185 FINAL EXAM Flashcards by Alayna Johnson

Benzodiazepine, anti-anxiety, muslce relaxant, anti-convulsant
- Short acting

Use: Sedative (given in pre-op)
- Amnesia effect, produces sleep

Side effects:
- Drowsiness
- Confusion
- Hypotension
- Hepatotoxicity
- Low HR

Interventions: Vitals

Antidote: Flumazenil (Romazicon)

Midazolam

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Dissolves chemical bonds w/in mucus making it separate/ liquiefying/ reducing viscosity
- Given as nebulizer

Use: Pneumonia, emphysema, asthma, & bronchitis

Side effects:
- N/V
- Tachycardia
- Hypotension
- Rotten egg oder
- Bronchospams (adverse)

Interventions:
- Vitals
- monitor cough & bronchial secretions
- Record GI symptoms before/after therapy

Antidote for Tylenol OD - Given PO

Mucomyst (Acetyl Cysteine)

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Inhibits interaction of acetylcholine at recepter site on bronchial smooth muscle, resulting in bronchodilation

Use: Asthma, long term Tx or reversible bronchospasms associated w/ COPD

Adverse:
- Mouth dryness
- Throat irritation
- Dizziness
- Nasal congestion

Serious effects:
- Tachycardia
- Urinary retention
- Exacerbation of symptoms

Interventions:
- Vitals
- monitor cough & bronchial secretions
- Record GI symptoms before/after therapy

Ipratropium (Atrovent)

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Corticosteroid - PO
- Decreases inflammation
- Caution w/ Diabetes (increases BS)

Use: severe inflammation, MS, asthma, COPD, pulmonary fibrosis

Side effects:
- Weight gain
- Depression, mood changes
- Poor wound healing
- Decreased immunity

Patient teaching:
- DO NOT STOP ABRUPTLY
- Taper off as Dr. directed

Prednisone

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Deficiency of Pituitary hormone (TSH - Secondary hypothyroidism)

Deficiency of TSH decreases secretion of thyroid hormones

S/s:
* Decreased metabolic rate
* Lethargy, forgetfulness, irritability
* Headache, constipation
* Decreased HR, dyspnea
* Swelling/edema, dry/thick skin
* Coarse hair

Tx:
* Hormone replacement therapy - most commonly Levothyroxine (Synthroid)

Hypothyroid

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Abnormal increased synthesis & secretions on the thyroid gland w/ overproduction of the thyroid hormone T3/T4 resulting inexaggeration of the metabolic processes
- Geaves disease & Multinodular goiter most common

S/s:
* Weight loss, hair loss, insomnia
* Intolerance of heat, personality changes
* Tachycardia, increased systolic BP/ HTN
* Afib, increased metabolic rate
* Edema to neck, termors, exophthalamos (eye buldging)

Tx:
* Radiation: destroys thyroid tissue, decreases homrone production
* Surgery: Thyroidectomy
* Drug therapy: Tapazole, PTU, Beta blockers, Iodides, Antithyroids, ect

Hyperthyroid

(Graves disease or Thyrotoxicosis)

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What labs determine the diagnosis of hypothyroid?

Determination of free T4 & TSH
* Free T4 is low w/ hypothyroidism

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Large amounts of thyroid hormone enter the bloodstream during surgery or when patients w/ severe hyperthyroidism develop a severe illness of infection

Approx. 12hrs after surgery is when s/s will occur

S/s:
- Tachycardia, cardiac dysrhythmias
- Vomiting, fever, confusion

Thyroid Storm

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What electrolyte deficiency may occur with a thyroidectomy?

Hypocalcemia

Hypomagnesemia

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low level of calcium in the blood (below 8)
* Results from diarrhea, inadequate dietary intake of vit. D, multiple blood transfusions, ect.

hypoalbuminemia is the most common

S/s:
* Trousseau’s sign
* Chvostek’s sign
* diarrhea
* tingling of fingertips and mouth, severe muscle cramps
* laryngospasms (most severe)
* Cardiac dysrhythmias, seizures

treat with oral or IV supplements

hypocalcemia

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Synthetic hormone - IV,IM, PO

Use: Hypothyroidism, Myxedema coma, Thyroid replacement

Side effects:
* Anxiety, tachycardia
* Angina, HTN,palpitations, tachycardia
* N/V/H, cramps
* Thyroid storm (Adverse)
* Cardiac arrest (Adverse)

Nursing considerations:
* Assess BP & pulses periodically
* Daily weight (same time, clothes, ect)
* Monitor cardiac status
* Monitor vitals & labs T3/T4

BBW: Obesity Tx - Not taken to decrease weight

Education:
* Don’t switch brands unless approved
* Take in AM on empty stomach 30 min before food
* Monitor anticoagulent level & adjust dose PRN

Levothyroxine (synthroid, eltroxin, Levo-T)

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Use: Makes thyroid hormones, bone & brain development in pregnancy

Route: PO, IV

Side effects:
* Burning mouth, throat, and stomach
* N/V/D/fever
* Weak pulse (adverse)
* Coma (adverse)
* Thyroid gland inflammaiton/cancer (adverse)

Nursing considerations:
* Monitor HR
* Monitor for hypersensitivity and GI bleed

BBW: Hepatic disease, No breastfeeding

Education:
* Take prenatals or Iodine supplements if preg
* Report abnormal bleeding

Iodine

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Use: Prep for thyroidectomy, thyrotoxic crisis, hyperthyroidism, & thyroid storm

Route: PO

Side effects:
* N/V/D/H
* Vertigo
* Rash, alopecia
* Jaundice
* Liver failure
* Death

Nursing consideration:
* Assess for weight loss, fever, constipation, & weakness
* Monitor T4 (increases)

BBW: Hepatic disease, No breastfeeding

Education:
* Report redness, swelling, sore throat, mouth lesions, yellow skin/eyes, and dark stool/urine

Propylthiouracil (PTU)

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Inhibits the synthesis of the thyroid hormones

Used after course of PTU

Used w/ a Lugol solution & SSKI (5% iodine & 10% SSKI)

