ADULT HEALTH II - III HESI

Monday, March 18, 2013

4:55 PM

Respiratory system
Pathophysiology

Nursing Assessment

A. Tachypnea: shallow respirations with use of

accessory muscles.
Inflammation of lower respiratory tract
B. Abrupt onset of fever with shaking and chills
Caused by infectious agents
(not reliable in O/A)
Organisms reach the lungs in 3
C. Productive cough with pleuritic pain
methods:
D. Rapid bounding pulse
1. Aspiration
E. In older adults sx include:
2. Inhalation
1. Confusion
3. Hematogenous spread
2. Lethargy
Pneumonia is classified according to
3. Anorexia
causitive agent
4. Rapid respiratory rate
1. Bacterial (gram pos and neg)
F. Pain and dullness to percussion over the
2. Viral
affected lung area
3. Fungal
G. Bronchial breaht sounds/crackles
4. Chemical
H. Chest radiography indication of inflitrates
Pneumonia may be community
with consolidation or pleural effusions
acquired or nosomcomial
I. Elevated white blood cell coung
High risk groups include
J. ABG of hypoxemia
1. Debilitated by lung secretions
K. On pulse oximetry a drop in O2 satruation (>
2. Cigarette smokers
90 and ideally 95)
3. Immoblie
4. Imunosuppressed
5. Expereincing a depressed gag
reflex
6. Sedated
7. Experiencing neuromusclar
disorders

Pneumonia:

Pathophysiology

Nursing assessment

Changes in breathing pattern (eg. An increase

with rate iand depth)
Description: chonic lung disease
Use of accessory breathing (barrel chest)
includes chonic bronchitis; pulmonary
Gernalized cyanosis of the lips, mucous
emphysema and asthma.
memrbanes, face, nail beds ("blue bloaters)
Emphysema and chonic boronchitis
Cough (dry or productive)
termed as chonic obstructive
Higher Co2 than average
pulmonary disease (COPD) are
Low O2 as determined by pulse oximetary
characterized bronchospasm and
Decreased breath sound
dyspnea. The damage to the lung is not
Coarse crackles in lung fields that tend
reversity and increases in the severity.
disappear after coughing, wheezing
Asthma, Unlike COPD, is an
Dyspnea, orthopena
intermittent disease with reversible
Poor ntuition
airflow obstruction.
Activity intolerance
Anxiety concerneing breathing manicested by:
1. Anger
2. Fear of being alone
3. Far of not being able to catch breath

Chronic airflow limitation

Analysis

Plans

A. Impaired gas exchange related to

B. Ineffective airway celarance related to
C. Activity intolerance related to
D. Risk for deficient fluid volume related to.
E. Ineffective breathing pattern related to

A. Assess suptum for volume, color,

consistency and clarity.
B. Assist client to cough productively
by:
1. deep breathing care every 2
hours (many use incentive
spiometer)
2. Using humidity to loosen
sevretions (may be
oxylgenerated)
3. Suctioning airway if necessary
C. Assess lung sounds before and after
coughing
D. Assess rate, depth, and pattern of
respirations regularly (normal adult
rate 16 to 20 breaths/min)
E. Monitor Abg's (pO2 > 80mm2; Pco2
< 45mm hg)
F. Monitor O2 saturation with pulse
oximetry (ideally > 95%)
G. Assess skin color
H. Assess mental status, restlessness,
and irritability
I. Administer o2 as prescribed
J. Monitor temperature regularly
K. Provide adequate rest periods,
including uniterrupted sleep.
L. Encourage at risk groups to annual
pneumonia and influenza (flu)
immuniziations.

Analysis

Plans

Ineffective airway clearance related to

Ineffective breathing pattern related to
Impaired gas exchage related to
Activity related to

Teach client to sit upright and bend

slightly forward to promote breathing
1. In bed teach client to sit with
arms resting on overbed table
(tripod position0
2. In chair teach client to lean
forward with elbows resting on
knees (tripod position)
Teach diaphragmatic and pursed lip
rbeathing. Teach prolonged expiratory
phase to clear trappped air
Administer O2 at 1 - 2 L per nasal
canula.
Pase activities to conserve energy
Maintain adequate dietary intake
1. Select small, frequent mealse
2. Inscreased calories and protein
Select foods that derive their calories
from high fat rather than high
carbohydrate level because Co2 that is
a natrual end product of carbohydrate
metablism and can elevate PaCo2
levels
3. Favorite
4. Dietary supplements
For people contiinuing to smoke
tobacco, adiditional vatamin C may be
necessary.
Magnesium and clacium, because of
their role in muscle contraction and
relaxation, may be important for
people with COPD.
Routine monitoring of magnesium and
phosphorus levels is important
because of their role related to bone
mineral density (osteoprorisis).
Provide an adequate fluid intake
(minimum 3 L day)
Fluids should be taken between meals
(rathern them) to prevent excess
stomach distention and to decrease
pressure on the diaphragm
Instruct the client in relaxation
techniques (teach when not in
distress)
Teach prevention of seconday
infections
Teach about medication regimen
Smoking cessation is imparative
Encourage health promoting activities.

Hints
High risk for pneumonia
Any person who has an altered level of
consciousness, has depressed or absent gag and
cough reflexes or is susceptible to aspirating
orophayngeal secretions, including alcoholics,
anesthesized, those with a brain injury and those in
a state of drug overdose and stroke victims are at
high risk
When feeding-- raise the head of the bed and
position the client on his or her side and not on the
back.
Bronchial brath sounds are heard over areas of
density or consolidation. Sound waves are easily
transmitted over consolidated tissues.

Hydration
Enables liquefication of mucous trapped in the
bronchioles and alveoli, facilitating expectoration
Is essential for client experiencing fever
Is important because 300 to 400 mL of fluid is lost
daily by the lugns through evaporation.
Irritably and restlessnes are early signs of cerebral
hypoxia; the cleint's brain is not recieiing enough of
O2.

Pneumonia Preventaives
Older adults: flue shots; pneumonia,
immunizations; avoiding soucres of infection and
indoor pollutants (dust, smoke and aerosols); no
smoking.
Immunosuppressed and debilitated persons:
infection avoidance, sensible nutition, adequate
intake, balanced rest and activy.
Comatose and immoblie persons: elevetion of head
of bed to fed and for 2 hours after/ frequently
turning
Hints
Exposrue to tobacco smoke is the primary cause of
COPD in the United States.
Compensation occurs over time in clients over time
in clients with chonic lung disease, and ABG's are
altered.
As COPD worsens the amount of O2 in the blood
decreases (hypoxemia) and the amount of carbon
dioxide (Co2) in the blood increases (hypercarbia),
causing chonic repisratory acidosis (increased
arterial carbon dioxide (paCo2), which results in
metabolic a (increased arterial bicarbonate) as
compensation.
Not all clients with COPD are Co2 retainers, even
when hypoxemia is present, because Co2 diffuses
more easliy across lung memebranes than O2.
In advanced emphysema, due to the alveoli bereing
affected hypercarbia is is a problem rather than
borchitis where the airway are affected.
It is imparitive that basline data be obtained for the
client.

Productive cough and comfort can be facilited by

semi fower or high power position, which lessens
pressure on the diaphragm by abdominal organs.
Gastric distention become a proity in these cliente
because it elevates the idaphragm and inhibits full
lung expansion.
NORMAl ABG values
Adult
pH 7.35 - 7.45
Pco2 35 - 45 mmHG
Po2 80 to 100 mmhg
Hco3- 21 to 28 mEq/L
Child
pH 7.36 - 7.44
Same as adult
Same as adult
Same as adult

Pink puffer: barrel chest is indicative of emphysema

and is caused by the use of accessory muscles to
breathe. The person works harder to breathe, but
the amount of O2 taken is adequate to oxygenate
the tissues.
Blue bloater-- insufficient oxygenation occurs with
chonic bronchitis and leads to generalized cyanosis
and often right sided heart failrue (cor pulmonale)
Cells of the body depend on O2 to carry out their
functions. Inadequate arterial oxygenation is
manifested by cyanosis and slow capillary refill (< 3
seconds). A chonic sign is clubbing of the fingers.

Caution must be used in administering O2 (not

greater than 2L of O20 to a COPD client. The
stimulus to breathe is hypoxia (hypoxic drive), not
the usualy hypercapnia, which is the stimulus to

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the usualy hypercapnia, which is the stimulus to

breathe for healthy persons. Therefore, if too mcuh
O2 is given they may stop breathing.

Helath promotion-Eatin consumes energy needed for breathing. Offer

mechanically soft diets, which do not require as
much chewing and digestion. Assist with feeding if
needed.
Prevent seconday infections: avoid corowds,
contact with persons who have infectious diseases,
and respriatory irritants (tobacco smoke)
Teach the client to report any change in
characteristics of sputum.
Encourage client to hydrate well (3L/day) and
decreases caffiene due to diuretic effect.
Obtain immunizationw when needed (flu and
pneumonia)
When asked to pioritize nursing actions use the ABC
rule:
Airway
Breathing
Circulation

Look and listen! If breath sounds are celar but the

client is cyanotic and lethargic, adequate
oxygenation is not occurring.
The key to respriatory status is assessment of
breath sounds as well asl visualization of the client.
Brath sound are better described, not named; e.g.,
sounds should be descrinbed as crackles, wheezes
or high pitched whisteling sounds rather than rales,
rhonchi, ect. Which may not mean the same thing
to each clinical professional.

Whatch out for NCLEX questions that deal with O2a

delivery. In adults, O2 it must bubblet hrough some
water solution so it can be humidified if given at >
4L/min or delivered directly to the trachea. If given
at 1 - 4/min or mask or nasal prongs the oropharynx
and nasal pharynx provided adequate
humidification.
Pathophysiology

Nursing assessment

A. Is often asymptomatic
B. Symptoms include
Communicable lung disease caused by
1. Fever with night sweats
an infection by mycobacterium
2. Anorexia, weight loss
tuberculosis
3. Malaise, fatigue
A. Transmission is airborne
4. Cough, hemoptysis
B. After initial exposrue, the
5. Dsypnea, pleuritic chest pain with
bacteria encapsulate, they form
inspiration
a ghon lesion
6. Cavitation or calicfication as
C. Bacteria remain dormant until
evidenced on chest radiograph
later time, when clinical
7. Positive sputum
sympoms appear

Tuberculosis:

Pathophysiology

Nursing assessment

A. Dry hacking cough, early with cough turning

productive disease progresses
Neoplasm of the lung
B. Hoarseness
A. Lung cancer is the elading cause
C. Dyspnea
of cancer related death in the
D. Hemoptysis-- rist colored or purulent
united states
sputum
B. Cigarette smoking is responsible
E. Pain in the chest area
for 80 - 90% of all lung cancers
F. Diminihed breath sounds, occasional
C. Exposure to occupational
wheezing
hazards such as asbestos and
G. Abnormal chest radiograph
radioactive dust poses significant
H. Positive sputum for cytology for plural fluid.
risk
D. Lung cancer tends to appear
years after exposrue; it is most
common sdeen in persons in the
fifth or sixth decade of life
E. Lung cancer has a poor
prognosis- 5 year survivial rate is
14%

Lung cancer

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Analysis

Plans

A. Knowledge deficiency (spefify) related to A. Provide cleint teaching

B. Risk for infection related to
B. Cough into tissues and dispose of
C. Imbalanced nutition less than body
immediately into special
requirements related to.
1. Take all priescribed
medication daily for 9 to 12
months
2. Wash hands using proper
handwashing technique
3. Report symptoms of
deteriorating condition,
especially hemorrhage
C. Collect sputum cultures as needed;
caliet many return to work after
three negatives cultrues.
D. Place client in respriatory isolation
while hospitalized
E. Administer anti-TB medications as
prescribed
F. Refer client and high risk persons to
local or state health department for
testing and phrophylactic treatment

Analysis

Plans

A. Chonic pain related to

B. Ineffective breathing pattern related to
C. Impaired gas exchange related to.
D. Imbalanced nutition: less than body
reuqirements related to
E. Anxiety related to.

A. Nursing interventions are simlar to

those implemented for clients with
COPD
B. Place client in SEMI fowler position
C. Teach pursed lip breathing to
imporve gas exchange
D. Teach relaxation techniques; client
often becomes anxious about
rbeathing difficulty]
E. Adminsister O2 as indicated by
pulse oximetry of ABG's
F. Take measures to allay anxiety
1. Keep client and family informed of
impending tests and procedures
2. Give client as much control as
possible over personal care
3. Encourage client and family to
verbalize concerns
G. Decrease pain to manageable level
by administering analgesics as
needed (within safety range for
respiratory difficulty
Surgery
1. Toractomy for clients who
have resectable tumor.
(unfoturnately detection
commonly occurs so late that
the tumor is no longer
localized and is amenable to
resection)
2. Pneumoectomy (removal of
the entire lung
a. Position client on operative
side or back
b. Chest tubes are not usually
used

Hints
Tuberculosis (TB) skin test
A positive TB skin test is exhibited by an inducation
10 mm orgreater in a diameter 48 hours after the
skin test. Anyone who has received bacillus
Calmette- Guerin (BCG) vaccine will have a positive
skin test and must evaluated with chest radiograph.
Teaching is very important with the client with TB.
Drug therapy is usually long term (9 months or
longer). It is essnetial that the cleint take the
medicatiosn as prescibed for the entire time.
Skipping doses or prematurlely terminating the
drug therapy can result in a public health hazard

Teaching points:
Rifampin reduces effectiveness of oral contceptives;
client should use other bierth control methods
during isoniazid (INH); increased dilantin levels
Ethambutol: vision check before starting therapy
and monthsy therafter; may have to take for 1 to 2
years. Teach rational for combination drug therapy
to increase compliance. Resistance develops slowly
if several anti TB drugs given instead of just one
drug at a time.
Hints
Some tumors are so large that they fil the entire
lobes of the lung. When removed, large spaces are
left. Chest tubes are not ususally used with these
clients because it is helpful if the mediastinal cavity,
where the lung used to be, fills up with fluid. This
fluid helps to prevent the shift of the remaining
chest organs to fill the empty space.
Chest tubes:
If the chest tube becomes disconnected do not
clamp! Immediately place the end of the tube in a
container of sterile saline or water until a new
drainge system can cbe connected.
if the chest tube is accidnetally removed from the
client, the nruse should apply pressure immediately
with an occlusive dressing and notify the HCP.
Chest tubes:
Fluctations tidaling in the fluid will occur if there is
no external suction. These fluctating movments are
a good indicator that the system is intact; they
should move upward with each inspiration and
downward with each expiration> if fluctutations
cease, check for kinked tubing; accumulation of
fluid in the tubing, occluaions or change the client's
position because expanding lung tissue may be
occluding the tube opening. Remember when
external sucation is applied, the flutations cease.
Most hospitals do not milk the chest tubes as a
means of clearning or preventing clots. It is too easy
to remove chest tubes. Mediastinal tubes may
involve orders to be stripped because of their
location compared to the larger thoracic cavity
tubes.

