2800 Exam Four Flashcards
(287 cards)
1
Q
Total blindness
A
absence of all sight
2
Q
legal blindness
A
central visual acuity of 20/200 or less in better eye with correction
OR very narrow peripheral vision field (20 degrees or less)
3
Q
severe visual impairment
A
being unable to read newsprint even with correction
4
Q
what is almost all blindness in the US caused by?
A
common eye diseases like cataracts, glaucoma, diabetic retinopathy, or age related macular degeneration
5
Q
what are nursing interventions to protect vision?
A
regular hand washing screening and early detection sunglasses regular eye exams for diabetics proper nutrition eye protection during hazardous activities
6
Q
what is the “sighted guide technique”?
A
the guiding person stands to the side and slightly in front of the visually impaired person, who is holding onto the guide’s elbow
7
Q
what are some ways to help clients adjust to decreased vision?
A
have corrective devices clean and available use large print books or magazines provide good lighting uncluttered/safe environment have things within reach introduce yourself speak before touching the client describe things and explain sounds
8
Q
what can vision problems lead to in older adults?
A
loss of freedom, functional ability, or self esteem
disorientation
confusion
social isolation
9
Q
what is conductive hearing loss?
A
hearing loss caused by problems in the outer or middle ear
10
Q
what are some common causes of conductive hearing loss?
A
otitis media
earwax accumulation
foreign bodies in the ear
11
Q
what is sensorineural hearing loss?
A
impairment of inner ear function or vestibulocochlear nerve damage
12
Q
what are some common causes of sensorineural hearing loss?
A
noise genetics nerve damage ototoxicity tympanic membrane trauma
13
Q
what are some assessment findings/manifestations for hearing loss?
A
not responding when spoken to answering questions inappropriately asking people to speak up/repeat things reading lips straining to hear impacted social/familial relationships
14
Q
what are some nursing interventions to prevent hearing loss?
A
control environmental noise use ear protection MMR immunization avoidance/proper use of ototoxic medications (chemo, loop diuretics, mercury) hearing screenings
15
Q
what are some good practices when communicating with a hearing impaired client?
A
use hand movements have face in good light speak into patient's good ear lower tone of voice minimize distractions speak normally and slowly dont over-enunciate write out hard words rephrase if necessary
16
Q
how can the nurse help a client adapt to using a hearing aid?
A
make sure it’s properly fitted
determine the patient’s readiness to use it
educate on care and use
have them start using it in a quiet environment to get used to it
17
Q
how do we care for hearing aids?
A
clean ear and hearing aid regularly make sure battery works protect it from heat and chemicals store in a cool dry place disconnect battery when hearing aid not in ear
18
Q
what intervention will help if a whistling or ringing is coming from the hearing aid?
A
reposition in the patient’s ear and adjust the volume level
19
Q
what is dementia?
A
a neurocognitive disorder characterized by dysfunction or loss of memory, orientation, language, judgment, and reasoning
20
Q
what is the most common type of dementia?
A
alzheimers
21
Q
what are general assessment findings with any type of dementia?
A
memory loss disorientation problems with words and numbers decreased judgment mood and behavior changes personality changes
22
Q
what is alzheimers disease?
A
the most common form of dementia. it’s a chronic, progressive neurodegenerative brain disease
23
Q
what are some early manifestations of Alzheimer’s?
A
getting lost in familiar areas memory loss time and place disorientation problems with calculations problems with familiar tasks language issues behavior/personality changes
24
Q
How do memory issues often manifest in alzheimers?
A
short term memory problems first
25
what are some later stage manifestations/complications of Alzheimers?
```
incontinence
delusions
wandering
all cognitive functions impaired
immobility
inability to speak or understand
need for complete care (loss of functional ability)
```
26
what is apraxia?
inability to manipulate objects or perform purposeful actions
27
what is visual agnosia?
inability to recognize objects by sight
28
what is dysgraphia?
difficulty communicating by writing or recognizing written language
29
what is retrogenesis?
process in alzheimer's disease where degenerative changes occur in reverse order in which they were acquired (person becomes more like an infant as disease progresses)
30
what is the top choice for a cognitive tool to screen for alzheimers and monitor disease progression?
