NUR2392 Final Exam Multidimensional Care II MDC 2 Final Exam Review, Exams of Nursing

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NUR2392 Final Exam Multidimensional Care II MDC 2

Final Exam Review (2024- 2025 )

Assessment and Care of Patients with Pain Concepts

• The priority concept in this chapter is comfort
• The interrelated concepts in this chapter are cognition sensory Perception Pain The Scope of the Problem
• Pain is a major economic problem and a leading cause of disability that changes the lives of many people, especially older adults.
• Chronic non-cancer pain such as osteoarthritis, rheumatoid arthritis, and diabetic neuropathy is the most common cause of long-term disability, affecting millions of Americans and others throughout the world. _- Universal, complex personal experience
• Is an impairment in comfort; major economic concern; leading cause of disability
• Failure to manage pain is a worldwide health problem
• Inter-professional pain initiatives help patients receive best treatment_ Definitions of Pain
• Unpleasant sensory and emotional experience associated with actual or potential tissue damage
• Whatever person experiencing it says it is; exists whenever person says it does
• Self-report always most reliable indication of pain Categorization of Pain by Duration
• Acute pain
• Short-lived
• Results from sudden, accidental trauma; surgery; ischemia; acute inflammation
• Chronic (persistent) pain
• Can last a person‘s lifetime
• Chronic cancer pain
• Chronic non-cancer pain
• Pain is treated inadequately in almost all health care settings.
• Populations at the highest risk in medical-surgical nursing are older adults, patients with substance use disorder, and those whose primary language differs from that of the health care professional.
• Older adults in nursing homes are at especially high risk because many residents are unable to report their pain. In addition, there often is a lack of staff members who have been educated to manage pain in the older-adult population. Acute Pain
• Acts as warning sign
• Activation of sympathetic nervous system
• ―Fight-or-flight‖ reaction s
• Increased vital signs
• Sweating
• Dilated pupils
• Restlessness
• Apprehension
• Distress of varying degrees

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Acute Pain (Cont.)

• Absence of physiologic and behavioral responses does not mean absence of pain
• Usually temporary with sudden onset, and easily localized
• Sensory perception of pain changes as injured area heals Chronic (Persistent) Pain
• Lasts or recurs for indefinite period (more than 3 months)
• Gradual onset
• Character and quality often change over time
• Serves no biological purpose
• Can result in emotional, financial, and relationship burdens, as well as depression/hopelessness Chronic Cancer Pain
• Usually result of tumor growth, nerve compression, tissue invasion, metastasis
• Cancer treatment can also cause acute pain (e.g., procedures, surgery, toxicities from chemo and radiation) Chronic Non-Cancer Pain
• Global health issue for people > 65 years old
• Formerly called chronic nonmalignant pain
• Neck, shoulder, low back
• Over half of veterans of recent wars have this condition
• Can cause depression, decreased sense of well-being Categorization of Pain by Underlying Mechanisms
• Nociceptive pain
• Somatic
• Visceral
• Neuropathic pain Pain Transmission
• Painful stimuli often originate in extremities
• If pain is not transmitted to the brain, person feels no pain
• Two specific fibers transmit periphery pain:
• A delta fibers
• C fibers Assessment: Noticing
• Patient‘s self-report is ―gold standard‖ for assessm ent
• Nurse‘s role
• Accept patient self-report
• Serve as advocate
• Act promptly to relieve pain
• Respect patient values and preferences Pain Assessment (Cont.)
• Location
• Intensity
• Quality
• Onset and duration
• Aggravating and relieving factors
• Effect of pain on function and quality of life

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• Comfort-function outcomes
• Other information Psychosocial Assessment
• Pain holds unique meaning for the person experiencing it.
• Remain objective; advocate for proper pain control
• Refer to resources su ch as ―10-S tep Program from P atient to Person‖ (a s needed) Assessment Challenges
• Patients who cannot self-report pain are at higher risk for under-treated pain
• Hierarchy of Pain Measures
• Checklist of Nonverbal Pain Indicators (CNPI)
• Pain Assessment in Advanced Dementia Scale (PAINAD) Different Pain Types
• Localized pain is confined to the site of origin.
• Projected pain is diffuse around the site of origin and is not well localized.
• Referred pain is felt in an area distant from the site of painful stimuli.
• Radiating pain is felt along a specific nerve or nerves.
• Intensity: Ask the patient to rate the severity of the pain using a reliable and valid assessment tool.
• Various self-report scales have been developed to help patients communicate pain intensity. Teaching how to respond to a pain scale
• Text book Table 4- Analgesic Groups
• Non-opioid analgesics
• Acetaminophen
• NSAIDs Non-opioid Analgesics
• Monitor patients taking acetaminophen for hepatotoxicity
• Reduced daily dose may be appropriate for older adults on long-term therapy
• Monitor patients taking NSAIDS for gastric side effects
• NSAIDS carry risk for cardiovascular and renal adverse effects through prostaglandin inhibition Analgesics by Classification: Opioid Analgesics
• Full or mu agonists
• Morphine, fentanyl, hydromorphone, oxycodone, oxycodone, hydrocodone
• Mixed agonists antagonists
• Butorphanol, nalbuphine
• Partial agonists
• Buprenorphine Drug Formulation Terminology
• Short acting, fast acting, immediate release (IR), normal release
• Onset in about 30 minutes; short duration of 3 to 4 hours
• Modified-release, extended release (ER), sustained release (SR), controlled release (CR)
• Release over a prolonged period
• Never crush, break, or have patients chew! Selected Opioid Analgesics

