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NURS 3525- Exam 3 Combined With Verified Solutions
Normal sinus rhythm (NSR)
- pulse present
- regular rhythm
- rate 60 - 100
- P waves: upright, rounded, 1 for every QRS complex
- PR interval: ≤ 0.20 seconds
- QRS complex: ≤ 0.12 seconds Sinus Bradycardia
- pulse present
- regular rhythm
- rate: < 60 bpm
- P waves: upright, rounded, 1 for each QRS complex
- PR interval: ≤ 0.20 seconds
- QRS complex: ≤ 0.12 seconds Sinus tachycardia
- pulse present
- regular rhythm
- rate: 101 - 180 bpm
- P waves: upright, rounded, 1 for each QRS complex
- PR interval: ≤ 0.20 seconds
- QRS complex: ≤ 0.12 seconds paroxysmal supraventricular tachycardia (SVT)
- pulse present
- regular or slightly irregular rhythm
- rate: 151 - 220 bpm
- P waves: distorted shape or hidden in T-wave
- PR interval: ≤0.20 seconds
- QRS complex: ≤0.12 seconds Premature Arterial contraction (PAC)
- ectopic beat
- not a rhythm (must identify underlying rhythm)
- rate: can be irregular
- P waves in PAC will appear differently than other P waves on strip
- PAC is followed by period of delay in electrical activity Atrial flutter ABNORMAL RHYTHMS Atrial Flutter
rate: 61 - 100 idioventricular rhythm
- pulse is present
- rhythm regular
- rate 20 - 50 bpm (accelerated rate 51 - 100)
- P waves absent
- PR interval: N/A
- QRS complex: wide >0.12 seconds premature ventricular contraction (PVC)nectopic beat is not a rhythm no P wave QRS > or = 0. followed by pause unifocal vs multifocal Ventricular tachycardia (VT) runs of 3 or more PVCs!! rate: 150 - 250 Wide QRS complex TX: CPR, defibrillation Ventricular fibrillation (VF) ventricle is quivering rate: unable to measure QRS: unable to measure
TX: CPR, Defibrillation Ventricular Standstill (Asystole)
- no electrical activity in the ventricle
- death will quickly occur if the arrhythmia is not reversed TX: CPR/Meds (very hard to treat with success) Pulseless electrical activity (PEA)
- mechanical heart activity is absent but there is electrical activity visible on the EKG
- patient DOES NOT HAVE A PULSE GI problem may present as nausea illnesses caused by nausea dehydration, electrolyte imbalance, metabolic alkalosis treat the nausea identify underlying cause and treat complications assessment for nausea precipitating factors, emesis contents, timing common predicating factors with nausea pregnancy, brain injury, gallbladder issues, MI, medications, motion sickness types of emesis content bright bed color, coffee ground like, partially digested food positioning for pt who cannot move independently with nausea side lying or high fowlers
drug therapy for GERD
- Proton pump inhibitors
- H2-receptor blockers
- Prokinetic drug therapy
- Cholinergic drugs
- Antacids surgical interventions for GERD LINX system, fundus Hiatal hernia herniation of part of the stomach into the esophagus through an opening in the diaphragm etiology for hiatal hernia wearing of the diaphragm, increased intraabdominal pressure clinical manifestation of hiatal hernia Asymptomatic, Heartburn, regurgitation, dysphagia, and epigastric pain (GERD S/S) physical exam for hiatal hernia may be able to palpate or see on x-ray a herniation complications of hiatal hernia strangulation, GERD, esophagitis, esophageal bleeding, esophageal stenosis management for hiatal hernia lifestyle modification, reduce intraabdominal pressures, avoid lifting/straining, surgical options Peptic Ulcer Disease (PUD)erosion of the GI mucosa from the digestive action of HCl acid and pepsin
types of peptic ulcer disease acute, chronic, gastric, duodenal acute PUD Superficial erosion Minimal inflammation Short duration, resolves quickly once cause is identified and removed chronic PUD Long duration—present continually for many months or periodically More common than acute erosion gastric PUD location is in the stomach duodenal PUD location is in the duodenal causes of PUD H. pylori and NSAIDs, and smoking clinical manifestations of duodenal ulcers discomfort below diploid process, can cause back pain
- pain is "burning" or cramp like
- S/S occur 2 - 5 hours after eating
- S/S occur when gastric acid comes into contact with ulcers
antacids teaching for endoscopy NPO 8 hours before, signed consent is required light, not full sedation do not allow food until gag reflex has returned post-procedure complications with PUD GI bleeding, perforation, gastric outlet obstruction S/S of perforation side dramatic increased pain, no bowel sounds, tenderness in palpation of abdomen, N/V, weaker pulses goals of bowel perforation care stop spillage of Gi juices in abdomen, notify provider, place an NG tube to suction. S/S of GI bleeding bright red or coffee ground vomiting S/S of gastric outlet obstruction more pain at end of day, N/V, projectile vomiting, distended abdomen, electrolyte and fluid issues gastric surgery use tx for stomach, cancer, perforation, chronic gastritis, PUD complication fo gastric surgies
dumping syndrome, postprandial hypoglycemia, bile reflux gastritis dumping syndrome resection of portion of stomach with pyloric sphincter, wekened, palpitations, N/V, barter bowel sounds, loss of regulation of bowel content movement postprandial hypoglycemia card bolus stimulates insulin secretion bile reflux gastritis Surgery necessary to correct nursing care related to post-op gastric surgery fluid and electrolyte balance maintained NG tube monitored, IV fluids maintained, respiratory complications obviated, tx pain, infection prevented prevention of respiratory complications post-op incentive spirometer, assessments of respiratory status, splinting encouraged, early ambulation when to call doctor about blood in NG tube after surgery? when it is more than 75 ml/hour gastritis inflammation of the stomach S/S of gastritis