Various pathophysiologic conditions can be related

used
3. Lobeectomy and segmental
resection
a. Position client on his or her
back
b. Check to ensure tubing is not
kindked or obstructed
c. Chest tubes are usually
inserted
4. Chest tubes
a. Keep all tubing coiled loosely
below chest levels, with
connections tight and taped
b. Keep water seal and suction
control chambers at the
aporopriate water levels
c. Monitor the fluid drainage
and amrk the time of
measument and the fluid
level
d. Observe for air bubbling in
the water seal chamber and
fluctuations (tidaling)
e. Monitor the client's clinical
status
f. Check the position of the
chest drainage system.
g. Encourage the client to
rbeathe deeply periodically
h. Do not empty collection
chamber
i. Do not strip or milk the tubes
j. Chest tubes are not clamped
routinelsy. If the drinage
system breaks, place the
distal end of the chest tubing
connectiion in a steril water
container at 2 cm level as
emergency water seal
k. Maintain a dry occlusive
dressing.
Chemotherapy
1. Attend to immunosuppresion
factor
2. Administer antiemetics prior
to administering
chemotherapy
3. Take precautions in
administering antineoplastics
Radiation therapy
1. Provide skin care according to
hcp
2. Instruct the client not to wash
off the lines drawn by the
radiologist
3. Instruct client to sear soft
connon garments only
4. Avoid use of powders and
creams on radiationg site
unless specified by radiologist

Pathophysiology

Assessment

Analysis

Plans

A. Magnetic resonance imaging

Nursing Diagnosis
A. Provide preoperative teaching.
B. Direct laryngoscopy
Client undergoing laryngectomy
1. allow client and fmily to
Neoplasm occurring in the larynx most
C. Assessing for hoarseness of longer than 2
A. Anxiety related to.
observe and handle
commonly squamous cell in origin
B. Ineffective airway clearance related to
weeks-- early changes
tracheostomy tubes and
A. Proolonged use of alcohol and
D. Assessing for color changes in the mouth or
C. Impaired verbal communication related
suctioning equipment
tobacco is directly related to the
tongue
to
2. Explain how and why
development
E. Assessing for dysphagia, dyspnea, cough,
D. Ineffective breathing pattern related
suctioning will take place after
B. Other contibuting factors include
hemotysis, weight loss, neck pain, radiating
to
surgery
1. Vocal straining
to the ear, enlarged cervical nodes, and
3. Plan for acceptable
2. Chonic laryngitis
communication methods after
halitosis (later changes)
3. Family predisposition
F. Radiographs of the head, neck and chest
surgery
4. Industrial exposure to
G. Computed tomography (CT scan of neck and
4. Consider literacy level
carcinogens
biopsy.
5. Refer the cleint to a speech
5. Nutitional deficiencies
patholgist
C. Men are affected 8 times more
6. Discuss the planned
often than women
rehabilitation program
D. Dx usually occurs between the
B. Provide postoperative care
age of 55 and 80
1. Use simple communication
E. The earliest sign is hoarseness or
2. Use planned alternative
a change in vocal quality
communication methods
F. Medical management incldues
3. Keep call bell/light within
radiation therapy, often with
reach at all times
adjuvant chemotherapy or
4. Ask client yes/no questions
surgical removal of the larynx-whenever possible
laryngectomy
C. Promote respiratory functioning
1. Assess respiratory rate and
characteristics every 1 to 2
hours
2. Keep bed in semi fowler
position at all times
3. Keep larygnal airway
humidified at all times
4. Auscultate lung sounds every
2 - 4 horus
5. Provide tracheostomy care
every 2 - 4 hours and PRN
6. Administer tube feedings as
prescribed
7. Encourage ambulation as
early as possible
8. Refer for sppch rehabiltiaion
with artificial larynx or learn
esophageal speech.

Cancer of the larynx

Various pathophysiologic conditions can be related

to the nrusing dx ineffective breathing patterns.
Inability of air sac to fill and empty propery
(empysema, cystic fibrosis)
Obstruction of the air passages (carcinoma, ashma,
chonic bronchitis)
Accumulation of fluid in the air sace (pneumonia)
respiratory muscle fatigue (COPD) pneumonia.

Hints
with cancer of the larynx the tongue and mouth
often appear white, gray, dark brown or black and
may appear patchy.
Tracheostomy care involves cleaning the inner
canula, suctioning and applying clean dressing.
Air entering the lungs is humidified along the
nasobronchial tree. This natural humidifying
pathway is gone for the client who has had a
laryngectomy. If the air is not humidified before
entering the lugns, secretions tend to thicken and
become crusty.
A laryngectomy tube has a larger lumen and is
shorter than the tracheostomy tube. Observe the
cleint for any signs of bleeding or occlusion, which
are the greatest immediate postoperative risks (first
24 hours)

Fear of choking is very real for lyngectomy clients.

They cannot cough as they could earlier because
the glottis is gone. Teach the glottal stop technique
to remove secretions (take a deep breath,
momentarily occlude the tracheostomy tube, cough
and simultaneously remove the finger from the
tube.

Renal System
Pathophysiology

Assessment

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Analysis

Plans

Hints

Acute Renal failure

Abrupt deteroiration of the renal
system
A. ARF occurs when metabolites
accumulate in the body and
urinary output changes
B. There are three major types of
ARF
C. There are 3 phases of ARF
1. Oliguric phase
2. Diuretic phase
3. Recovery phase

A. History of taking nephrotoxic drugs

(salicylates, antibiotics, nonsteroidal
antiinflammatory drugs NSAIDS)
B. Alteration in urinary output
C. Edema, weight gain (ask if wastbands have
suddenly become too tight
D. Change in mental status
E. Diagnostic findings in the oliguric phase
1. Increased blood urea nitrogen (BUN)
and creatinine
2. Increased potassium (hyperkalemia)
3. Decreased sodium (hyponatremia)
4. Decreased pH (Acidosis)
5. Fluid overload (hypervolemic)
6. High Urine specific gravity (> 1.020
g/ml)
F. Diagnostic findings in the diuretic phase
1. Decreased fluid volume (hypovolemia)
2. Decreased potassium (hypokalemia)
3. Further decrease in sodium
(hyponatremia)
4. Low urine specific gravity (< 1.020
g/ml)
G. Diagnostic lab works returns to normal in
the recovery phase

A. Excess fluid volume related to

B. Deficient fluid volume related to
C. Anxiety related to
D. Imbalanced nutrition: less than body
requirements related to

A. Monitor intake and output (I & O)

accurately: give only enough fluids
in oliguric phase to replace losses;
usually 400 to 500 ml/24 hr
B. Document and report any change in
fluid volume status
C. Monitor lab values of both serum
and urine to assess electrolyte
status, especially hyperkalemia
indicated by serum potassium levels
over 5 mEq/L and ECG changes
D. Assess level of consciousness for
subtle changes
E. Weigh daily: in oliguric phase; client
may gain up to 1 lb per day
F. Prevent cross-infection
G. Kayexalate may be prescribed if K+
is too high
H. Provide low protein, modlelrate fat,
high carbohydrate diet
I. Monitor cardiac rate and rhytm
(acute cardiac dysrhymias are
usually related to hyperkalemia
J. Monitor drug levels and
interactions

Normally kidneys excrete approximately 1 ml of

urine per kg of body weight per hour.
For adults totoal daily surine output ranges
between 1500 and 2000 ml depending on the
amount and type of fluid intake, amount of
perspiration, envionmental or ambient temp and
the presence of vomiting and diarrhea
Electrolytes are profoundly affected by kidney
problems. There must be a blanace between
extracellular fluid and intracellular fluid to maintain
homeostasis. A change in the number of ions or in
the amount of fluid will cause a hshift in one
direction or the other. Sodium and chloride are the
primary extracellular ions. Potassium and
phosphate are the primary intracellular ions
In some cases, persons in ARF may not experience
the oliguric phase but may progress directly to the
diruetic phase, during which the urine output may
be as much as 10 L per day.
Body weight is a good indicator of fluid retention
and renal status. Obtain accurate weights of all
clients with renal failure; obtain weight on the same
scale at the same time every day.

Fluid volume alterations

Excessive fluid sympoms
Dyspnea
Tachycardia
Jugular vein distention
Peripheral edema
Weight gain
Fluid deficient symptoms
Decreased urin output
Reduction in body weight
Decreased skin turgor
Dry mucsous membranes
Hypotension
Tachycardia
Weight loss
Watch for signs of hyperkalemia, dizziness,
weakness, cardiac irregularities, muscle cramps,
diarrhea and nausea

Potassium has a critical safe range (3.5 to 5.0

mEq/L) because it affects the heart and any
imbalance must be corrected by medications or
dietary modification. Limit high potassium foods
(bananas, orange juice, cantaloupe, strawberries,
avocados, spinach, fish) and salt substitutes, which
are high in potassium
Clients with renal failure retain diluted and serum
levels may appear near normal. With excessive
water retention, the sodium levels appear
decreased (dilution). Limit fluid and sodium intake
in ARF clients.
During oliguric phase, minimize protein breakdown
and prevent rise in BUN by limiting protein intake.
When the BUN and creatinine return to normal,
ARF if determined to be resolved.
Pathophysiology

Assessment

Analysis

A. History of high mediation usage

A. Excess fluid volume related to
B. Family history of renal disease
B. Imbalanced nutition: less than body
C. Increased blood pressure (BP) and/or
requirements related to
chonic hypertension
C. Decreased cardiac output related to
D.
Edema,
pulmonary
edema
Progressive, irreversible damage to the
E. Neurologic impairment (Weakness,
nephrons and glomeruli, resulting in
drowsiness)
uremia
F. Decreasing urinary function
A. Causes chonic renal failure are
1. HEMATURIA
multitudinous
2. PROTINURIA
B. As renal function diminishes,
3. CLOUDY URINE
dialysis becomes necessary
4. OLIGURIC (100 TO 400 ML/DAY)
C. Transplantation is an alternative
5. Anuric (< 100 ml/day)
to dialysis for some clients
G. Jaundice
H. Gastrointestinal GI upsets
I. Metallic taste in mouth
J. Ammonia breath
K. Dialysis
L. Previous kidney transplant
M. Lab information
1. Axotemia
2. Increased creatinine and BUN
3. Decreased calium
4. Elevated phosphorus and magnesium

Chronic Renal Failure

(CRF): end stage renal
disease (ESRD)

Study guides and Miscellaneous crap Page 4

Plans
A. Monitor serum electrolyte levels
B. Weigh daily
C. Monitor strict I & O
D. Check for jugular vein distention
(JVD) and other signs of fluid
overload
E. Monitor for edema and pulmonary
edema
F. Provide low protein, low sodium,
low potassium, low phosphate diet
G. Administer aluminum hydroxide
antacids to bind phosphates
because client is unable to excrete
phosphates (no magnesium based
antacids) timing is important!
H. Encourage client's protein intake to
be of high biologic values (eggs,
milk meat) because the client is on
a low protein diet
I. Alternate periods of rest with
periods of activity
J. :Encourage streict adherance to
medication regimen; teach client to
obtain health care provider's
permission before taking any over
the counter medications.
K. Observer for complications
1. Anermia (administer
antiaemetic drug)
2. Renal osteodystrophy
(abnormal clcium metabolism
causes bbone pathology)
3. Severe, resistant,
hypertension
4. Infection
5. Metabolic acidosis
L. Living related or cadaver renal
transplant
1. Monitor for rejection
2. Monitor for injection
3. Teach client maintain

Hints
Accumulation of waste products from potein
metabolsim is the primay cause of uremia. Protein
must be restricted in CRF clients. However, if
protein intake is inadequate, a negative nitrogen
balance occurs, causing muslce wasting. The
glomerular filtration rate (GFR) is most often used
as an indicator of the level of protein consumption.
All persons in the united states are eligeble for
medicare as of their first day of dialysis under
special ESRD funding
Medicare card will indicate ESRD
Transplatiation is covered by medicare procedure;
cover terminates 6 months postoperaively if dialysis
is no longer required.

Protein intake is restricted until blood chemistry

shows ability to handle the protein catabolites, urea
and creatinine. Ensure high calorie intake so protein
is spared for its own work; give hard candy, jelly
beans or flavored carbohydrate powders.
The biggest difference between dialysate for
hemodialysis and peritoneal dialysis is the amount
of glucose. Peritoneal dialysis dialysate is much
higher in glucose. For this reason, if the diasylate is
left in the peritoneal cavity too long, hyperglycemia
may occur.
As kidneys fail, medications must often be adjusted.
Of particular importance is digoxin toxicity because
digitalis preparations are extreted by the kidneys.
Signs of toxicity in adults include nausea, vomiting,
anorexia, visual disturbances, restlessnes,s
ehadache, cardiac dysrhymia, an pulses <60 bpm.