Mini-mental status examination (MMSE or mini-mental)
31
what other diagnosis should be screened for and ruled out when alzheimer's is suspected?
depression
32
why is early recognition and treatment important in Alzheimers?
in order to monitor disease progression and maximize functional ability at every stage, as well as ensure patient safety
33
what are some measures that may help prevent alzheimers?
```
regular exercise
challenging your mind
staying socially active
avoiding harmful substances
avoiding brain trauma (like repeat concussions)
treat depression early
sleep
healthy diet
diabetes and cardiovascular health management
```
34
what are some nursing interventions to prevent behavioral problems in Alzheimers?
```
assess physical status and for pain
assess environment
assess for infection frequently
redirect and distract
maintain familiar routines
```
35
what is sundowning?
patient getting more confused, disoriented, and combative in late afternoon and evening
36
what can be done to prevent sundowning?
calm environment, maximum exposure to sunlight, limit naps and caffeine, drug treatment if necessary
37
what are some good communication techniques for alzheimers patients?
```
don't rush them
minimize distractions
don't argue
ask simple questions
don't tell them no or ask why
```
38
what would some other signs of pain be in Alzheimer's patients if they cannot say they have pain?
agitation
withdrawal
increased vocalization
39
what nursing interventions can help with eating and swallowing difficulties in Alzheimers?
```
pureed food and thickened liquids
nutrition supplements
finger foods
moist foods
bite sized pieces
quiet and unhurried environment
```
40
what are oral care considerations for Alzheimers?
ensure good oral care (either by patient or by nurse)
| regular mouth inspection for pocketed food
41
how can nurses help support caregivers of those with Alzheimers?
assess stressors and coping strategies
assess caregiver expectations
support groups
teaching based on disease stage
42
what are top goals for patients with Alzheimers?
maintain safety and maximize remaining social and functional ability
43
what are autism spectrum disorders?
group of complex neurodevelopmental disorders
44
what are basic clinical manifestations in autism spectrum disorders?
core deficits in social interaction, communication, and behavior
45
what is seen in relation to social interaction with ASD?
less interest in socializing
abnormal eye contact
decreased imitation
decreased response to their own name
46
what is seen in relation to communication in ASD?
absent or delayed speech
| not meeting speech milestones
47
what does echolalia mean?
unsolicited, meaningless repetition of vocalizations made by another person (often seen in ASD)
48
what can improve prognosis for children with ASD?
early detection and intense early intervention
49
what is seen in terms of behavioral patterns with ASD?
unusual fixations, preferences, or repetitive behaviors
50
what are important interventions/actions when a child with ASD is hospitalized?
parent staying with child and being involved in planning
individualized assessment and treatment
decreased stimulation
presence of comfort items
as much structure and routine as possible
51
what should the nurse keep in mind in relation to physical contact for patients with ASD?
minimal holding and eye contact
52
what should the nurse keep in mind in relation to feeding and eating for patients with ASD?
may be fussy eaters
may gag or willfully starve themselves
may hoard food or swallow non-food items
may refuse food and end up with nutrient deficiencies
53
how should children with ASD be introduced to new things?
slowly and cautiously
54
what are good approaches in terms of communicating with patients with ASD?
tell them directly what to do
be brief and concrete
be appropriate to developmental level
reward desired behavior
55
how can the nurse support the family of a child with ASD?
educate the parent and make sure they know the autism is not their fault
direct them to expert counseling and resources
encourage care by the family as much/as long as possible
use creative approaches to managing child's care and behavior
56
an undesired change or removal of a valued person, object, or situation is..
loss
57
how is grief defined?
the physical, psychological, and spiritual responses to a loss
58
actual loss
a tangible, physical loss (loved one, loss of limb, etc)
59
perceived loss
a loss felt only by the person, such as loss of freedom, future, relationship, etc
60
what are some things that impact coping?
family and support system
spirituality
developmental stage
61
what is bereavement?
the process of mourning and the period of adjustment after a loss
62
what are some major factors that affect grief?