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• Morphine
• Fentanyl
  • Teach patients to refrain from applying heat to patches
• Hydromorphone
• Oxycodone
• Hydrocodone
• Methadone Dual Mechanism Analgesics
• Tramadol (Ultram)
• Tapentadol (Nucynta) Opioids to Avoid
• Meperidine
• Codeine Intraspinal Analgesia
• Analgesic administration via a needle or catheter in the epidural or intrathecal space
• Placed by an anesthesia provider
• Side effects depend on drug administered
• Complications are rare but can be life-threatening Adverse Effects of Opioid Analgesics
• Constipation
• Nausea
• Vomiting
• Pruritus
• Sedation
• Respiratory depression (less common, yet most concerning) Adjuvant (Co-Analgesic) Analgesics
• Anticonvulsants and antidepressants
• Gabapentin
• Imipramine (Tofranil)
• Clomipramine (Anafranil)
• Doxepin
• Local anesthetics
• Lidocaine Use of Placebos
• Any medication or procedure (including surgery) which produces an effect because of its intent
• Used as control in research
• Any other use has ethical and legal implications; violates nurse–patient relationship; deprives patient of appropriate assessment Nonpharmacologic Management
• Appropriate for mild- and some moderate-intensity pain
• Should complement, not replace, pharmacologic therapies for more severe pain
• Physical modalities
• Cognitive-behavioral strategies Physical Interventions (Examples)
• Physical therapy

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• Occupational therapy
• Aquatherapy
• Functional restoration
• Acupuncture
• Low-impact exercise such as walking or yoga
• Cutaneous stimulation (e.g.,TENS) Cognitive/Behavioral Strategies (Examples)
• Prayer
• Relaxation breathing
• Artwork
• Reading
• Watching television
• Mindfulness
• Meditation
• Guided imagery
• Hypnosis
• Biofeedback
• Virtual reality Care Coordination and Transition Management
• Home care management
• Self-management education
• Health care resources Chapter 4 Audience Response System Questions Question 1 The patient is receiving the first oral dose of an opioid analgesic for chronic pain. Which additional drug does the nurse anticipate will be prescribed?

A. NSAID B. Epidural C. Stool softener D. Anti-anxiety agent

Rational; Opioids inhibit peristalsis in the GI tract. Patients who take regular doses of opioids frequently become constipated. Interventions such as diet modifications and laxative agents may be needed to prevent or minimize the problem of constipation.

Question 2 Which patient does the nurse recognize that would benefit most from the use of a patient- controlled analgesia pump?

A. 19-year-old with head injury following MVA today B. 34-year-old with ankle fracture after skiing accident yesterday C. 56-year-old with slurred speech after falling and breaking hip one week ago D. 78-year-old with delirium and fever following surgery 2 days prior

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Rational; The mentally alert patient is the best candidate to receive PCA. When a patient is cognitively impaired or unable to push the PCA button, another method of administration should be considered.

Question 3 The nurse has discussed nonpharmacologic pain management measures with a patient who takes opioid medication for chronic pain. Which patient statement requires further nursing teaching?

A. ―I can practice meditation while taking opioid medication.‖ B. “Reading should be used in place of drug therapy.” C. ―Nonpharmacologic interventi ons can help to control pain.‖ D. ―I plan to practice relaxation breathing tonight.‖

Rational; Nonpharmacologic pain management measures can be used in addition to opioid medication; for patients with moderate to severe intensity pain, these measures should be used in tandem with (instead of in place of) opioid therapy.

Chapter 27 Assessment of the Respiratory System Health Promotion and Maintenance

• Minimize exposure to inhalation irritants
  • Home, occupation, work exposures
• S moking ce ssation (including hookah, w ater pipe, ―vaping‖)
• Limit or cease exposure to secondhand and thirdhand smoke Assessment: Noticing and Interpreting
• Family and personal data (including genetic risk) Family hx of COPD, Cancer, Asthma,
• Smoking (pack-years) 2 packs /day x 20 yrs
• Drug use (prescribed and illicit)
• Allergies - asthma
• Travel, geographic area of residence
• Veterans: location of deployments agent orange, gases
• Current health problems
• PND, paroxysmal nocturnal dyspnea. Physical Assessment: Pharynx, Trachea, and Larynx (Cont.)
• Pharynx the membrane-lined cavity behind the nose and mouth, connecting them to the esophagus.
• The trachea, colloquially called the windpipe, is a cartilaginous tube that connects the pharynx and larynx to the lungs
• Left: Structures of the larynx. the hollow muscular organ forming an air passage to the lungs and holding the vocal cords in humans and other mammals; the voice box.
• Right: Detail of the glottis (two vocal folds and the intervening space, the rima glottis). Physical Assessment: Lungs and Thorax
• Inspect thorax with patient sitting up
• Observe chest, compare one side with the other
• Work from the apex, move downward toward base (from side to side)
• Rate, rhythm, depth of inspiration as well as symmetry of chest movement Physical Assessment: Lungs and Thorax (Cont.)

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Examine AP diameter with lateral diameter Physical Assessment: Lungs and Thorax (Cont.)