Some relief w/in 24hrs

Can cause discoloration to teeth & gastric upset

Iodides

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Excessive cortisol

Hypersecretion of the adrenal cortex resulting in production of excess amounts of corticosteroids

Causes:
* Endogenous - Pituitary tumor/ Adrenal tumor
* Exogenous - Prolonged admin. of high dose corticosteroids

S/s:
* Moon face, Buffalo hump
* Trucal obestiy, purple straie on abd., breast, or butt
* Hypokalemia, hyperglycemia, poor wound healing
* HTN

Tx/ interventions:
* Drug therapy: Mitotane, Metyrapone
* Radiation: Internally/Externally, destroys tissue
* Surgery: Transsphenodial hypophysectomy (pituitary gland), Adrenalectomy (adrenal tumor)
* Vitals & labs
* Skin assessment
* Educate on wearing a medical band
* Monitor for SI
* Caution on long term use of some herbs (celery, juniper, licorice, & parsley - Causes hypokalemia)

Cushings syndrome

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What labs/tests can you use to Dx Cushings syndrome?

Labs:
* Plasma cortisol levels (High)
* ACTH (high)

Tests:
* Xray
* CT, MRI
* Angiography

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What patient education would be provided for a Pt Dx w/ Cushings syndrome?

Do not blow nose (after surgery)

Monitor bleeding

Wound care (packing)

S/s of infection (Smell breath & packing if drainage)

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What surgical intervention willl occur if their is a pituitary tumor causing Cushings disease?

Transsphenoidal microsurgery

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Removal of adrenal glans

Post-op care:
* Admit to ICU
* Monitor vitals for s/s of shock
* monitor kidneys & strict I/Os
* Give vasopressor to decrease BP & HR

Adrenalectomy

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Destructive disease process affecting adrenal glands that cause deficiencies of cortisol & aldosterone
* Most common cause is auto immune (adrenal tissue destroyed by antibodies formed by immune system)

Secondary adrenal insufficiency is the result of the hypothalamus or pituitary which caused decreased androgen & cortisol production
* Include oituitary tumors, radiation therapy, ect

S/s:
* Orthostatic hypotension
* Skin hyperpigmentation
* Hypoglycemia, hyponatermia, hyperkalemia
* Severe headaches, abd. pain, joint pain
* Wight loss, weakness/fatigue
* Salt cravings

Interventions/Tx:
* Restore fluids/ electrolytes
* Low K diet, high Na diet
* Replace adrenal hormone (Hydrocortisol)
* Assess for addisons crisis
* Carry medical kit & 100mg od IM hydrocortisone/dexamethasone
* Take meds as ordered
* Educate on life long therapy & monitoring

Addisons Disease (Adrenal Hypofunction of pituitary)

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Life threatening emergency caused by insuffieicient adrenocortical hormones / sudden sharp drop in hormones

S/s:
* hypotension
* Tachycardia
* Dehydration (N/V)
* High temp
* Cyanosis
* Progresses to vasomotor collapse/ possible death

Interventions/Tx:
* IV fluids (Isotonic/ Hypertonic/ D5LR)
* Hydrocortisone
* Electrolyes
* Dextrose to restore normal BP

Addisons crisis

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What electrolyte imbalances occur w/ Addisons disease?

Hypercalemia

Hyperkalemia

Hyponatremia

Hypoglycemia

Tip: Hyper before Hypo

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What electrolyte imbalances occur w/ Cushings disease?

Hypocalemia

Hypokalemia

Hypernatremia

Hyperglycemia

Tip: Hypo before Hyper

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Steroid - PO/IV/IM

Use:
* Severe inflammation, UC
* Adrenal Insufficiency, COPD

Side effects:
* Depression, mood changes
* Flushing, Increased appetite
* HF, HTN

Interventions:
* Vitals & labs (CBC,BMP)
* Monitor for depression

Hydrocortisone

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**Steroid - PO** Use: * Adrenal insufficiency * **Addisons Disease** Side effects: * Flushing, *sweating* * **Seizures, HTN** * **Tachycardia**, *hyperglycemia* Interventions: * **Daily weight** * Vitals & labs (**CBC, BMP**)

Florinef (Flurocortisone)

Interferes w/ cortisone production **Cytotoxic substance** that is used as a palliative treatment for inoperable **Use**: Cushings disease

Mitotane (Lysodren)

Used in combination w/ mitotane for enchanced effects Use: Cushings disease

Metyrapone (Metopirone)

What are the 2 types of hypothyroid?

**Cretinism**: * Congenital hypothyroidism * 1/4000 births **Myxedema**: * Denotes severe hypothyroidism in adults * Includes: Edema, to hands/face/feet/eye area (periorbital)

What are some interventions/ education for a Pt who is post-op from a thyroidectomy?

*Voice may be hoarse for 48hrs* *Turn neck slowly*, **Semi- fowlers position to enhance RR & decrease edema** Monitor incision site, labs, & vitals Assess for **hypocalcemia**: * *Chvostek/trousseau* * **Laryngospasm (most critical)** * Tetany, numbness/tingling in fingers/toes **Assess for hemorrhage, resp. distress, & thyroid storm** Lifelong thyroid replacement Assess resp. status

**Inhibits synthesis of thyroid storm by decreasing iodine use** in manufacture of thyroglobulin & iodothyronine Use: **Hyperthyroidism** Side effects: * Drowsiness * N/D/H * Enlarged thyroid * **Jaundice (adverse)** * **Hepatitis, nephritis (adverse)** * **Bone marrow supression (adverse)** * **Thrombocytopenia (adverse)** Interventions/education: * Assess for S/s of hypothyroism * **Monitor vitals & labs (liver function, T3/T4, TSH)** * **Daily weight**/ monitor weight * **Do not breast feed** * *Take as prescribed, DO NOT double dose*

Methimazole (Tapazole)

Fits around the face & directly into the nares by 2 prongs Low flow O2 **1-6L/ min** FiO2: **0.24-0.40 (24-40% O2)**

Nasal Canula

FiO2: **0.35-0.55 (35-55% O2)** Flow rate: **6-10L/ min** * Min flow rate of 6L/min is necessary to prevent any chance of CO2 build up from occuring

Simple O2 mask

FiO2: **0.7 (70%)** Specific flowmeter setting for desired FiO2

Ventimask / Venturi mask

What are some interventions for airway obstruction?