```
significance of the loss
support systems available
unresolved conflict
circumstances of the loss
other recent losses
spiritual beliefs and practices
time circumstances of the loss
```
63
how do infants and toddlers view death?
they cannot comprehend the absence of life and dont know how to accept permanence of death
64
how will infants and toddlers react to death of a loved one?
changes in eating and sleeping
| anxiety and sadness often caused by changes in routines and sadness of those around them
65
how do preschoolers understand death?
they struggle with the permanence of death
believe their thoughts can cause death (may struggle with guilt and shame)
may distance themselves from loss and grief
66
how do school aged children understand death?
guilt is an issue, but have a more concrete understanding of death
may be fascinated by death
fear unknown quality of death
67
how do adolescents understand and cope with death?
they understand it but struggle with guilt and shame
| have the most difficulty coping with death and may feel very alone in their grief
68
when do adults start to accept their own mortality?
usually between the ages of 45 and 65
69
why might coping with death be challenging for older adults?
because they are preparing for/thinking of their own deaths, and often have experienced lots of cumulative losses
70
uncomplicated/normal grief
natural response to a loss, with intense emotions that gradually diminish. person can still take care of themselves during grief process
71
complicated grief
prolonged acute grief that lasts for longer than 6 months with maladaptive and overwhelming grief responses
72
how do we distinguish whether a person's grief is complicated or normal?
by evaluating their functional/self-care abilities
73
definition of death
irreversible cessation of all functions of the brain and brainstem
74
higher brain death
irreversible cessation of higher brain function even if the brainstem still works (respiration and cardiac activity might continue)
75
what are the stages of grief?
```
denial
anger
bargaining
depression
acceptance
```
76
what are some goals of palliative care?
```
regard dying as a normal process
provide pain relief
not hastening death or postponing it
enhance quality of life
support patient to live as actively as possibly until death
support patient's family
```
77
what is the difference between palliative care and hospice?
palliative care allows for both curative and comfort cares, while hospice is only comfort cares
78
what are the two criteria for admission to a hospice program?
patient must desire the service and agree to only hospice care (not curative care)
patient must be considered eligible with 2 physicians saying they probably only have 6 months or less to live
79
why is spiritual assessment important in the dying and grieving process?
Because spirituality shapes how people view death and cope with it, as well as the rituals people have surrounding death
80
what are some characteristics of spiritual distress?
anger towards God
changes in mood or behavior
desire for spiritual assistance
displaced anger towards clergy
81
what are some ways that culture affects reactions to death?
culture impacts rituals around death, how grief is expressed, and how families find comfort
82
what is the nurses role in regards to spiritual and cultural practices surrounding death?
facilitate and support these practices
83
who makes the decision to donate organs?
the patient before death or the family after death
84
who on the healthcare team makes organ donation requests?
specially trained professional for that specific role
85
what are advanced directives?
document signed by a competent individual regarding the patient's wishes about care and their designated medical spokesperson
86
what is a living will?
document in lay terms giving specific directions about future care and life sustaining measures
87
what is a durable power of attorney for healthcare?
a document stating who makes your healthcare decisions if you cannot (and if the living will is not clear on an issue)
88
what does DNR mean?
do not resuscitate (take comfort measures only, but no CPR or intubation)
89
describe AND (allow natural death)
pain control and symptom management are allowed and done, but natural progression to death is not hindered
90
why do opioids not hasten death at the end of life?
because pain is the counteracting agent to opioid-induced respiratory depression, so the opioids given for comfort will not depress respirations fatally
91
what happens to our senses at the end of life?
