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Nsg 430 exam 2 study guide
Adult Health Nursing II (NSG-430)
Grand Canyon University
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N-430 Stu Gud
Exa
Her Fale
✽ Heart Failure Review
○ Pathophysiology: insufficient blood supply/oxygen to body - key manifestations: diastolic dysfunction (vent. fill)/(HFpEF) or systolic dysfunction (vent. ejection)/(HFrEF) - Ejection fraction (EF): blood pumped out by LV with heartbeat ○ Risk factors: HTN, CAD ○ End-stage: heart transplant - Immunosuppressive therapy: steroids, calcineurin inhib, antiproliferative drugs - Monitor infection - Endomyocardial biopsy (EMB) - detect rejection
✽ Acute Decompensated Heart Failure
✽ HF exacerbation usually related to pulmonary/systemic congestion and volume overload - Early response - inc. pulmonary nervous pressure: RR inc., PaO2 dec. - Later - interstitial edema: tachypnea - Further - alveolar edema: respiratory acidosis ✽ Complication: pulmonary edema ✽ Hemodynamic Monitoring: Swanz Ganz/pulmonary artery catheter; normal 2-8 mmHg ✽ Drug therapy: diuretics, vasodilators (nitrogly, nitropruss, nesiri), morphine, digoxin, beta agonist (dopamine, dobutamine, norepin) - key manifestations: diastolic dysfunction (vent. fill)/(HFpEF) or systolic dysfunction (vent. ejection)/(HFrEF)
✽ Chronic Heart Failure
○ Dx: echocardiogram, BNP (normal<100), Stress test, 6 minute walk, EF (55-70% norm, 40% or less bad) ○ Clinical Manifestations: Left Sided Right Sided ● Pulmonary edema ○ Peripheral edema
● Crackles ● Hematoptysis ● Dyspnea ● Orthopnea
○ Weight gain ○ Jugular Vein Distention (JVD) ○ Ascites ○ Hepatomegaly ○ Splenomegaly
- Dysrhythmias: atrial fibrillation
- Renal failure ○ Drug therapy
- First line for HFrEF: ACE inhibitors
- Block RAAS: inhib angiotensin 1 to 2 conversion
- Captopril: hypotension, hyperkalemia, angioedema, renal insuf
- Monitor first dose hypotension/syncope
- Spironolactone: assess male for gynecomastia
- Carvedilol
- Digoxin
- Diuretics - loop/thiazide (K waste)
- VasodilatorL nitroglycerin, sodium nitroprusside ○ Interventions: HOPE. HOB 45 higher, supplemental O2, push furosemide/morphine/digoxin, Na/fluid restriction, rest
Car Valr Dise
✽ Mitral Valve Stenosis
○ Cause: rheumatic heart disease - scar - fish mouth shape
○ Left atrial pressure/volume increase - higher pulmonary vasculature pressure ○ Complication: atrial fibrillation, stroke ○ Clinical manifestation: extertional dyspnea (main symptom), loud S1 and low-pitched diastolic murmur (apex), hoareness, hemoptysis, chest pain
✽ Mitral Valve Regurgitation
○ Problem with leaflets - blood backflow ○ Causes: MI, rheumatic heart disease, mitral valve prolapse ○ Acute - pulmopnary edema and cardiogenic shock; Chronic - left atrial enlargement, LV dilation/hypertrophy, decreased CO ○ Manifestations
○ Pulmonary regurgitation: pulm. HTN, surgical repair of TOF, congenital - lead to RV dilation, usually asymp. ○ Pulmonary stenosis: always congenital with TOF, RV HTN/hypertrophy, S/S - syncope, dyspnea, angina
✽ Interprofessional Care