3. Teach client maintain

immunosuppressive drug
therapy meticulously

Pathophysiology

Assessment

A. Signs of infection including fever and chills

B. Urinary frequency, urgency, or dysuria
Infection or inflammation at any site in
C. Hematuria
the urinary tract (kidney,
D. Pain at the costovertebral angle
pyelonephritis; urethra, urethritis,
E. Elevated serum WBC's (> 10,000)
bladder, cystitis; prostate, prostatitis)
A. Normally the entire urinary tract
is sterile
B. The most common infectious
agent is escherichia coli
C. Persons at the highest risk for
acquiring UTI's
1. Diabetics
2. Pregnant women
3. ;men with prostatic
hypertrophy
4. Immunosuppressed
persons
5. Catherized clients
6. Anyone with urinary
retention either short term
or long term
7. Older women-- bladder
prolapse
D. Diagnosis
1. Clean catch midstream
urine collection for culture
to identify specific
causitive organism
2. Intravenous pyelogram
(IVP) to determine kidney
functioning
3. Cystogram to determine
bladder functioning
4. Cystoscopy to determine
bladder or urethra
abnormalities

Urinary tract infection

Pathophysiology

Assessment

A. Pain, usually quite severe, acute

B. Sympoms of obstruction
Partial or completeblockage of the
1. Fever, chills
flow of urine at any point in the
2. Nausea, vomiting, diarrhea
urinary system
3. Abdominal distention
A. Urinary tract obstruction may be
C. Change in voiding pattern
caused by a
1. Dysuria, hematuria
1. Foreign body (calculi)
2. Urgency, frequency, hesitancy,
2. Tumors
noturia, dribbling
3. Strictures
3. Difficulty in starting a stream
4. Functional (e.g.,
4. Incontinence
neurogenic bladder)
D. Those with the following condition are at
B. When urinary tract obstruction
risk for developing calculi
occurs, urine is retained above
1. Strictures
the point of obstruction
2. Prostatitic hypertrophy
1. Hydrostatic pressure
3. Neoplasms
builds causing dialation of
4. Congenital malformations
the organs above the
5. History of calculi
obstruction
6. Family history of calculi
2. If hydrostatic pressure
continues to build,
hydrohnephosis develops,
and it can lead to renal
failure

Urinary tract Obstruction

Analysis

Plans

A. Acute pain related to

B. Imparied urinary elimination related to.
C. Deficient knowedge related to

A. Administer antibiotics specific to

infectious agent
B. Instruct client in the appririate
medication regimen
C. Encourage fluid intake of 3000 ml of
fluid/day
D. Maintain I/O
E. Administer mild analgesics
(phenazopyridine (pyridium),
acetaminophen, or aspirin)
F. Encourage clint to void every 2 to 3
hours to prevent residual urine
from Stagnating in bladder
G. Develop and implement a teaching
plan
1. Take entire presciption as
directed
2. Consume oral fluids up to
3L/day (water juices)
3. Shower rather than bathe as a
preventive measure. If
bathing is necessary, never
take a bubble or oil bath and
avoid feminine hygine sprays
4. Cleans from the front to the
back after toileting (women
and girls)
5. Avoid cavvine
6. Void immediately after
intercourse (women)
7. Void every 2 to 3 hours during
the day
8. Wear cotton undergarments
and loose clothing to help
decrease perineal moisture
9. Practice good handwashing
technique
10. Obtain follow up care

Analysis

Plans

A. Acute pain related to

B. Risk for infection related to
C. Risk for injury related to

A. Administer narcotic analgesics

B. Apply moist heat to the painful area
unless prescribed otherwise
C. Encourage high oral fluid itake to
help dislodge the stone
D. Administer intravenous (IV)
antibiotics if infection is present
E. Strain all urine
F. Send any stones found when
straining to the laboratory for
analysis
G. Accurately document I & O
H. Enedourologic procedures
1. Cystoscopy
2. Cystolitholapraxy
3. Ureteroscopy
4. Percutaneous nepholitotomy
I. Lithotripsy
1. Ultrasonic
2. Electrohydraulic
3. Laser
4. Extracorporeal shock wave
J. Surgical therapy
1. Nepholitotomy
2. Pyelothitomy
3. Ureterolitotomy
4. Cystomy
K. Develop and implement a teaching
plan to include:
1. Persue follow up care,
because stones tend to recur
2. Maintain a high fluid intake of
3 to 4 L/day
3. Follow prescribed diet (based
on composition of stone)
4. Avoid long periods of
remaining in supine position.

Pathophysiology

Assessment

Analysis

Plans

Benign Prostatic
Hyperplasia (BPH)

A. Increased frequency of voiding with a

decrease in amount of each voiding
B. Nocturia
C. Hesitancy
D. Terminal dribbling
E. Decrease in size and force of stream
F. Acute urinary retention
G. Bladder distention

A. Chronic pain related to

B. Risk for injury: hemorrhage related to
C. Risk for injury: infection related to

A. Preoperative teaching: include

information concerning pain from
bladder spasms occuring post
operatively.
B. Maintain patent urinary drainage
system (large three way indwelling
cathter with a 30 ml baloon) to
decrease the spasms.
C. Provide pain relief as prescibed:
analgesics, narcotics, and
antispasmodics
D. Minimize cathter manipulation by
taping cathter to abdomen or leg
E. Maintain gentle traction on urinary
cathter
F. Check the urinary drainage system
for clots
G. Irrigate bladder as prescribed (may
be continous or rarely
intermittent). If continuous, keep
foley bag emptied to avoid
retrograde pressure
H. Observe the color and content of
urinary output
1. Normal drainage after

Enlargement or hypertrophy of the

prostate (sometimes called
hypertrophy of the prostate)
A. BPH tends to occur in men over
40 years of age
B. Intervention is required when
sympoms of obstruction occur
C. The most common treatment is
transurethral resection of the
prostate gland (TURP). The
prostate is removed by
endoscopy (no surgical incision is
made), allowing for a shorter
hospital stay.

Study guides and Miscellaneous crap Page 5

Hints
The dkey to resolving UTIs with most antibiotis is to
keep the blood level of the antibiotic constant. It is
important to tell the client to take the antibiotics
aroudn the clock and not to skip doses so that a
consistent blood level can be maintained for
optimal effectiveness.

Hints
Location of the pain can help to determine the
location of the stone
Flank pain usually means the stone is in the kidney
or upper ureter. If the pain radiates to the
abdomen or scrotum, the stone is likely to be in the
ureter or bladder.
Excruciating spastic type pain is called colic
During kidney stone attacks it is preferrable to
administer pain medications at regularly scheduled
intervals rather than PRN to prevent spasm and
optimize comfort.
Percutaneous nephrostomy: a needle or cather is
inserted through th e skin into the calyx of the
kidney the stone may be dissolved by percutaneous
irrigation with a liquid that dissolves the stone or by
ultrasonic sound waves (lithotripsy) that can be
directed through the needle or cathter to break up
the ston, which can then be eliminated through the
urinary tract.

Hints
Bladder spasms frequently occur after TURP. Inform
the client that the presence of the oversized baloon
on the catheeer (30 to 45 ml inflated) will cause
continuous fleeing of needing to void. The client
should not try to void around the cathter because
this can preceptiate bladder spasms. Medications
to reduce or prevent spasms should be given.
Instillation of hypertonic or hypotonic solution into
a body cavity will cause a shift in cellular fluid. Use
only sterile saline for bladder irrigation after TURP
because the irrigation must be isotonic to prevent
fluid and electolyte imbalance.

Inform the client prior to discharge that some

bleeding is expected after TURP. Large amoutns of
blood or frank bright bleeding should be reported.
However, it is normal for the client to pass small
amounts of blood as well as small clots during the
healing process. He should rest quietly and
continue drinking large amounts of fluid.

1. Normal drainage after

prostate surgery is reddish
pink clearing to light pink
within 24 hours after surgery.
Some small to medium sized
blood clots may be present
2. Monitor for bright red
bleeding with large clots and
increased viscosity
I. Monitor vital signs frequently for
indication of circulatory collapse
J. Monitor hemoglobin (HgB) and
hematocrit (HCt) for pattern of
decreasing values that indicates
bleeding.
K. After cathter is removed:
1. Monitor amount and number
of times client voids
2. Encourage fluids
3. Have client use urine cups to
provide a specimen with each
voiding
4. Observe for hematuria after
each voiding (urine should
progress to clear yellow color
by the fourth day).
5. Inform client that buring on
urinarion and urinary
frequency are usually
experienced during first
posoperative week.
6. Generally the client is not
improtent after surgery, but
sterility may occur
7. Instruct the client to report
andy frank bleeding to
physician immediately
L. Instruct client to increase fluid
intake to 3000 ml/day
M. Prepare client for discharge with
instruction to:
1. Continue to drink 12 to 14
glasses of water a day
2. Avoid constipation staining
3. Avoid strenuous activity,
lifting intercourse and
engaging in sports duing the
first 3 - 4 weeks after surgery
4. Schedule follow up
appointment

Cardiovascular System
Pathophysiology

Assessment

Analysis

A. Pain
A. Acute pain related to
1. Mild to severe intensity, described as B. Anxiety related to
Chest discomfort or pain that occurs
heavy, squeezing pressing, burning,
when myocardial O2 demand exceeds
choking, aching, and feeling of
supply
apprehension.
Common Causes
2. Substernal, Radiating to left arm and/
A. Atherosclerotic heart disease
or shoulder, jaw, right shoulder
B. Hypertension
3. Transient or prolonged, with gradual
C. Coronary artery spasm
or sudden onset; typically of short
D. Hypertrophic cardiomyopathy
duration
4. Often preciptiated by exercise,
exposure to cold, a heavy meal,
mental tension, sexual intercourse
5. Relieved by rest and/or nitroglycerin
B. Dyspnea, tachycardia, palpitations
C. Nausea, vomiting
D. Fatigue
E. Diaphoresis, pallor, weakness
F. Syncope
G. Dysrhymias
H. Diagnostic information
1. ECG: is generally at client baseline
unless taken during anginal attack,
when ST segment depression and T
wave inversion may occur
2. Exercise stress test: shows ST segment
depression and hypotension
3. Stress echocardiogram: looks for
changes in wall motion (indicated in
women)
4. Coronary angiogram: detects coronary
artery spasms
5. Cardiac cathterization: detects arterial
blockage
I. Risk factors
1. Nonmodifiable
a. Heridity
b. Gender: Male > Female until
menopause, then equal risk
c. Ethic background: african
americans
d. Age
2. Modifiable
a. Hyperlipidemia
b. Total serum cholesterol above
300 mg/dl: four times greater
risk for developeing coronary
artery disease (CAD) than those
with levels less than 200 mg/dl
(desirable level)
c. Low density lipoprotein (LDL)
bad cholesterol: a molecule of
LDL is approximately 50%
cholestrol by weight (< 100
mg/dl desirable)

Angina

Study guides and Miscellaneous crap Page 6

Plans
A. Monitor medications, and instruct
client in proper administration
B. Determine factors precipitating
pain, and assit client and family in
adjusting lifestyle to decrease these
risk factors
C. Teach risk factors, and identify
client's own risk factors
D. During an attack
1. Provide immediate rest
2. Take vital signs
3. Record and ECG
4. Administer no more than
three nitroglycerin tablets 5
minutes apart
5. Seek emergency treatment if
no relief has occurred after
taking nitroglycerin
E. Physical activity
1. Teach avoidance of idometric
activity
2. Implement an exercise
program
3. Teach that sexual activity may
be resumed after exercise is
tolerated, usually when able
to climb two flights of stairs
withotu excretion.
Nitroglycerin can be taken
prophylactically before
intercourse.
F. Provide nutitional information
about modifying fats (satruated)
and sodium) antilipemic
medications may be prescibed to
lower cholesterol elvels
G. Medical interventions include
1. Percutaneous transluminal
coronary angioplasty (PTCA).
A baloon cathter is repeatedly
inflated to split or fracture
plaque and the arterial wall is
stretched, enlarging the
diameter of the vessel. A
rotoblade is used to pulverize
plaque.
2. Arthrectomy: a catheter with
a collection chamber is used
to remove plaque that is
trapped in the chamber
3. Coronary artery bypass graft
(CABG)
4. Coronary laser therapy
5. Coronary stent

Hints
What is the relationship of the kidneys to the
cardiovascular system?
The kidneys filter about 1 L of blood per minute
If the cardiac output is decreased, the amount of
blood going through the kidneys is decreased;
urinary output is decreased. Therefore, a decreased
urinary output may be a sign of cardiac problems.
When the kidney produce and excrete 0.5 ml of
urine/kg of body weight or average 30 ml/hr
output, the blood supply is considered to be
minmially adeuqate to perfuse the vital organs.

mg/dl desirable)
d. High density lipoprotein (HDL)
Good cholesterol: HDL is
inversely related to the risk for
developing Cad (> 60 mg/dl is
desirable). In fact, HDL may
serve to remove cholesterol
from tissues
e. Hypertension
f. Cigarette smoking
g. Obesity
h. Physical inactivity
i. Diabetes mellitus
j. Stress
Pathophysiology

Analysis

Plans

A. Sudden onset of pain in the lower sternal

region (substernal)
Distruption in or deficiency of coronay
1. Severity increases until it becomes
artery blood dupply resulting in
nearly unbearable.
necrosis of myocardial tissue.
2. Heavy and viselike pain often radiates
Causes of MI
to the shoulders and down the arms
A. Thrombus or clotting
and/or the neck and jaw. Common
B. Shock of hemorrhage
lcoations for pain are substernal,
retrosternal, or epigastric areas.
Women may also present with
shortness of breath or fatigue.
3. It differs from angina pain in its
sudden onset
4. Pain is not relieved by rest
5. Pain may persist by nitroglycerin
6. Pain may persist for hours or days
7. Client may not have pain (silent MI)
especially those with diabetic
neuropathy.
B. Rapid irregular, and feeble pulse
C. Decreased level of consciousness indicating
increased cerebral perfusion.
D. Left heart shift sometimes occurring Post MI
E. Cardiac dysrhymias, occuring in about 90%
of MI clients
F. Cardiogenic shock or fluid retention
G. Serum cardiac markers
1. Creatine kinase (CK) intracellular
enzymes that are relased into
circulation after an MI
a. Rise 3 to 12 hours after an MI
b. Peak in 24 hours
c. Return to nromal within 2 to 3
days
2. Ck MB band is specific to myocardial
cells and can help quantify myocardial
damage
3. Cardiac specific troponin is a
myocardial muscle protein released
into circulation after MI injury with
creaster sensitivvity and specificty for
myocardial injury than Ck MB.
a. Cardiac specific troponin T
(cTnT) and caridac specific
troponin I (CtnI)
b. Increase 3 to 12 hours after the
onset of MI
c. Peak at 24 to 48 horus
d. Return to basline over5 to 14
days
H. Narrowed pulse pressure eg. 90/80 mmgh
I. Bowel sounds are absent or high pitched
indicating possibelity of mesenteric artery
thrombosis which acts as an intestinal
obstruction
J. Heart failure indicated by wet heart sounds
K. eCG changes occur as early as 2 hours post
MI or as late as 72 horus post MI