• Lung sounds – Normal sounds
  • Bronchial
  • Bronchovesicular
  • Vesicular
• Adventitious sounds – Pathologic
  • Crackles
  • Wheezes
  • Rhonchus
  • Pleural friction rub Physical Assessment: Lungs and Thorax (Cont.)
• Lung chart Other Indicators of Respiratory Adequacy
• Skin and mucous membrane changes
• General appearance
• Endurance Promoting smoking cessation is a sensitive and sometimes uncomfortable issue for nurses and other health care professionals to approach with patients who smoke. However, this opportunity for a ―teachable moment‖ may be the beginning support a patient needs to be successful in this healthful pursuit, especially if the patient is hospitalized for a smoking-related illness (Keating, 2016). Acute care settings have automatic smoking-cessation protocols that attach to the patient's electronic medical record when an active smoking history is recorded. The Joint Commission requires documentation of screening for tobacco use and that a tobacco treatment program be offered or provided as part of their quality measures. Ask about the patient's desire to quit, past attempts to quit, and the methods used. A ―yes‖ response to any of the following questions indicates nicotine dependence. The mor e ―yes‖ respons es , the gr eater the nicotine dependence. Ask the smoker these questions: • How soon after you wake up in the morning do you smoke? • Do you wake up in the middle of your sleep time to smoke? • Do you find it difficult not to smoke in places where smoking is prohibited? • Do you smoke when you are ill? Diagnostic Assessment
• Laboratory assessment
• RBC
• ABG
• Sputum
• Imaging assessment
• x-rays
• CT
• Other noninvasive diagnostic assessments
• Pulse oximetry
• Capnometry and capnography
• PFTs
• Exercise testing Invasive Diagnostic Assessment
• Endoscopic examinations

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• Bronchoscopy Lung biopsy A biopsy is a medical test commonly performed by a surgeon, interventional radiologist, or an interventional cardiologist involving extraction of sample cells or tissues for examination to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically. When an entire lump or suspicious area is removed, the procedure is called an excisional biopsy

Chapter 27 Audience Response System Questions

Question 1 Which assessment finding for an older adult patient does the nurse ascribe to the natural aging process?

A. Tightening of the vocal cords B. Decrease in residual volume C. Decrease in the anteroposterior diameter D. Decrease in respiratory muscle strength

Rational; As a person ages, vocal cords become slack, changing the quality and strength of the voice; the anteroposterior diameter increases; respiratory muscle strength decreases; and the residual volume increases.

Question 2

The nurse knows that under normal physiologic conditions of tissue perfusion, a patient will have what percent of oxygen dissociate from the hemoglobin molecule?

A. 25% B. 50% C. 75% D. 100%

Rational; Oxygen dissociates with the hemoglobin molecule based on the need for oxygen to perfuse tissues. Under normal conditions, 50% of hemoglobin molecules completely dissociate their oxygen molecules when blood perfuses tissues that have an oxygen tension (concentration) of 26 mm Hg. This is considered a ―normal‖ point at whi ch 50% of hemoglobin molecules are no longer saturated with oxygen.

Question 3 Which assessment finding does the nurse interpret that is associated most closely with lung disease?

A. Cough B. Dyspnea C. Chest pain

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D. Sputum production

Rational; Cough is a main sign of lung disease. Dyspnea (difficulty in breathing or breathlessness) is a subjective perception and varies among patients. A patient’s feeling of dyspnea may not be consistent with the severity of the presenting problem. Sputum production may be associated with coughing and indicate an acute or chronic lung condition. Chest pain can occur with other health problems, as well as with lung problems.

Chapter 28 Care of Patients Requiring Oxygen Therapy Or Tracheostomy Why Do We Need Oxygen?

• Essential for life and function of cells/tissues
• Respiratory, cardiovascular, hematologic systems work together, providing sufficient tissue perfusion to the body
• Oxygen therapy improves oxygenation and tissue perfusion Clinical Manifestations of Respiratory Distress
• Dyspnea
• Nasal flaring
• Use of accessory muscles to breathe
• Pursed-lip or diaphragmatic breathing
• Decreased endurance
• Skin, mucous membrane changes (pallor, cyanosis) Respiratory Assessment
• Nose and sinuses
• Pharynx, trachea, larynx
• Lungs and thorax
• Movement/symmetry/fremitus
• Resonance
• Breath sounds
• General appearance (muscle development)
• Skin and mucous membranes Oxygen Intake and Oxygen Delivery The purpose of oxygen therapy is to use the lowest fraction of inspired oxygen (FiO2) to have an acceptable blood oxygen level without causing harmful side effects. Restoration of adequate oxygenation and tissue perfusion by oxygen delivery adjustments and oxygen therapy when respiratory problems interfere with meeting tissue oxygen needs. Hgb, Hemoglobin. RBCs, red blood cells. Assessment of Oxygenation
• ABG analysis is best way to determine need for oxygen therapy. Oxygen Therapy
• Purpose—relieves hypoxemia
• Hypoxemia—low levels of oxygen in the blood
• Hypoxia—decreased tissue oxygenation
• Goal—use lowest fraction of inspired oxygen for acceptable blood oxygen level without causing harmful side effects.
• Chart 28-1 Best Practice for Patient Safety & Quality Care

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Hazards & Complications of Oxygen Therapy