○ RF & IE prophylactic antibiotic ○ Prevent exacerbation of HF, pulm. Edema, thromboembolism, recurrent endocarditis ○ Atrial dysrhythmia common; anticoagulant for atrial fibrillation ○ Sodium restriction ○ Percutaneous Transluminal Balloon Valvuloplasty (PTBV) - stenosis ○ Surgery: - Valve Repair: usually in mitral/triscupid - Open valvuloplasty: sutures torn parts, treat mitral/tricuspid regurgitation - Minimally invasive - Commissurotomy (valvulotomy) - Annuloplasty - Valve Replacement - both subject to leaking and risk of IE - Mechanical - Durable, last longer but increase risk for thromboembolism - need anticoagulation therapy - Biological valves - Less durable, no anticoagulation therapy, early calciication, tissue degen., stiffening ○ Nursing: - Early tx of strep inf., prophylactic antibiotics, rest - If on anticoagulants (warfarin) - INR 2.5-3 normal, even green leafy veggies - Avoid dental procedures 6 mo after surgery, take antibiotics before
Perdi an Caryoh
✽ Cardiomyopathy (CMP)
○ All low CO = low blood/O ○ Primary cause: idiopathic, heart muscle is only part of heart involved ○ secondary: myocardial disease is know and due to other disease process ○ 3 types: dilated, hypertrophic, restrictive ○ Dx: echocardiogram/EF, angiography (rule out blockages), BNP ○ Clinical manifestations: low oxygen, restlessness, agitation, altered LOC, syncope, dizzy, fatigue, HF, embolism
○ Takotsubo- transient heart syndrome mimicking acute coronary syndrome - Chest pain, st elevation, elevated biomarkers like MI ○ Care: low sodium, adequate fluid, wgt. mngment/avoid large meals, avoid alc/caffine/diet pills/OTC cold med, rest and activity, avoid heavy lifting or vigorous isometric exercises ○ Drugs: nitrates (not hypertrophic), beta blockers, antidysrhythmics, ACE inhibitors, diuretics, digoxin (not hypertrophic unless afib), anticoagulants ○ Surgery/Devices: ventricular assist device, cardiac resync. therapy, implantable cardioverter-defib, surgical repair, heart transplant, cardiac rehab
✽ Dilated CMP
○ Most common type; acute or chronic onset due to infection or other process; more severly ill ○ Inflammation and rapid degeneration of heart fibers ○ Ventricular dilation, impaired systole function, atrial enlargement, blood stasis in the left ventricle ○ Dx: dopply echo, chest x-ray, heart cath ○ Clinical manifestations: HF (common), activity intolerance, fatigue, dyspnea at rest, dry cough, palpitations, abdominal bloating, n/v, anorexia; S3, S4, dysrhythmia, heart murmur, pulm. crackles, edema, weak peri. pulses, hepatomegaly, JVD, clots, cardiomegaly ○ Interventions around HF, heart transplant, permanent/implantable VAD/destination therapy
✽ Hypertrophic CMP
○ Asymmetric left ventricular hypertrophy (no dilation) ○ Impaired diastolic LV filling (unable to relax) - obstructed LV outflow; caution can block aorta ○ Cause of sudden cardiac death (SCD) in young/athletes, males ○ 4 characteristics: massive ventricular hypertrophy, rapid/forceful LV contraction, impaired relaxation (diastole), obstruction to aortic outflow; thickened intraventricular septum and ventricular wall - stiff ○ Dx: echocardiogram ○ Clinical manifestations: asymptomatic, exertional dyspnea, fatigue, angina, syncope, exaggerated apical impulse displaced to the left, S4, systolic murmur between apex and sternal border at 4th intercostal space ○ Care: - Betablocker, calcium channel blocker (verapamil), amiodarone or sotalol (antidysrhythmic) - NO vasodiltor (nitroglycerin), digoxin (unless afib), diuretics - AV pacing, ventriculomyotomy and myectomy, percutaneous transluminal septal myocardial ablation - Nursing focus on S/S, avoid strenuous activity and dehydration, rest and feet elevation for chest pain
