PBDS RETAKE STUDY – Flashcards
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PNEUMONIA symptoms
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Crackles, shortness of breath, productive cough, fever, chills, loss of appetite, sharp chest pain with deep breathing, nasal congestion, decreased activity
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Pneumonia interventions
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1. Assess lung sounds for signs of crackles, Check RR, TEMP, AND O2 SAT, pulse, BP. 2. Call MD stat 3. Place patient in high fowlers 4. TCDB/Incentive spirometry 5.Collect sputum sample if ordered 6. Anticipate an order for respiratory to obtain breathing treatments 7.Give oxygen if needed 8.Anticipate an order for a chest X-ray, ABG, CBC 9.Give fluids
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Pneumonia Rationales
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1. Auscultate for sounds of crackles/mucous in the lungs. Establish a baseline for the vitals obtained and compare to future assessments. 2. Let MD aware of patients condition, await orders 3. To open up airway in the lungs 4. Tcdb/ Incentive spirometry loosens up secretions in the lungs and makes it easier to clear out the lungs of these secretions when done routinely. 5.Sputom samples/blood cultures are taken to identify the bacteria involved in the condition. 6.Anticipate an order for respiratory can deliver nebulizer/inhalant medications that is beneficial for the patient. Can take ABG 7.Oxygen can improve o2 sat if decreased. 8. Check for an elevated WBC, chest X-ray will show what side of the lungs are affected by pneumonia. 9. Prevents dehydration
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Pneumonia Consults
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Infectious disease/ Respiratory therapist
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Hypovolemic Shock
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Tachycardia, Hypotension, Pallor/cyanosis, Cold skin, weakness, dizziness, fainting, nausea, dehydrated, diminished/absent peripheral pulses
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Hypovolemic Shock interventions
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1. Call MD stat 2.Monitor BP, pulse, RR, oz sat and weights daily 3.Place patient's legs elevated 4.Administer fluids 5.Provide oxygen as needed 6.Monitor patients for signs of Fluid overload such as: Crackles in the lungs, swelling, weight gain 7.Antcipate an order for CBC, Electrolytes, BUN, Creatinine 8. Recheck BP, PULSE, O SAT, and monitor every 1-2 hours.
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Hypovolemic shock rationales
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1. Notify of status, obtain orders 2. Compare current vitals to baseline, document the significant change. 3.Increases in vascular fluid volume 4.Fluids(NACL/Lactated Ringers) may be used to boost intravascular volume when there is fluid loss found in hypovolemic shock. 5.When given a large amount of fluids in a short time, fluid overload can occur and should be monitored very carefully when giving vast amount of fluids at once. 6. Oxygen reduces cyanosis, and increases tissue perfusion. 7. Reevaluate to determine if interventions were successful in stabilizing the patient.
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CVA SYMPTOMS
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muscle weakness, facial drooping, slurred speech, numbness of the face/arm/legs, headache, blurred vision.
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CVA Interventions
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1.Obtain BP, Pulse, RR, Temp, O2 sat. -Assess Nuero sys. -Check Blood Sugar 2.Call Rapid Response 3.Call MD stat 4.Anticipate a CT of head 5. If Ischemic, Anticipate an order for TPA/Anticoagulants. Administer BP meds if Pressure is elevated. -If hemorrhagic, await orders for surgery (coiling procedure) 6.Position patient in neutral position (Semi fowlers) 7. Monitor CBC, Electrolytes, PT, PTT, and Platelet levels. 8. Do neuro checks and recheck BP/Pulse O2 sat and Blood sugars every hour until stable. 9. Reposition every 2 hours after stable **Transer to ICU**
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CVA consults
