NUR 265 EXAM 2 With Correct Answers Latest Update 100% GUARANTEED PASS
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Course
NUR 265
Institution
NUR 265
EXAM 2 NUR 265
● Pulmonary embolism: clot that travels to the lungs
○ Risk factors
■ Prolonged immobility
■ Central venous catheter surgery
■ Obesity
■ Advancing age
■ Conditions that increase blood clotting (DIC)
■ Distort of thromboembolism
■ Smoking
■ Pregnancy N...
● Pulmonary embolism: clot that travels to the lungs
○ Risk factors
■ Prolonged immobility
■ Central venous catheter surgery
■ Obesity
■ Advancing age
■ Conditions that increase blood clotting (DIC)
■ Distort of thromboembolism
■ Smoking
■ Pregnancy
■ Hormonal birth control (estrogen therapy)
■ Heart failure
■ Stroke
■ Cancer
■ Trauma
■ Afib
○ S/s:
■ Dyspnea - SUDDEN ONSET
■ Pleuritic chest pain (sharp, stabbing type pain on inspiration)
■ Crackles
■ Wheezes
■ Apprehension
■ Anxiety
● Give O2
■ Restlessness
■ Impending doom
■ Cough (productive or dry)
■ Tachypnea
■ Pleural friction rub
■ S3 or s4 heart sound
■ Diaphoresis
■ Low grade fever
■ Petechiae (fat embolism , does not impede blood flow, causes actual
damage to the blood vessels) over chest and a axillae
■ If really big you can see EKG changes
■ hemoptysis - bloody sputum
■ Decreased Sao2
■ Sudden dyspnea and chest pain= immediately notify rapid response team
○ Labs:
■ Hyperventilation (caused from pain and hypoxia) = respiratory
alkalosis (low paco2 <35, high PH >7.45) = blood shunting from right
side to left
, lOMoARcPSD|3013804
side without picking up O2 from the = respiratory acidosis (high paco2
>45, low PH <7.35)= build up of lactic acid = metabolic acidosis (low
HCO3 <22, low PH <7.35)
■ D-dimer rises (positive)
○ Dx:
■Pulmonary angiography = gold standard
● Only if stable
● Inject dye, use imaging
■ CT
■ Chest X-ray
■ Doppler ultrasound
○ Nursing intervention:
■ Call rapid
■ O2 - use pulse ox
● Nasal cannula
● Mask
● Mechanical ventilation
■ Tele
■ IV access
■ Monitor VS. lung sounds and cardiac/ respiratory status Q1-2hrs
● Assess for and document increasing dyspnea, dysrhythmias,
JVD, pedal or sacral edema, crackles, cyanosis
■ CTPA, pulmonary angiography
■ Bleeding precautions
● Monitor and record amount of bleeding
● Asses Q2 hours
■ Measure abdominal girth Q8 Hours
■ Monitor labs daily
● Monitor CBC to watch for blood loss
○ Blood loss= RBC, plasma
○ Monitor platelet count = decreased platelet count = HIIT
■ Drug therapy
■ Make sure antidote is on the floor
● Anticoagulants - keep clots from getting bigger
○ Unfractionated heparin
■ Check PTT (normal 20-30) before
administering (range between 1.5-2.5 times the
control) (therapeutic 46-70) (>75 =
complication)
■ 5-10 days (for 24 hours)
■ Protamine sulfate = antidote
○ Then transferred to oral warfarin
■ Monitor INR (2.0-3.0)
■ Vitamin K = antidote
, lOMoARcPSD|3013804
○ Heparin 5-10 days, most patients started on warfarin on
day 1-2, both are continued together until the INR
reaches 2-3, heparin will be continued for 24 hours after
INR is >2
●
○ Heparin induced thrombocytopenia
■ Body creates antibodies to the heparin = increased
thrombin - prothrombin = increased clotting
■ Risk factors include:
● Duration of heparin use longer than 1 week
● Exposure to unfractionated heparin
● Post surgical prothrombin prophylaxis
● Being female
■ S/s:
● DVT
● PE
● Thrombocytopenia (hallmark sign) =
platelets <150,000
● Can through thrombus
■ Treatment:
● Argatroban and lepirudin (direct thrombin
inhibitors)
● Inferior vena cava filtration - bedside procedure
○ Filter that catches things before it gets to the lungs
● Mechanical ventilation for respiratory acidosis + pao2 <60
= respiratory failure
●
● TPA
○ Antidote = clotting factors, frozen plasma,
aminocaproic acid
● Mechanical ventilation
○ Mode:
■ A/C : assistive control ventilation
● Most restrictive - vent takes control of breathing completely
● Complications:
○ Hyperventilation
○ Respiratory alkalosis ( paco2 <35, ph >7.45)
● Resting mode: to try to allow patient to breath on their own, if
not working then the vent takes over and breathing pattern is
established
■ SIMV: synchronized intermittent mandatory ventilation
● Can be used as a main ventilator or as a weaning method
● Allows for spontaneous breathing at patients own rate
■ CPAP: continuous positive airway pressure
○ Rate
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