of bleeding
(hematuria, blood in stool, ecchymosis, petechiae, altered LOC (cranial bleed);abd pain,(abd bleed)); VS (tachycardia, hypotension);
Antidotes available (Protamine sulfate= Heparin; Vit K warfarin); Monitor Labs (aPTT=heparin; PT/INR=warfarin/low molecular
heparin); apply prolong pressure over venipuncture site; when admin subQ heparin apply pressure over site do NOT massage;
discharge teaching: use electric razor, avoid injury (avoid use of hammers, saws); Report S/S of bleeding (blood in urine or stool;
nosebleeds; ecchymosis's, altered LOC); take meds at prescribed time ;don’t stop taking rx abruptly; HCp will taper off anticoags
gradually
Page 724 drug alert
Page 591 Heparin induced thrombocytopenia =immune response platelet low (below 150,000) ; thrombocytopenia after 10 days
after initiation of any heparin
-S/S-DVT, PE, pain, swelling, tenderness on extremities, petechiae, bruising, bleeding, oozing
-Treatment – Platelet transfusion or anther anticoag or admin thrombin inhibitor Lepirudinor, Bivalirudin (angiomax)
argatroban; can give warfarin if platelet count has recovered
-Complications- venous thromboembolism
Venous air embolism- entry of air into venous ; put pt in Trendelenburg and turn to left side = trap are in right atria
-Cause- central line insertion, trauma, severity depends of amt of air; “ Pt just had mid or picc line inserted”
-S/S = dyspnea, chest pain, tachycardia, heart murmur, hypotension, decreased LOC, circulatory shock, sudden death
-prevent – prime IV tubing; secure connections in central lines protect from dislodgement
Acute Respiratory failure EMERGENCY= ventilation failure or oxygenation failure (respiratory acidosis)
-Types- Hypoxemic (low O2) PaO2 less than 60 and hypercapnic (high Co2) PaCO2 over 50
-Cause- VQ mismatch, (overdose low slow RR); vent problem, trauma , PE, Overdose, sleep apnea, low RR
-S/S- hypoxemic (low o2), hypercapnic (high Co2); dyspnea, change in LOC #1 restlessness, confusion, tachycardia,
hypertension, dysthymias, decreased LOC, alterations of resp & breath sounds, headache, lethargy seizures
-Patho- insufficient o2 to blood or Co2 not removed in capillaries; o2 reaches alveoli not absorbed properly
-Labs- ABG (paco2 below than 60, SaO2 below 90) respiratory acidosis
-Nursing interventions- O2 (keep Pa02 over 60-70); high fowlers; deep breath, mech vent, intubation prior/post vent abg
-Meds- bronchodilators
-Treatment-intubation (prior/post ABG)
Page 593 Critical values for acute resp failure= PaO2 less than 60 & SaO2 90%; OR PaCO2 more than 45 w/ pH less than 7.35
acidosis AND SaO2 90%
Acute Respiratory Distress Syndrome- swollen and fluid in lungs aka “White lungs” (acidosis)
2
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