• Combustion
• Oxygen-induced hypoventilation
  • Hypercarbia—retention of CO
  • CO2 narcosis—loss of sensitivity to high levels of CO
• Oxygen toxicity
• Absorption atelectasis—new onset of crackles/decreased breath sounds
• Drying of mucous membranes
• Infection Nursing Safety Priority Action Alert
• Assess the tubing system used for oxygen delivery to recognize buildup of condensation. Respond by draining condensation.
• To prevent bacterial contamination of the oxygen delivery system, never drain the fluid from the water trap back into the humidifier or nebulizer. Oxygen Delivery Systems
• Type used depends on:
• Oxygen concentration required/achieved
• Importance of accuracy and control of oxygen concentration
• Patient comfort
• Importance of humidity
• Patient mobility Low-Flow Oxygen Delivery Systems
• Does not provide enough flow to meet total oxygen and air volume
• Nasal cannula (1-6 L)
• Face-mask o Simple o Partial rebreather o Non-rebreather Nasal Cannula
• Flow rates of 1-6 L/min
• O2 concentration of 24%-44% (1-6 L/min)
• Flow rate >6 L/min does not increase O2 because anatomical dead space is full
• Assess patency of nostrils
• Assess for changes in respiratory rate and depth Simple Face-mask
• Delivers O2 up to 40%-60%
• Minimum of 5 L/min
• Mask fits securely over nose and mouth
• Monitor closely for risk of aspiration Partial Rebreather Mask
• Provides 60%-75% with flow rate of 6-11 L/min
• One third exhaled tidal volume with each breath
• Adjust flow rate to keep reservoir bag inflated Non-Rebreather Mask
• Highest O2 level
• Can deliver FIO2 greater than 90%

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• Used for unstable patients requiring intubation
• Ensure valves are patent and functional High-Flow Oxygen Delivery Systems
• High-flow—can deliver 24%-100% at 8-15 L/min
• Venturi mask
• Face tent
• Aerosol mask
• Tracheostomy collar
• T-piece Venturi Mask
• Adaptor located between bottom of mask and O2 sources
• Delivers precise O2 concentration—best device for chronic lung disease
• Switch to nasal cannula during mealtimes - A Venturi mask for precise oxygen delivery. T-Piece
• Delivers desired FIO2 for tracheostomy, laryngectomy, ET tubes
• Ensures humidification through creation of mist
• Mist should be seen during inspiration and expiration - A T-piece apparatus for attachment to an endotracheal or tracheostomy tube. Noninvasive Positive-Pressure Ventilation (NPPV)
• Uses positive pressure to keep alveoli open, improve gas exchange without airway intubation
• BiPAP
• CPAP CPAP (Cont.)
• Delivers set positive airway pressure throughout each cycle of inhalation and exhalation
• Opens collapsed alveoli
• Used for atelectasis after surgery or cardiac-induced pulmonary edema; sleep apnea Transtracheal Oxygen Delivery (TTO)
• Long-term delivery of O2 directly into lungs
• Small flexible catheter is passed into trachea through small incision
• Avoids irritation that nasal prongs cause; is more comfortable
• Flow rates prescribed for rest, activity Home Oxygen Therapy
• Criteria for equipment
• Patient education:
• Compressed gas in tank or cylinder
• Liquid oxygen in reservoir
• Oxygen concentrator Tracheostomy
• Tracheotomy—surgical incision into trachea for purpose of establishing an airway
• Tracheostomy—stoma (opening) that results from tracheotomy
• May be temporary or
• Permanent

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- tracheostomy is a surgically created opening into the windpipe (trachea). This is done to relieve and bypass obstruction of the windpipe, to help ventilate comatosed patients or to allow for clearance of secretions pooling in the upper windpipe. Possible Complications of Tracheostomy

• Pneumothorax
• Subcutaneous emphysema
• Bleeding
• Infection Tracheostomy Tubes
• Disposable or reusable
• Cuffed tube or tube without cuff for airway maintenance
• Inner cannula disposable or reusable
• Fenestrated tube Care Issues for the Patient with a Tracheostomy
• Prevention of tissue damage:
• Cuff pressure can cause mucosal ischemia
• Check cuff pressure often
• Prevent tube friction and movement
• Prevent/treat malnutrition, hemodynamic instability, hypoxia Causes of Hypoxia in the Tracheostomy
• Ineffective oxygenation before, during, after suctioning
• Use of catheter that is too large for the artificial airway
• Prolonged suctioning time
• Excessive suction pressure
• Too frequent suctioning Tracheostomy Care
• Assess the patient
• Secure tracheostomy tubes in place
• Prevent accidental decannulation Air Warming and Humidification
• Tracheostomy tube bypasses nose and mouth, which normally humidify, warm, and filter air
• Air must be humidified
• Maintain proper temperature
• Ensure adequate hydration Suctioning
• Maintains patent airway, promotes gas exchange
• Assess the need in patients who cannot cough adequately
• Done through nose or mouth Complications of Suctioning Hypoxia
• Tissue (mucosal) trauma
• Infection
• Vagal stimulation, bronchospasm
• Cardiac dysrhythmias from induced hypoxia Bronchial and Oral Hygiene

