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PHYSIOLOGICAL INTEGRITY: PHYSIOLOGICAL ADAPTATION
NCLEX PREP UPDATED STUDY GUIDE QUESTIONS AND
CORRECT ANSWERS
- assess client's ability to speak and/or cough
- for infants: give 5 back blows between shoulder blade w/ heels of hand followed by 5 chest thrusts over the sternum. continue until airway is clear or infant becomes unconscious
- for children & adults: give abdominal thrusts (heimlich maneuver) until the airway is clear or the client becomes unconscious upper airway obstruction plan/immplementation facilitate removal of secretions for ETT pt's encourage fluids to? to prevent aspiration and facilitate mechanical ventilation purpose of cuff w/ trache leads to risk for aspiration under inflation of trache cuff
- noisy respirations
- restlessness
- increased pulse
- increased rr
- presence of mucous in airway indications for suctioning tracheostomy
- diarrhea
- constipation
- tarry stools GI distress cardiopulmonary arrest Breathless, pulse-less, unconscious 100 - 120/min compression rate at least 2 in compression depth adults at least 1/3 anterior posterior diameter or 2 in (5 cm) compression depth kids at least 1/3 anterior posterior or about 1 1/2 in (4cm) compression depth infants jaw thrust airway HCP suspected trauma v-fib and pulseless v-tach attach and use AED asap for _________ 360 joules mono phasic device 120 - 200 joules biphasic device
amiodarone 300 mg bolus IV or IO as first dose, 150 mg bolus IV or IO as second dose, if indicated or lidocaine 1 - 1.5 mg/kg IV or IO as first dose 0.5-0.75 mg/kg IV or IO as second dose, if indicated v-fibrillation or pulseless v-tach that is unresponsive to defibrillation
- hypovolemia
- hypoxia
- hydrogen ion (acidosis)
- hypo/hyper-kalemia
- hypothermia
- tension pneumo
- tamponade, cardiac
- toxins
- thrombosis, pulmonary
- thrombosis, cardiac reversible causes for defibrilation
- victim responds
- another qualifies person takes over
- victim is transferred to an emergency room
- rescuer is physically unable to continue continue CPR until one of the following occurs decompensation croup syndrome...decrease in noisy respirations may mean?
- bark-like cough
- use of accessory muscles
- dyspnea
- inspiratory stridor
- cyanosis Croup Assessment larnyx croup is an infection of _________
- streamy shower
- sudden exposure to cold air
- sleep w/ cool humidified air croup care at home
- increasing respiratory distress
- hypoxia or depressed sensorium
- high temp croup hospitalization required
- antipyretics
- bronchodilators
- nebulized epi
- steroids croup meds
- systolic BP below 80 mmHg
- gray facial color
- lethargy
- cold diaphoresis
- peripheral cyanosis
- tachycardia OR bradycardia
- weak pulse shock s/s oliguria: UO of less than 20ml/hr MI GU? elevated ESR during MI?
address underlying cause Ca channel blockers (diltiazem) beta blockers (metoprolol) digoxin cardioversion warfarin Atrial Fibrillation tx ventricular dysrhythmias occur when one or more ectopic foci arise w/in the ventricles PVC (Premature Ventricular Contraction) one or more ectopic foci stimulate a premature ventricular response
- ischemia due to a MI
- infection
- mechanical damage due to pump failure
- deviations in concentration of electrolytes (K & Ca)
- nicotine
- coffee, tea, alcohol
- digitalis and reserpine
- psychogenic factors (stress, anxiety, fatigue)
- acute or chronic lung disease PVC causes
- angina
- SOB
- "heart flip" feeling PVC s/s
- amiodarone
- beta-blockers (metoprolol)
- procainamide PVC tx ventricular tachycardia (^) a very rapid heartbeat that begins within the ventricles. 3 or more PVCs occurring in a row at a rate exceeding 100 bpm large MI, low EF, same as for PVCs v-tach causes hypotension, pulmonary edema, confusion, cardiac arrest v-tach s/s determine if....
