Acid Base Balance/other
metabolic acidosis S/S
Diabetic ketoacidosis-the body produces excess blood acids when it doesn't have enough insulin
priority intervention for a PE and S/S
SOB, Chest pain, anxiousness, Low O2
apply O2 via non rebreather mask
Priority intervention for atrial fibrillation
Administer a beta blocker & monitor heart rate
A-fib is an arrhythmia leading to rapid heart rates causing symptoms of palpitation, SOB, and fatigue. So controlling heart rate is a priority
Cariogenic shock S/S
chest pain, SOB, St elevation shows acute MI
Hypotension, tachycardia cold extremities and crackles in both lungs shows pulmonary edema.
which caused by the heart's inability to pump sufficient blood to meet the body's needs due to severe heart muscle damage from the MI
most significant Lab showing an MI
Elevated troponin
elevated CK=MB
Acid numbers for respiratory acidosis with renal retention of bicarbonate
pH below 7.35-7.45
pCO2 higher than 35-45
The body attempts to compensate by retaining bicarbonate HCO2, which is renal metabolic mechanism
COPD shows this
What is a priority intervention for chest pain
Obtain a 12 lead ECG a rapid diagnosis is crucial for a timely intervention
S/S of pneumothorax
sharp chest pain, difficulty breathing, decreased breath sounds on affected side, hyper resonance to percussion
purpose of a diary wearing a holter monitoring the heart
For patient to record daily activities and symptoms experienced such as palpitations, dizziness, or chest pain at the exact time of occurrence This in turn is matched to the ECG data.
interventions for anaphylaxis
prepare for airway support
administer epinephrine per protocol
stop the IV medication immediately
values of partially compensated respiratory acidosis
pH below 7.35-7.45 shows acidic
PaCO2 above 35-45 shows respiratory acidosis
HCO3 above 22-26 shows metabolic compensation
body compensate by increasing bicarbonate since pH is outside normal range gives partially compensated
pulseless ventricular tachycardia (VT) intervention
Chest compressions and early defibrillation
Start CPR while someone puts on the defibrillator
monitoring required during antidysrhythmic therapy
ECG monitoring for QT interval and continuous vital signs-monitoring show worsening arrhythmias such as tornadoes de Pointes and patient stability
Order of interventions for an unconscious, unresponsive patient
Activate the emergency response
begin CPR
open airway to check and check breathing
AED
deliver shock when advised by AED
What position should a patient with a DVT avoid
Crossing the legs it increases venous pressure and obstruct blood flow
results for respiratory acidosis
Decreased pCO2 and increased pH
occurs when lungs cannot remove all of the carbon dioxide produced by the body. causing body fluids especially blood to become too acidic
Nursing intervention for a acute MI
Administer O2 increases myocardial O2 supply
assessments of Obtaining vitals and pain level-
provide baseline data
ID complication such as cardiac dysrhythmias and cariogenic shock which are life threatening
Order of nursing intervention for pneumonia
Assess vital signs and oxygen saturation
apply O2
collect sputum
encourage coughing and deep breathing
minister antibiotics per order
Side effects of a Bata blocker to report
Dizziness, depression, fatigue, erectile dysfunction
what is high quality CPR
Correct compression depth 2" or 5 cm for adults-100-120 compression per minute
adequate chest recoil allowing heart to fill with blood
minimal interruptions when switching less than 5 sec.
minimal pauses for ventilation or pulse checks ensuring continuous blood flow to organs
concerning symptoms of abdominal aortic aneurysm (AAA)
lower back pain & drop in BP
Which are signs of a life threatening ruptured AAA
Causes of dysrhythmias
Ischemia-lack of blood flow to heart
Electrolyte imbalances-affect electrical impulses in heart
Caffeine, alcohol, tobacco use-stimulants or toxins altering heart rate and rhythem
Drug toxicity-meds affecting impact of heart function and electrical stability
Next steps for a patient in respiratory failure
if respiratory failure does not improve with high flow O2 via a non rebreather next step is noninvasive positive pressure ventilation
airway opening technique for a spinal cord injury
Jaw thrust which minimizes movement of the head and neck reducing risk of further spinal damage
Pleural effusion nursing interventions
1st intervention Position upright
most important assessment monitor O2 rate and work of breathing, assess for tracheal deviation or asymmetrical chest movement
outcome complications respiratory distress
lung collapse (atelectasis)