250 Study Cards for the Final Flashcards
(117 cards)
1
Q
What is the difference between head-to-toe, shift, and focused assessments?
A
The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition. Any unusual findings should be followed up with a focused assessment specific to the affected body system. A focused assessment may also be done when there is a specific complaint. Shift assessments will be agency specific and may involve vital signs, etc.
2
Q
What is the Z-track method?
A
The Z-track method, a technique for pulling the skin…is recommended for IM injections.
3
Q
What are the benefits of the Z-track method?
A
It prevents leakage of medication into subcutaneous tissues, seals medication in the muscle, and minimizes irritation.
4
Q
How do you perform the Z-track method?
A
- Pull the overlying skin and subcutaneous tissues approximately 2.5 to 3.5 cm (1 to inches) laterally to the side with the ulnar side of the nondominant hand.
- Hold the skin in this position until you have administered the injection.
- Inject the needle deeply into the muscle…
- Keep the needle inserted for 10 seconds to allow the medication to disperse evenly.
- Release the skin after withdrawing the needle.
- This leaves a zigzag path that seals the needle track wherever tissue planes slide across one another.
- The medication is sealed in the muscle tissue.
5
Q
How do medications enter the body tissues and circulatory system when using the pareteral route?
A
By injection
6
Q
What are advantages of the parenteral route of medication administration?
A
- Can be used for drugs that are poorly absorbed, inactive or ineffective if given orally
- The IV route provides immediate onset of action
- The intramuscular and subcutaneous routes can be used to achieve slow or delayed onset of action
- Patient concordance problems can be avoided
7
Q
What are disadvantages of the parenteral route of medication administration?
A
- Staff need additional training and assessment
- Can be costly
- Can be painful
- Aseptic technique is required
- May require additional equipment, for example programmable infusion devices
8
Q
What are the four most common parenteral routes?
A
- Subcutaneous
- Intramuscular
- Intradermal
- Intravenous
9
Q
Define subcutaneous injection.
A
Injection into tissues just under the dermis of the skin.
10
Q
Define intramuscular injection.
A
Injection into the body of a muscle
11
Q
Define intradermal injection.
A
Injection into the dermis just under the epidermis.
12
Q
Define intravenous injection or infusion.
A
Injection into a vein.
13
Q
What can the nurse do to promote patient comfort with parenteral injections?
A
- Use the correct technique
- Rotate injection site to prevent indurations or abscesses
- Explain the benefits of the injection to the patient
- Position the patient so the muscles are relaxed
- Use distraction
- Insert and remove the needle smoothly and quickly
- Hold the syringe steady during the procedure
- Inject medication slowly but smoothly
- Provide education about procedure
14
Q
Do ampoules contain single or multiple doses?
A
Single
15
Q
Do vials contain single or multiple doses?
A
Both
16
Q
What do you need to remember to write on a multi-use vial?
A
The date the vial is opened.
17
Q
What influences the needle size selection for intramuscular injections?
A
- Viscosity of the medication
- Injection site
- Patient’s weight
- Amount of adipose tissue
18
Q
Which medications are only given intramuscularly?
A
Hepatitis B and tetanus, diphtheria, and pertussis (Tdap) immunizations
19
Q
What does the concept of Fluid and Electrolytes refer to?
A
“Process of regulating the extracellular fluid volume, body fluid osmolality, and plasma concentrations of electrolytes”
20
Q
How is water balanced in the body from a physiological perspective?
A
Lean body mass is rich in water, while adipose tissue has a lower percentage – because of this, a person who is overweight or obese has a lower % of water mass overall compared with someone who is lean or muscular. – so, women typically have less and elderly have less due to decreased muscle mass due to age. Children tend to have higher.
21
Q
Name of a solution with the same osmolarity as blood plasma.
A
Isotonic
22
Q
Name of a solution with higher osmotic pressure; pulls fluid from cells causing them to shrink.