Assessment

A. Ineffective tissue perfusion (speficy type)

rlelated to
B. Decreased cardiac output related to
C. Activity intolerance related to
D. Acute pain related to

A. Administer medications as
prescribed
1. For pain and increase O2
perfusion, IV morphine
sulfate (acts as a peripheral
vasodilatior and decreases
venous return)
2. Other medication foten
prescibed include
a. Nitrites (e.g.
nitroglycerine)
b. Beta blockers
c. Calcium channel
blockers
d. Aspirin
e. Antiplatelt aggregates
B. Obtain vital signs including ECG,
rhythm strip
C. Administer O2 at 2 to 6 L per nasal
cannula
D. Obtain cardiac enzymes as
prescibed
E. Provide a quiet, restuful
envionment
F. Assess breath sounds for rales
(indicating pulmonary edema)
G. Maintain patent IV lin for
adminsitration of emergenc
medications
H. Monitor fluid balance
I. Keep in semil fowler postiition to
assit with rbeathing
J. Maintain bed rest for 24 hours
K. Encourage the client to resume
activity tradually
L. Encourage verbalization of fears
M. Provide infromation about the
disease process and cardiac
rehabiltiation
N. Consider edical interventions
1. Thrombolytic agents within 1
to 4 horus of Mi
2. Intraaortic baloon pump
(IABP) to improve perfusion)

Pathophysiology

Analysis

Myocardial infarction:

Assessment

A. BP equal to or greater than 140/90 mm HG A. Deficient knowldege rlelated to

on two sepserate occasions
B. Noncomplicance related to
Persistent seated BP levels equal to or
1. Obtain BP while client is lying down, C. Ineffective tissue perfusion (speficy tpe
greater than 140/90 mmhg
sitting and standing.
A. Essential (primary) hypertension
2. Compare reqdings taken lying down,
has no known cause
sitting and standing. A difference of
B. Second hypertension develops in
more than 10 mm HG of either
response to an identifiable
systolic or diastolic indicates postural
mechansim
hypotension.T ake pressure in both
arma.
B. Genetic risk factors (nonmodifiable)
1. Positive family history for
hypertension
2. Gender (men have a greater risk fo
being hypertensive at an earlier age
than women)
3. Age (risk increases with increasing
age).
4. Ethnicity (african americans are at
greater risk than whites)
C. Lifestyle habits that increase risk for
becoming hypertensive (modifiable)
1. Use of alcohol, tobacco and caffine
2. Sedentary lifestyle, obesity
3. Nutition history of high salt and fat
intake
4. Use of oral contraceptoves or
estrogens
5. Stress
D. Associated phyiscal problems
1. Renal failure
2. Respiratory problems, especially
COPD

Hypertension

Study guides and Miscellaneous crap Page 7

Plans
A. Develop a teaching plan to Include:
1. Information about diease
process
a. Risk factors
b. Causes
c. Long term
complications
d. Lifestyle modifications
e. Relationship of
treamtnt to prevention
of complication
2. Information about a
treatement plan
a. How to take own Bp
b. Reasons for each
medication
c. How and why to teach
each medication
d. Necessity of consistency
in medication regimen
e. Need for ongoing
assessment while taking
antihypertensives
f. Need to moniotr serum
electrolytes every 90 to
120 days for a duration
of treatment
g. Need to monitor renal
functioning (BUN and
creatinine) every 90 to
120 days for duration of
treatment
h. Need to monitor BP and

Hints
Angina is caused by myocardial ischemia. Which
cardiac medications would be appropriate for acute
angina?
Digoxin: no appropriate; increases the strength and
contractility of the heart muscle; the problem in
agina is that the msucle is not receiving enough O2.
digoxin will not help
Nitroglycerin: appropriate; cause sdialatin of the
coronary arteris, allows more O2 to get the heart
muscle.
Atropiene: not appropirate; increasesheart rate by
blockign vagal stimulation, which suppresses the
heart rate; does not address the lask of O2 to get
the heart msucle.
Atropine: not approiate increase heart rate by
blocking vagal stimulation, which suppresses the
heeart rate; does not address address the lack of
O2 the heart rate muscle.
Proproranolol (inderal) not appropriate for acute
agina attack; however it aporpiate for long term
management of stabe angina because it acts as a
beta blocker to control vasoconstriction.

Hints
Blood pressure is creasted by the difference in the
pressure of the blood as it leaves the ehart and the
resistance it meets flowing out to the tissue.
Therefore, any factor that alters cardiac output or
pheripheral vascualar resistance will alter blood
pressure. Diet and exercise, smoking cesssation,
weight control and stress management can control
many factors that influence the resistance blood
meats as it flows from the heart.
Remember that the reisk factors for hypertention
are: heridity, race, age, alcohol abuse, increased
salt intake, obesity and use of oral contracptives.
The number one cause of a stroke in hypertensive
clients ins noncomplicance with medication
regimen. Hypertension is often sympomless and
antihypertensive medications are expensive and
have side effects. Studies have shown that the
more clients know about their antihypertensive
medications, the more likley they are to take them;
teaching is important!

COPD
3. Cardiac problems especially valvular
disorders
E. Pharmacologic history
1. Steroids (increase BP)
2. Estrogens (increase BP)
F. Assess for headache, edema, noturia,
noesbleeds, and vision changes (may be
asympommtic)
G. Assess levels of stress and source of stress
(rleated t0 job, economics, family)
H. Assess personality type (ie. Determine
whether clidnt exhibits type A behavior).

h. Need to monitor BP and

pulse rate usually
weekly
B. Encourage client to implement
nonpharmacologic measures to
assist with BP control, such as:
1. Stress reduction
2. Weight loss
3. Tobacco cessation
4. Exercise
C. Determine medication side effects
expierienced by client
1. Impotence
2. Insomnia
D. Provide nutition guidance, inclduing
a sample meal plan and how to dine
out (low salt, low fat, low
cholesterol diet).

Pathophysiology

Assessment

Analysis

Plans

Peripheral vascular
Disease (PVD)

A. The signs, symptoms and treatment of PVD

can vary widely, depending on the source of
pathology. Therefore careful assessment is
very important.
B. Predisposing factors
1. Arterial
a. Arteriosclerosis (95% of all cases
are caused by atherosclerosis)
b. Advanced age
2. Venous
a. History of deep vein thrombosis
(DVT)
b. Valvular incompetence
C. Associated diseases
1. Arterial
a. Raynaud disease
(nonatherosclerotic, triggered
by extreme heat or cold)
b. Buerger disease (occlusive
inflammatory disease, strongly
associated with smoking0
c. Diabetes
d. Acute occlusion
(emboli/thrombi)
2. Venous
a. Varicose veins
b. Thrombophlebitis
c. Venous statsis ulcers
D. Skin
1. Arterial
a. Smooth skin
b. Shiny skin
c. Losss of hair
d. Thickened nails
2. Venous
a. Brown pigment around ankles
E. Color
1. Arterial
a. Pallor on elevation
b. Rubor when dependent
2. Venous -- cyanotic when dependent
F. Temperature
1. Arterial
a. Cool
2. Venous
a. Warm
G. Pulses
1. Arterial
a. Decreased or absent
2. Venous
a. Normal
H. Pain
1. Arterial
a. Aharp
b. Increases with alsking and
elevation
c. Intermittent Claudication:
classic presenting sympom;
occurs in skeletal muscles
during exercise, is relieved by
rest
d. Rest pain: occurs when the
Extremities are horizontal; may
be relieved by dependent
position; often appears when
collateral circulation fails to
develop
2. Venous
a. Persistent, aching, full feeling,
dull sensation
b. Releived when horizontal
(elevate and use compression
stockings)
I. Ulcers
1. Arterial
a. Very painful
b. Occur on lateral lower legs,
toes, heels
c. Demarcated edges
d. Necrotic
e. Not edmatous
2. Vneous
a. Slightly painful
b. Occur on medial legs, ankles
c. Uneven edges
d. Superficial
e. Marked edema

A. Ineffective tissue perfusion

B. Activity intolerance related to
C. Impaired skin integrity related to
D. Risk for infection related to
E. Acute pain related to

Treatment:
A. Noninvasive treatments
1. Arterial
a. Eliminiation fo smoking
b. Topical antibiotic
c. Saline dressing
d. Bed rest, immoblization
e. Fibrinolytic agents if
clots are the problem
(not used for Raynaud
ro Buerger disease)
2. Venous
a. Systemic antibiotics
b. Compression dressing
(snug) or alignate
dressing if ulcerated
c. Limb elevation
d. For thrombosis:
fibrinolytic agents and
anticoagulants
B. Surgery
1. Arterial
a. Embolectomy: removal
of clot
b. Endarterectomy:
removal of clot and
stripping of plaque
c. Arterial bypass: teflon
or dracon graft or
autograft
d. Percutaneous
transluminal
angioplasty (PTA):
compression of plaque
e. Amputation: removal of
extremity
2. Venous
a. Vein ligation
Thrombectomy
b. Debridement

Circulatory problems that can be due

to arterial or venous pathology.

Study guides and Miscellaneous crap Page 8

Nursing plans and interventions

A. Monitor extremities at designated
intervals
1. Color
2. Temperature
3. Sensation and pulse quality in
extremities
B. Schedule activities within client's
toldrance level
C. Encourage rest at the first sign of
pain
D. Encourage client to keep
extremities elevated (if venous)
when sitting and to change proition
often.
E. Encourage client to avoid crossing
legs and wear nonrestrictive
clothing.
F. Encoruage client to keep
extremities warm by wearing extra
clothing, such as socka and slippers
and not to use external heat souces
such as electric heating pads
G. Teach methods of preventing
further injury
1. Change position frequently
2. Wear nonrestrictive clothing
(no knee high hose)
3. Avoid crossing legs or keeping
legs in a dependent position
4. Wear support hose or
antiembolism stockings
5. Wear shoes when ambulating
6. Obtain porper foot and nail
care
H. Discourage cigarette smoking
(causes vasoconstriction and spasm
of the arteries)
I. Provide preoperative ans
postoperative care if surgery is
reuqired
1. Prepoperative: maintain
affective extremity in a level
position if venous) or in a
slightly dependent position (if
arterial; 15 degrees), at room
temperature, and protect
from trauma

Hints
Decreased blood flow results in diminished
sensation in the lower extremities. Any heat source
can cause severe burns before the client realizes
the damage is being done

from trauma
2. Postoperative; assess surgical
site frequantly for
hemohhage, and check
peripheral puslses
3. Anticoagulants may be
continued after surgery to
prevent thrombus at the
initiating site
Pathophysiology

Assessment

A. Bruit (swooshing sound heard over a

constricted artery when auscultated) heard
over abdominal aorta, pulsation in upper
Dialation of the abdominal aorta
abdomen
caused by an alteration in the integrity B. Abdominal or lower back pain
of its wall
C. Abdominal radiograph(aortogram,
A. the most common cause of AAA
angiogram, abdominal ultrasound) to
is atherosclerosis. It is a late
confirm diagnosis if andurism is clacified.
manifestation of syphilis.
D. Symptoms of rupture; hypovolemic or
B. Without treatment, rupture and
fardiogenic shock with sudden severe
death will occur
abdominal pain.
C. AAA is often asymptomatic
D. The most common sympotom is
abdominal pain or low back pain,
with the complaitn that the
client can feel his or her heart
beating.
E. Those taking antihgypertensive
drugs are at risk for developing
AAA.

Abdominal aortic
aneurysm (AAA)

Pathophysiology

Assessment

A. Calf painif calf is involved, positive Homan

sign (noted: only about 10% of cleints with
Inflammation of the venous walls with
phlebitis manifest this sign, and there are a
the formation of a clot; also known as
lot of false positives)
venous thrombosis,
B. Functional impirment of extremity
phelebothrombosis, DVT.
C. Edema and warmth in extremity
D. Asymmetry
1. Inspect legs from groin to feet
2. Measure diameters of calves
E. Tender areas on affected extremity with
very gentle palpation
F. Occlusion with diagnostic testing
1. Venogram
2. Doppler ultrasound
3. Fibrinogen scanning
G. Risk factors
1. Prolonged strict bed rest
2. General surgery
3. Leg trauma
4. Previous venous insufficiency
5. Obseity
6. Oral contraceptives
7. Pregnancy
8. Malignancy

Thrombophlebitis

Analysis

Plans

A. Activity intoleracne related to

B. Impaired skin integrity related to
C. Anxiety related to

A. Assess all peripheral pusles and vital

signs regulraly
1. Radial
2. Femoral
3. Popliteal
4. Posterior tibial
5. Dorsalis pedis
B. Observe for signs of occlusion after
graft.
1. Change in pulses
2. Severe pain
3. Cool to cold extremities
below graft
4. White or blue extremities
C. Observe renal functioning for signs
of kidney damage (artery clamped
during surgery may result in kidney
damage).
1. Output of less than 30 ml/hr
2. Amber urine
3. Elevated BUN and creatinine
(early signs of renal failure)
D. Observe for postoperative ileus
1. Nasogastric (NG) tube to low
continuous suction for 1 to 2
days postoperative (may help
to prevent ileus)
2. Bowel sounds checked every
shift.

