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NUR 504 Exam 2 with revised questions
and answers
Purpose of the hematologic system - Correct Answer - blood formation
- transport of O2, CO2, metabolites, nutrients and hormones
- involved in immune reactions
- hemostasis
- acid-base balance
- fluid balance
- temperature regulation components of the hematologic system - Correct Answer - blood (solids-RBCs, WBCs, thrombocytes and liquid-plasma)
- bone marrow (RBCs, WBCs and platelets are formed here)
- liver (produces prothrombin and other clotting factors such as Vit K formation, stores RBCs and extra iron/ferritin)
- spleen (major antibody production site. Those w/o a spleen are at an increased risk for infection).
- lymphatic system
- kidneys *This system includes all organs that make blood or store blood hematological system labs - Correct Answer - Vitamin B12, iron and copper (needed for RBC production)
- RBC normal values= 4.6-6.3x106/mm3 M and 4.2-5.4x106/mm
- reticulocytes (baby RBCs)
- H&H (Hemoglobin carries O2 t/o the body. M 14 - 18 and F 12 - 16. Hematocrit is the % of your blood volume that is RBCs. Usually 42 - 52% M and 37 - 47% F).
- iron (this is needed to form hemoglobin, binds with transferrin and is absorbed in the small intestine)
- TIBC (total iron binding capacity) and ferritin: determines how much iron is stored in the body
- WBC (neutrophils, basophils and eosinophils)
- platelets: should be 105,000-400,000. 20% are stored in the spleen, short lifespan and function is to decrease blood loss by clotting.
- clotting related labs: PT (11-12.5 seconds), INR, aPTT (30- 40 seconds and 1.5-2. times control value if pt is on heparin therapy) and fibrinogen (200-400) abnormal hematocrit levels - Correct Answer Low: may be d/t a chronic illness such as cancer, anemia or blood loss. High: may be d/t dehydration or polycythemia vera abnormal iron levels - Correct Answer high: d/t hep B or a vitamin deficiency low: low iron consumption, blood loss or absorption deficiency clotting cascade - Correct Answer This is a series of events that leads to hemostasis. This prevents blood loss and promotes healing. It is activated d/t blood vessel injury or damage.
- Platelets are first to arrive and stick to the damaged BV and recruit more platelets to the site.
- fibrin is a sticking substance used to create the platelet plug
- plasmin is a a protein and digests fibrin 1)Platelet finds exposed collagen of damaged vessel 2) Platelet releases chemical that causes neighboring platelets to adhere to each other (platelet plug) 3)collected platelets and damaged tissue both released thromboplastin
- Thromboplastin and calcium and vit.K converts inactive prothrombin to its active form thrombin
- Thrombin converts fibrinogen into fibrin
- fibrin threads coat damaged area and trap blood cells to form clot nursing actions for the hematological system - Correct Answer Ask pt. about drug use, diet, alcohol use, age, sex, liver fxn, s/sx of liver problems, PMH, hemophilia, jaundice, JVD, tongue changes (smooth and beefy=pernicious anemia), paresthesia, bruising, sickle cell disease, nose bleeds, med hx, hemorrhages, heavy menstrual cycles, lymph node swelling, excessive bruising, SOB upon exertion, infection, HA, fever, weight loss, paresthesia, edema, arrhythmias, proteinuria, hematuria, GUAC, assess CNS. Heparin-induced thrombocytopenia (HIT) - Correct Answer Def: Severe complication d/t heparin exposure and results in an unexplainable decrease in platelets (thrombocytopenia). This leaves patients in a hypercoagulable state (increased risk of clots) and a thrombosis (blood clot that blocks BV) can occur. Patho: PF4 (stored in platelets and is released upon activation) binds to heparin and results in IgG, IgA or IgM. Cause: Type 1=non-immune mediated. This is mild and platelets can recover on their own. Type 2=immune antibody mediated. This is severe and life-threatening.