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Neurologist, Respiratory therapist, physical therapy, occupational therapy
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CVA Rationales
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1. Often caused by a high Blood Pressure, assessing the patient Heart rate, RR, O2 SAT will identify the cause of the situation. Neuro checks will show any deficiency in neurology. 2.Hyperglycemia is common in the early phases 3.Help is needed to get the patient stabilized 4. To await orders and to let MD know of situation 5.Thrombolytics can dissolve clots formed in ischemia, anticoagulants thins the blood and prevent clots from reforming. Coiling is used to fill the sidewall aneurysm. 6.Promotes confort, Venous drainage that reduces ICP 7. To ensure safety and prevent a low/high clotting factor. To document abnormalities regarding RBC, hematocrit, hemoglobin. 8. To see if interventions are successful. 9. Prevents pressure ulcers
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Bowel Obstruction Symptoms
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Abdominal distention, abdominal pain, hyperactive bowel sounds, constipation, nausea, vomiting, diarrhea
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Bowel Obstruction Interventions
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1. Call MD stat 2.NPO 3. Begin IV therapy of Antibiotics, Fluids, pain medications as ordered 4. Monitor Intake and output 5. Get CT of Abdomen/xray of abd 6.Anticipate an order of an NG tube if needed(Normal saline Lavage) 7. Monitor Electrolytes, CBC 8. colonscopy/endoscopy 9. TPN
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Bowel obstruction consults
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Gastroenterologist, Nutrition specialist
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Bowel obstruction rationales
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1. To get orders, make aware of patients condition 2. Decreases GI activity that can worsen patient's condition. 3.IV fluids help prevent dehydration and Antibiotics are used to kill bacteria from the patient's system 4. When patient is receiving IV fluids, its important to document how much of that output is excreted. Assess stool for signs of it being tarry, loose, having diarrhea. 5. Will show the area of the bowels affected by the obstruction. 6.NG will decompress the stomach if vomiting, and can be used to administer contrast for the CT scan. 7. Recurrent Vomitting can lead to Hypokalemia and frequent diarrhea can lead to Hyperkalemia. Monitor WBC count
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DKA SYMPTOMS
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Dehydrated, Frequent thirst, frequent urination, Hot, Nausea/Vomiting, Tachypnea, abdominal pain, Fruity breath, difficulty breathing, confused, metabolic acidosis.
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DKA INTERVENTIONS
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1. Call MD stat 2.Check Blood sugar 3.Correct hyperglycemia with insulin (IV if Ordered) 4. Provide patient with Fluids(NACL) 5. Monitor Input and Output 6.Become aware of hospital's Hypoglycemic protocol/Potassium protocol 7.Monitor ABG's 8. Recheck Blood sugar, and monitor every 2 hours 9. Educate on insulin/diabetic diet compliance **Transfer patient to ICU**
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DKA RATIONALE
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1. To await orders and let know of patients condition 2. To compare current findings to the baseline 3.Insulin will reduce the patient's Sugar and will also reduce Potassium levels. 4. Fluids will improve fluid loss, Patient often dehydrated due to condition. 5. Monitor the amount of fluids that are given IV/PO, AND compare that to the patients output to ensure adequate hydration. 6.Protocols are essential to know for Hypoglycemia/Hypokalemia because they are often found from giving too much insulin. 7.Patients are often in Acidosis, which is caused by an increase in ketone bodies found in fatty acids. monitor for a change in condition. 8.Recheck blood sugar to see if interventions were successful. 9. teach patient about the importance of taking insulin daily and adhering to a diabetic diet that will ensure a safety/comfort for the patient.