Analysis

Plans

A. Acute pain related to

B. Ineffective tissue perfusion related to...

A. Administer anticoagulat therapy as

prescibed
1. Oberve for side effects
especially bleeding
2. Teach client side effects of
medication included in
teaching regimen.
3. Monitor laboratory data to
determine the efficacy of
medication insluced in
treatment regimen.
4. Note on all lab requrests that
client is receiving
anticoagulants.
5. Partial thromboplastin time
(PTT) determins efficacy of
heaprin.
6. Prothrombin time
(PT)/international normalized
ration determins efficacy of
coumadin.
7. Maintain pressure on
venipuncture sites to
minimize hematoma
formation.
8. Notify physician of any
unusual bleeding
a. Abnormal vagninal
bleeding
b. Nosebleeds
c. Melena
d. Hematuria
e. Gums
f. Hemoptysis
9. Advise client ot use soft
toothbrush, floss with waxed
floss.
10. Advise client to wear medical
alert symbol.
11. Advise client to avoid
alcoholic beverages.
12. Advise client to avoid safety
razors if taking coumadin.
13. Advise client to avoid safety
razors if taking coumadin.
B. Advise client to wear antiembolic
stockings and to elevate extremity
and use shock blocks at foot of
bed. .
C. Advise bed rest; strict if presribed,,
means no bathroom privledges!
Advise client to avoid straining.
D. Monitor for decreasing
symptomatology
1. Pain
2. Edema
E. Monitor for pulmonary embolus
(chest pian, shortness of breath).
F. Teach the client that there

Pathophysiology

Assessment

Analysis

Plans

Dysrhymias

A. Change in the pulse rate or rhythm

1. Tachycardia: fast rates (> 100 bpm)
2. Bradycardia: slow rates (< 60 bpm)
3. Irregular rhythm
4. Pulselessless
B. ECG changes

A. Ineffective tissue perfusion related to

B. Activity intolerance rleated to...

A. Determine medications client is

currently taking
B. Determine seum drug levels,
especially digitalis.
C. Determine serum electrolyte levels,
especially K+ and Mg++

Disturbance in heart rate or heart

rhythm
A. Dysrhythmias are caused by a
disturbance in the electrical
conduction of the heart, not by

Study guides and Miscellaneous crap Page 9

Hints
A client is admitted with severe chest pain and
states that he feels a terrible tearing sensation in
his chest. He is idagnosed with a dissecting aortic
aneurysm.. What assessments should the nurse
obtain in the first few hours
Vital sighs every your
Neurologica vital signs
Respiratory status
Urinary output
Peripheral pulses
During aortic aneurysm repari, the large arteries are
clamped for a peiod of time, and kindey damge can
result. Monitor daily BUN and creatinine levels.
Normal BUN is 10 to 20 mg/dl, and normal
creatinine is 0.6 to 1.2 mg/dl. The ratio of BUN to
crreatinine is 20:1. When this rratio increases or
decreases, suspect renal problems.

Hints
A positive Homa sign is considered an early
indication of thombophlebitis. However, it may also
indicate muscle inflammation. If a DVT has been
confirmed, a homan sign should not be elicited
because of an increased risk of embolism.
Heparin prevents conversion of fibrinogen to fibrin
and prothrombin to thrombin, therby inhibiting clot
formation. Because the clotting mechnism is
prolonged do not cause tissue, trauma which may
lead to bleeding when giving heparin
subcutaneously . Do not massage area or aspirate;
give in the abdomen between the pelvic bones. 2
inches from the umbilicus rotate sites.
Anticoagulants
Heparin
Antagonist; protamine sulfate
Lab: PTT or APTT determines efficacy
Keep 1.5 to 2.5 times normal control
Warfarin
Antagonist: vitamin K
Lab: PT determines efficacy
Keep 1.5 to 2.5 times normal control
INR (international normalized ration);
desirable therapuetic level usually 2 to
3 seconds (reflects how long it takes to
a blood sample to clot)

Hints
A holdter monitor offers continuous observation of
the client's heart rate. To make assessment of the
rhytm strips most meaningful, teach the client ot
keep a record of:
Medication times and doses
Chest pain episodes: types and duration

conduction of the heart, not by

abnormal heart structure.
B. Client is often asymptomatic
until cardiac output is altered
C. Common causes of dysrhymias
1. Drugs (e.g., digoxin,
quinidine, caffeine,
nicotine, alcohol)
2. Acid base and electrolyte
imbalances (potassium,
clacium and magnesium)
3. Marked thermal changes
4. Disease and trauma
5. Stress

B. ECG changes
C. Complaints of:
1. Palpitations
2. Syncope
3. Pain
4. Dyspnea
D. Diaphoresis
E. Hypotension
F. Electrolyte imbalance
Selected Dysrhymias
A. Atrial fibrillation
1. Description
a. Chaotic activity in the AV node
b. No true P wave visable
c. Irregular ventricular rhythm
2. Assessment and treatment
a. Anticoagulant therapy due to
risk for stroke
b. Antidysrhymic drugs
c. Cardioversion to treat atrial
dysrhymiax
B. Atrial flutter
1. Description
a. Saw tooth waveform
b. Fluttering in chest
c. Ventricular rhythm states
regular
2. Assessment and treatment
a. Cardioversion to treat atrial
dysrhymias
b. Antidysrhmic drugs
c. Radiofrequency cathter ablation
C. Ventricular tachycardia
1. Description
a. Wide bizzar QRS
2. Assessment and treatment
a. Pulse
b. Impaired cardiac output
c. Synchonized cardioversion if
pulse present (if no pulse, treat
as ventricular fibrillation)
d. Antidysrhmic Drugs
D. Ventircular fibrillation
1. Description
a. Cardiac emergency
b. Irregular undulation of varying
amplitudes, from coarse to fine
c. No cardiac output
2. Assessment and treatment
a. CPR
b. Defibrillation as quickly as
possible
c. Antidysrhmic drugs

especially K+ and Mg++

D. Obtain ECG reading on admission
and monitor continuously
E. Aporpach client in a calm,
reassuring manner
F. Monitor client's alctivity,a nd
observe for any sympoms occuring
during activity
G. Ensure proprier administration of
medications and monitor for side
effects
H. Be prepared for emergency
measures such as cardioversion or
defibrillation
I. Be prepared for pacemaker insrtion
1. Temporary pacemaker; used
temporarily in emergency
situations. A pacing wire is
trheaded into the right
ventricle via the superior vena
cava, or an epicardial wire is
put in place (through the
client's chest incision) during
cardiac surgery.
2. Permanent internal
pacemaker with pulse
generator implanted in the
abdomen or shoulder; may be
single or dusal chambered.
Programmable pacemakers
can be reprogrammed by
placing a magnetic device
over the generator.
3. Instruct the client to:
a. Reprot pulse rate lower
than the set rate of the
pacemaker.
b. Avoid leaning over an
automobile with the
engine running
c. Stand 4 to 5 feet away
from electromagnetic
sources, such as
operating microwave
ovens and radar
detectors that are
operating
d. Avoid MRI diagnostic
testing
J. Recognize and treat premature
ventricular contractions (PVCs) as
prescribed (they tend to be
precursors of ventircular
tachycardia and ventricular
fibrillation. A pVC is a contraction
originating in an ectopic focus in the
ventiricles. It is the premature
occurance of a QRS complex that is
wide and distorted in shape.
1. If they occur more often than
once in 10 beats
2. If they occur in groups of tw
or three
3. If they occur near the T wave
4. If they take on multiple
configurations

Pathophysiology

Assessment

Analysis

Plans

Heart Failure

A. Observe for symptoms associated with leftsided or right sided failure

1. Left sided heart failure: pulmonary
edema (left ventricular failure)
a. Description: results in
pulmonary congestion duet ot
the inability of the left ventricle
to pump blood to the periphery
b. Symptoms
i. Dyspnea
ii. Orthopnia
iii. Wet lung sounds
iv. Cough
v. Fatigue
vi. Tachycardia
vii. Anxiety
viii. Restlessness
ix. Confusion
2. Right sided heart failure: peripheral
edema (right ventricular failure)
a. Description: Results in
peripheral congestion due to
the inability of the right
ventircle to pump blood out the
lungs; often results from left
sided failure or pulmoanry
disease
b. Symptoms
i. Peripheral edema
ii. Weight gain
iii. Distended neck veins
iv. Anorexia, nausea
v. Nocturia
vi. Weakness
B. Enlargement of ventricles as indicated by
chest radiograph

A. Decreased cardiac output related to

B. Impaired urinary elimination relted to
C. Activity intolerance related to
D. Anxiety related to
E. Ineffective tissue perfusion related to

A. Monitor vital signs at least every 4

hours for changes
B. Monitor apical hear rate with vital
signs to decrease dysrhymias, S3 or
S4.
C. Assess for hypoxia
1. Srestlessness
2. Tachycardia
3. Angina
D. Auscultate lungs for indication of
pulmonary edema (wet sounds or
crackles).
E. Administer O2 as needed
F. Elevated head of bed to assit with
breathing
G. Observe for signs of edema
1. Weight daily
2. Monitor I & O
3. Measure abdominal girth,
observe ankles and fingers
H. Limit sodium intake
I. Elevate lower extremities while
sittings
J. Check apical rate prior to
administration of digitalis; withold
medication and call phsyician if rate
is < 60 bpm
K. Administer diuretic in the morning if
possible
L. Provide periods of rest after prieods
of activity.

Inability of the heart to pump enouch

blood to meet the tissue's O2
demands.
A. Primary underlying conditions
causing HF:
1. Ischemic heart disease
2. MI
3. Cardiomyopathy
4. Valvular heart disease
5. Hypertension

Pathophysiology

Assessment

Analysis

Plans

Inflammatory and
infectious heart disease

A. Endocarditis
1. Fever
2. Chills, malaise, night sweats, fatigue

A. Decreased cardiac output rleated to

B. Risk for injury: emboli related to

A. Endocarditis
1. Monitor hemodynamic status
(vital signs, level of

Inflammation and infectious process

Study guides and Miscellaneous crap Page 10

Chest pain episodes: types and duration

Valsalva maneuver (straining at stool,
sneezing, coughing)
Sexual activity
Exercise and other activities
Cardioversion is the delivery of synchonized
electrical shocks to the myocardium
Differnce in synchonous and sasynchonous
pacemakers:
Synchonous or demand: pacemaker ires only
when the client's heart rate falls below a rate
set on the generator.
Asynchonous or fixed: pacemaker fires at a
constant rate.

Hints
Restricting sodium reduces salt and water
retention, therby reducing vascular volume and
preload.
Digitalis
Side effecto of digitalis are increased when
the client is hypokalemic
Digitalis has a negative chronotropic effect
(i.e., it slows the heart rate). Hold the digitalis
if the pulse rate is < 60 or > 120 bpm (< 90
bpm in an infant) or has markely changed
rhythm.
Bradycardia, tachycardia, and dysrhymias
may be signs of digitalis toxicity; these signs
include nausea, vomiting and headache in
adults
If withheld, consult the physician

Hints
Inefective endocarditis damage to heart valves
occurs with the growth of vegetative lesions on
valve leaflets. These lesions pose a risk for

(vital signs, level of

consciousness, urinary
otuput0
2. Administer antibitics IV for 4
to 6 weeks. The american
heart association
recommends administration
erythromycin before dental
administration of
erythromycin before dntal or
genitourinay procedures.
Clients may be instructed in IV
therapy for home health care
3. Teaches clients about
anticoagulant therapy if
prescibed
4. Encourage client to maintain
good hygiene
5. Instruct client to inform
dentist and other helath care
providers of history
B. Pericarditis
1. Provide rest and maintain
position of comfort
2. Administer analgesics and
antiinflammatory drugs

2. Chills, malaise, night sweats, fatigue

Inflammation and infectious process
3. Murmurs
involving the endocardium and
4. Symptoms of heart fialure
pericardium
5. Atrial embolization
A. Endocarditis is an inflamamtory B. Pericarditis
disease involving the inner
1. Pain: sudden, asharp, severe
surface of the heart, including
a. Substernal, radiating to the back
the valves. Organisms travel
or arm
through the blood to the heart,
b. Aggragated by coughing,
where vetations adhere to the
inhaltion deep breathing
valves surface or endocardium
c. Relieved by leaning forward
can break off and become
2. Pericardial friction rub
emboli.
3. Fever
B. Cuases of endocarditis
a. Rheumatic heart disease
b. Congenital heart disease
c. IV drug abuse
d. Cardiac surgery
e. Immunosuppression
f. Dental procedure
g. Invasive procedures
C. Pericarditis is an inflammation of
the outer lining of the ehart
D. Causes of pericarditis
1. MI
2. Trauma
3. Neoplasm
4. Connective tissue disease
5. Heart surgery
6. Idiopathic infections

Acute and subacute infective endocarditis

There are two types of infective endocarditis: aucte,
which often affects individuals with previously
normal hearts and healthy valves and caries a high
mortality rate; and subacute, which typically affects
individuals with preexisting conditions, such as
rheumatic heart diease, mitral valve prolapse, or
immunosuppression. Intravnous drug abusers are
at high risk for both acute and subacute bacterial
endocarditis. When this population develops
subacute infective endocarditis, the valves on the
right side of the heart (tricuspid and pulmonic) are
typically affected because of the introduction of
common pathogens that colonize the skin
(staphylococcus epidermis ro candida sp.) into the
venous system.
Pericarditis
The presence of a friection rub is an indication of
pericarditis (inflamamtion of the lining for the
heart). St segment elevation and T wave inversion
are also signs of pericarditis.

Pathophysiology

Assessment

Analysis

Plans

Valvular heart disease

A. Fatigue
B. Dyspnea, ortopnea
C. Hemoptysis and pulmonary edema
D. Murmurs
E. Irregular cardiac rhythm
F. angina

A. Decreased cardiac output related to..

B. Impaired gas exchange rleated to
C. Activity intolerance related to.

A. See heart failure

B. Monitor for atrial fibrillation with
thrombus formation
C. Teach the necessity for prophylactic
antibiotic therapy before any
invasive procedures, that is likely to
produce gingival or mucosal
bledding, bronchoscopy,
esophageal dialation, upper
endoscopy, colonoscopy,
sigmoidoscopy, or cystoscopy.
D. Prepare the client for surgeical
repair or relpolacement of heart
valves
E. Instruct clients receivign valve
repalcement of the need for lifelong
anticoagulat therapy to prevent
thrombus formation.

Heart valves that are unable to open

fully (stenosis) or close fully
(insufficiency or regurgitation)
A. Valve dysfunction commonly
occurs on the left side of the
heart; the mitral valve is most
commonly involved, follwed by
the aortic valve.
B. Common causes of valvular
disease
1. Rheumatoc fever
2. Congenital heart disease
3. Syphilis
4. Endocarditis
5. Hypertension
C. Prevention of rheumatic heart
disease would reduce the
incidence of valvular heart
disease.

valve leaflets. These lesions pose a risk for

embolization,e rosion or perforation of the valve
leaflets or abscesses within adjacent myocardial
tissue. Valvular stenosis or reguritation
(insufficiency), most commonly of the mitral valve,
can occur depending on the type of damage
inflicted by the lesions and can lead to sympoms of
left or rightsided heart failure.

