1
Q
what needs to happen before use of parenteral nutrition?
A
verification of placement by XRay
2
Q
nursing management of parenteral nutrition
A
- acuchecks q6h
- only use after xray
- check IV sites because they’re at risk for infection
- daily weights
3
Q
what to give if TPN is unavailable
A
D10
4
Q
complication of giving lipid emusions
A
fat embolism syndrome: monitor for fever, increased triglycerides, and clotting problems
5
Q
most common side effect of enteral nutrition
A
diarrhea, which makes you acidotic
6
Q
nursing care for enteral nutrition
A
- acuchecks q6h
- elevate HOB
- Open system good for 4 hours and rinse tubing in between; closed systems good for 24 hours
- Change dressing every 7 days or when borders are no longer intact
- aspirate for residual
7
Q
if residual is consistently over 200 mL…
A
give Reglan to increase peristalsis
8
Q
pH for gastric placement
A
should be 4-5
9
Q
ph for intestinal placement
A
7 or higher
10
Q
how to know when patients are improving on enteral nutrition
A
- sufficient weight gain (2lbs or 1 kg a week)
- albumin/prealbumin improving
11
Q
diet for ostomies
A
Avoid foods that cause excessive odor and gas: foods from the cabbage family, eggs, asparagus, fish, beans, high-cellulose products such as peanuts
12
Q
diverticulosis
A
- small outpouches of the intestinal wall
- Caused by chronic constipation
- Want them to increase water, fiber and exercise
- Can cause peritonitis if not treated
13
Q
diverticulitis
A
- pouches are inflamed
- Put on 2 antibiotics, flagyl and bactrim
- Low fiber, low residue, bland diet, lots of water
- Don’t want to give a GI stimulant
- Can give a softener
14
Q
diverticulitis is getting better if:
A
- WBCs go down
- Pain in LLQ will go away
- Temperature will go away
- KUB (kidney urinary bladder) result
- Free air = peritonitis
15
Q
short bowel syndrome
A
- Occurs after colon resections
- Removal of portions of the colon results in less absorption of nutrients and water.
- Leads to nutritional deficiencies and diarrhea
- Need nutritional support- enteral feedings or TPN.
16
Q
postop liver biopsy
A
monitor vitals frequently for at least 2 hrs, monitor for bleeding, direct pressure applied to site after sample obtained and needle removed, place on right side with pillow under costal margin for hrs., avoid coughing and straining, activity restriction x 1wk
17
Q
type of cirrhosis associated with alcoholism
A
laennec’s
18
Q
most common sites of varices
A
esophageal and gastric areas
19
Q
increased portal venous pressure causes:
A
-formation of varices that shunts blood to decrease pressure, which causes massive blood loss
20
Q
manifestations of cirrhosis
A
- Gets backed up into esophagus and causes GI bleed
- Jaundice (look up complications)
21
Q
manifestations of portal hypertension
A
- Dilated veins over abdomen
- Splenomegaly
- Prominent distended abdominal vessels
- Distended vessels in esophagus, stomach, and rectum which may rupture and cause hemorrhage
22
Q
hepatic encephalopathy
A
- From buildup of ammonia
- Ammonia builds up from breakdown of proteins, so limit protein in diet
23
Q
manifestation of hepatic encephalopathy
A
- Inappropriate behavior – confusion, agitation
- Disorientation
- Flapping tremors (asterixis)
- Twitching extremities
- Stupor
- Coma
24
Q
early sign of encephalopathy
A
Asterixis (flapping tremor)
25
treatment of hepatic encephalopathy
- lactulose to make them poop out the ammonia (will make them acidotic)
- reduce protein in diet
26
heart failure
Heart failure is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients.
27
Signs of Right-Sided HF
```
Peripheral edema*
Hepatomegaly-jaundice, liver tenderness*
Hepatojugular reflex*
Splenomegaly*
Ascites*
Jugular venous distention
Increased CVP
Pulmonary hypertension (depending on cause)
```
28
HF nandas
NANDA: Impaired tissue perfusion; activity intolerance, excess fluid volume, anxiety, powerlessness, noncompliance
29
Fluid status/signs of fluid overload
- Daily weight and I&O
- Tell them to weigh every day in the same amount of nakedness of in the same exact clothes
- If they gain or than 3 lbs in one day they need to call their provider
- If they gain more than 5 lbs in one week call provider
- If they have to add pillow to sleep or sleep in the recliner
- Reclined is good but never have them sleep with elevated feet
- CHF and pulmonary edema pts should always have legs dangled
30
cardiogenic shock
- The will inadequately perfuse primary organs: decreased urine output, confusion, chest pain, dyspnea
- Don’t give fluids
31
what is treatment of HF focused on?
improving tissue perfusion
32
beta blockers for HF
- decrease chronotropy
- decrease HR, BP, and contractility
- metoprolol (Lopressor®),
- carvedilol (Coreg®)
33
ACE for HF
decreases preload
34
angiotensin II for HF
decreases preload
35
Dig for HF
increases contractility
36
nitrates for HF
- decreases SVR/afterload, decreases myocardial oxygen demands
- Nitroglycerin (Tridil®)
37
natriuretic factors
-decreases filling pressure (wedge, CVP), reduces vascular resistance (SVR, PVR), increased urine output
-Nesiritide (Natrecor®)
-NATRECOR (Nesiritide BNP)
(non inotropic drug used in CHF) is a recombinant form of human B-type natriuretic peptide (h BNP) a naturally occurring hormone secreted by the ventricles
-***causes smooth muscle dilation and decreases workload of heart by decreasing preload and afterload, decreasing BP by dilating arteries and veins.
