What are the classic signs of a myocardial infarction?
Crushing substernal chest pain radiating to the left arm, jaw, or back. Diaphoresis, nausea, dyspnea, and anxiety. Women may present atypically with fatigue, indigestion, and back pain.
What is the immediate nursing management for suspected MI?
MONA: Morphine if pain is unrelieved, Oxygen if SpO2 is below 94 percent, Nitroglycerin sublingual, and Aspirin chewed 325 mg. Obtain a 12-lead ECG within 10 minutes of arrival.
What are the signs of left-sided heart failure?
Pulmonary symptoms including dyspnea, orthopnea, crackles in the lungs, paroxysmal nocturnal dyspnea, pink frothy sputum, cough, and fatigue. Remember Left equals Lung.
What are the signs of right-sided heart failure?
Systemic venous congestion including bilateral peripheral edema, jugular vein distension, hepatomegaly, ascites, and weight gain. Remember Right equals the Rest of the body.
What is the most reliable daily assessment for heart failure?
Daily weight at the same time, same scale, and same clothing. A gain of 2 to 3 pounds overnight indicates fluid retention and requires intervention.
What is the nurse’s priority for a patient with pulmonary edema?
Position upright in high Fowler’s, administer high-flow oxygen, administer the prescribed IV diuretic such as furosemide, monitor respiratory status closely, and prepare for possible intubation if the patient continues to deteriorate.
What are the signs of a stroke using the FAST acronym?
Face drooping, Arm weakness, Speech difficulty, and Time to call 911. Additional signs include sudden confusion, vision changes, severe headache, and dizziness.
What is the treatment window for tPA in ischemic stroke?
Within 3 to 4.5 hours of symptom onset. Strict inclusion and exclusion criteria must be met. Monitor closely for bleeding which is the most dangerous complication. Avoid anticoagulants for 24 hours after tPA administration.
What is Cushing’s triad?
Hypertension with a widening pulse pressure, bradycardia, and irregular respirations. This is a late sign of increased intracranial pressure and indicates brainstem herniation which is a medical emergency.
What is the priority nursing assessment for a patient with DKA?
Potassium level is the priority because even if initially normal or elevated potassium will drop rapidly with insulin and fluid treatment. Cardiac monitoring is essential. Also monitor glucose, pH, and fluid status.
What is the difference between DKA and HHS?
DKA occurs primarily in Type 1 diabetes with ketosis, pH below 7.30, Kussmaul respirations, and fruity breath. HHS occurs primarily in Type 2 with severe hyperglycemia often above 600, profound dehydration, NO significant ketosis, and higher mortality.
What are the signs of thyroid storm?
Extreme hyperthyroidism presenting with very high fever above 104 degrees Fahrenheit, tachycardia, agitation, delirium, hypertension followed by cardiovascular collapse. Treatment includes beta-blockers, antithyroid medications, and cooling measures.
What is myxedema coma?
Severe hypothyroidism presenting with hypothermia, bradycardia, hypotension, altered consciousness, and respiratory depression. Treatment includes IV thyroid hormone, gradual warming, and supportive care. This is a medical emergency.
What is Addisonian crisis?
Acute adrenal insufficiency causing severe hypotension, dehydration, hyperkalemia, hyponatremia, hypoglycemia, and shock. Treatment is IV hydrocortisone and aggressive fluid resuscitation. It can be triggered by stress, infection, or abrupt steroid withdrawal.
What is the nurse’s priority for a patient with ARDS?
Maintain oxygenation by anticipating mechanical ventilation with PEEP and low tidal volumes. Implement prone positioning. Monitor ABGs closely. Treat the underlying cause such as sepsis, pneumonia, or aspiration.
What are the hallmark findings of ARDS?
Bilateral white-out infiltrates on chest X-ray, refractory hypoxemia that does not improve with supplemental oxygen, PaO2 to FiO2 ratio below 300, and non-cardiogenic pulmonary edema.
What should the nurse do if a chest tube is accidentally dislodged?
Cover the insertion site immediately with petroleum jelly gauze taped on three sides. The open side allows trapped air to escape while preventing air from entering the chest. Notify the provider immediately.
What is a tension pneumothorax?
Air trapped in the pleural space under pressure compressing the heart and great vessels. Signs include tracheal deviation AWAY from the affected side, JVD, hypotension, and absent breath sounds on the affected side. Emergency needle decompression is needed.
What is the nursing management for sickle cell crisis?
Aggressive hydration with IV fluids, pain management with opioids and do not undertreat the pain, oxygen therapy, blood transfusion if severe, and monitoring for complications including acute chest syndrome, stroke, and organ damage.
What are the signs of acute chest syndrome in sickle cell disease?
Chest pain, fever, cough, hypoxemia, and a new pulmonary infiltrate on chest X-ray. This is a medical emergency that can progress rapidly to respiratory failure and requires immediate intervention.
What is the difference between hypovolemic and distributive shock?
Hypovolemic shock involves decreased volume from bleeding or dehydration with cold and clammy skin. Distributive shock involves vasodilation from sepsis or anaphylaxis with initially warm and flushed skin that progresses to cold and clammy.
What are the early signs of sepsis?
Temperature above 38.3 degrees Celsius or below 36 degrees, heart rate above 90, respiratory rate above 20, altered mental status, and WBC above 12000 or below 4000. Late signs include hypotension and organ dysfunction.
What is the sepsis 1-hour bundle?
Measure serum lactate, obtain blood cultures before antibiotics, administer broad-spectrum antibiotics within 1 hour, begin 30 mL per kg IV crystalloid for hypotension or elevated lactate, and reassess volume status and tissue perfusion.
What is the Parkland formula for burn fluid resuscitation?
4 mL multiplied by body weight in kg multiplied by percent total body surface area burned equals total fluid for the first 24 hours. Give half in the first 8 hours and the remaining half over the next 16 hours. Use Lactated Ringer’s solution.