Hints
Take prophylactic antibiotics prior to dental work.

Respiratory System Drug

therapy

Pneumonia-- Antiinfectives
Drugs

Indications

Adverse Reactions

Nursing Implications

Procaine Penicillin G (wycillin)

Benzathine penicillin (bicillin L-A)
Penicillin V (Pen Vee K)

Antiinfectives
Used primarily for gram positive infections

Allergic reactions
Anaphylaxis
Phlebitis at IV site
Diarrhea
GI distress
Superinfection

Used with caution in clients allergic to cephalosporins

Monitor for allergic reactions
Observe all clients at least 30 minutes following parenteral administration
Oral penicillin G should be taken on an empty stomach
Probenecid decreases renal excretion, therby resulting in an increased blood level of the
drug
Alters contraceptive effectiveness

Drugs

Indications

Adverse Reactions

Nursing Implications

Oxacillin Sodium
Nalficillin Sodium
Cloxacillin Soldium
Dicloxacillin Sodium

Antiinfectives
Used primarily for gram-positive infections

Allergic reactions
Anaphylaxis
Superinfections
See penecillins

Cannot be used in clients allergic to penicillin

Caution in clients allergic to cephalosporins
Monitor for superinfection (sore mouth, vaginal discharge, diarrhea, cough)
See penicillins

Drugs

Indications

Adverse Reactions

Nursing Implications

Ampicillin
Ticarcillin + Clavulanate (Timentin)
Piperacillin + Tzaobactam (Zosyn)
Ampicillin + Sulbactam (Unasyn)

Antiinfectives
Broad spectrums

Similar to penicillin
Ampicillin rash

Contraindicated to clients allergic to penicillins

See penecillins

Drugs

Indications

Adverse Reactions

Nursing Implications

Tetracycline HCL
Doxycycline Hyclate (vibramycin)

Antiinfectives

Hypersensitivity reactions
Photosensitivity

Decrease the effectiveness of oral contraceptives

Avoid concurrent use of antacids, milk products
Inspect IV siete frequently
Monitor for superinfections
Avoid exposure to sunlight during use
Avoid use in pregnant clients and children under 8 years, can cause yellow brown
discoloration of teeth and growth retardation

Drugs

Indications

Adverse Reactions

Nursing Implications

Gentamicin Sulfate
Tobramycin sulfate (nebcin)
Amikacin sulfate

Antiinfectives
Used with gram - bacteria

Hypersensitivity reactions
Photosensitivity

Monitor renal function, BUN, Cratinine and I & O

Monitor for ototoxicity: headache, dizziness, eharing loss, tinnitus
Monitor for superinfection

Drugs

Indications

Adverse Reactions

Nursing Implications

Penicillins

Semisynthetic

Antipseudomonal Penicillins and

Combinations

Tetracyclines

Aminoglycosides

Miscellaneous
Vancomycin hydrochlorids
Metronidazole (Flagyl)
Drugs

Monitor for serum drug concentrations

Flagyl-- Antabuse effect-- no alcohol.
Indications

Study guides and Miscellaneous crap Page 11

Adverse Reactions

Nursing Implications

Cephalosporins
First Generation
Cefazolin (Kefzol)
Cephalexin (Keflex)
Second generation
Cefalcor (ceclor)
Cefamandole (mandol)
Cefuroxime (Ceftin, PO, Zinacef, IV)
Cefoxitin (Mefoxin)
Third generation
Cefotaxime (Calforan)
Ceftriaxone (Rocephin)
Cefazidime (Fortaz)
Cefepime (maxipime)

Antiinfectives

Allergic reactions
Thrombophlebitis
GI distress
Superinfection

Used with caution in clients allergic to penicillin and cephalosporins

See penicillins

Drugs

Indications

Adverse Reactions

Nursing Implications

Indications

Adverse Reactions

Nursing Implications

Azactam

Pseudomonas aeruginosa + many otherwise resistant organsims

Most effective against gram negatives

Phlebitis
Pseudo membranous colitis
CNS changes
EEG changes
Headache, kiplopia
Hypotension

Monitor renal and hepatic function, especially in older adults

Carefully monitor for diarrhea
Assess motor sensory function and cardiac rhythm

Drugs

Indications

Adverse Reactions

Nursing Implications

Clarithromycin (Biaxin)
Azithromycin (Zithromax)
Erythromycin

Biaxin (PO): URI, including streptococci as adjusnt treatment for H.

Pylori
Aithromax (IV): gram negative and gram positive organisms

Pseudomembranous colitis
Phlebitis-- a vesicant
Superinfections
Dizziness
Dyspnea

Give biaxin XL with food

Space MAO inhibitors 14 days before start and after end of biaxin
Report diarrhea, abdominal cramping (all macrolides)
Monitor liver renal labs
PO zithromax: give on empty stomach

Drugs

Indications

Adverse Reactions

Nursing Implications

Ciprofloaxcin (Cipro)
Levofloacin (levaquin)
Gatiflo(Tequin)

Used to treat respiratory infections, UTI's, Skin , bone, and joint

infections
Has been used as conjunctive treatment for TB and AIDS

Superinfections
CNS disturbances
Arroyos and cataracts possibel with CIPRO
Cipro is a vesicant

Prompt onset
Crosses placenta and in breast milk
Can lower the seizure threshold
Monitor liver, renal and blood counts
Safety for children not known
Many drug-drug interactions

Drugs

Indications

Adverse Reactions

Nursing Implications

Clindamycin

Pneumocystis carinii pneummonia (PCP) in AIDS

Severe infections resistant to penicililns and cephalosporins
Used in penicillin and erythomycin sensitive clients

Agranulocytosis
Pseudomembranous colitis
superinfections

Highly toxic drug, use only when absolutely necessary

Periodic liver, renal and blodo count monitoring
Report diarrhea immediately

Drugs

Indications

Adverse Reactions

Nursing Implications

Quinupristin/dalfopristin (synercid)

Life threatening vanco resistant enterococcus (VRE)

Arthralgia, myalgia
Severe vesicant
Pseudomemrbanous colitis
Nausea/vomiting diarrhea
Rash, Puritis

Incompatible with any saline solution or heparin

Functionally related to both macrolides and lincosamides
Monitor total billirubin
Many drug -drug interactions

Drugs

Indications

Adverse Reactions

Nursing Implications

Carbapenems
Imipenem (primaxin)
Meropenem (merrem)
Ertapenem (Invaz)
Drugs

Monobactam

Macrolides

Fluroquinolones

Lincosamides

Streptogramin

Oxazolidinone
Zyvox

Life threatening VRE and Methicillin resistant staphylococcus aureus Gi disturbance

(MRSA)
Headache
Pancytopenia
Pseudomembranous colitis
Superinfections

Monitor renal and liver labs and blodo count

May exacebate hyeprtension, especially if ingests foods with tyramine
Report diarrhea immediately

Indications

Adverse Reactions

Nursing Implications

Epinephrine
Isoproterenol HCL (isuprel)
ALBUTEROL (PROVENTIL)
ISOETHARINE (BRONUMETER)
Terbutaline (brethine)
Salmetrol (serevent)
metaproterenol (inhaled) (alupent)
Levabuterol (xopenex)

Bronchodilaltor

Anxiety
Increased heart rate
Nausea, vomiting
Urinary retention

Check heart rate

Monitor for urinary retention esepcially in men over 40
Instruct poper use of inhaler
Use bonchodialator inhaler before steroid inhaler
May cause sleep disturbance

Drugs

Indications

Adverse Reactions

Nursing Implications

Aminophylline (IV)
Theophyline (PO)

Bronchodialator

Gi distress
Sleeplessness
Cardiac dysrhymias
Hyperactivity

Administer oral forms with food

Acoid food containing ceffeine
Check heart rate
Instruct use of inhaler
Monitor therapeutic range of 10 to 20 mg/ml
Cross placenta

Drugs

Indications

Adverse Reactions

Nursing Implications

Prednisone (PO)
Solu- medrol (IV)
Beclomethasone dipropionate (inhaled)
(vanceril)
Budesonide (inhaled) (pulmicort)
Fluticasone (inhaled) (flovent)
Triamcinolone (inhaled) (Azmacort)
Flunisolide (inhlaed) (Aerobid)

Antiinflammatory

Cardiac dysrhytmias occur with long term

steroid use

See endocrine disorders in medical surgical nursing

Instruct proper use of inhaler

Drugs

Indications

Adverse Reactions

Nursing Implications

Chronic Airflow limitation-Broncodialators and

Corticosteroids
Drugs

Adrenergics and sympatnomimetics

methalxanthine

Corticosteroids

Study guides and Miscellaneous crap Page 12

Drugs

Indications

Adverse Reactions

Nursing Implications

Ipratropium (atovent)

Bronchidialator
Control of rhinorrhea

Dry mouth
Blurred vision
Cough

Do not exceed 12 doses in 24 hours

Drugs

Indications

Adverse Reactions

Nursing Implications

See individual drugs

See individual drugs

See individual drugs

Mechansim of Action

Side Effects

Comments

Isoniazid (INH)

Interferes with DNA metabolism of tubercle bacillus

Nausea, vomiting, abdominal pain

Rare: neurotoxicity, optic neuritis, and
hepatotosicity

Metabolism primarily by liver and excretion by dkidneys; pyridoxine (vitamin B6)

administration during high dose therapy as prophylactic measure, use as single prohylactic
agent for active TB individuals whose PPD convers to positive; aboity to cross the blood brain
barrier

Rifampin (Rifadin)

Has broad spectrum effects inihibts RNA polymerase of tuberlce

bacillus

Hepattis, febrile retraction, GI

disturbances, peripheral neuropathy,
hypersensititiy

Used in conjunction with at least one other antitubercular agent; low incidence of side
effects; suppression of effect of birth control pills; possible orange urine

Ethambutol (myambutol

Inhibits RNA synthesis and is bacteriostatic for the tubercle bacillus

Skin rash, GI distubance, Malaise,

peripheral neuritis, optic neuroitis

Side effects uncommon and reversible with discontinuation of drug; most common use as
substitude drug when toxicity occurs with isoniazid or rifampin

Streptomycin

Inhibits protein synthesis and is bacteriacidal

Ototoxicity (eigth cranial nerve),

nephrotoxicity, hypersensitivity

Caution use in older adults-- those with renal disease and pregnant women must be given
parenterally

Pyrazinamide

Bactericidal effect (exact mechanism is unknown)

Fever, skin rash, hyperuricemia, jaundice

(rare)

High rate of effectiveness when used with streptomycin ro capreomycin

Ethionamide (trecator, SC)

Inhibits protein synthesis

Gi disturbance, hpatotoxicity,
hypersensitivity

Valuble for treatment of resistant organisms; contraindicated in pregnancy.

Capreomycin (Capastat)

Inhibits protein sytnhesis and is bactericidal

Ototoxicity, nephrotoxicity

Cautious use in older adults

Kanamycin (kantrex) and amikacin

Interferes with protein synthesis

Ototoxicity, nephrotoxicity

use in selceted cases or treatment of resistant strains

Para- aminosalycilic acid (PAS)

Interefers with metabolism of tubercle bacillis

Gi disturbance (common),
hypersensitivity, haptotoxicity

Interferes with absoption of rifampin, used uncommonly

Cycloserine (Seromycin)

Inhibits cell wall synthesis

Personality changes, psychosis, rash

Contraindicated in individualws with histories of psychosis. Used in treatments of resistant

strains.

Anticholinergics

Combination products
Sluticasone + Salmetrol (advair)
Ipatropium + albeterol (combivent)

Drug therapy For Tuberculosis

Drug

First line drugs

Second Line drugs

Renal System Drug Therapy

Drugs

Indications

Adverse Reactions

Nursing Implications

Erythopoietin (epogen)

Anemia due to decreased production of erythropoeitin in end stage

renal disease
Stimulates RBC production increases Hgb, reticulocyte count, and
HCt

Use with caution in older adults because

of increased risk for thrombosis

Monitor HCt weekly, report levels over 30% to 33% and increases of more than 4 points in
less than 2 weeks
explain that pelvic an dlimb pain should dissipate after 12 hours
do not shake vial, shaking may inactivate the glycopoeitin
Discard unused contents; does not contain preservatives

Indications

Adverse Reactions

Nursing Implications

Nitroglycerin (NTG)
Isosorbide dinitrate (isordil)
Isosobide Mononitrate (Imdur)

Anginal prophylaxis
Acute attack
Reduces vascular resistance

Headache
Flushing
Dizziness
Weakness
Hypotension
Nausea

Monitor relief
Have client rest
Monitor vital signs
Stor medicaiton in original container
Protect from light

Drugs

Indications

Adverse Reactions

Nursing Implications

Propranolol HCL (inderal)

Atenolol (Tenormin)
Nadolol (Corgard)

Antinal prophylaxis
Reduces O2 demand

Fatigue
Lethargy
Hallucinations
Impotence
Bradycardia
Hypotension
HF
Wheezes

Monitor apical heart rate

Assess for decreased BP
Do not stop medication abruptly
Clients with HF, bronchitis, asthma, COPD, or renal or hepatic insufficency have increased
lielihood of incurring adverse reactions

Drugs

Indications

Adverse Reactions

Nursing Implications

Anginal prophylaxis
Inhibits influx of caicum ions

Dizziness
Hypotension
Fatigue
Headache
Syncope
Peripheral edema
Hypokalemia
Dysrhymias
Heart Failure

Clients with heart failure and older adults have an increased likelihood of incurring adverse
reactions
Assess for decreased BP
Monitor serum potassium
Swallow pills whole
Store at room temperature
Do not stop abruptly
Take one hour before meals or two hours after meals

Indications

Adverse Reactions

Nursing Implications

Colestipol HCL (Clestid)

Colesevelam (Welchol)
Cholestyramine (Questram)

Treat type IIA hyperlipidemia (hyper cholesterolemia) when dietary

changes fail

Abdominal pain, nausea and vomiting,

distention, flatulence, belching
constipation.
Reduced absoption of lipid solube
vitamins, A, D, E, K
Alteration in absoption of other oral
medications

Teach client to mix powder forms with adeuqate amounts of liquid or fluids high in moisture
ocntent such as applesauce to prevent accidental inhilation or esophageal distress
Monitor prothombin times
Assess for visual changes and rickets
Administer other oral medications after 1 hour befroe or 6 horus after giving bile
sequestrants.