A
Hypertonic solution
23
Q
Name of a solution with an osmotic pressure lower than plasma; moves fluid into the cells causing them to enlarge
A
Hypotonic
24
Q
What does the concept of fluids and electrolytes refer to according to Giddens?
A
Process of regulating the extracellular fluid volume, body fluid osmolality, and plasma concentrations of electrolytes
25
What percentage is water in the normal adults body?
60%
26
Why is water % less in women and obese people?
Have more adipose tissue and adipose contains less water.
27
Define intracellular fluid.
the fluid within the tissue cells, constituting about 30-40% of the body weight.
28
Define extracellular fluid.
* The interstitial fluid and the plasma, constituting about 20% of the weight of the body.
* Sometimes used to mean all fluid outside the cells, usually excluding transcellular fluid.
29
Where is extracellular fluid found?
* Vascular compartment (plasma)
* interstitial space
30
What is the normal extracellular concentration of sodium in the adult body?
135 - 145 mmol/L
31
What is the normal intracellular concentration of sodium in the adult body?
10-14 mmol/L
32
What is the normal extracellular concentration of potassium in the normal adult body?
3.5-5 mmol/L
33
What is the normal intracellular concentration of potassium in the normal adult body?
140-150 mmol/L
34
What is the normal extracellular concentration of chloride in the adult body?
98-106 mmol/L
35
What is the normal extracellular concentration of bicarbonate in the adult body?
24-31 mmol/L
36
What is the normal extracellular concentration of calcium in the adult body?
2.1 - 2.6 mmol/L
37
What is the normal extracellular concentration of phosphorus in the adult body?
0.8-1.45 mmol/L
38
What is the normal extracellular concentration of magnesium in the adult body?
0.75 - 1.25 mmol/L
39
What is the normal intracellular concentration of chloride in the adult body?
3-4 mmol/L
40
What is the normal intracellular concentration of bicarbonate in the adult body?
7-10 mmol/L
41
What is the normal intracellular concentration of calcium in the adult body?
\<0.25 mmol/L
42
What is the normal intracellular concentration of phosphorus in the adult body?
75 mmol/L
43
What is the normal intracellular concentration of magnesium in the adult body?
variable
44
Define osmosis.
45
What is the normal range of serum osmolality?
275-295 mOsm/kg
46
Which types of solutions have the same osmotic pressure as blood?
Isotonic (isomolar)
E.g. Normal saline or 0.9% NaCl, Lactated Ringer's solution, 5% dextrose in water (D5W)
47
Which solutions have lower osmotic pressure than blood?
Hypotonic (hypo-osmolar)
48
Which solutions have higher osmotic pressure than blood?
Hypertonic (hyper-osmolar) solutions.
49
\_\_\_\_\_\_\_\_\_\_\_\_ solutions pull fluid into the vascular space by osmosis, resulting in an increased vascular volume that could result in pulmonary edema.
A. Hypotonic B. Hypertonic C. Isotonic D. Osmotonic
B. Hypertonic
50
Define homeostasis.
* • State of equilibrium in the body
* •Naturally maintained by adaptive responses
* Body fluids and electrolytes are maintained within narrow limits
51
List the forms of fluid intake.
* Oral Fluids•
* Foods•
* Tube Feedings•
* IV fluids•
* Metabolism/Oxidation
52
Where does fluid output take place?
* Bowels•
* Kidneys•
* Skin•
* Lungs
Output – Fecal, diarrhea (increased loss), urine (largest amount lost – *essentia*l output averages 300-500ml/day but averages about 1500ml/day), vomitus, NG suction, skin (sweat), respiratory (exhalation)
53
Define 1st spacing.
Normal distribution within ECF and ICF
54
Define 2nd spacing.
Accumulation within the interstitial compartments: Edema formation but available for physiological exchange between compartments
55
Define 3rd spacing.