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• Turn/reposition every 1 to 2 hours, support out-of-bed activities, encourage early ambulation
• Coughing and deep breathing, chest percussion, vibration, and postural drainage promote pulmonary cure
• Avoid glycerin swabs or mouthwash containing alcohol for oral care; assess for ulcers, bacterial/fungal growth, infection Nutrition with Tracheostomy
• Swallowing can be a major problem for patients with tracheostomy tube
• If balloon is inflated, can interfere with passage of food through the esophagus
• Elevate head of bed for at least 30 min after eating to prevent aspiration during swallowing Weaning from a Tracheostomy Tube
• Weaning—gradual decrease in tube size; ultimate removal of tube
• Cuff is deflated when patient can manage secretions; does not need assisted ventilation
• Change from cuffed to uncuffed tube
• Size of tube decreased by capping; use smaller fenestrated tube
• Tracheostomy button has potential danger of getting dislodged Chapter 28 Audience Response System Questions

Question 1

True or False: Flammable solutions containing high concentrations of alcohol or oil should not be used in rooms with oxygen. Therefore, hand hygiene using alcohol-based foams or gels should be avoided when caring for patients on oxygen therapy.

True False

Rationale: Flammable solutions containing high concentrations of alcohol or oil are not used in rooms in which oxygen is in use. However this does not include alcohol-based hand rubs. (Source: Accessed March 27, 2014 from http://www.cdc.gov/handhygiene/Basics.html.)

Question 2

The nurse is caring for a patient with a cuffed tracheostomy and is aware the patient is at risk for developing which complication?

A. Pneumothorax B. Tracheomalacia C. Subcutaneous emphysema D. Trachea–innominate artery fistula

Rationale: Tracheomalacia can develop because of the constant pressure exerted by the cuff, causing tracheal dilation and erosion of cartilage. Pneumothorax can develop during any tracheostomy procedure if the thoracic cavity is accidentally entered. Subcutaneous emphysema can develop during any tracheostomy procedure if air escapes into fresh tissue planes of the

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neck. Trachea–innominate artery fistula can occur any time a malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy.

Question 3

While suctioning a patient, vagal stimulation occurs. What is the appropriate nursing action?

A. Instruct the patient to cough. B. Place the patient in a high Fowler‘s position. C. Oxygenate the patient with 100% oxygen. D. Instruct the patient to breathe slowly and deeply.

Rationale: Vagal stimulation may occur during suctioning and result in severe bradycardia, hypotension, heart block, ventricular tachycardia, asystole, or other dysrhythmias. If vagal stimulation occurs, stop suctioning immediately and oxygenate the patient manually with 100% oxygen. Repositioning the patient, slow deep breathing, and coughing will not address the cardiovascular effects of vagal stimulation.

Chapter 33 Assessment of the Cardiovascular System Surface Anatomy of the Heart

_- About 25% of all heart attacks occur without any previous warning signs.

• Individuals often mistake a heart attack for a symptom of the flu or reflux disease, which_ causes heartburn. Blood Flow Through the Heart
• Cardiovascular System Assessment
• Patient history
• Nutritional history
• Family history and genetic risk
• Current health problems
• Pain, discomfort
• Dyspnea, DOE, orthopnea, PND
• Fatigue
• Palpitations
• Edema
• Syncope
• Extremity pain Cardiac Valves the lub-dub

1. Tricuspid valve 1close 2 open
2. Mitral valve 1close 2 open
3. Pulmonic valve 1 open 2 close
4. Aortic valve 1 open 2 close

S (^) 1 Lub sound = beginning of ―s ysto le‖ mitral and tricuspid valves close (aortic and pulmonary

valves open).

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S (^) 2 Dup sound =beginning of ―diasto le ‖ aortic and pulmonary valves close (mitral and tricuspid

valves open) Cardiac Valves the lub-dub

1. Tricuspid valve
2. Mitral valve
3. Pulmonic valve
4. Aortic valve 3 2 S When present, occurs immediately after S produced from ventricular filling.

S

When present, heart sound occurs just before S

produced from atrial contraction and

indicates impaired ventricle compliance or fluid overload. Perfusion Concept Exemplar: Hypertension

• Desired blood pressure
  • For people over 60
  • Below 150/
  • For people younger than 60
  • Below 140/
  • According to Joint National Committee 8 (JNC 8) guidelines, patients whose blood pressures are above these goals should be treated with drug therapy Blood Pressure Regulation
• Autonomic nervous system:
• Baroreceptors
• Chemoreceptors – Hypercapnia
• Renal system
• Endocrine system
• External factors also affect BP Mean Arterial Pressure (MAP)
• Normal 70 – 100 mm Hg
• Must be at least 60 mm Hg to maintain adequate blood flow through coronary arteries and perfuse major organs (brain).
• If the M A P falls below this number for an appreciable time, vital organs will not get enough oxygen perfusion, and will become hypoxic, a condition called ischemia. Chapter 36 Care of Patients with Vascular Problems Point to Remember…
• Best indicator of fluid balance is weight
• 2.2 lb = 1 kg = 1 L of fluid Assessment: Noticing Abdominal Aortic Aneurysm (AAA)
• Pain related to AAA is usually steady with a gnawing quality, unaffected by movement, may last for hours or days
• Pain in abdomen, flank, back
• Abdominal mass is pulsatile
• Rupture is most frequent complication and is life threatening Cardiovascular System Physical Assessment
• General appearance