✽ Restrictive CMP
○ Impaired diastolic filling and stretch with normal systole; unknown cause ○ Exercise intolerance
- S. aureus, strep., coag. Staph ○ Main risk factors: age, IV drug use, prosthetic valve, hemodialysis ○ Stages: bacteremia, adhesion, vegetation
- Vegetation: fibrin, leukocytes, plt, microbes stick to valve/endocardium
- Parts break off and enter circulation (embolization)
- Left side: brain, kidneys, spleen; Right side: lungs ○ Dx: 3 blood cultures over 1 hr from 3 sites (+), ESR, CRP, Duke criteria ○ Clinical manifestations: clots in heart and brain (stroke - agitation, altered LOC/splinter hemorrhages under fingernails), crackles, fever, clubbed fingers
- Roth spots (hemorrhagic retinal lesions), Osler’s nodes (painful, tender, red or purple, pea sized lesion on fingertips and toes), Janeway lesions (flat, painless, small, red spots on fingertips, palms, soles, toes) (immune response)
- Fever, chills, weakness, malaise, fatigue, anorexia
- HF, systolic murmur, septic embolism! ○ Monitor infection, oral care (2x/day no floss), dental visits/surgery - antibiotic adherence! ○ Prophylactic antibiotic: dentist, respiratory, tonsillectomy, adenoidectomy ○ 2 sets of blood culture every 24/48 hrs until clear, follow up echo and markers 1, 3, 6, 12 mo ○ Valve replacement, antipyretics (aspirin, acetam), fluids, rest
Cory Arey Dise & Acu Cory Syro
✽ Coronary Artery Disease (CAD)
○ Etiology: atherosclerosis - characterized by lipid deposits within artery intima ○ CRP inc ○ Fatty streaks - lipid filled smooth muscle cells, earliest lesions, yellow tinge ○ Cardiac cath - gold ○ Collateral circulation: angiogenesis and presence of chronic ischemia ○ No early signs ○ Care: - Avoid red meat, egg yolks, whole milk - Drugs: - Lipid lowering - Statin: inhibit cholesterol, dec. LDL, inc. HDL - monitor liver dmg and myopathy that can progress to rhabdomyolysis (skeletal muscle breakdown) - Niacin: vitamin B, lower LDL and triglyceride, inc. HDL, SE: flushing, pruritus, GI, ortho. hypoTN
- Flush within 20 min, last for 30-60 min; premedicate with aspirin/NSAID 30 min before
- Fibric acid derivative (Gemfibrozil): removal VLDL, no effect on LDL, SE: GI irritability, caution with stain for increased risk of myopathy; warfarin-bleeding, repaglinide-hypoglycemia
- Antiplatelet
- Low dose aspirin rec. (81 mg), clopidogrel for aspirin intolerent
✽ Chronic Stable Angina
○ O2 demand>O2 supply - myocardial ischemia ○ Angina: normally substernal, may radiate to jaw, neck, shoulders, arm, epigastric (indigestion/burn) ○ Angina subsides with rest, SL nitroglycerin ○ Ischemia: 12 lead - ST depression, T wave inverseon ○ Acute care: pt upright, O2, VS, cont. EKG, pain relief with NTG then IV opioid, cardiac biomarkers, x-ray - SL NG: 911 if unresolved after 3 doses
○ Anxious, cool, clammy skin, angina attack - systolic murmur/mitral regurg
○ QRS interval: <0. ○ QT interval: 0-0. ○ PDA: connects aorta and pulmonary artery
✽ Sinus Bradycardia
○ NSR for athletes and when sleeping ○ Manifestations: pale, cool skin, hypotension, weakness, angina, dizziness, syncope, SOB, confusion ○ Tx the cause: if due to drugs, then held; IV atropine, if ineffective: transcutaneous pacing, dopamin, epinephrine, possible permanent pacemaker
✽ Sinus Tachycardia
○ 100 - 180?