Accumulation in parts of the body where it’s not available for exchange between the different compartments: ascitis, tissue inflammation, edema from burns/surgery.
56
Which 2 forces control movement of fluid from capillaries into the interstitial area?
•Hydrostatic Pressure•
Osmotic Pressure
57
True or false: Most electrolytes require a transport system.
True
58
What are some types pf abnormal losses of fluid?
emesis, fistulas, open/weeping wounds, hemorrhage, tubes for drainage (gastric suction) – normally, the body will compensate for such fluid losses; however, if the deficit exceeds intake, fluid imbalance will occur.
59
What is sensible fluid loss?
measurable; urine, feces, wounds
60
What is insensible fluid loss?
Immeasurable; evaporation through skin (affected by humidity), lungs (affected by respiratory rate/depth) – fever causes loss through skin and lungs.
61
What are the two main mechanisms for regulating water?
* Thirst
* Antidiuretic hormone
62
Describe the steps of the renin-angiotensin-aldosterone mechanism.
* Renin - Enzyme secreted by kidneys when arterial pressure or volume drops
* Interacts with angiotensinogen to form angiotensin I (vasoconstrictor)
* Angiotensin - Angiotensin I is converted in lungs to angiotensin II using ACE (angiotensin converting enzyme) - Produces vasoconstriction to elevate blood pressure - Stimulates adrenal cortex to secrete aldosterone
* Aldosterone - Mineralocorticoid that controls Na+ and K+ blood levels - Increases Cl- , HCO3- concentrations and fluid volume
* Aldosterone negative feedback loop - ECF & Na+ levels drop → secretion of ACTH (adrenocorticotropic hormone – response to stress) by the anterior pituitary → release of aldosterone by the adrenal cortex → fluid and Na+ retention
63
What is ADH?
* Antidiuretic hormone
* Also called vasopressin, Released by posterior pituitary when there is a need to restore intravascular fluid volume, Release is triggered by osmoreceptors in the thirst center of the hypothalamus - Fluid volume excess ⇒ decreased ADH, Fluid volume deficit ⇒ increased ADH
64
List some causes of hypovolemia.
* Fever with Diaphoresis
* GI dysfunction (most common)
* Diarrhea
* Fluid and electrolyte Loss
* Renal dysfunction
* Endocrine dysfunction
* Diabetes
* Excess dietary sodium
* Overuse of diuretics
* Hemorrhage
* Burns
* Ascites
✔F
65
Are cations positive or negative?
positive
66
Are anions positive or negative?
Negative
67
List some causes of hypervolemia.
* Cardiac dysfunction
* Chronic heart failure, pulmonary edema
* Cirrhosis (with ascites and portal hypertension)
* Renal dysfunction
* Serum protein depletion and hyponatremia
* Endocrine dysfunction
* IV fluid excess
68
What are some signs and symptoms of hypovolemia?
* Restlessness, lethargy, confusion, weakness•
* Thirst•
* Decreased BP•
* Increased serum sodium•
* Decreased skin turgor, dry mucous membranes•
* Postural hypotension•
* Decreased urine output
* Increased respiratory rate•
* Weight loss
* Seizures, coma
69
What are some signs and symptoms of hypervolemia?
* Headache, confusion, lethargy•
* Restlessness, anxiety•
* Distended neck veins (JVD)•
* Bounding pulse•3rd heart sound (S3)•
* Polyuria•Dyspnea, crackles•
* Pulmonary edema•
* Weight gain•
* Increased BP•
* Seizures, coma
70
Which laboratory values are important for monitoring patients with risk of refeeding syndrome?
A. TriglyceridesB.
B. AlbuminC.
C. Liver function testsD
D. Electrolytes (K, Mg, phosphorus)
D. Electrolytes (K, Mg, phophorus)
With refeeding syndrome, electrolytes (K, Mg, phosphorus) shift into the cell with glucose, and serum levels drop, requiring careful monitoring and additional supplementation.