Admin antimicrobuals, decongestant, & expectorants as ordered Deep breathing, & a good cough to break up secretions * ***Antitussive medications** can be given if pt become fatigue by coughing* * *Pts w/ weak cough may need suctioned* Encourage *position change Q2h* to help mobilize secretions Chest physiotherapy, *aerosol therapy* Provide tissue & a receptable for disposal of secretions * **Note amount, color, consistancy** **Auscultate lung sounds frequently** to assess interventions

How do you assess gas exchange?

Monitor vitals, lung sounds, & skin assessment Alert for S/s of hypoxemia: * **Restlessness, tachycardia, tachypnea** ABG meaures, report abnormalities to HCP Monitor hemoglobin (Hgb) * *low levels indicate reduced O2-carrying capacity of RBCs* Elevate HOB, maintain O2 therapy as ordered **Semi-fowlers** to decrease pressure of abd. organs on diaphram so pt can breath easier

What are some interventions for a pt who is fatigued & dyspnic?

Restrict activity for pt w/ pneumonia * Ranges from complete bed rest to limited activity Organize care to prevent overtiring & allow period of uninterrupted rests Provide assistance as needed (ADLs) until pt can do them on own, evaluate tolorance of ADL Keep converations short & encourage visitor to not tire pt

What are some interventions for inadequate nutrition?

Assess clients usual dietary habits to provide baseline information * **Individualize diet** **Monitor weight** same time every day before breakfast using the same scale **Monitor albumin, electrolyes, glucose, & BUN/Cr to detect inadequate nutrition**

What is the typical diet for a Pt w/ pneumonia?

Diet: **High protien, soft diet**

what interventions would you implement for a Pt w/ pneumonia?

**Interventions**: * *Provide diet as ordered* * *Document intake* * Assess w/ feeding if needed * Provide *oral care before & after meals* * Elevate HOB * Arrange tray in attractive & convenient manner * If O2 required, apply NC * If fatigued easily, do frequant small meal

T/F - Iodized salt is the best way to obtain adequate amounts of Iodine in the diet of someone Dx w/ hyperthyroidim

True

Rare chronic condition that causes the body to produce too much urine and feel extremely thirsty Classified as: * **Nephrotoxic** - Inherited defect in which renal tubules of kidney do not respond to ADH, resulting inadequate water reabsorption by kidneys * **Neurologic (central / hypothalamic)** - Can result from hypothalamic tumors, head trauma, infection, surgical procedures (hypophysectomy) or metataic tumors originating in lungs. *Triggered by CVA, aneurysm, or intracranial hemorrhage* * **Dipsogenic** - Disorder of thirst timulation. *When pt ingests water, serum osmolality decreases causing reduced vasopressin secretion*. Other factors are associated by habitual water intake/ psych. conditions

Diabetes Insipidus (DI)

Affects **ONLY epidermis** - mildest S/S: * **Pink/red** * Painful, minor swelling * *Dry* w/o blisters * Blanches * *No vesicles* Healing time: * **3-6 days** * *Superficial layer overskin may peel off in 1 or 2 days* Ex: **Sunburn**

Superficial Burn (1st Degree)

Affects **epidermis & dermis** S/s: * Painful * Large, **moist, weepy blister** * *Pale, pink, red* Ex: **severe sunburn**, large blister

Superficial partial thickness burn (2nd degree)

**Exposed dermis** * Skin, fat, muscle S/s: * Large, **thick walled blister/edema** * *weeping, cherry red* * Painful, **sensative to cold air** Tx: * Hospitalization * monitor for shock * Keep covered

Deep partial thickness burn

Involves **epidermis, dermis, & underlying tissues** *including fat, muscle, & bone* S/s: * Dry, **leathery, eschar** * May be red, brown, black, or white * **Lacks sensation** Tx: * Hospitalization * monitor for shock * Keep covered

Full thickness burn

What are the percentages of each body part involved in the rule of nine? Head (Front & back) Arms (Front & back) Abd (2 sections - upper/lower (Front & back)) Legs (Front & back) Groin (Front & back)

*Head (Front & back)* - **4.5%** *Arms (Front & back)* - **4.5%** *Abd (2 sections - upper/lower (Front & back))* - **9%** *Legs (Front & back)* - **9%** *Groin (Front & back)* - **1%**

When is fluid resuscitation the most critical in a burn pt?

24-48 hrs after injury I/O's strictly monitored to prevent shock

What is the most common skin infection for a burn patient that is found in the U.S?

Methicillin-resistant staphylococcus aureus (MRSA)

Releases chemicals that cause increased capillary permeability * **Tissue injury** caused by **thermal/chemical**/ect. burns **Permits excess Na to enter the cell & allows K to escape into the extracellular compartment** Shift causes edema & decreases cardiac output, & decline in blood volume (Olguria, hypovolemic shock) * **18-36 hrs after injury**, capillary permeability *normalizes & reabsorption of edema fluid begins. Cardiac o/p normalizes & increases to meet increased metabolic demands* *Decreased blood flow* a **ileus may occus** *Stress* ulcer may occur (**Curling ulcer**)

Pathophysiology of Burn injuries

What is the most common skin infection for a burn patient that is found OUTSIDE of the U.S?

Acinetobacter

What lab should you draw for a military pt who has returned to the U.S for treatment?