○ Caused by vagal inhibition or sympathetic stimulation ○ Manifestations: dizziness, dyspnea, hypotension ○ Tx cause: analgesic, vagal manueuver, IV beta blockers, adenosine, calcium channel blockers (diltiazam); unstable - sync. cardioversion
✽ Premature Atrial Contraction (PAC)
○ Contraction from ectopic focus in atrium sooner than next beat ○ Rhythm is irregular, P wave diff. or hidden in T wave, PR shorter or longer but still normal ○ Causes: stress, fatigue, caffeine, tobacco, alc, hypoxia, COPD, heart disease ○ Manifestations: palpitations, skipped beat ○ Tx: withdrawal of stim./drugs (epi, dopamine), betablockers
✽ Paroxysmal Supraventricular Tachycardia (PSVT)
○ Ectopic focus above bifurcation of bundle of His ○ Cause: reentrant phenomenon (rexcitation of atria with 1 way block) ○ PAC triggers run of repeated beats; abrupt onset and ending, brief period of asystole ○ Causes: overexertion, stress, deep inspiration, stimulants, heart disease, digoxin toxicity ○ HR: 151 - 220, regular or slightly irreg rhythm, P wave abnormal or hidden ○ HR>180 -low CO and SV, hypotension, palpitations, dyspnea, angina ○ Tx: vagal stimulation, drug - Valsalva, carotid massage, coughing - IV adenosine (1st line): may feel chest pressure, site should be close to heart as possible, give over 1-2 sec followed with NS, stopcock, brief asystole common; assess flushing, dizziness, chest pain, palpitations - IV beta blockers, calcium channel blockers; if unstable - sync. Cardioversion - Recurrent PSVT - radiofreq. cath. ablation
✽ Atrial Flutter
○ Recurring, regular, sawtooth flutter waves from single ectopic focus in right atrium ○ Causes: CAD, HTN, mitral valve disorders, pulmonary embolism, etc., drugs (digoxin, epi) ○ Atrial rate: 200 - 350/min, ventricular rate 150/min (2:1 conduction) ○ Both usually regular ○ Symptoms from high v. rate and loss of atrial kick - decreased CO - HF - increased risk of stroke ○ Tx: calcium channel/beta blockers to control vent. Rate, elect. cardiovert for convert to NSR in emergency, antidysrhytmic, warfarin/anticoagulant, tx of choice - radiofrequency catheter ablation
✽ Atrial Fibrillation
○ Total disorganized electrical activity from multi. ectopic foci - loss of effective atrial contraction - Paroxysmal or persistent ○ Associated with heart disease, CAD, valve disease, cardiomyopotathy, throtoxicosis, stimulants ○ Atrial rate: 350-600,. Irreg., controlled ventricular response if normal v. rate ○ Low CO, thrombus/stroke ○ V rate control - priority - calcium/beta blockers, amiodarone, digoxin - Drug or electrical cardioversion - If last longer than 48 hrs, anticoag. with warfarin for 3-4 weeks before cardioversion - Radiofrequency cath ablation, AV node ablation, Maze procedure with cryoablation
✽ AV Blocks
○ First AV Block: - Prolong AV conduction - regular but prolonged PR interval (#>20 secs) - Asymptomatic but monitor EKG ○ Third Degree/Complete Heart bloc - Severe heart diseaese, CAD, MI, cardiomyopathy, systemic diseases, drugs - S. rate: 60-100, V. rate: (AV node) 40-60 or (His-pur) 20- - Reduced CO with ischemia, HF, shock, syncope from brady or periods of asystole - Tx: transcutaneous pacemaker until temp. Transvenous pacemaker can be placed - dopamine, epi to increase HR and support BP - Need permanent pacemaker as soon as possibel
Venca Dyhhi
✽ Premature Ventricular Contractions
○ Wide and distorted, premature QRS complex
○ Overdrive pacing: pacing atrium at rates of 200 to 500 impulses per min to stop atrial tachycardias ○ Permanent: SQ over pectoral muscle on nondominant side ○ Temporary: - Transvenous: emergency, lead to perma. PM. or until tx cause; central line - Epicardial: prophylaxis for brady/tachydysrhythmia occurs in early postop; chest wall postop - Transcutaneous: adequate HR/rhythm in emergency; emergency ○ Failure to sense: doesn’t sense activity and fires inappropriately; can cause VT ○ Failure to capture: electrical charge is not enough to produce contraction; brady, asystole ○ Failure to pace: does not fire when it should ○ Teaching: limit affected arm movement, incision dry for 4 days, avoid direct blows to sit, MRI must be approved, can use microwaves, avoid standing near anti-theft store devices, travel is okay/wand should not be placed directy over pacemaker