71
Define electrolytes.
* Substances whose molecules dissociate into ions (charged particles) when placed into water•
* Cations (+ charged)
* Anions (- charged)
72
What are the main functions of electrolytes?
* Promote neuromuscular irritability
* Regulate acid & base balance
* Regulate distribution of body fluids among body compartments
73
What is the prevalent cation and anion in the ICF?
Cation: K+
Anion: phosphate
74
What is the prevalent cation and anion in the ECF?
Cation: Na+
Anion: Cl-
75
Define diffusion.
Move from area high concentration to area of low until concentrations are equal.
76
Define facilitate diffusion.
Passive transport that allows substances to cross membranes with assistance of special transport proteins.
77
Define active transport.
Movement of a substance across a cell membrane against its concentration gradient (from low to high concentration) – uses chemical energy of ATP (high-energy molecule that stores the energy we need to do just about everything we do; present in the cytoplasm and nucleoplasm of every cell – used by sodium and potassium to move in/out of cells.
78
Define osmosis.
Particles cross semipermeable membrane from area of low solute concentration to high.
79
Define hydrostatic pressure.
Pressure exerted by a fluid at equilibrium due to the force of gravity; pressure of fluids at rest.
80
Define osmotic pressure.
Pressure which needs to be applied to a solution to prevent the inward flow of water across a semipermeable membrane – minimum pressure to nullify osmosis.
81
What can cause hypokalemia?
•Can be caused by GI losses, diarrhea, insufficient intake, non-K+ sparing diuretics (thiazide, furosemide)
82
What are signs and symptoms of hypokalemia?
* **Think S-U-C-T-I-O-N**
* Skeletal muscle weakness
* U wave (EKG changes)
* Constipation, ileus
* Toxicity of digitalis glycosides
* Irregular, weak pulse
* Orthostatic hypotension
* Numbness (paresthesias)
83
What are signs and symptoms of hyperkalemia?
* Irritability
* Paresthesia
* Muscle weakness (especially legs)
* EKG changes (tented T wave)
* Irregular pulse
* Hypotension
* Nausea, abdominal cramps, diarrhea
84
What are signs and symptoms of hypochloremia?
* Agitation, irritability
* Hyperactive DTRs, tetany
* Muscle cramps, hypertonicity
* Shallow, slow respirations
* Seizures, coma
* Arrhythmias
85
What are some signs of metabolic acidosis?
* Decreased LOC
* Kussmaul’s respirations
* Weakness
86
What are some signs of hypernatremia?
* Agitation
* Tachycardia, dyspnea, tachypnea, HTN
* Edema
87
What types of patients are at high risk for hypomagnesemia?
High risk clients
* Chronic alcoholism
* Malabsorption
* GI/urinary system disorders
* Sepsis
* Burns
* Wounds needing debridement
88
What are CNS signs of hypomagnesemia?
* Altered LOC
* Confusion
* Hallucinations
89
What are Neuromuscular signs of hypomagnesemia?
* Muscle weakness
* Leg/foot cramps
* Tetany
90
What are Cardiovascular signs of hypomagnesemia?
* Tachycardia
* Hypertension
* EKG changes
91
What are Gastrointestinal signs of hypomagnesemia?
* Dysphagia
* Anorexia
* Nausea/vomiting
92
What are signs and symptoms of hypermagnesemia?
* Decreased neuromuscular activity
* Generalized weakness
* Occasionally nausea/vomiting
93
What are signs and symptoms of hypocalcemia?
* Neuromuscular
* Anxiety, confusion, irritability, muscle twitching, paresthesias (mouth, fingers, toes), tetany
* Fractures
* Diarrhea
* Diminished response to digoxin
* EKG changes
94
What are signs and symptoms of hypercalcemia?