Culture on admission to rule out any infection (*Acinetobacter* / MRSA)

**Begins when burn starts & ends when fluid shifts stabilize** * First 12-48 hrs critical S/s: * *Hemoconcentration* (Increased Hct) * *Acute renal failure* (ARF), **olguria** * **Hyperkalemia, hyponatremia** * **Hypovolemic shock** * **Metabolic acidosis** * Risk of cardiac dysrhythmias Tx: * **ABCs, ABGs** * Start IV (PIV/central) * **Insert cath. & NGT, tetanus** prophylaxis * Pain managment/assessment & **tetanus** * Clean/debride wounds, topical antibiodics * **Blood for baseline** blood studies (*Hct, electrolytes*) * Assess for **smoke inhalation injury** - intubate if needed * **Hydrotherapy** (softens eschar), **escharotomy** * ROM, **skin graft**

Emergent / hypovolemic stage of burn injury (1st of 3 stages of burn injuries)

Begins 48-72 hrs after fluids stabilize * Some marked when all but 10% of burn wounds are closed or until all wounds are closed S/s: * **Hemodilution** (decreased Hct) * CHF risk * **Metabolic acidosis** * **Hypokalemia, hyponatremia** * **Circulatory overload / hypervolemia** *(Main concern)* * **Polyuria** (**kidney problem** - *Insert fowly cath*)

Acute/Diuretic stage of burn injury (2nd of 3 stages of burn injuries)

Goal: Prevent infection & return pt to "normal" * Can take months Overlaps w/ acute stage * Starts when pt is stable PT/OT begin tx Interventions: * Restore independence * Adjusting to body image * Preventing contractures * Coping

Rehabilitation stage of burn injury (3rd of 3 stages of burn injuries)

Which burn may blister, peel & heal w/ minimal long-term effects? A) Partial-thickness B) Full-thickness C) Deep Partial-thickness ## Footnote Chpt 57 pg 1165

A) Partial-thickness

Which burn is often covered by a thick, leathery layer of burned tissue/eschar that shelters microorganisms & inhibits healing? A) Partial-thickness B) Full-thickness C) Deep Partial-thickness ## Footnote Chpt 57 pg 1165

B) Full-thickness

Removal of debris & necrotic tissue from a wound * **Eschar must be removed** or healing will not take place Types: * Surgical excision: Escharotomy * **Mechanical**: Removing eschar/ necrosis w/ scissors/ forcepts * **Enzymatic**: Use of *topical medications* containing enzymes capable of *dissolving necrotic tissue*. (**Cause pain & bleeding**)

Debridement

What is the goal of wound care after a burn injury?

Promote healing Prevent infection Controll heat loss Retain function Minimize disfigurement

What are the 2 standard wound care treatments for patients w/ burns?

**Open care method**: * *Topical antimicrobials but no dressings* * Less restrictive & simpler but provides *increased opportunity for loss of fluid & heal through wounds surface* **Closed care method**: * Topical antimicrobials but covered by dressings Examples of Topical medications: * Silvadiazine (**Silvadene**) * **Mafenide acetate (Sulfamylon)**

What is the preferred IV solution for burn patients?

Lactated Ringers (LR)

Surgical procedure done by making an **incision through the eschar to relieve underlying pressure**, *measuring the pressure in the compartment, closed space nerves, muscle tissue, & blood vessels* **Used to relieve circulatory construction**

Escharotomy

What are 3 different types of grafts used for plastic surgery?

***Autograft (skin graft)*** * A burn **covered by the pts own skin** * *preferred sites are thigh or butt* removed by **dermatome** (tool used to remove graft) ***Split-thickness graft*** * A type of **skin graft applied to a thin layer of skin** * May be an intact layer of skin or meshed graft * *Meshed grafts have multpile tiny slits to allow skin to be stretched to cover a large area* ***Full thickness graft*** * A type of **skin graft used for deep burns to face, neck, & hands** * *Include subq tissue & skin* * Cosmetically provied better results

What are some nursing interventions for a pt w/ a skin graft?

Assess site for bleeding *Immobilization of affected area for 3-7 days to ensure attachment of the graft* Remove dressings and allow wound to air dry 24 hrs after surgery * Can use heat lamp to dry area * While site dries, a fine-mesh gaze or Zeroform will lift off of the skin

What s/s should you notify the HCP immediatley for in a client w/ burn injuries?

**Take vitals first** & report: * Restlessness, Tachypnea (**Hypoxia**) * Bounding pulse, HTN (**Fluid volume excess**) * Tachycardia, hypotension (**Hypovolemia**) * Fever, Tachycardia (**Infection**)

What intervention should be done ASAP during an inital assessment of a stable pt w/ a burn injury?

Height & weight

Occurs w/ flame burns or from being trapped in an enclosed space filled w/ smoke Pts *can have pulmonary edema resulting in resp. failure* S/s: * *Facial burns* * Redness, **swelling of pharynx** * Restlessness, Tachypnea (**Hypoxia**) * *Dyspnea, sooty sputum* * Death Interventions: * **Protect airway** (intubate) and *evaluate for resp. distress syndrome* * Apply O2 * *pulmonary function studies* done before discharge to complete lung function

Smoke inhalation

Carbon monoxied displaces O2 on _____ , so the blood is unable to transport O2 into the tissues A) Hgb B) Hct C) WBC D) platelets

A) Hgb

What type of pain meds would you give to a burn pt?

Morphine, fentanyl, & other opioids * Pre-medicate priot to any procedure (Required)

What do the letters stand for in R.A.C.E & P.A.S.S?

**R**: Rescue **A**: Alarm **C**: Contain fire **E**: Extinguish/ Evacuate **P**: Pull **A**: Aim **S**: Squeeze **S**: Sweep

2 Types: * **Aesthetic (cosmetic)** procedures: Performed to improve apperance * **Reconstructive** procedures: Performed to correct abnormalities/ disfigured scars Ex: * **Rhytidectomy** (*facelift*): Remove wrinkles & tightens sagging tissue * **Blepharoplasty**: Removal of excess tissue arround the eyes imparing vision, aesthetic procedure * **Chin implants**: Done by placeing a prosthesis to correct a receding chin * **Rhinoplasty**: Nose job, alters shape/size * **Abdominoplasty**: Excess skin & adipose tissue are removed & abd. muscles are tightned * **Breast augmentation**: Breast enlargment * **Breast reduction**

Plastic surgery

What is the purpose of a reconstructive procedure?

Repair disfigured scars Restore body contours after radical surgery (Mastectomy) Restore features damaged from trauma/disease Correct developmental defects

How would you educate a burn patient?