Ren Dyunn
✽ Acute Kidney Injury
○ Definite increased Cr and reduced urine output - rapid loss of kidney fxn ○ Most common cause: acute tubular necrosis ○ Dx: MRI with contrast is contraindicated, hold metformin 48 hrs prior ○ Azotemia: accumulation of urea nitrogen, cr in blood ○ Prerenal: reduce systemic circulation and renal blood flow; cardiogenic shock, burn, FVD, HF - Prerenal oliguria: no kidney damage, caused by decreased blood volume - Prerenal azotemia: reduced sodium excretion, increased water/retention, decrease UO ○ Intrarenal: direct kidney damage - Prolonged ischemia - blood deficiency in one or both kidneys - Acute tubular necrosis (ATN): result of ischemia, nephrotoxins, sepsis, nonoliguric ○ Postrenal: mechanical obstruction in urine outflow - Urine reflux into renal pelvis - Most common causes: benign prostatic hyperplasia (BPH), prostate cancer, stones, trauma, extrarenal tumors ○ Stages: - Oliguric - UO<400 mL/day, UA may inc. RBC/WBC - Hypovolemia, metabolic acidosis (Kussmaul), sodium intake (hyponatremia - cerebral edema), potassium excess, infection, Cr
- Diuretic
- UO may inc. to 5L, hypovolemia, hypotension; monitor hyponatremia/kalemia
- Recovery
- GFR increase, BUN/Cr decrease ○ RIFLE: Risk, Injury, Failure, Loss, End-stage ○ Care: loop diuretics, fluid restriction (600 mL + prev. 24 hour fluid loss), hyperkalemia (insulin, sodium bicarbonate, calcium gluconate; polystyrene sulfonate, patiromer, dialysis remove)
- Renal Replacement therapy (RRT)
- PD (not often), HD (emergent; anticoag)
- CRRT: over 24 hrs through cannulation of a vein or cath placement, slower flow
- Daily weights, strict I/O, VS
✽ Dialysis
○ Hemodialysis - AV Fistula (AVF): placed 3 mo before HD, thrill/buzzing during palpation, bruit, no venipuncture - Before tx: assess fluid status, patency, temperature, VS q30- - Advantages: rapid fluid/urea/Cr/K removal - Disadvantages: diet/fluid restriction, hypotension common ○ Peritoneal - Dextrose in dialysate, home-based - Preop: empty bladder/bowel, weight - Postop: when site is healed, can shower and pat cath/exit site dry - Complications: - Peritonitis: abdominal pain, rebound tenderness, cloudy ○ Cont. Renal Replacement Therapy (CRRT) - Vascular access: double-lumen cath in jugular/femoral vein - Dialyze over 24 hours; anticoagulant - Contra in hyperkalemia, pericarditis - Solute removal can occur by convection (w/o dialysate), less risk of hypotension - Weight, fluid, electrolyte, hourly assessment
✽ Kidney Transplant
○ Deceased (cadaver) donors - irreversible brain injury/braind dead- must have effective CV function and ventilated - Kidneys removed and preserved for up to 72 hours; prefer before 24 hours
- Endourology, lithotripsy, open surgical removal: too large, symptomatic inf., impaired renal fxn, paralytic ileus, only 1 kidney - Endourology: cystoscopy, cystolitholapaxy, cystoscopic lithotripsy, flexible ureteroscopes, percutaneous nephrolithotomy - Lithotripsy: hematuria common postop, gradually to dark red/smoky., antibiotics, experience severe colicky pain; self-retaining ureteral stent then removed 2 wks after
- Don’t force fluids, 3L/day, at least 2/day UO, strain all urine ○ Pathophysiology: infection causing increased mucus production + inflammation - cold-like symptoms ○ RN interventions: heated high flow nasal cannula (humidified O2 + CPAP), pulsox + supp. O2 <90%, suctioning/NS in bulb syringe (esp. before feeding/bedtime), IV fluids, contact+droplet precautions, 5 - 10 mL fluids/10 min ○ Prevention: breastfeeding, avoid smoke, handwashing, palivizumab vacc. - high risk infants
Nsg 430 exam 2 study guide
Course: Adult Health Nursing II (NSG-430)
University: Grand Canyon University
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