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• Skin
  • Cyanosis, rubor (red/flushing)
• Extremities
  • Clubbing, edema
• Blood pressure
  • Hypotension and hypertension
  • Postural (orthostatic) hypotension Aortic Dissection
• May be caused by sudden tear in aortic intima
• Pain described as tearing, ripping, stabbing
• Life threatening
• Emergency care goals
• Eliminate pain
• Reduce blood pressure
• Decrease velocity of left ventricular ejection
• Nonsurgical treatment
• Surgical treatment Assessment: Noticing Thoracic Aortic Aneurysm
• Assess for
• Back pain o Manifestation of compression of aneurysm on adjacent structures
• Assess for shortness of breath
• Hoarseness
• Difficulty swallowing
• Mass may be visible above suprasternal notch
• Sudden excruciating back or chest pain symptomatic of thoracic rupture Precordium
• Assessment
• Inspection
• Palpation
• Percussion
• Auscultation
• Normal heart sounds
• Paradoxical splitting
• Gallops and murmurs
• Pericardial friction rub Serum Markers of Myocardial Damage
• Troponin: Troponin T and troponin I
• Creatine kinase (CK)
• Myoglobin
• Serum lipids
• Total cholesterol < 200 mg/dL
• Triglyceride < 150 mg/dL
• HDL > 40 mg/dL
• LDL < 70 mg/dL for cardiovascular patients

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• Homocysteine
• Highly sensitive C-reactive protein Laboratory Assessment
• Microalbuminuria
• Blood coagulation studies
• PT/INT
• PTT
• ABG
• F&E
• Erythrocyte count
• H&H
• Leukocyte count Management of Cardiac Arrest
• CPR
• Maintain patent airway
• Ventilate with mouth-to-mask device
• Start chest compressions
• Advanced cardiac life support Automated External Defibrillation
• AEDs create an opportunity for laypersons to respond to cardiac arrest
• AEDs analyze the rhythm and shocks are delivered for ventricular fibrillation or pulseless ventricular tachycardia only Defibrillation
• Asynchronous countershock that depolarizes critical mass of myocardium simultaneously to stop re-entry circuit and allow sinus node to regain control of heart Diagnostic Assessment
• PA and lateral CXR
• Angiography
• Arteriography
• Cardiac catheterization Cardiac Conduction System Normal Sinus Rhythm Normal sinus rhythm. Both atrial and ventricular rhythms are essentially regular (a slight variation in rhythm is normal). Atrial and ventricular rates are both 83 beats/min. There is one P wave before each QRS complex, and all the P waves are of a consistent morphology, or shape. The PR interval measures 0.18 second and is constant; the QRS complex measures 0.06 second and is constant. and Transition Management Care Coordination
• Self-management education
• Medication therapy o Antidysrhythmics o Anticoagulants
• Health care resources Non-surgical Interventions
• Non-surgical interventions

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• Electrical cardioversion
• Left atrial appendage closure
• Radio frequency catheter ablation
• Bi-ventricular pacing
• Surgical interventions
• Maze procedure Pacemakers
• Temporary pacing—invasive and noninvasive
• Permanent pacemakers Normal Sinus Rhythm (Cont.)
• Rate: 60 to 100 beats/min
• Rhythm: Regular
• P waves: Present, consistent configuration, one P wave before each QRS complex
• PR interval: 0.12 to 0.20 second and constant
• QRS duration: 0.04 to 0.10 second and constant ECG Rhythm Analysis
• Determine heart rate
• Determine heart rhythm
• Analyze P waves
• Measure PR interval
• Measure QRS duration
• Interpret rhythm Normal ECG ECG Complexes,Segments, and Intervals
• P wave
• PR segment
• PR interval
• QRS complex
• QRS duration
• ST segment
• T wave
• U wave
• QT interval Cardiac Conduction System (Cont.)
• Sinoatrial node
• Electrical impulses 60 to 100 beats/min
• P wave on ECG
• Atrioventricular junction
• PR segment on ECG
• Contraction known as ―atrial kick‖
• Bundle of His
• Right bundle branch system
• Left bundle branch system Cardiac Catheterization

Other Diagnostic Assessment

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• ECG
• Electrophysiologic study (EPS)
• Stress test
• Echocardiography
  • Pharmacologic stress echocardiogram
  • TEE
• Myocardial nuclear perfusion imaging (MNPI) Hemodynamic Monitoring
• Invasive system provides quantitative information about vascular capacity, blood volume, pump effectiveness, tissue perfusion
• Pulmonary artery catheter
• Invasive arterial catheter
• Impedance cardiography Hemodynamic Monitoring (Cont.)

Chapter 33 Audience Response System Questions

Question 1

What atypical symptoms might a woman who is having a myocardial infarction experience?

A. Sudden, intermittent, stabbing chest pain B. Moderate ache in the chest that is worse on inspiration C. Indigestion, feelings of chronic fatigue, and a choking sensation D. Pain that spreads across the chest and back and/or radiates down the arm

Rationale: Some patients, especially women, do not experience pain in the chest with a myocardial infarction, but instead feel discomfort or indigestion. Women often present with a ―tr iad‖ of symptoms. In addition to indigestion or feeling of abdominal fullness , feeli ngs of chronic fatigue despite adequate rest and feelings of ―inability to catch one’s breath‖ are also attributable to heart disease. The patient may also describe the sensation as aching, choking, strangling, tingling, squeezing, constricting, or viselike.

Question 2

A patient is admitted with a weight loss of 2.3 kg over 36 hours, diarrhea, nausea, and vomiting. Based on this information, the nurse should assess which cardiovascular parameter more closely?