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CHF symptoms
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Peripheral edema, crackles in the lungs, JVD, weight gain, tachycardia, shortness of breath, fatigue
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CHF Interventions
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Call MD STAT 1. Auscultate heat/lung sounds 2.raise head of bed 3.place on EKG/Chest xray/ABG 4.Anticipate an order for Echogram(Give dobutamine) 5.Administer diuretics/antiarrythmic/blood pressure meds 6.Administer o2 as needed 7.Monitor pulse, respirations, temp, BP, o2 sat, and weights daily. 8.Educate patient on sodium/fluid restrictions. 9. Consultations: Cardiology/Respiratory
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CHF rationales
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Let MD know of condition, anticipate orders 1. Assess signs of tachycardia, shortness of breath and crackles that signify heart failure. 2.To expand lung expansion 3.To diagnose the condition and help identify the extent of the HF. 4.Echogram and dobutamine are used to test the heart's condition when under strenuous activity. 5.diurectics reduce retention/excess fluids on the heart. Antiarrhythmics treat abnormal heart rhythms, antihypertensives decrease blood pressure, and reduces the workload of the heart. 6.oxygen is given for low o2 sat and shortness of breath 7.Monitor vitals and weights to test if implementations were successful 8. sodium and excess fluids can increase edema and retention. 9.Cardiologist will develop procedures for CHF/Respiratory will get ABGs
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CHF labs to anticipate
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O2, ECG, chest X-ray, ABG's, cardiac monitor, diuretics, potassium, Labs-electrolytes, BUN & creatinine, BNP, cardiac enzymes, echocardiography
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Hypoglycemia symptoms
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cold, clammy, dizzy, fainting, sweating, shakiness, headache, confusion, seizures
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Hypoglycemia interventions
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Call MD stat 1. Check patient's blood sugar (Start hypoglycemia protocol) 2. If under 70 giveD50WIV 3.If over 70 provide light sugars(orange juice) with a carb/protein (crackers,cheese, peanut butter) 4.recheck blood sugar 5.teach about hypoglycemia symptoms/compliance of diet,insulin 6. Get nutritional consult 7. Recheck BS every 4 hours, giving insulin as needed
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Hypoglycemia rationales
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GET ORDERS/LET AWARE OF CONDITION 1. check to see if hypoglycemic 2. D50w increases BS if patient is unconscious/unable to swallow or under 70. 3.OJ is given to increase BS. Carbs/proteins will keep the sugar maintained after it increases 4. To test if interventions were successful 5.Compliance will reduce chances of hypoglycemia 6.To help identify diabetic diets for the patient 7. Rechecking before and after meals will ensure that the BS are maintained.
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ETOH Withdrawal symptoms
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N/V, diarrhea, tremors, hallucinations, insomnia, agitation, anxiety, seizures, instability
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ETOH withdrawal interventions
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Call MD STAT 1. Obtain bp, pulse, rr, temp, o2 sat. Assess LOC 2.Decrease environmental stimuli/noise 3.Reorient frequently 4.Adminsiter Benzodiazepine/barbiturates/antianxiety 5.Prevent falls/Secure safety 6.Stay with patient/get a sitter 7.Monitor for seizures (Seizure precautions) 8 Administer multi vitamin infusions/Fluids(NACL/KCL) 9. Consult with Social worker
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ETOH Withdrawal rationale
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Anticipate orders/let know of pt's condition 1.Document abnormal vitals (Increases in BP, pulse) Monitor level of conscious (Lethargic, faitugued) 2. reduces delusions/hallucinations. should decrease noise/lighting to eliminate stress. 3.Allows the patient to be oriented when confused. 4.Antianxiety agents help reduce agitation/anxiety. Barbiturates suppress alcohol withdrawals. 5. keep bed low, 3/4 side rails up, bed alarm on, call bell in place. 6. Needs to be monitored to prevent safety hazards/change in condition. 7.Grand mal seizures are common. (Pad side rails, place nothing in mouth, remove restricted clothing, Document, onset and duration of seizure, administer 02 as needed.) 8.increases nutrition/minerals, and prevent dehydration/chemical imbalance 9. To get help with alcoholism, provides stable environment if doesn't have one.
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Hypoxia/Effusion Symptoms
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Cyanosis, sharp chest pain, shortness of breath, cough, tachypnea, lung crackles, decreased o2 sat (less than 90), nasal flaring, restlessness, confusion
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Hypoxia/Effusion interventions
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Call MD STAT 1.Listen to lung/heart sounds. Monitor respiration, O2 sat. 2. If short of breath,place in high fowlers 3.Anticipate an order of IV Diuretics, antibiotics, pain meds 4. Place patient on o2 THERAPY 5.Anticipate an order of CBC, ABG, Electrolytes, Chest X-ray, EKG, and monitor on cardiac monitor 6. Encourage rest periods between activities 7. Prepare for thorencelntesis if needed (Document drainage)
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Plural effusion
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A buildup of fluid between the tissues that line the lungs and the chest.