-Monitor BNP lab values
38
what to give for diastolic dysfunction
CCBs
39
what to give for stable HF
beta blockers
40
inotropes for HF
- augment C.O. by increasing contractility and enhancing tissue perfusion
- Cardiac glycosides - digoxin
- Sympathomimetics – epinephrine, dopamine, norepinephrine, dobutamine, isoproterenol
- Phosphodiesterase inhibitors – milrinone (Primacor®), inamrinone (Inocor®)
41
vasodilators for HF
- lowers preload and afterload = >LVEF, >C.O., lessens cardiac remodeling
- Direct smooth muscle relaxants – Nitroprusside (Nipride®), Nitroglycerin, Hydralazine (Apresoline ®)
- Calcium channel blockers – nicardipine (Cardene®), nifedipine (Procardia®)
- ACE inhibitors – captopril (Capoten®), enalapril (Vasotec®), fosinopril (Monopril®)
42
marfan syndrome
excess GH and usually boys; arterial system gets stretched out
43
meds for MI
- Aspirin: 325 chew
- 02: 2-4 L
- Morphine decreases pain and afterload
- Nitro
44
Nitro
- Sublingual, patch, IV, or Use spray if on lots of diuretics
- Sensitive to light
- Should tingle
- Onset is 3 mins, give q5min 3x
- Need to be sitting when they take it
- Never put patches where you would use a defibrillator
- IV:
- Glass bottles with special tubing
- Vitals q15 min
45
Lovenox
- reduce risk of DVT
| - used for AFib and AFlutter
46
Coumadin
- Avoid leafy greens/ Vit K
- Blood checked every week
- INR 2
- PT 2-3x normal range
47
ace inhibitors are contraindicated in
asthmatics
48
why do we give ace inhibitors to MI pts?
to keep BP low (130/80 or lower)
49
digoxin
- For tachy, AFib,Flutter
- Toxicity: N/V, halo vision (0.8 - 2.0)
- Check apical pulse bc PVCs don’t give radial pulse (Hold if
50
timeline for cath lab and TPA
- 90 mins for cath lab
| - 4 hrs for TPA
51
side effects of TPA
- Can make them go into arrhythmias
- Working when they have reperfusion arrhythmias (VTach, frequent PVCs, or VFib
- Side effects: bleeding and hypotension
52
tx if MI is in the left main artery
CABG (coronary artery bypass grafting)
53
manifestations of chronic arterial PVD
- Intermittent claudication
- Extremity cool with diminished pulses
- Delayed healing
- Atrophy of skin with loss of hair
- Pallor with elevation
- Superficial gangrene ulcerations of toes
- Cap refill greater than 3 sec
54
manifestations of venous PVD
- Aching, heavy sensations with muscle cramps
- Prominent superficial veins
- Increased pigmentation and edema of lower leg
- Scaling and thickening of skin
- Ankle ulcers
- Temperature warm
55
Tx of PVD
-Non-surgical – exercise, positioning and promote vasodilation. If it hurts – STOP & rest, resume when it subsides. Teach foot care like DM. No smoking.
56
what to do during an acute anginal attack
Oxygen, Vital Signs, 12-lead EKG, Pain Relief (Nitrate then Narcotic), Physical Assessment of the chest, Position comfortably
57
BP during a HTN crisis
180/120
58
thoracic aortic aneurism
- Sudden, tearing chest pain radiating to shoulders, neck, and back
- Cough, hoarseness, weak voice resulting from pressure against recurrent laryngeal nerve
- Dysphagia caused by pressure on the trachea
- Dyspnea resulting from pressure on trachea
- Know if the patient is bleeding because heart sounds are muffled
59
abdominal aortic aneurysm
- most common type
- Pulsation in abdominal area
- Dull abdominal or low back pain or ache (impending rupture)
- N/V (pressure against the duodenum)
- Severe, sharp, sudden abdominal pain: continuous, radiates to back, hips, scrotum, pelvis (rupture)
- Syncope
60
aortic dissections
- Acute severe and instantaneous chest pain, radiating to back, neck, jaw or abdomen
- “Ripping,” “tearing” sensation
- Differentiated from AMI by its instantaneous, severe onset and absence of central pulses
- Neurologic symptoms (15%) – syncope, presyncope, paralysis, numbness, aphasia
- Arm pain
- Dyspnea
61
most sensitive indicator of MI
Troponin I
62
chest Xray
- Heart will look white and take up no more than 1/3 of the xray
- See size, lung fields, plaque
- for xray: need to know if they’re pregnant, have metal anywhere, allergies to iodine, know which tests have contrast or not, kidney function if contrast; if ESRD- can’t filter die, could be toxic and cause fluid overload, know which test they need to be NPO on, or not have stimulants, know weight
63
MUGA
- Blood Pool Imaging, ejection fraction study, MUGA
| - Assists in assessing the “pumping action” of the heart
64
normal ejection fraction
55%-65%
65
cardiac cath care (post op)
Post op for cardiac cath pts: procedure can dislodge the plaque: assess for s/s of clots (s/s of stroke, MI), pneumothorax (breath sounds, know baseline O2 and keep eye on it) aspiration (pts aren’t always honest about being NPO), hemorrhage (look behind them), sedation (put them on their sides so their tongues don’t fall back)
66
tracheostomy complications
- Complications include bleeding, pneumothorax, aspiration, subcutaneous or mediastinal emphysema, laryngeal nerve damage, posterior tracheal wall penetration.
- Long-term complications include airway obstruction, infection, rupture of the innominate artery, dysphagia, fistula formation, tracheal dilatation, and tracheal ischemia and necrosis.
67
DASH diet
Dietary Approaches to Stop Hypertension: low sodium/ low cholesterol diet
68
Treatment of cardiogenic shock
- Administer O2
- Medications to increase CO
- Treat dysrhythmias
- Monitor for fluid overload
Process 2
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Decks in class (5)
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