A. Preload B. After load C. Heart rate D. Stroke volume

Rationale: The variables preload, afterload, and contractility influence stroke volume and preload is determined by the amount of blood returning to the heart from both the venous system (right heart) and the pulmonary system (left heart). Dehydration and overhydration directly

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influence preload. Blood flow from the heart into the systemic arterial circulation is measured clinically as cardiac output (CO), the amount of blood pumped from the left ventricle each minute. CO is derived from the patient’s heart rate and stroke volume. Stroke volume is the amount of blood ejected by the left ventricle during each contraction.

Question 3

The nurse understands that which assessment finding is the best indicator of fluid retention?

A. Tachycardia B. Weight gain C. Crackles in the lungs D. Increased blood pressure

Rationale: Weight gain is the best indicator of fluid retention and is commonly called edema.

Week 2 Chapter 9 Care of Patients with Common Environmental Emergencies

Concepts

• The priority of this chapter is tissue integrity.
• The interrelated concept in this chapter is comfort. Heat-Related Illnesses
• High environmental temperature
• High humidity
• At-risk populations
• Older adults
• Those with mental health conditions
• Those who work outside
• Homeless individuals
• Users of illicit drugs
• Outdoor athletes
• Military in hot climates Heat Exhaustion
• Heat exhaustion often occurs when people work or play in a hot, humid environment and body fluids are lost through sweating which causes the body to overheat and become dehydrated. The temperature may be elevated, but not above 104 F (40 C).
• Dehydration from heavy perspiration and inadequate fluid and electrolyte intake during heat exposure over hours to days
• Flu-like symptoms
• Treatment
• Stop physical activity,
• transfer to a cool place
• Cooling measures
• Rehydration therapy Heat Stroke

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• Heat stroke (also called heatstroke or sunstroke) also is a heat-related illness, and it is a life-threatening medical condition. It usually develops because of untreated heat exhaustion. The body's cooling system, which is controlled by the brain, stops working and the internal body temperature rises to the point at which brain damage or damage to other internal organs may result (temperature may reach 105 F or greater [40.5 C or greater]).
• True medical emergency
• Body temp may exceed 104° F (40° C)
• High mortality rate without treatment
• Exertional—sudden onset; from strenuous physical activity in hot, humid conditions
• Non-exertional (classic)—occurs over period of time from chronic exposure to hot, humid environment Heat Stroke (cont.)
• Can be fatal if untreated.
• Treatment;
• Oxygen therapy
• IV lines
• Urinary catheterizing
• Continuous cooling
• Benzodiazepines if shivering
• Monitor organs and electrolytes. Snakebites, and Arthropod Bites and Stings - Most North American snakes aren't dangerous to humans. Some exceptions include the rattlesnake, coral snake, water moccasin and copperhead. Their bites can be life- threatening. 8,000 snakebites happen in the U.S. each year. Even a bite from a "harmless" snake can cause infection or allergic reaction in some people. Snakebite Hospital Care
• Supplemental oxygen anxiety sympathetic nervous system
• IV lines for NSS or RL
• Continuous cardiac, BP monitoring
• Opioids for pain
• Tetanus prophylaxis
• Wound care
• Broad-spectrum antibiotics
• Baseline laboratory values with CBC, CK, crossmatch _Before ER
• Wash the bite with soap and water.
• Keep the bitten area still and lower than the heart.
• Cover the area with a clean, cool compress or a moist dressing to ease swelling and discomfort.
• Monitor breathing and heart rate.
• Remove all rings, watches, and constrictive clothing, in case of swelling.
• Note the time of the bite so that it can be reported to an emergency room healthcare provider if needed._

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- If possible, try to remember to draw a circle around the affected area and mark the time of the bite and the initial reaction. If you are able, redraw the circle around the site of _injury marking the progression of time.

• It is helpful to remember what the snake looks like, its size, and the type of snake if you_ _know it, in order to tell the emergency room staff.
• Don't apply a tourniquet.
• Don't try to suck the venom out.
• At the emergency department you may be given:
• Antibiotics to prevent or treat developing infections
• Medicine to treat your pain
• A special type of antivenin depending on the type of snake that bit you and the severity of_ your symptoms Arthropods
• Spiders
• Scorpions
• Bees
• Wasps Table 9-2
• See Table 9-2 for detailed information about organisms, characteristics, pathophysiology, and associated care Lightning Injuries
• Usually highly preventable.
• Cardiopulmonary and central nervous system highly effected.
• Treatment;
• Immediate CPR in the field. (Victim is not not charge so there is no danger to rescuer)
• Provide for advance life support management.
• ECG, CT of head, CK, tetanus prophylaxis. Cold-Related Injury: Hypothermia
• Occurs at core body temperature <95° F (35° C)
• Mild: 90 to 97° F (32 to 36° C)
• Moderate: 82 to 90° F (28 to 32° C)
• Severe: Below 82° F (<28° C) Hypothermia (Cont.)
• Treatment
• Shelter from the cold
• Remove wet clothing
• Engage in rewarming
• Monitor hospitalized patients for cardiovascular instability, ARDS, acute renal failure, pneumonia Cold-Related Injury: Frostbite
• Occurs when body tissue freezes and causes tissue integrity damage
• Categorized between first-degree and fourth-degree - Edema and blister formation 24 hours after frostbite injury occurring in an area covered by a tightly fitted boot. Frostbite (Cont.)