Nursing actions: constant and freq. assessment, s/sx of end organ damage, blood gases, sit pt. in semi-fowler's, skin assessment, hematoma, urine output, labs, IM injection for meds, use A-line for labs, minimize BP cuff readings, gentle with oral care, suction and prevent trauma. endotracheal tube intubation (ETT) - Correct Answer This is when a tube is placed down a patient's trachea. This is done when we are unable to oxygenate the patient, unable to ventilate or protect the airway. C/I for mouth intubation: neck immobility/trauma, broken neck, unable to open mouth (anaphylaxis) or locked mouth. INSTEAD, do nasal intubation or cricothyroidotomy. Cause: neurological dysfunction (decreased central drive), respiratory issues (increased secretions, poor gas exchange, drug withdrawals, psych (manic-hyperventilation and catatonic depression), paralysis, MI, drugs, poor nutritional status, electrolyte imbalances, hypothyroidism, adrenal insufficiency and increased carbohydrate feedings (tube feedings). Equipment: pillows, blankets, pulse ox, capnography, BP cuff, ampu bag, oxygen, suction catheter, IV access, meds (sedative, rapid sequence meds), intubation kit, endotracheal tube, securing tape, stethoscope, CO2 detector, CXR and staff. Nursing actions: document size of endotracheal tube and placement, mark how deep tube is inside someone, provide oral care, monitor connections, restraints and listen to breath sounds after intubation. tracheostomy - Correct Answer Creation of an artificial opening into the trachea and is for patients needing ventilation for 2+ weeks (otherwise pneumonia can occur). trach care: know if the cuff is inflated or deflated, know size, know what kind of cuff, deflate trach once per shift to prevent pressure ulcers, stoma care, trach ties, suction tubing at bedside, monitor for crepitus, use humidified air to prevent mucous plugs, change inner cannula every shift and give pt. board for communication. mechanical ventilation - Correct Answer Mechanical breathing using a ventilator Types-see next slide Ventilation weaning criteria: pt. has adequate oxygenation, needs to be hemodynamically stable, no fever, no acid-base imbalances, hemoglobin is greater or equal to 8 - 10 g/dL-no low hemoglobin, no LOC, should have stable electrolytes and need to have a desire to breathe/initial. Spontaneous breathing trial (SBT) criteria:
- Pt must have O2 saturation of 90% or higher, RR <35 BPM, HR <140 and SBP of 80 - 160
- no acute distress
- cannot have an increased work of breathing
- must have a cough and a gag reflex
- must have a resolution of the acute phase mechanical ventilation types - Correct Answer Types:
- Assist control or continuous mandatory ventilation (set min. # of breaths and ventilation will increase if RR are too low)
- Pressure regulated volume control (PRVC or PC)-ventilator adjusts pressure from breath to breath. This is good for patients needing extra help.
- Synchronized intermittent mandatory ventilation (SIMV or IMV)-only the set breathes are supported
- Pressure support-patient has no sedation and goal is to wean pt. off ventilator.
- CPAP (continuous positive airway pressure)-good for patients with heart failure, too much fluid or for those who snore at night. Ventilator Associated Pneumonia (VAP) - Correct Answer When pneumonia occurs in a patient who is ventilated or has been ventilated. The longer amount of time a patient is intubated, the more likely VAP is to occur. Prevention: extubate the patient and increase HOB (30- 40 degrees) Tx: antibiotics, chest PT Dx: increased temp, increased WBCs, thick secretions, lung sounds w/ rhonchi, CXR, culture and sensitivity via sputum sample and watch ABGs. Risks: those who have been ventilated, 55 plus years, upper abdominal surgery, chronic lung disease, aspirated, previous antibiotic treatment, re intubated, acute respiratory distress syndrome, trauma, malnourished, renal failure or anemic. Richmond Agitation Sedation Scale (RASS) - Correct Answer +4 combative +3 very agitated +2 agitated +1 restless 0 alert and calm
- 1 drowsy
- 2 light sedation
- 3 moderate sedation
- 4 deep sedation
- 5 un-rousable Types of sedation - Correct Answer 1) Inhaled: Ex. Nitrous Oxide (short acting and used for dental procedures) 0 to - 1. Pt. is not agitated.