Tx for C.diff oral vancomycin fecal incontinence involuntary loss of stool interventions for fecal incontinence H&P, bowls management, high fiber diet, bulk forming laxatives, skin assessment, offer support what skin disorder is associated with fecal incontinence? incontinence associated dermatitis (IAD) biofeedback therapy for fecal incontinence electrical stimulation to promote continence constipation less than 3 stools a week T?F constipation is a disease False, it is a symptom. not a disease risk factors for constipation low fiber diet, decreased physical activity, ignore urge to poop, slowing of GU transit, medications clinical manifestations of constipation
- abdominal discomfort,
- hard, dry, difficult to pass stools
- abdominal distention
- bloating complications of constipation hemorrhoids, perforation, diverticulosis management of constipation 𝖳 fiber intake, 𝖳 activity level, enemas + laxatives, dedication schedule irritabel bowel syndrome (IBS) characterized by chronic abdominal pain and altered bowel patterns S/S of IBSAbdominal distentionExcessive flatusdiarrhea or constipationmucus in the stool types of IBS IBS-C (constipation) IBS-D (diarrhea) IBS-M (mixed) IBS-undefined diag/tx of IBS H&P, dietary changes, lifestyle changes, probiotics, antispasmodics diagnostics for acute abdominal pain physical assessment, CBC, UA, abdominal x-ray, ultrasound, CT, pregnancy test clinical manifestations for acute abdominal pain pain, N/V/D/C, farting, fatigue, fever, rebound tenderness, bloating goal of acute abdominal pain tx
clinical manifestation of peritonitis
- severe, continuous abdominal pain
- rebound tenderness
- rigid abdomen
- movement worsens pain
- abdominal distention
- VS changes
- N/V inflammatory bowel disease (IBD) autoimmune disease, chronic inflammation- cures widespread tissue destruction ulcerative colitis (UC) usually limited to the colon, inflammation and ulceration occur in mucosal layer Crohn's disease can affect any segment of the GI tract, Skip lesions, cobblestone appearance, Deep lesions Clinical manifestations for Crohn's disease Diarrhea, cramping abdominal pain, weight loss, rectal bleeding, fever, fatigue clinical manifestations ulcerative colitis bloody diarrhea, cramping abdominal pain, fever, fatigue, large loss of fluids and electrolytes with diarrhea complications of Crohn's disease and UC
hemorrhage, strictures, perforation, abscesses, fistulas, toxic megacolon, increased risk for colon cancer diagnostics for Crohn's disease and UC CBC, electrolyte, albumin, ESR and CRP, small bowel series, US/CT/MRI management of IBD bowel rest, control inflammation (steroids +food intake), manage nutrition, S/S relief, improved QOL Diverticula abnormal side pockets in the intestinal wall diverticulitis inflammation of the diverticula contributing factors of diverticulitis lack of fiber and constipation, lifestyle factors clinical manifestations of diverticulitis abdominal pain, bloating, farting, change in bowel habits, may have bleeding, acute pain, distention, N/V management of diverticulitis colon rest, clear liquids or NPO, fluids, antibiotics, tx systemic symptoms (fever), surgery if indicated hernias loop of bowel extended through abdominal muscle wall
types of stroke ischemic and hemorrhagic non modifiable risk factors for strokes age, gender, ethnicity, race (African American), family hx nested modified risk factors for strokes HTN, heart dz (a-fib), smoking, DM, sleep apnea, lack of exercise, poor diet, drug/alcohol use Transient Ischemic Attack (TIA) minit strokes, blood supply to part of the brain is blocked for a period and then a full recovery T/F TIAs don't increase risk for stokes false, they do increase the risk for stokes types of ischemic stroke thrombotic (clot formation) and embolic (clot that has traveled) clinical manifestations for strokes decreased motor function, communication, affect, intellectual function, spatial perceptual problems, elimination issues receptive aphasia cant understand what is being said expressive aphasia slurred speech or inability to speak global aphasia When both production and understanding of language is damaged
T/F stoke patient are emotional true elimination issues with a stroke constipation, and bladder control Diagnostic tests fro strokes non-contrast head CT or MRI CTA or MRA cardiac imaging what is the indication of CTA and MRA in stroke diagnostics? Looks at vessels and shows exactly where stroke is TX for ischemic stroke tPA (within 3 - 4.5 hours of onset of symptoms) endovascular therapy exclusions for tPA recent surgery, GI bleed, Hx of brain bleed, hemorrhagic stroke, hx of head injury assessment for strokes description of event, Hx of other events, current meds, presence of RFs, family Hx, complete neuro exam complications of stroke pneumonia, aspiration, venous thrombosis, contractures, muscle atrophy, foot drop, skin breakdown, constipation, UI, malnutrition/dehydration, communication barrier prevention of foot drop
