Nursing Interventions
Name 3 nursing interventions to prevent hospital- acquired pneumonia.
- infection control/hand hygiene
- HOB elevated
- good oral hygiene
- aspiration precautions
- cough/deep breath & incentive spirometry (open alveoli) exercises: prevent collapse (atelectasis), removes secretions
What is the peak flow meter is used for?
Peak flow meter: Asthma monitoring by measuring maximum airflow out of your lungs.
Peak expiratory flow rate (PEFR)
What blood test is done to check for cardiac muscle damage.
Troponin: a protein found in muscle cells (some specific to cardiac muscles). When heart muscle is damaged, such as during a heart attack, troponin leaks into the bloodstream. Normal troponin 0.04 ng/ml
In heart attack (heart muscle damage)- levels rise (peak 24hours), then start to fall.
1) Left sided heart failure causes _____ symptoms
2) Right sided heart failure causes _____ symptoms
1) Left-Lungs: impaired gas exchange, pulmonary edema. hypoxia, orthopnea, activity intolerance
2) Congestion in peripheral tissues (dependent edema, ascites, GI/liver congestion)
Describe the difference between sickle cell disease and sickle cell crisis.
Bonus 100: What is sickle cell anemia?
Sickle Cell Disease- broad term for hemoglobin mutation
Sickle cell crisis- Vaso-occlusive crisis
Sickle Cell Anemia- most severe & most common form of sickle cell disease
Name 2 interventions for Thrombocytopenia.
Thrombocytopenia: low platelets count
Safety/reduce bleeding risks: prevent falls, manage bleeding (holding pressure after blood draws, etc), soft tooth brush, avoid ETOH, hydration, no contact sports
What type of bronchodilators are rescue medications? Name one of the medications.
- short-acting beta-agonists (SABA)- Albuterol, levalbuterol
What blood test is done to monitor heart failure.
BMP (B-type natriuretic peptide): hormone released by the heart when it is under stress, such as in heart failure
- normal levels < 100 pg/mL
- abnormal (probable HF) > 100 pg/mL
A patient with Atrial fibrillation is at risk for what possible complications? Why? (Name one)
Blood clots (stoke, PE):irregular heartbeat can cause blood to pool in the atria, increasing the risk of blood clot formation. These clots can lead to a stroke or a pulmonary embolism
Heart failure: AFib can weaken the heart muscle over time, leading to heart failure
This condition is the most common inherited bleeding disorder.
Bonus 200: Describe what occurs with the protein in this condition
What is Von Willenbrands Disease.
Bonus: People with vWD have a problem with a protein called won Willenbrand Factor (VWF) which helps blood clot
What two nursing interventions would the nurse expect for a patient in sickle cell crisis?
Pain relief
Hydration
LABA (ong-acting beta-agonists) bronchodilators are always combined with _____ to treat asthma. Why?
Bonus 100: Name one combined medication
Inhaled corticosteriods. LABA alone does not treat the underlying inflammation and increases the risk of asthma-related deaths
Medications: Advair, Symbicort, Dulera
1) Acute Kidney Injury (AKI) is diagnosed when ______ levels rise by 0.3 mg/dL within 48 hours or by 50% within 7 days
2) ____measures how much waste and fluid your kidneys filter from your blood in one minute
1) Creatine
2) Glomerular filtration rate (GFR)
1) What is the treatment for Ventricular fibrillation?
2) What is the treatment for Atrial fibrillation?
3)Why are they different?
1) Defibrillation
2) Medications (beta-blockers, calcium channel blockers, digoxin, anti-arrhythmic)
Stoke prevention- anticoagulant
Ablations
3) Vfib is a fatal arrhythmia
In this autoimmune condition _________, the immune system mistakenly attacks and destroys platelets.
What is ITP: Immune thrombocytopenia purpura
Name 4 nursing interventions for a patient with severe COPD
Pursed lip breathing/breathing exercises
Airway clearance (deep breath and cough)
Raised HOB, Positioning
Incentive spirometry
Small frequent meals
Smoking cessation education
Proper inhaler use
Infection Prevention
Minimizing exertion
Name 4 types of pneumonia. What are 2 common symptoms of pneumonia?
Bacterial, Viral, Fungal, Parasitic, Atypical, Community-Acquired, Hospital-Acquired, Ventilator-Associated pneumonia
Symptoms: SOB, cough, fever, chest pain, fatigue
How can we test for latent TB and TB disease? What is the difference between the two?
Latent TB lives but does not grow in the body. It does not make a person feel sick. It is NOT contagious, however it could advance to TB disease.
TB disease is an active infection & grows in the body. It IS contagious. Can lead to death if not treated.
Testing- Skin PPD (either), blood test (either), Chest x-ray (active TB disease only)
Renal: What are AKI, AKD, CKD? How are they different?
AKI- Acute kidney injury 0-7 days: rapid decline in kidney function (medication, dehydration, infections). reversible or it progreses to AKD.
AKD- Acute Kidney Disease- 7-90 days: broader category that includes all abnormalities of kidney function/structure lasting less than 3 months. Can be rapid or gradual onset. Reversible or it progresses to CKD.
CKD- Chronic Kidney Disease >90 days: Gradual, progressive and typically irreversible. May be caused by chronic conditions like diabetes or high blood pressure.
Blood transfusion: the nurse must check vital signs at what intervals?
How long will the nurse remain with the patient, name at least 3 symptoms are they monitoring for?
Bonus 100: What will the nurse do if any symptoms occur?
Vitals: Before transfusion, 15 minutes after, 1 hour after (and if any symptoms appear).
Symptoms: fever, chills, hives (urticaria), and itching. More serious reactions can present with difficulty breathing (dyspnea), chest or back pain, low blood pressure (hypotension), and dark or red-colored urine.
Bonus: Immediately stop the transfusion. Contact the physician
A patient who quit smoking a week ago is experiences more coughing. They state "I shouldn't have bothered to quit if I'm going to be even sicker now." What should the nurse educated the patient?
Quitting smoking at any time reduces damage to the lungs. After quitting it common to have coughing because the tiny hair-like structures in your lungs (cilia) start to heal and work again to clear built-up mucus and toxins. This is a temporary and positive sign that your body is cleaning itself, although it may last for a few weeks to a year.
COPD- a mixture of both _____ and chronic_____ in different proportions. Name and describe those conditions.
Bonus 100: Is it reversible?
Emphysema- damages air sacs (alveoli), loose elasticity, collapse, difficult to exchange blood
Chronic bronchitis- inflammation & mucous
No, the lung damage is permanent and cannot be reversed.
___ is the measurement of how much blood the heart's left ventricle pumps out with each beat.
The normal value is _____
Ejection fraction EF
Normal 50%-70%
Mildly reduced 41-49%
Reduced <40
Name these types of heart disease:
1) abnormally enlarged, thickened, or stiffened heart muscle, making it harder to pump blood.
2) Plaque buildup that narrows the arteries supplying the heart
3) Conditions affecting the pericardium, the sac that surrounds the heart
4) Chronic condition where the heart can't pump enough blood to meet the body's needs
1) Cardiomyopathy
2) CAD- coronary artery disease
3) Pericardial Disease (pericarditis)
4) Heart failure
How does Heparin Induced Thrombocytopenia (HIT) occur?
Immune system mistakenly identifies heparin as a foreign substance
- produces antibodies that bind to it and platelets, activating them.
- platelets clump together causing reduction in the number of platelets (thrombocytopenia)
-increases the risk of forming blood clots