Drugs

Indications

Adverse Reactions

Nursing Implications

Side effects similar to bile sequestrants

May elevate liver enzymes
Hepatis or pancreatitis

Obtain liver enzyme baseline and monitor every 6 months

Monitor CPK levels
Review specific drug food interactions; avoid grapefruit juice

Cardiovascular System Drug

Therapy
Antianginals
Drugs

Nitrates

Beta Blockers

Calcium Channel blockers

Verapamil (Calan)
Nifedipins HCL (procardia)
Diltiazem HCl (Cardizem, Norvasc)

Antilipemic
Drugs

Bile sequesttrants

HMG- COA Reductase Inhibitors

(Statins)
Atrovastatin (lipitor)
Fluvastatin (Lescol)
Pravastatin (pravachol)

Study guides and Miscellaneous crap Page 13

 Pravastatin (pravachol)
Simvastatin (zocor)
Lovastatin (Mevacor)

Hepatis or pancreatitis
Rhabdomyolysis

Review specific drug food interactions; avoid grapefruit juice

Timing with or without food varies with drug
Instruct client to report any msucle tenderness

Indications

Adverse Reactions

Nursing Implications

Gemfibrate (lopid)
Fenofibrate (Tricor)
Clofibrate (Clariplex)

Used with diet changes to lower elevated cholesterol and

triglycerides.

Abdominal and epigastric pain, diarrhea-most common

Flatulance, nausea and vomiting
Heartburn
Dyspepsia
Gllstones
Tricor: weakness, fatigue, headache
Myopathy

Obtain baseline labs: liver function CBC and electrolytes, monitor every 3 to 6 months
Administer
Lopid 30 minutes beflre breakfast and dinner
Tricor-- with meals

Drugs

Indications

Adverse Reactions

Nursing Implications

Large doses decrease lipoprotein and triglyceride synthesis and

increases HDL

Flushing of face and neck puritis

Headache
Orthostatic hypotension
(ER form) heptotoxicity
Hyperflycemia
Hyperuricemia
Upper GI distress

Give with milk and food to avoid gi irritation

Client to hcange positions slowly
Instruct client taking extended relase (ER) form to report darkened urine, light colored
stools, anorexia , yellowing of eyes or skin, severe stomach pain.

Drugs

Fibric acid derivatives

Water soluble vitamins

Niacin (niaspan)
Nicotinic acid (Nicobid)

Fibrinolytic Agents
Drugs

Indications

Adverse Reactions

Nursing Implications

Streptokinase (Streptase) (Kabikinase)

Deep vein thrombosis

Pulmonary embolism
Arterial thombosis and embolism
Coronary thrombosis
Dissolving clots in arteriovenous cannula

Anaphylactic response ranging from

breathn gdifficulties to bronchhospasm,
periorbital swlling or angineurotic edema
Increased risk for bleeding
Hemorrhagic infarction at site of
myocardial damage
Reperfusion dysrhymias

Assess for bleeding at puncture site apply pressure to control bleeding

Assesss for allertgic reactions and dysrhymias during intracoronary perfusion
Immoblize client's leg for 24 hours after femoral coronay cannulation and perfusion; assess
pedal pulses for inadequate circulation
Monitor for clients thrombin time after therapy. Do not administer heparin or oral
anticoagulants until heparin time is less than twice that of control
Do not shake vial when reconstiuting; roll and tilt vial to genly mix

Tenecteplase (TNKase)
Reteplase

Acute management of coronary thrombosis

Do not give if history of uncontrolled

hypertension
Can cause hypotension

Obtain baseline studies prior to administration: PTT, PT, CBC fibrinogen level, renal studies,
cardiac ensymes.
Check for abnormal pulse, neuologic vital signs and presence of skin lesions which may
indicate coagulation defects
Avoid needle puncture because of the possiblity of bleeding apply pressure for 10 minutes to
venous puncture sites and for 30 mintues to arterial puncture sites, follow with pressure
dressing.
Be prepared to treat reperfusion dysrhymias

Urokinase (Abbokinase)

Pulmonary emblisim
Coronary thombosis
IV cathter clearance

Is nonantigenic and does not cause allergic Infuse heaprin and an oral anticoagulant following urokinase therapy to prevent
reactions, otherwise has the same adverse rethombosis
reactions as those cited for strepokinase
Is much more expensive than streptokinase but does not cause allergic reactions found with
streptokinase therapy
Reconstitute immediatley before use

Ateplase (activase)
Anistreplace (Eminase)

Deep vein thrombosis

Pulmonary embolism
Coronary thrombosis

Interacts with heparin oral anticoagulants

and antiplatelet drugs to increase risk for
bleeding

Alters coagulation only at the thrombus, not systemically (bleeding complications associated
with streptokinase and urokinase are reduced with t-PA therapy)
Because t-PA is a human portein allergic respons is unlikly to occur
Half life is 3 to 7 minutes; use immediately

Indications

Adverse Reactions

Nursing Implications

Chlorthilidone (hygroton)
Hydrochlorothiazide (Esidrix, microzide)
Indapramide (lozol)
Metolazone (Zaroxolyn)

To decrease fluid volume

Inexpensive
Effective
useful in severe hypertension
Effective orally
Enhances other antihypertensives

Hypokalemia symptoms include

Dry mouth
Thirst
Weakness
Drowsiness
Lethargy
Muscle aches
Tachycardia
Hyperuricemia
Glucose intolerance
Hypercholesterolemia
Sexual dysfunction

Obasrve for postural hypotension can be potentiated by :

Alcohol
Barbiturates
Narcotics
Caution with:
Renal failure
Gout
Client taking lithium
Hypokalemia increases risk for digitalis toxicity
Administer potassium supplements

Drugs

Indications

Adverse Reactions

Nursing Implications

Furosemide (lasix)
Torsemide (Demanadex)
Bumetanide (Bumex)

Rapid action
Potent for use when thiazides fail
Cause voluem depletion

Hypokalemia
Hyperuricemia
Glucose intolerance
Hypercholesterolemia
Hypertriglyceridemia
Sexual dysfunction
Weakness

Volume depletion and electrolyte depletion are rpaid

All nursing implications cited for thiazides

Drugs

Indications

Adverse Reactions

Nursing Implications

Spinolactone (Aldactone)
Amiloride (midamor)

Volume depletion without significant potassium loss

Hyperkalemia
Gynecomastia
Sexual dysfucntion

Watch for hyperkalemia and renal failure in those treated with ace inhibitors or nsAIds
Watch for increase in serum litium levels
Give after meals to decrease GI distress

Drugs

Indications

Adverse Reactions

Nursing Implications

Decreases fluid volume while minimizing K+ loss

Side effects individual drug offset or

minimized by its partner

Caution client previously on a loop or thiazide alone not to overdo K+ foods now because of
K+ sparing component in new drug.
Follow scheduing doses to avoid sleep disruption

Indications

Adverse Reactions

Nursing Implications

Prazosin HCL (minipress)

Terazosin (hytrin)
Phentolamine mesylate (Regitine)
Doxazosin (Cardura)

Used as peripheral vasodialator which acts directly on the blood

vessels
Used in extrreme hypertension of phenochomocytoma

Orthostatic hypotension
Weakness
Palpitations

Use cautiously in older clients

Occaional vomiting and diarrhea
Warn clients of possible
Drowsiness
Lack of energy
weakness

Drugs

Indications

Adverse Reactions

Nursing Implications

Diuretics
Drugs

Thiazides

Loop

Potassium sparing

Combination Loop and potassium

sparing
HCTZ and Triamterene (Maxidex)
HCTZ + Amiloride (moduretic)
HCTZ + spironolactone (Aldactiazide)

Antihypertensives
Drugs

Alpha adrenergic blockers

Combined Alpha/beta blockers

Study guides and Miscellaneous crap Page 14

Combined Alpha/beta blockers

Labetalol (normodyne)
Carvedilol (Coreg)

Produces decrease in BP without reflex tachycardia or bradycardia.

HF
Ventircular dysrhymias
Blood dyscrasias
Bronchospasm
Orthostatic hypotension

Contraindicated with
HF
Heart block
COPD

Drugs

Indications

Adverse Reactions

Nursing Implications

Metoprolol tartrate (lopressor)

Nadolol (corgard)
Propranolol HCL (inderal)
Timolol Maleate (blocardren)
Atenolol (Tenzormin)
Biioprolol (zabeta)
Metoprolol (lopressor, toprol)

Blooks sympthetic nervous system, especially to the ehart

Produces a slower heart rate
Lowers blood pressure
Reduces o2 consumption during myocardial contraction

Bradycardia
Fatigue
Insomnia
Bizarre Dreams
Sexual Dysfunction
Hypertriglyceridemia
Decreased HDL
Depression

Check apical or radialy pulse daily

Monitor for Gi distress
Do not discontinue abuptly
Watch for shortness of breath/give cautioulsy with bronchospasm
Do not vary how taken (with or without food)
Do not vary time taken
May mask sympoms of hypoglycemia or may prolong a hypoglycemic reaction

Drugs

Indications

Adverse Reactions

Nursing Implications

Clonidine (catapres)
Guanabenz acetate (Wytensin)
Methyldopa (aldomet)

Decreased BP by stimulating central alpha recpeors, resulting ind

decreased sympthetic outflow from the brain

Drowsiness
Dry mouth
Fatigue
Sexual dysfunction

Watch for rbound hypertension if abruptly discontinued

Use caution to make position changes slowly, avoid standing still and taking hot baths and
showers.

Drugs

Indications

Adverse Reactions

Nursing Implications

Hydralazine HCL
Minoxidil (Loniten)

Decrease BP by decreasing peripheral resistance

Headache
Tachycardia
Fluid retention (HF, Pulmonary Edema)
Postural hypotension

Monitor BP, pulse routinesly

Observe for peripherl edema
Mionitor I & O
Weigh daily

Drugs

Indications

Adverse Reactions

Nursing Implications

Beta blockers

Central acting inhibitors

Vasodilaltors

Angiotensin Ii receptor antagonsits

Losartan (Cozaar)
Valsartan (Dinovan)
Irbesartan (Avapro)

Blocks the vasoconstrictor and aldosterone producing effects of

Hypotension
angiotensin II at various sites (Vascular smooth msucles and adrenal Fatigue
glands)
Hepatitis
Renal failure
Hyperkalemia (Rare)

Monitor liver enzymes electrolytes

Monitor for angioedema in those with a history f it when on ACE inhibtors previously

Drugs

Indications

Adverse Reactions

Nursing Implications

Captopril (Capoten)
Enalapril maleate (Vasotec)
Lisinopril (Zestril)
Ramipril (Altace)
Benzepril (lotensin0
Quinapril (Accupril)

Decreases Bp by suppressing renin angiotensin aldosterone system

and inhibitng conversion of angiotensin I into angiotensin II
Useful with diabetics

Protinuria
Neutopenia
Skin rash
Cough

Observe for acute renalfailure (Reversible)

Routine renal functin tests
Remain in bed 3 hours after first dose

Drugs

Indications

Adverse Reactions

Nursing Implications

Inhibits clacium ion influx during cardiac depolarization

Decreases SA/AV node conduction

Headache
Hypotension
Dizziness
Edema
Nausea
Consstipation
Tachycardia
Heart failure Dry cough

Check BP and pulse routinely

Lipit caffine consumption
Take medicatiosn before emdals
Avoid graperfulit with these drugs; it increases serum levels causing hypotention
High fat meals elevate serum levels

Angiotensin converting Enzyme

Calcium channel blockers

Diltiazem (Cardiziem)
Nifedipine (procardia, adalat)
Varapamil HCL (Calan, Isoptin)
Nisoldipine (Sular)

Anticoagulants
Drugs

Indications

Adverse Reactions

Nursing Implications

Heparin Sodium (hepalean, Hep-Lock)

Administered parenterally (Sq or IV) as an antagonist to thrombin

and to prevent the conversion of fibrinogen to fibrin

Hemorrhage
Agranulocytosis
Leukopenia
Hepatitis
Heparin induced thrombocytopenia

Assess PTT, HGb, HCt, platelets

Assess stolls for occult blood
Avoid IM injection
Notify anyone peffoming diagnositc testing of medication
Antagonist: Protamine sulfate

Warfarin Sodium (Coumadin, coumarin,

panwarfin)

Blocks the fomration of prothombin from vitamin K

Hemorrhage
Agranulocytosis
Lukopenia
Hepatitis

See heaprin
Given orally
Assess PT
Avoid sudden change in intake of food high in vitamin K
Antagnoist: Vitamin K

Antiplatelt agents
Ticlopidine (ticlid)
Dipyridamole (Persantine)
Clopidogrel (plavix)

Short term use after cardiac interventions

Reduce risk for thrombolitic stroke for intolerant to asprin
Prevention of thrombolytic disorders

Neutropenia
Thrombocytopenia
Agranulocytosis
Leukopenia
Hemorrhage
Gi irrigation
Bleeding
Pancytopenia

Give PC or with food to decrease gastric irritation (Ticlid)

Advise not to take antacids within 2 horus of taking ticlopidine
Monitor CBC every 2 weeks for 3 months, and therafter if signs of infection develop
Monitor for signs of bleeding
Give 1 hour AC 9Persantine); (Plavix) nor regard for meals

Hemorrhage
Gi irritation, bleeding
Thrombocytopenia

Monitor for signs of bleeding

Give subcutaneously
Monitor CBC
Use soft toothbrush avoid cuts

Indications

Adverse Reactions

Nursing Implications

Quinidine
Disopyramide phosphate (norpase)
Moricizine (Ehmozine)
Lidocaine HCL (xylocaine)
Mexiletine (mexitril)
Torcainide HCl (tonocard)
Phenytoin Sodium (Dilantin)
Propafenone (Rythmol)
Flecainide Acetate (Tambocor)

Premature beats
Atrial flutter, Fibrillation
Contraindicated in heart block
Ventircular dysrhymias
Unlabeled use; digitalis for induced dysrhymias
Ventircular dysrhymias