Practice *good hygiene & avoiding others w/ infections* **Eat 6 small frequent meals a day plus supplements** * Make sure to eat all food on plate *Change positions, exercise, & use splints to **help prevent stiffening of the joints, skin breakdown, & blood clots in legs*** Pain managment * Contact HCP if pain is uncontrolled Protect grafts from pressure & shearing Clothing, make-up, hairpieces, & prostheses can be used to conceal scars & improve apperance *Adaptive devices are avalible to compensate for disabilities* *Rehabilitation resources will be provided once the acute phase has passed*

A burn pt on the unit is showing signs and symptoms of inadequate circulation. What signs and symptoms would you see?

S/s: * **Hypotension** d/t blood volume not being maintained causing *impaired tissue perfusion* * **Tachycardia**, *decreased urine o/p* (blood volume) * *Cool, pale, cyanotic skin* (impaired tissue perfusion) * **Restlessness**, *confusion* (impaired tissue perfusion)

what interventions would be in place for a burn pt who is showing signs and symptoms of inadequate circulation?

Monitor vital (BP & HR especially) Monitor cardiac o/p (Pulmonary artery cath) Monitor I/O, strict I/O Admin IV fluids as ordered w/ close continuous monitoring of fluid status Neuro assessment / skin assessment

A burn pt on the unit is showing signs and symptoms of fluid volume excess. What interventions would the nurse perform?

Monitor vitals for HTN, dyspnea, & full, bounding pulse (increased risk for heart failure) Measure urine o/p & compare to intake Aminister IV fluids as ordered & monitor pt closely Document data collected during assessments

what interventions would be in place for a burn pt on who's temp is declining?

Monitor temp to detect changes Keep room about **76 degrees on the floor an 85 degress or higher on ICU** Attempt to *limit body surface exposure during wound care* Body heat loss may increase is pt is on *air-fluisized bed* - **monitor temp of the bed**

what interventions would be in place for a burn pt who is showing S/s of inadequate nutrition?

**Consult w/ dietitian** about nutritional needs & preferences * *Calorie needs may be as much as twice the pts baseline needs* Try to create an environment conductive to eating & encourage the pt to eat all food served *Provide tube feeding or total parenteral nutrition (TPN)* to meet calorie needs if needed Encourage pt to drink *protein drinks rather than water* Calorie count at bedside to ensure pt is consuming enough calories to meet increased metabolic needs associated w/ burns

what interventions would be in place for a burn pt who is showing S/s of infection?

Monitor for local infection * Pus, foul odor, increased redness Strict handwashing from anyone who enters the room * Infection can come from anywhere/anyone *Shave body hair around wound w/ exception of eyebrows (can grow back disorganized)* *Carry out wound care as ordered or according to specialty unit*

Used to avoid / treat skin infections in patients with burns Side effects: * Back, leg, or stomach pain * *Blistering, peeling, lossening skin* * **Blue/green to black skin discoloration** (*dark urine*) * Increased light sensitivity (especially w/ burns on large areas) * **Light colored stools** * Lower back pain

Silver Sulfadiazine

Used to treat severe/serious bacterial infections Side effects: * **Hearing loss**, roaring sound in ear * Severe/ongoing **dizziness** * Weak, shallow breathing * **Numbness**/ tingling * Muscle tightness/contraction

Garamycin

Opiod / narcotic Relieves acute/ chronic / mod-severe pain **Can be used for pre-op or supplement to anesthesia** Side effects: * *Noisy breathing, sighing, shallow breathing, sleep apnea* * Confusion, extreme happiness or sadness * *Severe weakness or drowsiness* * *Light-headedness, dizziness* * *Vomiting, anorexia* Adverse effects: * **Resp. depression** * **Urinary retention** * *Excessive use / abuse* * *Increased effect w/ CNS depression*

Dilaudid

**Beta-blocker** Affects the heart & circulation (blood flow through arteries & veins) Used to treat: * Tremors * **Angina (CP)** * **HTN** * Heart rhythm disorders * Heart / circulatory conditions Side effects: * **Bradycardia** * **Hypotension** * *Light-headedness* * Wheezes * Liver problems Interventions: * **Always take BP** before admin.

Propranolol (Inderal)

**Opioid** - **IV, TD** (patch), nasal spray, buccal (Gums/cheek) Used for *mod-severe pain* Side effects: * **Bradycardia** * Euphoria * Sedation, **resp. depression** * Dizziness * **Hypotension**

Fentanyl (Subliminze)

When *water is less than normal amount in the body* S/s: * *Hypotension* * *Weak, rapid pulse* * Decreased temperature * Weight loss * *Decreased urine output* Tx: * Correct the cause * Fluid replacement & electrolyte replacement * Daily weights * **Monitor I/O** * Encourage oral fluids

Fluid volume deficit (FVD) / Hypovolemia

When there is **too much water in the body** S/s: * Edema and or pulmonary edema * Weight gain * *Pupils will be sluggish to light* * **Hypertension** * **Increased respiration (crackles)**

Fluid volume excess (FVE) / Hypervolemia

Decreased sodium Causes: * excessive intake of H2O * **loss of sodium, diarrhea, vomiting** S/s: * headache, fatigue, * *muscle weakness, cramps, weakness* * confusion * *hypotension* Tx: * fluid restriction * **NS or LR, Lasix** * increased sodium in diet * Monitor I&O, lab results, & VS * Safety precautions

Hyponatremia

Increased sodium S/s: * Thirst * Flushed skin, * Dry mucous membranes, low urine output * Increased heart rate * Convulsions * Flushed skin Tx: * IV or fluid replacement * Low Na diet * Monitor IV infusion * Reinforce diet (Na restriction) * Monitor Renal function tests

Hypernatremia

Decreased K Causes: * Vomiting, diarrhea * NG-tube suction * DKA * Diuretics S/s: * Vomiting, diarrhea * Muscle cramps * Dysrthythmias * Abdominal distention * Hypotension Tx: * Correct the problem * Replace K (Give PO/IV) * Monitor heart rate & rhythm * High K diet