- monomorphic (procainamide, sotalol, amiodarone)
- polymorphic (Mg, isoproterenol)
- pulseless (CPR, defibrillation, epi, amiodarone) v-tach tx ventricular fibrillation (^) several ectopic foci w/in the ventricles are discharged at a very rapid rate, most serious of all dysrhythmias b/c of potential cardiac standstill acute MI HTN rheumatic or atherosclerotic heart disturbances hypoxia v-fib causes unresponsive, pulseless, apneic v-fib s/s CPR unless blood flow is restored by CPR and the dysrhythmia is interrupted by defibrillation, death will result w/in 90 seconds to 5 min v-fib tx
heart block delay in the conduction of impulses w/in the AV system first degree heart block AV junction conducts all impulses, but at a slower than normal rate digitalis Ca channel blocks beta blockers MI increased vagal tone first degree heart block causes asymptomatic first degree heart block s/s second degree heart block AV block in which occasional electrical impulses from the SA node fail to be conducted to the ventricles infection, digitalis toxicity, CAD second degree heart block causes may note hypotension, dyspnea, and syncope second degree heart block s/s atropine or temporary pacemaker second degree heart block tx third degree heart block AV junction blocks all impulses to the ventricles, causing the atria and ventricles to dissociate & beat independently (each w/ its own pacemaker est a rate, ventricular rate is low, 20 - 40 bpm) congenital defects, vascular insufficiency, fibrosis of myocardial tissue, or MI third degree heart block causes shock s/s, syncope third degree heart block s/s pacemaker, atropine, dopamine, epi if not tx immediately, may lead to death third degree heart block tx P wave atrial depolarization PR interval represents passage of the impulse through the AV node QRS complex represents ventricular activity T wave represents repolarization of the ventricles U wave may or may not be present holter recorder 24 hr continous EKG tracing while the pt keeps a diary of activities cardioversion elective procedure for dysrhythmias such as a-fib
- assess for infections, bleeding
- monitor HR and rhythm; for preset rate pacemakers, pts rate may vary 5 beats above or below set rate
- provide emotional support
- check pulse daily, report any sudden increase or decrease in the rate
- carry an ID card or wear identification
- request hand scanning at security checkpoints at airports
- avoid situations involving electromagnetic fields
- periodically check generator
- take frequent rest periods at home and work
- wear loose-fitting clothing
- all electrical equipment used in the vicinity of pt should be properly grounded
- immobilize extremity if temp electrode pacemaker is used to prevent dislodgment
- document model of pacemaker, date and time of insertion, location of pulse generator, stimulation threshold, pacer rate
- place cell phone on the side opposite generator nursing consideration for pacemakers epidural hematoma a hematoma located on top of the dura, pt has short periods of unconsciousness, followed by lucid interval w/ ipsilateral pupillary dilation, weakness of contralateral extremities subdural hematoma decreased LOC, pupil dilation, personality change, slow onset
- x-ray
- CT scan
- lumbar puncture
- EEG
- MRI head injury diagnostics 30 degrees elevate the HOB to _____ to decrease ICP decrease cerebral metabolic rate barbiturate therapy w/ head trauma to sucking sound on both inspiration and expiration pain hyper resonance decreased resp excursion diminished/absent BS on affected side wake, rapid pulse anxiety, diaphoresis alt ABGs open pneumothorax assessment
- dyspnea, pleuritic pain
- absent or restricted movement on affected side
- decreased or absent BS, cyanosis
- cough and fever
- hypotension pneumothorax assessment open pneumothorax An open or penetrating chest wall wound through which air passes during inspiration and expiration, creating a sucking sound; also referred to as a sucking chest wound.
pneumothorax collapse of lung due to air i the pleural space caused by surgery, disease, or trauma tension pneumo pressure builds up ; shifting of heart and great vessels
- monitor for shock
- humidified O
- pain mgmt
- monitor ABGs
- encourage turning, deep breathing, and coughing flail chest plan
- thoracentesis
- chest tubes open pneumothorax Blunt abdominal trauma abdominal pain, rigidity, distension ; n&v, shock, ecchymosis indicative of retroperitoneal bleeding, bruits indicate renal artery injury, resonance over spleen with client of left side (balance sign) indicates rupture of spleen ; resonance over liver indicates pathology
- x-ray
- CT
- exploratory laprotomy abdominal injuries diagnostics penetrating abdominal injuries open wound resulting in hemorrhage if major blood vessels/liver/spleen/pancreas/kidney are involved ; increased risk of infection (peritonitis) from rupture of bowel blunt abdominal injuries usually injury to solid organ (spleen, liver, pancreas) NPO, NG, monitor drainage, BS, indwelling catheter, monitor output carefully, assess for hematuria penetrating abdominal injuries plan
- IV w/ large bore needle in upper extremities
- monitor CVP
- check hematological values
- ABGs
- serum electrolytes
- liver and kidney function
- clotting studies
- cardiac monitor
- indwelling cathe blunt abdominal injuries plan shock sudden reduction of O2 and nutrients ; decreased blood volume causes a reduction in venous return, decreased CO, and a decrease in arterial pressure hypovolemic shock loss of fluid from circulation