acute respiratory failure - Correct Answer This occurs when insufficient oxygen is transported to the blood or inadequate CO2 is removed from the lungs. Here, the compensatory mechanisms fail the patient. There is no acid-base balance. Low pH will stimulate RR and depth to make the patient more alkalotic. High pH will decrease RR and become shallow do pH decreases to make pt more acidic. Sx: SOB, increased RR, HA, restlessness, decreased LOC, accessory muscle use, tripod, confusion, increased HR, HTN, dysrhythmias, periorbital cyanosis and short sentences. Tx: Identify the cause and tx! Oxygen, deep breathing, high fowler's, VS, ABGs, ventilator, capnography, lung sounds, steroids, diuretics, nebulizer and TPN. Types:
- Type 1 "hypoxemia" and examples are COPD, flu, pulmonary edema, and pneumonia. PaO2 is <60 mmHg w/ a normal to low PaCO2.
- Type 2 "hypercapnic" PaCO2 is > 50 mmHg. CO2 is too high, pt is usually hypoxic as well. D/t neuromuscular disease and drug OD. Type 3 "perioperative respiratory failure" d/t to lung or alveoli atelectasis d/t a perioperative issue. May be caused anesthesia, shock, lung/alveoli atelectasis, obesity and smokers. Acute respiratory distress syndrome - Correct Answer ARDS A form of acute respiratory failure that occurs as a consequence of some other condition. Caused by lung injury and leads to extra, vascular lung fluid. Leads to poor perfusion. Alveoli collapse and interstitial edema causes terminal airway compression and leads to decreased lung volume. Cause: Trauma Pulmonary infection Aspiration Prolonged cardiopulmonary bypass Shock Fat emboli Sepsis Sx: increased RR, SOB, decreased breath sounds, decreased lung sounds, poor ABG values, hypoxia and decreased pulmonary compliance.
Dx: look at symptoms, how patient is responding to oxygen and decreased respiratory complicance. Tx: maintain airway, provide adequate oxygen, support hemodynamic needs. Perfusion, positioning (turn pt. to break up secretions), protective lung ventilation, protocol weaning and preventing complications (such as DVT, ROM, stockings, anti-coagulants, pressure ulcers, nutrition, waffles mattress, VAP). pulmonary arterial hypertension (PAH) - Correct Answer A group of clinical conditions presenting with abnormal elevation in the pulmonary circulatory phase. Abnormal pressure in lungs (HTN). Normal is 11 - 17 mmHg PAH is >25 at rest or >30 with activity Types: idiopathic, drug/toxin induced and disease related (lupus, HIV, portal HTN, congenital HD, HF, cystic fibrosis). Sx: syncope, leg swelling, anorexia, abdominal distention, JVD, Kussmaul respirations. Dx: PMH, physical assessment, EKG, echo, cardiac catheterization, MAP, labs, exercise stress test, pulmonary fxn test, ABG, rule out HIV, liver and HF, BNP And CXR. Tx: Decrease weight, aerobic exercise, non-live vaccines, sodium restrictive diets, oxygen, meds (CCB), nitrous oxide, vasodilators, epoprostenol (SE: SJS, jaw pain, facial flushing, N,V,P, musculoskeletal pain, infections and infusion interruption can be life threatening.) pneumothorax - Correct Answer Accumulation of air in the pleural space that leads to partial or complete lung collapse. Venous return to the heart may be blocked and can lead to tension pneumonthorax (all three types will lead to this). Types: Traumatic (open or closed injury) Iatrogenic (HCP causes this-accidental punctured lung) Spontaneous (closed) Sx: absent breath sounds, cyanotic, mottled, decreased chest expansion, unequal chest expansion, SOB, hypotensive, sharp chest pain, SQ emphysema, increased RR and HR, tracheal deviation, pleuritic pain and chest asymmetry. Dx: CXR and ABG