Hypokalemia

Increased K Causes: * Decreased renal function * Metabolic acidosis * Burn patients S/s: * Bradycardia, then tachycardia * Cardiac arrest * Muscle cramps * Weakness Tx: * K restriction * IV calcium gluconate * IV insulin * Kayexalate (PO) * Place on heart monitor * Monitor labs New drugs used: * Veltassa * Zirconium

Hyperkalemia

Low Ca S/s: * Neuromuscular irritability * Tingling sensation to face, hands & lips * Muscle twitches, muscle cramps

Hypocalemia

T/F: Hypercalcemia is a complication of certain cancers

True

A systemic inflammatory response to a documented/ suspected infection S/s: * **Hypotension, tachycardia** * Fever, elevated WBCs * Lethargic * **S**hivers/very cold * **E**xtreme pain/general discomfort * **P**ale/discolored skin * **S**leepy/*difficult to arrouse, disoriented* * "**I** feel like i might die" * **S**OB, **tachypnea** Tx: * **IV antibiodics** * *NS bolus (over an hour)* * Antipyretics (*Tylenol & Ibuprofen*)

Sepsis

Inadequate tissue perfusion resulting in impaired cellular metabolism Derives cells of essential oxygen & nutrients forcing cells to rely on anaerobic metabolism Stages: **1. Preshock** * Tachycardia & peripheral vasoconstruction may maintain BP * Mild elevation of lactic acid levels (Observe tachycardia & slight BP increase) **2. Shock** * S/s of organ dysfunction become apparent as compensatory mechanisms become overwhelmed **3. End-organ-dysfunction** * Multiple organ failure and death will occur if not corrected * Blood vessel constricts & prevents blood flow to organs

Shock

What are S/s of the End-Organ Dysfunctional stage of shock?

Decreased mental status Hypotension Tachycardia Elevated temp Cyanosis, Necrosis Decreased urine O/P

Occurs when the **circulating blood volume is inadequate to maintain the supply of oxygen & nurtients to body tissue** Results from blood loss or extreme dehydration Causes: * **GI loss d/t severe diarrhea, blood loss, or vomiting** * Diuresis (urinating) from diabetes insipidus or too much diuretic * DKA S/s: * Tachycardia * Hypotension * Tachypnea * Decreased urine output * Decreased central venous pressure Tx: * IV fluids (**NS/LR**) replacement * *If blood loss, may have transfusion of blood or blood products* * Correct the cause * *If dehydration is cause, replace electrolytes & fluid replacement* * Oxygen

Hypovolemic shock

Caused by ***pathogens (bacteria, fungi, viruses) that release toxins that case blood vessels to dilate**, thereby decreasing vascular resistance & increasing capillary permeability* S/s: * Hypotension * Olguria * **Metabolic acidosis** * Acute encephalopathy * Coagulation disorders * Extreme elevated temperature * *Elevated lactic acid* * **Multiple organ dysfunction syndrom (MODS - worst case)** Tx: * IV antibiodics (**Zosyn, meropenem**) * Fluids (NS) * Corticosteroids * **Antipyretics (Tylenol)** * **Vasopressors (Epinephrine, norepinephrine & dopamine)**

Septic Shock

Heart fails as a pump **Decrease in myocardial contractility results in decreased cardiac output & impaired tissue perfusion** Difficult to treat Causes: * Malignancies, uremia, idiopathic pericarditis, infectious disease S/s: * Fluid collects in pericardial sac, causing compression of the myocardium resulting reduced cardiac output & iscemia

Cardiogenic shock

*Severe allergic reaction that results in relase of chemicals that dilate blood vessels* & increase capillary permeability Causes: * Food * Drugs, Vaccines, Contrast Media * Mold, Pollen * Insects S/s: * SOB, unable to swallow * **Hives, itchy rash** * **Redness, swelling** * Cramps, N/V/D * **Drop in BP** * **Increased tachycardia, weak pulse** * Feeling faint

Anaphylactic shock

*Vasoconstriction* in skin, viscera, & mucous membranes * Relaxation of bronchi * **Given IV/IM** Use: * Anaphylactic shock * Hypotension * Bronchial construction Side effects: * Hypertension * Tachycardia * Dysrthymias Interventions: * Monitor vitals * Monitor IV site

Epinephrine (Adrenaline)

Catercholamine * **Given IV** Use: * **Shock (Cardiogenic/septic)** Side Effects: * Palpitations * Hypotension * N/V/D/H * Anxiety Nursing interventions: * Vital signs Q15 min * Cardiac monitor * Monitor I/O * monitor angina/ HF

Dopamine

Anti-infective (broad spectrum) * **Given IV** Uses: * Resp. Infection * UTIs * E-coli Side effects: * Lethargy * N/V * Rash * **Liver damage** * **Steven-Johnson-syndrome** Interventions: * Monitor vitals * **Monitor labs: AST, ALT, Renal function**

Zosyn (Piperacillin)

Anti-infective Use: * Multiple Infections Side effects: * N/V * Rash * Hepatotoxicity * Gastritis * Jaundice Interventions: * CBC * Monitor liver function * Monitor vital signs

Meropenem (Merrem)

What are the antidotes for the following medications? Warfarin/Coumadin Heparin Tylenol/Acetominophen Opioids Lovenox

Warfarin/Coumadin - **Vitamin K** Heparin - **Protamine Sulfate** Tylenol/Acetominophen - **Mucomyst** Opioids - **Narcan** Lovenox - **Protamine Sulfate**

Growths found in **sigmoid & rectal regions of colon** * Third most common cancer in the U.S Cause remains unknown Risk factors: * Adenomatous polyps * *UC, Diverticulitis* * Heredity * High fat, low fiber diet * Smoking S/s: **Right side** * Right sided abd. pain * Vage cramping until advances * Anemia, unexplained blood loss * Weakness & fatigue **Left Side** * Diarrhea or constipation * Blood in stool * May report feeling full or pressure in the abd. or rectum Medical Tx/Interventions: * Surgery - depending on location * **If rectum is removed, permanent colostomy will be created** * **Chemotherapy done post-op, radiation** * IV antibiodics * Treat pain * Assess & monitor vitals * coping w/ change * Sexual dysfunction

Colorectal Cancer

Where are colostomies placed & what type of stool do they collect?