* Fatigue, confusion, lethargy, coma
* Muscle weakness, hyporeflexia
* Bradycardia ⇒ cardiac arrest
* Anorexia, nausea/vomiting, decreased bowel sounds, constipation
* Polyuria, renal calculi, renal failure
95
True or False?
Exercise programs to increase the strength and endurance in the older adult population may help delay the onset of the age-related functional consequences of decreased strength and endurance
True
96
What are some age related changes that impact functional abilities?
* Decline in visual acuity
* Decline in reaction time
* Decrease musculoskeletal function
* Nutritional deficits
* Gait changes
* Physical inactivity
* Hormonal changes
97
Why should we exercise as we get older?
* Our skeletal muscles get worked; this helps to keep them built up and strong
* As you age, muscles can become fatigues a little easier, they break down
* Motor neurons that control your muscles can be directly affected in all ADLs
* Result of the these changes is decline in motor function, loss of strength and endurance, even in healthy adults
* Exercise can help delay the onset of age-related consequences and the loss of function
* Exercise helps to keep them independent, keep range of motion
98
What are the functional and psychosocial consequences of inactivity and immobility?
* Slowed ability to perform activities of daily living (writing, bathing, putting shoes and socks on, climbing stairs)
* Impaired balance and coordination
* Diminished strength, endurance, and coordination
* Decreased independence
* Increased depression
* Shortened life expectancy
* Social isolation
* Increased caregiver burden due to fear of falling
* Increased susceptibility to falls
* Increased susceptibility to fractures and other fall related injuries
* Developing a fear of falling
99
What are some risk factors that influence the safety and mobility of older adults?
* Age-related functions and systems changes
* Visual function
* Musculoskeletal function
* In the musculoskeletal system, osteoporosis is the age-related change that has the most significant overall impact
* Age related changes that affect bone and its density:
* Increased bone resorption
* Diminished calcium resorption
* Increased serum parathyroid hormone
* Impaired regulation of osteoblast activity
* Decreased estrogen in women and testosterone in men
* Fewer functional marrow cells
* Neurological function
* Slowed reaction time
* Less weight-bearing activities
* Reduced calcium and vitamin D
* Tobacco smoking
* Disease
* Adverse medication reactions
* Environmental factors
* Gait changes
* Decreased sensory functioning
* Physical inactivity and nutritional deficits
* Low intake of high quality protein, folic acid and vitamin B12
* Hormonal deficiency/changes
* Excessive alcohol intake
* Common risk factors for in-hospital falls include:
* Dementia
* Increased age
* Altered mental status
* Adverse medication effects
100
What are some nursing interventions directed toward safe mobility and the elimination of risks for falls in a clinical setting?
* Teaching about exercise
* Teaching about prevention of osteoporosis
* Actions and strategies to prevent falls
* Rearrange cupboards, putting most accessible items lowest
* Observe someone in their home environment and completing activities; they may have a skewed sense of how safely they are performing the task; if that is not a possibility, can refer to home care nursing as part of the discharge plan
* Use yak traks on winter icy surfaces and non-slip foot wear indoors
* Seek out assistant for snow removal
* "Two interventions for preventing fall-related"
* Evidence based measures for osteoporosis
* Adapt environment to reduce risk of falls
* Note: restraints not proven to be an effective tools and can cause further injuries
* Interventions for older adults with impaired musculoskeletal systems are evaluated by the degree to which the person can remain independent and safe
* Interventions for older adults with high risk for osteoporosis are evaluated based on how much preventative activity the older person incorporates into their lives
101
What are some strategies to include in a fall prevention program in a clinical setting?
* Have high fall risk residents close to the nurses' desk; be prepared to respond quickly
* Risk assessment and identification
* Refresh on fall prevention training
* Be proactive/check in regularly
* Education for patients on mobility devices and checking to see if using/fit appropriately
* encourage to ask for help/reassured
* Non-slip footwear/stored safely
* Make sure clearance before bed; bed in lowest position
* Fall mats if ordered
102
What is cognition?