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Hypoxia/Effusion rationale
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Anticipate orders/let aware of condition 1.To note respirations abnormalities that can lead to hypoxia 2. Lung expansion 3.Diurectics to reduce fluid retention, antibiotics to kill bacteria, pain meds for comfort 4.Maximazes oxygen available for cellular uptake 5.Diagnostic procedures such as chest X-ray, EKG help identify the extent of the Effusion. Labs are drawn to identify the Blood gases, Hemoglobin/hematocrit, RBC/wbc count found in CBC 6. lIMTIS Fatigue and promotes wellness 7.Releases fluids found between tissues that line the lungs.
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Pulmonary edema symptoms
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difficulty breathing, chest pain, fatigue, coughing up frothy sputum, grunting/gurglin/wheezing when breathing.Feeling of Air hungry/ Drowning
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Pulmonary edema intervention
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Call MD STAT 1. Assess heart and lung sounds. Obtain BP, pulse, temp, o2 sat, and respirations 2. Place in high fowlers 3.administer oxygen as needed 4.Anticipate orders of Chest X-ray, ABG, 5.Anticipate Diuretics/Nitro/Blood pressure/morphine as ordered 6.Consult with Respiratory/Cardiologist
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Pulmonary edema rationale
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Make aware of pt's condition/ Get orders 1. Listen for crackles, cardiac abnormalities. Check for increase in BP, pulse, And o2 to identify the extent of the PE 2.To expand lungs 3. To promote oxygen promotion and cellular uptake 4.Diagnostic procedures used to identify the extent of the Situation 5.Diuretics reduce fluid retention, nitro dilates blood vessels and reduces preload of the heart, blood pressure meds reduces blood flow to heart, morphine relieves shortness of breath and anxiety. 6. Cardiologist and Respiratory therapist can assist with patients condition.
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Acute renal failure symptoms
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decrease urine output, fluid retention, elevated bun/creatinine, hyperkalemia, drowsiness, shortness of breath, hypertension, change in mental status, flank pain, N/V
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ARF interventions
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1. Call MD STAT 2.Monitor BP, PULSE, RESP, TEMP, O2) listen to heart/lung sounds 3.Monitor urine output(color, amount, description, 4.Check weights daily 5.Low protein diet with carbs/low potassium foods 6.Provide renal replacement or dialysis as needed 7.Consult nephrologist/Infectious disease
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ARF rationales
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1. Obtain orders/change of condition 2. monitor signs of hypertension which can make the situation worst. 3.decreased urine output will cause fluid retention, monitor for hematuria/proteinuria 4.increased weight will show an increase in fluid retention 5.prescibed diet will reduce workload of the kidneys to filter out proteins it can't excrete. ARF have hyperkalemia, low potassium food reduce this. 6. Helps excrete waste, and prevents metabolic acidosis 7. TO discuss future procedures/treatment options.
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Septic shock symptoms
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Tachycardia, fever,hypotension (SYSTOLIC lower then 90), pallor, fatigued, cold, reduced urine output, SOB, Decreased LOC,N/V, sweating,
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Septic shock interventions
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Call Rapid response (Code sepsis) 1 Call MD STAT 2. Assess BP, pulse, rr, temp, o2 sat. Assess LOC and Neurological status. 3 Maintain Iv access and give Fluid therapy 4 Maintain oxygen therapy 5Anticipate an order for vasopressors/positive inotropic 6 Monitor cbc, electrolytes, urinalysis, Lactic acids, input and output 7. place urinary catheter if applicable to measure output
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Septic shock rationales
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1.TO await orders/ become aware of patients condition 2 compare results to baseline, assess skin color for signs of cyanosis/paleness 3 Fluids will increase Blood pressure and blood flow.Urine output will improve from fluids. 4. to improve o2 sat, and to increase oxygen perfusion 5Dopamine, norepinephrine and dobutamine maintain perfusion pressure and cardiac output. 6When the oxygen level is low, carbohydrate breaks down for energy and makes lactic acid.