Diarrhea
Hypotension
ECG changes
Cinchonism
Interacts with many common drugs
Hypotension
CNS effects
Seizures
GI distress
Bradycardia
Dizziness
Slurred speech
Ventricular dysrhymias

Instruct the client to monitor pulse rate and hrythm

Monitor ECG
Monitor for tinnitus and visual disturbances
Lidocaine administered IV bolus and by infusion
Monitor for confusion, drowsiness, slurred speech, seizures with lidocaine
Administer oral drugs with food
May cause digoxin tocitity

Drugs

Indications

Adverse Reactions

Nursing Implications

Low molecular weight heparin, enoxaparin Prevention of thombolytic formation (deep vein)
(Lovenox)

Antidysrhymics
Drugs

Class I (A, B, C)

Class II
Study guides and Miscellaneous crap Page 15

Class II
Propranolol HCL (inderal)

Superventircular tachydysrhymias

Hypotension
Bradycardia
Bronchospasm

Monitor vital signs

Contrainidcated in ashtma COPD

Drugs

Indications

Adverse Reactions

Nursing Implications

Bretylium tosylate (Retylol)

Amiodarone HCL (Cordarone)
Milrinone (primacor)
Amirone (incor)
Sotalol (betapace)

Ventricular dysrhmias

Dywrhymias
Hypertension or hypotension
Muscle wakness, tremors
Photophoia

Amidarone is now one of the first choice drugs

Monitor vital signs, ECG
Instuct client taking amidarone to wear sunglasses and sunscreen when outside

Drugs

Indications

Adverse Reactions

Nursing Implications

Verapamil HCL (Isoptin Calan)

Superventricular dysrhymias

Hypotension
Bradycardia
Constipation

Monitor Bp and pulse

Instruct client to change position slowly

Drugs

Indications

Adverse Reactions

Nursing Implications

Atropine sulfate (atropisol)

Bradycardia

Chest pain
Urinary retention
Dry mouth

Monitor heart rate and rhythm

Assess for chest pain
Assess for urinary retention
Avoid use with glaucoma

Digoxin (lanoxin)
Digitoxin (crystogin)

Supraventicular dysrhymias
Atrial fibrillation

Bradycardia
Dysrhymias
Anorexia, nausea, vomiting, diarrhea,
visual disturbances

Monitor pulse rate and rhythm

Instruct client to report signs of toxicity
Hypokalemia increases the risk for toxicity
Causes hypercalcemia

Epinephrine (Adrenaline)

Cardiac arrest

Tachycardia
Hypertension

Impaired renal function can cause toxicity; monitor BUN and creatinine
Monitor puse return in asystol
Monitor vital signs

Indications

Adverse Reactions

Nursing Implications

Class III (intropics)

Class IV

Miscellaneous agents

Antidysrhymics-- Additional
drugs that promote
cardiovascular perfusion in
the failing Heart
Drugs

Vasopressors
Norephinephrine bitartrate (levophed)

Dilated coronary arteries and causes peripheral vasoconstriction for Can cause severe tissue necrosis,
emergency hypotensive states not caused by blood loss, vascular
sloughing andd gangrene if infiltrates
trhombosis or anesthesia using cyclopane or halothane
(blanching along vein pathway is a
preliminary sign of extravasation)

Rapidly inactivated by various body enzymes needed to ensure need to ensure IV patency
Use cautiously in previeously hypertensive clients
Check Bp every 2 to 5 minutes
Use larve veins to avoid complications of prolonged vasoconstriction
Pressore effects potentiated by many drugs; check drug- drug interactions
Have phentolamine (regitine) diluted per protocl for local injection if infltrates

Drugs

Indications

Adverse Reactions

Nursing Implications

Nesiritide (atrecor)

Treatment of acutely decomponsated HF in clients who have

dyspnea at rest or with minimal activity
Reduces PCWP and reduces dyspnea

Hypotension is primary side effect and can

be dose lmiting
Dyrhymias
Headache, dizzinesse, insomnia, tremors,
paresthesias
Abdominal pain, nausea, and vomiting

Many drug-drug interactions

Mointor BP and telemetry
As diuresis occurs, monitor electrolytes especially K+
Watch for overresponse to treatment in older adults

Drugs

Indications

Adverse Reactions

Nursing Implications

Acute coronary syndrome (unstable angina or non-Q waver MI)

Used in combination with heparin, aspiran and in selected solutions
Ticlid and plavix

Bleeding most frequent

Hypotension
Acute toxicity; decreased muscle tone,
dyspnea, loss of rigting reflex

Check drug to drug interactions before giving other medications

Obtain baseeline PT/aPtt, hig, HCT and platelt coutnt and monitor
Dose adjusted by weight for older adults
Same client teaching as with haeparin; review acitvities to avoid
Watch for bleeding
Quickly reversible, so emergency procedures may still be performed shortly after
discontinuoing infusion

Cardiotonic/vasodialator (Human BType natiuretic peptide: HBNP)

Group Iia- IIIb inhibitor (platelet

atiaggregate)
Eptifibate (integrilin)

Digitalis Preparations
Drugs

Indications

Adverse Reactions

Nursing Implications

Digoxin (crystodigin, purodigin)

Digoxin (Lanoxin, lanoxicaps)

HF
Increases the contractility of cardiac muscle
Slows heart rate and conduction

Severe: av block
Headache
Dysrhymias
Nausea
Vomiting
Blurred vision
Yellow green halos
Hypotension
Fatigue

Monitor serum electrolytes; hypokalemia, increased risk for digoxin toxicity

Moinitor serum digitalis levels if any side effects are present
Check apical pulse prior to administration; call health care provider if rate is < 60 bpm in
adults
Theraputic range: 0.5 to 2.0 mg
Teach client to take the radial pulse prior to administration and call health care provider if
< 60bpm in adults

Digoxin- immune fab (digibind)

Antidote for digitalis toxicity

Binds with digoxin or digoxin to prevent binding at their site of
action

Decreased cardiac output

Atrial tachydrysrhymias
Use with caution in children and older
adults

Used with 22 um filter

Place client on continououls cardiac monitor
Have resucitation equipment at bedside before giving first dose.

Chronic Airflow Limitation

Chronic Bronchitis

Emphysema

Asthma

Reduced gas exchange, surface area

Increased air trapping (increased AP diameter)
Decreased capillary network
Increased work, increased O2 consumption

Narrowing or closure of the airway due to a variety

of stimulants

Cigarette smoking
Envionmental and/ or occupational exposure
Genetic

Mucosal edema
V/Q abnormalitis
Increased work of breathing

Pathophysiology
Chronic suputm with cough production ofn
a daily basis for a minmum of 3 months per
year
Chonic hypoxemia, cor pulmonale
Increase in mucous cilia production
Increase in bronchial wall thckness
(obstructs air flow)
Reduced responsivenessl of respriatory
center to hypoxemic stimuli
Participating factors
Higher incidence in smokers

Study guides and Miscellaneous crap Page 16

 Genetic

Increased work of breathing

Beta blockers
Respiratory infection
Allergic reaction
Emotional stress
Exercise
Envionemntal or occupational exposure
Refulx esophagus

Pink puffers
Barrel chest
Pursed lip breathers
Distant, quiet breath sounds
Wheezes
Pulmonary blebs on radiograph

Dyspnea, wheezing, chest tightness

Assess precipitating factors
Medication history

Lowest Fio2 possible to prevent Co2 retention

Monitor for signs and sympoms of fluid overload
Maintain Pao2 between 55 and 70
Baseline ABG's
Teach pursed lip breathng and diaphragmatic breathing
Teach tripod position

Administer bronchodialators
Administer fluids and humidification
Education (causes, medication regimen)
ABG's
Ventilatory patterns

Assessment
Generalized cyanosis
Blue bloaters
Right sided heart failure
Distended neck veins
Crackles
Expiratory wheezes
Nursing plans and interventions
Lowest Fio2 possibel to prevent Co2
retention
Miontor for signs and sympoms of fluid
overload
Maintain Pao2 between 55 and 60
Baseline ABG's
Teach pursed lip breathing and
diaphragmatic breathing
Teach tripod positioning

Nursing Skills Respiratory Client

Suctioning Tracheal
Suction when adventitious breath sounds are heard, when secretions are present at endotracheal tube, and when
gurgling sounds are noted
Use aseptic/sterile technique throughout procedure
Wear mask and goggles
Advance cathter until resistance is felt
Apply suction only when withdrawing cathter (gently rotate cathter when withdrawing)
Never suction for more than 10 - 15 seconds and pass the cathther only three or fewer times
Oxygenate with 100% O2 for 1 to 2 minutes before and after suctioning to prevent hypoxia

Ventilator Setting Maintinance

Verify that alarms are on
Maintain settings and check often to ensure that they are specifically set as prescribed by health care provider
Verify functioning of ventilators at least Every 4 hours

Oxygen Administration
Nasal cannula, low O2 for low O2 Concentrations (good for COPD)
Simple face mask: low flow, but effectively delivers high O2 concentrations, cannot deliver < 40% O2
Nonrebreather mask: low flos, but delivers high O2 (concentrations 60 - 90%)
Partial rebreather mask: low flow O2 reservoir bag attached, can deliver high O2 concentrations
Venturi mask: high flow system; can deliver exact O2 concentration

Pulse oximetry
Easy measurment of O2 saturation
Should be > 905 and ideally above 95%
Noninvasive-- fastens to finger, toe or earlobe
No nail polish
Must have good peripheral perfusion to be accurate

Tracheostomy Care
Aseptic technique Remove inner canula only from Stoma
,Clean nondisposable inner calula with H2o2 : rinse with sterile saline
4x4 gause dressign butterfly folded

Respiratory isolation Technique

Mask is required for anyone entering room
Private room is required with negative air pressure
Cleint must war mask if leaving room

Proper use of an inhaler

Have cleint exhale completely
Grip mouthpeiece (in mouth) only if client has a spacer; otherwise keep the motuh open to bring in volume of air with
misted medication. While inhaling slowly push down firmly on the inhaler to release the medication
Use bronchodialator inhaler befor esteroid inhaler
Wait at least 1 minute between puffs (inhaled doses)

Acute Renal Failure

Types

Descriptions

Causative Factors

Prerenal

Interference with renal perfusion

Hemorrhage
Hypovolemia
Decreased cardiac output
Decreased renal perfusion

Intrarenal

Damage to renal parencyma

Prolonged prerenal state

Nephrotoxins
Intratubular obstructions
Infections (glomeruloneprhitis)
Renal injury
Acute pyelonephritis

Postrenal

Obstruction in the urinary tract anywhere

from the tubules to the urethral meatus

Calculi
Prostatic hypertrophy
tumors

Renal Dialysis
Types of dialysis

Description

Nursing Implications

Hemodyalysis

Requires venous access (AV shunt, fistula, or

graft)
Treamtment is 3 to 8 hours in length, 3 times
per week
Correction of fluid and electrolyte imbalace is
rapid
Potential blood loss
Does not result in protein loss

Heparinization is required
Requires expensive equipment
Rapid shifts of fluid and electorlytes can
lead to disequilibrium syndrome (an
unpleasant sensation and potentially
dangerous situation)
Potential hepatitis B and C
Do not take blood pressure or perform
venipunctures on the arm with the AV
shunt, fistula or graft.

Study guides and Miscellaneous crap Page 17

shunt, fistula or graft.

Assess acces ssite for thrill and bruit
Continuous
arteriovenous
hemofiltration (CAVH)

Requires vascular access: usually femoral or

subclavian cathters
Slow process
Correction of fluid and electrolyte imbalance
is slow
Does not cause blood loss
Does not result in protein loss

Requires heparinization of filter tubing

Filters are costly
Equipment is simple but requires
specilaized training to monitor
Limited to sepcial care units, not for home
use
Filter may rupture causing blood loss

Peritoneal

Surgical placement of abdominal cathter is

required (tenkhoff, goretex, column disk)
Slow process of 8 to 10 hours for repeated
cycles
Correction of fluid and electrolyte imbalance
is slow
Does not cause blood loss protein lost in
dialysate

Heparinization is not required

Failrly expensive
Simple to perform
Easy to use at home
Dialysate is similar to IV fluid and prescibed
for the individual client's electrolyte needs
Potential complications
Bowel or bladder perforation
Exit site and tunnel infection
Peritonitis

Postoperative Care: Kidney Surgery

Assessment

Nursing interventions

Rationale

Respiratory status

Auscultate lung sounds to detect "wet"

sounds indicating infection
Demonstrate method of splinting incision
for comfort when coughing and deep
breathing

Flank, incision causes pain with both

inspiration and experiation. Therefore, cleits
avoids deep breathing and coughing, this can
lead to respriatory difficulties, including
pneumonia.

Circulatory Status

Check vital signs to detect early signs of

bleeding, shock
Monitor skin color and temperature (pallor
and cold skin are signs of shock)
Monitor urinary output (decreases with
circulatory collapse)
Monitor surgical site for frank bleeding

The kidney is very vascualr

Bleeding is a constant threat
Circulatory collapse will occur with
hemorrhage and can occur very quickly

Pain relief status

Administer narcotic analgesics as needed to Relief of pain will improve the client's
relieve pain
cooperation with deep breathing exercises
Relief of pain will improve client's
cooperation with early ambulation

Urinary status

Check urinary output and drainage from all

tubes inserted during the surgery
Maintain accurate intake and output

Mechanical drainage of bladder will be

implemented after surgery

Post- myocardial infarction cardiac Enzyme Elevations

Enayme marker

Onset

Peak

Return to normal

CK-2 (not cardiac specific)

3 - 6 hrs

12 -24 hrs

3 to 5 days

CK- MB (recognized
indicator of MI by most
clinicans)

2 to 4 hours

12 to 20 hr

48 to 72 hours

Myoglobin

1 to 4 hours (elvate piror 4 to 8 hours

to CK - MB)

24 hours

Cardiac troponins

As early as 1 hour post

injury

10 to 24 horus

5 - 14 days

LDH total

24 hours

3 to 6 days

10 to 14 days

LDH (a higher LDH than

LDH2 indicates MI)

12 to 24 hr

48 hr

10 days

LDH 2

12 to 24 hours

48 hours

10 days

Study guides and Miscellaneous crap Page 18