Ascending colon - Liquid stool Transverse colon - Pasty stool Descending & sigmoid - Semi-formed

How would you perform nursing care for a pt with a colostomy?

Perform focus assessment Assess the capatability to manage colostomy self-care Irrigate the colostomy everyday to mantain regular & controlled elimination Administer prescribed medications Monitor labs Help with coping

What dietary teachings would you teach a for a pt w/ an ostomy?

Avoid Cabbage, alcohol, onions, & eggs * Cause gas Avoid corn, popcorn, seeds, & nuts * Especially w/ ileostomies

Most common malignancy of the urinary tract Causes: * Chemical carcinogens, smoking, aniline dyes found in industrial compounds, & tryptophan all have been implicated in the development of bladder cancer S/s: * *Painless* (most common) * *Intermittent hematuria* * *Bladdered irritability* * infection w/ dysuria * Frequency & urgency * Decreased stream of urine Tx: * Malignancy is present * **Cystectomy** is surgery of choice * Chemotherapy, radiation * Immunotherapy * Urinary diversion * **Laser photocoagulation** (Intense beam of light (argon laser) that destroy tissue)

Bladder cancer

What tests would you run to Dx bladder cancer?

Urinalysis with urine cytology Cystoscopy to visualize the bladder & obtained biopsy CT/MRI Intravenous pyelogram (IVP) CT-urogram Chest radiography Radionuclide bone scan

What are nursing interventions for a post-op pt who underwent elimination surgery?

**Assess bowel sounds & abdomen in general** *Assess stool* *Assess stoma site for s/s of infection, bleeding & pain* Monitor & chart I/O Teach pt about coping Cleans site daily & as needed Empty pouch & irrigating bag Change pouch daily or as needed per order Splinting the incision Antibiodics **Ambulation after surgery** *Splinting w/ pillow while coughing* **Irrigating the stoma can help train the bowel**

Antibiodic * **Vesicant** 2 toxicities: * **Nephrotoxic** - Toxic to kidneys * **Ototoxic** - Can't hear well Should monitor peak & trough **Monitor BUN/Cr** Side effects: * Nephrotoxcicity * Red man syndrome Assess for hearing problems (ototoxicity)

Vancomycin

**Used for diarrhea** Combinations meds: * *Atropine* = anticholinergic, can be used to dry things * *Diphenoxylate* = decrease spasms & slows the gut Know it works when there is no diarrhea

Lomotil (Atropine/Diphenoxylate)

Antibiodic Used for skin, vaginal, & GI infections Side effects: * Dark urine * Metallic taste * GI upset (No alc. puts GI in distress) * Diarrhea

Flagyl (Metronidazole)

**Used to prep the bowel** for colonoscopy or surgical procedure * NPO at midnight Tips: * *Make icy cold - don't freeze* * Do NOT use straws * Clear liquid diet

Golytely (Polyethylene Glycol)

Give SubQ in fatty tissue Stimulates production of RBCs Use: * Treats anemia * Anemia related to chemo

Procrit /Epogen (Epoetin Alpha)

Given SubQ Stimulates production of neutrophilic white cells * Reduces neutropenia interval in bone marrow transplantation

Neupogen (Filgramtim)

What are the 9 steps for suctioning traches?

1. Sterile tech. & Face shield 2. Lube on tubing 3. Oxygenate patient before suction 4. Open vent during cath. insertion 5. Suction intermittently while rotating and moving cath back and forth while withdrawling 6. Suction no longer than 10-15 seconds 7. Rinse cath suctioning w/ NS 8. Oxygenate patient after suction 9. Document status before & after

What are the 10 steps for proper trach care?

1. Standard precaution 2. suction before removing old dressings 3. Don sterile gloves 4. Use sterile solution (NS) to clean the inner cannula 5. Rinse and dry inner cannula. Reinsert into outer cannula 6. Cleans stoma and surrounding skin 7. Dont get solution into stoma 8. Change tracheostemy ties 9. Replace trach dressing w/ precut pad/ gauze 10. Tie the ties at sides

What are 4 nursing responsibilities for a patient who has a trach?

1. Keep airway clean 2. Keep inner cannula clean 3. Prevent impairment of surroundings 4. Provide patient a means for communication

What are nursing interventions for a patient who has a trach?

Evaluate - Look for **secretions & suction** Provide - **Constant airway humidification/ oxygenation** Change/clean - All **equipment q8h or PRN** Remove - **Water** condensed in equipment tubing Provide - **Mouth care** (moisturize lips), communication board/ tablet, & safety

What are the 10 care essentials for patients on a vent?

1. Review communication board 2. Check vent settings (**resp rate, tidal volume, peak (PIP)**) 3. Suction appropriately 4. Assess pain & sedation needs 5. Prevent infection 6. Prevent hemodynamic instability 7. Manage airway 8. Meet nutritional needs 9. Wean off vent 10. Education

What 6 interventions would you provide for a patient on a vent?

1. Monitor settings to ensure they match 2. Ensure high & low pressure alarms are set 3. Have manual resuscitator & O2 avalible 4. Don't allow water to accumulate in tubing 5. Monitor vitals & breath sounds, suction PRN 6. Establish communication methods

What are the 3 main things community nursing focuses on?

1. Improving the health status of communities or groups of people 2. Screening for early detection of disease 3. Providing service for people who need care outside of acute care setting

T/F: Home health nursing blends community health nursing & direct nursing

True

Process of restoring an individual to the best possible health & functioning after a physical or mental impairment Concepts: 1. Process of restoration 2. Impairment is disturbance in functioning 3. Disability is measurable loss of function Goal: * Maximize quality of life of pt * Assist pt w/ adjusting to alternate lifestyle * Directed towards promoting wellness & minimizing complications * Assist pt in attending the highest degree of function & self-sufficiency * Assist pt w/ home & community reentry

Rehabilitation

How does impairment effect motor functioning?