1. Rapid rewarming.

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2. Pain control.
3. Management of compartment syndrome.
4. Debridement or amputation may be needed. Altitude-Related Illness

• High altitude il lness, or d isease (HAD)— ―altitude sickness‖
• Acute mountain sickness (AMS)
• High altitude cerebral edema (HACE)
• High altitude pulmonary edema (HAPE) Acute Mountain Sickness
• Assessment: Noticing
• Throbbing headache
• Anorexia, nausea, and vomiting
• Ma y feel like ―alcohol-inducted hangover‖
• HACE
• Apathy, ataxia, mental status changes
• HAPE
• Persistent dry cough
• Lip and nail bed cyanosis
• Pink, frothy sputum Acute Mountain Sickness Planning and Implementation: Responding
• Descend to lower altitude
• Oxygen
• Acetazolamine
• Admission with possible critical care management Drowning
• Prevention is key
• Safe rescue of victim and removal from water
• Spine stabilization
• Oxygen, ET intubation, CPR, defibrillation may be necessary
• Gastric decompression Chapter 9 Audience Response System Questions

Question 1

A patient brought to the ED after becoming ill while hiking reports weakness, nausea, and vomiting, and severe right lower leg pain. Blood pressure is 90/60, and the right lower leg has localized swelling and redness. What condition does the nurse anticipate?

A. Snakebite B. Heat exhaustion C. Altitude sickness D. Brown recluse spider bite

Effects of snakebite include weakness, nausea, vomiting, hypotension, seizures, coagulopathy, severe pain, and localized tissue swelling or redness. The brown recluse spider produces an ulcerative lesion. Leg pain is not characteristic of myocardial infarction or heat exhaustion.

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Question 2

A 24-year-old patient comes to the ED with respiratory distress, reporting being stung by a bee while gardening. The patient‘s history includes one prior bee sting. What is the appropriate nursing intervention?

A. Prepare to administer epinephrine IM, oral diphenhydramine, and oxygen. B. Remove the stinger, apply ice to the sting site, administer oral diphenhydramine. C. Obtain vital signs, administer oxygen, prepare to administer epinephrine IV. D. Establish an IV infusion with normal saline, apply heat to the sting site, administer acetaminophen.

Once in a clinical setting, patients who sustain serious reactions to bee or wasp stings need epinephrine administration IM. An antihistamine such as diphenhydramine (Benadryl, Allerdryl), or chlorpheniramine (Chlor-Trimeton, Novopheniram) is also given. Oxygen administration and continuous cardiac and blood pressure monitoring are also initiated. The nurse will also establish an IV infusion with normal saline solution to support blood pressure. Advanced life support drugs and equipment should be immediately available.

Question 3

A patient who was hiking and caught in a blizzard is brought to the ED by friends who report applying dry chemical warmers to the feet. The patient is vigorously rubbing both feet. After the ED physician diagnoses frostbite, the nurse teaches the patient of which further outcome?

A. Reduced area of injury B. Possible further tissue injury C. Reduced swelling of the injured area D. Less pain during the rewarming session

Dry heat should never be applied, nor should the frostbitten areas be rubbed or massaged as part of the warming process. These actions produce further tissue injury. For all degrees of partial- to full-thickness frostbite, rapid rewarming in a water bath at a temperature range of

Patients often experience severe pain during the rewarming process.

Chapter 11 Assessment and Care of Patients with Problems of Fluid and Electrolyte Balance

Fluids

• Water accounts for about one half to two thirds of an average person‘s weight.
• Fat tissue has a lower percentage of water than lean tissue and
• Women tend to have more fat tissue, therefore percentage of body weight that is water in the average woman is lower (52 to 55%) than it is in the average man (60%). - Intracellular Fluid (ICF)

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_- Inside the cells

• 70% of body water
• Primary cation = Potassium (K+)
• Extracellular Fluid (ECF)
• Outside the cells
• 30% of body water
• Primary cation = Sodium (Na+)
• Intravascular o Inside the blood vessels o 20% of ECF o Primarily blood plasma
• Interstitial o In the tissues, outside blood vessels o 80% of ECF
• Fluid Definitions
• Solution – A substance containing both a liquid (solvent) and particles (solutes)
• Solvent – Liquid in which particles are dissolved or carried
• Solutes – P articles which are dissolved in a solution
• Example:
• Solution = Salt Water
• Solvent = Water
• Solute = Sodium Chloride_ Differences in % of Fluid Weight to Body Weight
• The percentage of body weight that is water is higher (70%) at birth and in early childhood
• The percentage of body weight is also lower in older and obese people.. Body Fluids
• A 154-pound (70-kilogram) man has a little over 10.5 gallons (42 liters) of water in his body:
• 7 gallons (28 liters) inside the cells,
• 2.5 gallons (about 10.5 liters) in the space around the cells, and
• slightly less than 1 gallon (3.5 liters, or about 8% of the total amount of water) in the blood. Homeostasis
• Proper functioning of all body systems; requires fluid and electrolyte balance
• Normal distribution of total body water in adults.
• Intracellular Fluid (ICF) o Inside the cells o 70% of body water o Primary cation = Potassium (K+)
• Extracellular Fluid (ECF) o Outside the cells o 30% of body water o Primary cation = Sodium (Na+)
• Intravascular