Causes: โ HCO3 Antacids, sodium bicarbonate administration, โ H NG suctioning, prolonged vomiting Symptoms: Confusion, Dysrhythmias, Tachycardia from โ K Compensatory, hypoventilation, Dizzy, irritable Nausea, vomiting, diarrhea, Anxiety, Seizures, Tremors, muscle cramps, tingling fingers and toes (From โ Ca Treatment), Monitor K, Ca, Monitor for respiratory distress, Safety precautions, Administer potassium chloride, Treat underlying issue respiratory acidosis - Correct Answer โpH โpCO Causes: โ respiratory stimuli (anesthesia, overdose), COPD, pneumonia, atelectasis Symptoms: Hypoventilation - > hypoxia Rapid, shallow respirations ,โ BP, Dyspnea, Headache, Hyperkalemia, Dysrhythmias (from โ K), Drowsiness, dizziness, disorientation, Muscle weakness, hyperreflexia Treatment: Monitor respiratory status, O2, Semi-fowlers, Coughing and deep breathing, Give fluids Suction secretions, Monitor electrolytes, Treat underlying problem, Intubate. respiratory alkalosis - Correct Answer โpH โpCO Causes: Hyperventilation, mechanical ventilation, pain, fever Symptoms: Hyperventilation, Tachycardia, โ BP, Hypokalemia, Numbness and tingling of extremities, Hyper reflexes, and muscle cramping, Seizures Anxiety, irritability Treatment: Assess respiratory distress, Emotional support, Monitor electrolytes, Administer calcium gluconate. endocrinology system - Correct Answer The goal of this system is to regulate and integrate the metabolic activities of the body. This consists of endocrine glands, hormones (chemical messengers that transfer info from cells to other cells to coordinate bodily functions. Ex is oxytocin) and receptors (hormones bind to this). endocrine organs - Correct Answer pituitary gland (master gland), hypothalamus (pineal gland + pituitary), thyroid, adrenal, testes, ovaries, thymus and pancreas diabetes insipidus - Correct Answer This is a life threatening disease where there is excretion of copious amounts of dilute urine. Up to 2 L per 30 minutes. Here the priority is dehydration and the goal is to balance out water and electrolytes. Types:
- inadequate/impaired secretion of ADH (aka central/nephrogenic DI)
- impaired/insufficient renal response to ADH (nephrogenic DI) Cause (of central DI): d/t CNS injury (neoplasia, ischemia to hypothalamus, brain radiation, meningitis, cerebral edema) or familial disease. Cause of both types: idiopathic, drug toxicity (gentamycin, lithium, loop diuretics), kidney disease, pregnancy and sickle cell crisis. Sx: increased thirst, increased water intake, dry skin and constipation Dx: urine osmolality, urinary output and VS Tx (central DI):
- vasopressors
- DDAVP (desmopressin)
- thiazide diuretics Tx (nephrogenic DI):
- correct low potassium and high calcium
- discontinue drugs that lead to nephrogenic DI
- thiazide diuretics Nursing interventions: Daily weights, I&Os, assess for dehydration, hypovolemic shock, educate pt. how to administer drugs, give stool softener, report polyuria, wear med alert bracelet, have meds with patient at all times, take meds with water to decrease abdominal pain. SIADH - Correct Answer Syndrome of inappropriate antidiuretic hormone Very common cause of hyponatremia This is increased levels of ADH d/t the unsuppressed release of ADH. This causes fluids retention and hyponatremia. Cause: central nervous system disturbances (stroke, hemorrhage, infection, trauma, mental illness (psychosis), malignancies (small cell lung cancer), drugs (thiazide diuretics, SSRIs, tricyclics, vasopressin, oxytocin, opioids, NSAIDS, haldol, ecstasy), surgery, idiopathic, HIV infection and pulmonary disorders (pneumonia, COPD, asthma, ARF and pneumothorax). Dx: The Schwartz and Bartler clinical criteria
- serum osmolality <
- serum sodium <
- urine osmolality >
- urine sodium >
This is easily misdiagnosed and has a higher mortality rate This is DKA with no ketones Cause: diuretics, beta blockers, dilantin and corticosteroids Tx: IV fluids and insulin drip