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ARF orders
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cardiac monitor, urinalysis, urine electrolytes/osmolality, creatinine, magnesium, renal profile, angiogram, cystoscopy, bleeding time, renal scan, CT scan,kidney ultrasound, daily weight, IV fluids
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MI symptoms
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Dyspnea, SOB, diaphoresis, Chest pain that radiates to the jaw, anxiety, light headedness, tachycardia, tachypnea
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MI interventions
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RAPID RESPONSE 1.Call MD stat( Assess level of pain) heart/lung sounds. BP, pulse, rest, temp, o2 sat 2.Get IV access AND Place on EKG 3.ADMINSTER Oxygen 4.Adminster nitro, aspirin and morphine 5.encourgae bedrest 6. Get chest X-ray, Echocardiogram, CBC, electrolytes, myoglobin,ABG, CK-MB, troponin LEVELS MONITORED 7.Transfer to higher level of care
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MI rationales
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1.Let know of condition/aWAIT ORDERS 2.to monitor heart condition, and to have access for IV meds/fluids if indicated. 3.Oxygen increases tissue perfusion, maintains o2 saturation 4.nitro-dilates blood vessels, aspirin reduces clot formation, morphine reduces pain and shortness of breath 5. promotes wellness/ prevent exertion by rest 6. Diagnostic procedures are used to identify the extent of the MI. CK-MB are released in response to damaged tissue. Troponin levels increase 3-4 hours following infarction. Hemoglobin/hematocrit may reduce 7. Needs to be on an Intensive care unit on cardio monitors.
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MI/abdominal Patients
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Assess level of pain (OLD CARTS)
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Anaphylactic Shock orders
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Stop the tranfusion/med, O2, ET tube, large bore IV access, IV fluids, bronchodilators, Epinephrine pen,
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Anaphylactic shock interventions
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Maintain airway, obtain SaO2, elevate head of bed, O2, continually monitor respiratory rate, depth, breath sounds & heart rate, comfort patient
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Anaphylactic shock labs/DX
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Normal saline/lactated ringers, epinephrine, diphenhydramine, prednisone, bronchodilators, aminophylline antihistamines, vasopressors
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DVT Symptoms
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Assess for limb pain, limb swelling, Holman's sign, palpable tender area in limb, warmth & redness of skin over area
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DVT Orders
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CBC, platelet count, PTT, PT/INR, ultrasound, bed rest, close observation for embolic events, Vital (bp, pulse, resp, o2)
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Digoxin Toxicity symptoms
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Changes in ECG -accelerated junctional rhythms, A-flutter, P-R changes, Q-T changes, blurred vision, confusion, halos around lights, Yellow Aura, headache, diarrhea, nausea/vomiting
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Digoxin Toxicity
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O2, cardiac monitoring, discontinue digitalis(GET dig level), serum electrolytes, ECG, maintain airways, Cardiac enzymes, low salt, low fat diet, bed rest, IV fluid plus electrolyte therapy
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Digoxin MEDS/LABS
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procainamide, dig bind if severe, life- threatening arrhythmias, lidocaine for ventricular arrhythmias, magnesium, potassium
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Hemorrhagic Stroke SYMPTOMS
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Impaired LOC, headache, nausea/vomiting, mobility, speech patterns, one sided weakness, blood pressure, respiratory status, pulse rate
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Hemorrhagic Stroke orders
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O2, Carotid ultrasonography, ECG, transthoracic, echocardiogram, cardiac monitor, EEG, PIT, PT, INR, cardiac enzymes, CT of head, MRI scan of brain
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Pulmonary Emboli symptoms
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History - access legs for swelling & pain, percussion of lungs for flatness, auscultate for friction rub, wheezing, auscultate heart for splitting of 2nd heart sound, headache, stabbing right side chest pain, tachypnea
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Pulmonary Emboli interventions
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Monitor respiratory rate, ECG, response to IV fluids, monitor SaO2, bed rest, IV access, IV heparin, warfarin, vasopressors if hypotensive, chest X-ray, VQ scan, ABG
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Abdominal complications symptoms
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History - type of pain, nature & onset of pain, location, quality (sharp, dull, crampy), changes in bowel habits, Hx of trauma, gynecological Hx, anorexia, malaise, tachycardia, hypertension, fever, nausea/vomiting. Inspect - look, listen, feel abdomen
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Abdominal complications ORDERS
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Labs, IV fluids, nasogastric suction, antiemetic, narcotics, and/or analgesics, surgical consultation. CBC, urinalysis, pyuria, hematuria, glucosuria, ketenes, serum lipase, serum HCG, serum electrolytes & glucose. NPO, Pain meds.