“the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses
103
What are the components of cognition?
* Executive function
* Perception
* Memory
104
What is perception?
: Interpretation of the environment and is dependent on the acuity of sensory input
105
What does memory refer to?
Refers to the retention and recall of past experiences and learning.
106
What % of dementia does Alzheimer's account for?
Accounts for 60% to 80% of the cases of dementia
107
What are the hallmark pathologic characteristic of Alzheimer's disease?
* Amyloid plaques in the spaces between the neurons: abnormal deposits of a protein fragment called b-amyloid, which is formed from the breakdown of a larger protein called amyloid precursor protein
* Neurofibrillary tangles inside the neurons: abnormal clusters of a protein called tau
* Loss of synaptic connections between neurons
* Cell death causing brain atrophy "
108
What are some examples of behavioural and psychological symptoms of dementia (BPSD)?
* Agitation: abnormal level of verbal, vocal or motor activity (e.g., aggression, screaming)
* Psychiatric symptoms: delusions, hallucinations
* Personality changes, disinhibition
* Mood disturbances: apathy, depression, euphoria, emotional lability
* Aberrant motor movements: pacing, rummaging, wandering
* Changes in sleep, eating, appetite
* Hypersexual behaviour: inappropriate statements, sexually aggressive actions, masturbation in public place
109
What is delirium?
* A serious, preventable, treatable, commonly occurring and often unrecognized condition that disproportionately affects older adults.
* Delirium is a syndrome that develops over hours or days, fluctuates over the course of the day and can persist for months.
* Changes in mental status involve problems with attention and consciousness and several or many additional changes, including altered sleep–wake patterns.
110
What are the three subtypes of delirium?
* Hyperactive: restlessness, agitation, combativeness, anger, wandering, laughing, swearing, emotional lability and fast or loud speech
* Hypoactive: lethargy, staring, slowed movement, paucity of speech and unresponsiveness
* Mixed: fluctuations between hyperactive and hypoactive
111
What is dementia?
* Dementia is the medical term that includes a group of brain disorders characterized by a gradual decline in cognitive abilities (e.g., memory, understanding, judgment, decision-making, communication) and changes in personality and behaviour.
* Dementia is not a single disease but a group of diseases, and each type is associated with a different cause and unique combination of manifestations.
112
What are the four most common types of dementia?
* Alzheimer's Disease
* Vascular dementia
* Lewy body dementia
* Frontotemporal de-generation.
113
What does the term sundowning refer to?
* When BPSD or increased confusion or restlessness occur only or primarily in the early evening, this is called sundowning. Factors associated with sundowning include fatigue, overstimulation, fear of darkness and altered circadian rhythm.
114
What does executive function refer to?
Refers to the higher thinking processes that allow for flexibility, adaptability, and goal directedness. Determines the contents of consciousness, supervises voluntary activity and is future-oriented
115
True or false: Delirium is a medical emergency.
True
116
What are some consequences of cognitive impairment?
* Increased risk for falls
* Complicates disease management
* High incidence of hospitalization and long-term care
* Decreased capacity for independent living and normal social interaction
* Financial hardship and caregiver burden Withdrawal of social interaction
117
What does the mnemonic OCD CAMPS refer to in relation to delirium and dementia?
O (onset): Delirium is rapid, dementia is insidious
C (course): Delirium is fluctuating, dementia is progressively worse
D (duration): Delirium, days to weeks and is reversible, Dementia is irreversible, months to years
C (consciousness): altered in delirium, often normal in delirium
A (attention): delirium, significant inattention and lack of concentration, in dementia, attention may be somewhat normal
M (memory): Delirium, immediate recall is usually impaired, Dementia, immediate recall is often normal
P (psychomotor changes): In delirium, hyperactive or hypoactive, in dementia, no disturbances usually present
S (sleep-wake cycle): Delirium, often reversed, dementia, often normal