Impairment may either be physical or psychological Ex: Paralysis of limbs d/t stroke or mental impairment (AD)

How does a disability effect motor functioning?

Measurable loss of function & usually delineated to indicate a diminished capacity for work Ex: Injured back may be classifie as 50% disabled

What are the 4 levels of diability?

1. **Slight limitation** in one or more ADL, *able to work* 2. **Moderate limitation** in one or more ADL, *may work but need modifications* 3. **Severe limitation** in one or more ADL, *unable to work* 4. **Totally disabled**, characterized by nearly complete dependence on others for assistance w/ ADL, *unable to work*

Who is included in, but not limited to, the rehab team?

The patient Dr Rehab RN/LPN PT/OT/ST Recreational therapist Chaplin SW Dietician Pharmacy

Slowing down initation & execution of movement (bradykenesia), increased muscle tone (rigity), tremors, & impaired postural reflexes S/s: * Tremors * Bradykenesia * Rigity * Shuffling * Pill roll * Dementia * Speech changes

Parkinsons

Antiparkinsonian Use: Parkinsons, restless leg syndrom Helpts tremors & rigidity Side effects: * Hypotension * Severe depression * Hallucinations * Urinary retention * Dry mouth Nursing intervention: * Assess for tremors, pill rolling, drooling, rigidity, shuffuling gate * Monitor BP, RR, & mood

Carbidopa-levodopa (Sinemet)

Antiparkinsonion, antiviral Use: Prophylaxis or Tx of influenza A, parkinsons Side effects: * Change in mood, suicidal thoughts * Vision & color changes, eye pain * Confusion, hallucinations * Seizures * N/V Interventions: * Monitor labs: BUN. CBC, Cr * Monitor vitals * Monitor for decrease S/s of parkinsons

Symmetrel / Amantadine

Class: Erectial agent, Antihypertensive, vasodialoator Use: Erectile dysfunction (Viagra), HTN (Revatia) * Women may use too Side effects: * Sudden death * MI, TIA, CP * Flushing * Orthostatic Hypotension * Dysrhythmias * Headache, dizziness, nasal congestion Interventions: * Monitor vital signs * Monitor for vision loss * Maintain safety (bad if erection does not go away) BBW: Contradiction w/ people who take nitroglycerin/ nitro paste

Sildenafil (Revatio, Viagra)

Class: Sedative / hypnotic Use: Insomnia, skeletal muscle relaxer Side effects: * Dizziness, drowsiness, sedation * Poor coordination * Resp. depression Interventions: * Maintain safety * Monitor vitals (RR) * Monitor sleep pattern * Teach not to drink alcohol

Zolpidem (Ambien)

Anticoagulant **Inhibits activity of Vit K, which activates certain clotting factors** *Use*: DVT, PE, embolization from Afib or heart valve replacements BBW: Monitor for bleeding Lab value (PT/INR): 2-3 * *Less than 2 = give* * *Greater than 3 = hold* **Antidote: Vit K** * Teach to avoid dark green leafy foods

Warfarin (Coumadin)

Anticoagulant - **SubQ (in abd)**, IV push, infusion Use: DVT after hip replacement/ abd surg, AM, combined w/ aspirin (ASA) Common adverse effects: * Hematoma, bleeding at site Serious side effects: * Bleeding * Thrombocytopenia **Monitor PTT, platelets, hematocrit** **Antidote: Protamine sulfate**

Low-molecular- weight **Heparin** (LMWH)

What are the general principles of emergency care?

**Remain calm** *Survery scence* Primary survey (detect and further prevent life-threatening injuries) Secondary survey (conducted once the patient is relatively stable and includes fact-finding about what may have happened) First aid Tx Assessments & interventions done quickly & efficiently to identify & treat needs immediately **Priority: Preserve life & minimize effects of injuries**

During disaster planning, what 2 orginizations can you expect to quickly move in to help?

American Red cross Sulvation Army

Extraordinary situation that is brouhgt about by events w/in the health care facility Ex: Fire

Internl Disaster

Originates outside facility & result in a influx of casualities brought to the facility Rely on outside agencies for help: * Fire department * Police * Health department * County * Hospital Ex: Explosion in chemical plant, tornado, train accident

External Disaster

**Deliberate release of pathogens to kill / injure people** * *Easily spread* - potential to cause many deaths Most common biologic agents: * Anthrax * Botulism * Plague * Smallpox * Tularemia HCPs must know how to protects themselves & others * Staff should know how to obtain PPE & the precaution types

Bioterrorism

How do you DON PPE from the very begining? TIP: Start from identifying the type of isolation

Identify and gather the proper PPE * *Blood-borne* = gloves, a mask, protective eyewear / goggles * *Airborne* = gloves, gown, & N95 * *Droplet* = gloves, gown, & mask Hand hygiene Gown Mask Face shield or goggles Gloves Enter the patient's room

Stay in one area/country * Does not cross oceans Ex: Smallpox, measles, polio Nursing responsibilities: * Recognize casualty of biologic attack & carry out roles assigned during the attack

Epidemic

Disease that emerges rapidly at an uncharacteristics time or is an unusual pattern * Crossss continents Ex: COVID, Flu Nursing responsibilities: * Recognize casualty of biologic attack & carry out roles assigned during the attack

Pandemic

Antiplatelet Use: CVA, post MI, TIA Side effects: * Dizziness * HTN * Bleeding * Diarrhea * Anemia

Plavix (Clopidogrel)

**Nonopioid analgesic, NSAID, antipyretic, antiplatelet** Use: mild pain, RA, OA, TIA, CVA, post mis, angina, kawasaki disease Side effects: * Bleeding * Tinnitus * N/V * Rash **BBW: Do not give to children (Reyes syndrome)**

Aspirin (ASA)

Antihypertensive, ACE inhibitor Use: HTN, HF, acute MI Side effects: * Vertigo, dizziness * Depression * Headaches * Nasal congestion * N/D

Lisinopril (Prinivil)

185 FINAL EXAM Flashcards

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