```
hearing is the last to go
decreased sensation and pain perception
blurred vision
glazed eyes
absent blink reflexes
eyes half open
```
92
what are cardiovascular manifestations at the end of life?
increased HR, then decreased
irregular heart rhythm
decreased BP
delayed drug absorption
93
respiratory manifestations at end of life
increased respirations
| inability to clear secretions
94
death rattle
noisy, congested breathing due to not being able to clear secretions
95
cheyne stokes respirations
alternating periods of apnea and deep, rapid breathing
96
urinary manifestations at the end of life
decreased urinary output or anuria
| incontinence
97
GI manifestations at the end of life
```
slowed/stopped GI processes
gas accumulation
nausea
incontinence
bowel movement right before or at time of death
```
98
musculoskeletal manifestations at the end of life
loss of ability to move
loss of muscle tone and gag reflex
difficulty speaking and swallowing
jaw sagging
99
integumentary manifestations at the end of life
mottling
cold/clammy skin
cyanosis
wax-like appearance
100
psychosocial manifestations at the end of life
```
altered decision making
anxiety/restlessness
fear
decreased socialization
life review
peacefulness
saying goodbye
unusual communication or vision-like experiences
```
101
what are some psychosocial nursing interventions for end of life care?
```
converse with the patient
encourage family to talk to them whether conscious or not
affirm dying person's experience
allow privacy
assess spiritual needs
```
102
what are four specific fears associated with death?
pain
shortness of breath
loneliness/abandonment
meaninglessness
103
how can nurses help alleviate the fear of pain?
prompt pain assessment and management
| management of drug side effects
104
how can nurses alleviate fear of shortness of breath for the dying patient?
use of opioids, bronchodilators, oxygen, and anti-anxiety meds
105
how can nurses alleviate the fear of loneliness in dying patients?
hold their hands and use touch
listen
be present and have loved ones present too
106
how can nurses help alleviate the fear of meaninglessness for the dying patient?
facilitate life review process and listen
107
how can nurses help children deal with loss?
```
dont force them to go to the funeral
spend as much time with them as possible
use play therapy
care for the whole family
reassure child that it's not their fault
```
108
how can nurses manage end of life dehydration?
assess mucous membranes often
know that dying patient might be comfortable being dehydrated
moist swabs in mouth
don't force them to eat or drink
109
how can nurses manage end of life dyspnea?
```
elevate head
fan or air conditioning
pursed lip breathing
expectorants
opioids
suction
oxygen
```
110
how can nurses manage end of life skin breakdown?
control drainage
dress wounds properly
manage incontinence
use blankets (not heat) for warmth
111
how can nurses manage end of life bowel patterns?
```
assess function
assess for impaction
use laxatives as needed for comfort
watch for constipation
fiber/fluids/movement as wanted and tolerated
```
112
what is involved in post-mortem care?
```
close eyes
replace dentures
wash the body
remove tubes and dressings
straighten body and prop up head
allow family time and privacy with the body
```
113
how do we support families and caregivers after a death?
```
recognize their stress and grief
watch for abnormal grieving and those dealing with concurrent crises
keep them informed
refer to counseling
encourage use of support systems
```
114
what is included in an assessment of mental health?
```
physical assessment
psychosocial history
stress level
coping ability
spiritual/religious/cultural beliefs
mental status
```
115
what are stigmas that exist in relation to mental health?
belief that it is taboo or not real
belief that you are crazy
belief that it's all a spiritual influence/possession
116
what is included in a mental status examination?
level of consciousness
physical appearance
behavior
cognitive and intellectual abilities
117
what are the four stages of mental status/alertness?
alert
lethargic
stuporous
comatose
118
alert
patient is responsive and responds appropriately
119
lethargic
patient can open eyes and respond but is drowsy and falls asleep easily
120
stuporous
vigorous or painful stimuli is necessary to elicit even a brief response in the patient
121
comatose
unconscious, with no response to painful stimuli
122
what is the difference between mood and affect?
mood is the emotion the client is feeling
| affect is the objective expression of the mood (flat, blunted, smiling, crying, etc)
123
what are some elements of cognitive and intellectual ability that the nurse should note?
```
orientation
memory
level of knowledge about illness and perception of illness
ability to calculate
abstract thinking
judgment
rate and volume of speech
```
124
what are some standardized screening tools used in screening mental status?
mini mental state examination (MMSE)
| pain assessment
125
what are some questions included in a mini-mental?
orientation
attention span
registration and recall of objects
language abilities
126
what should the nurse ask children/adolescents in a mental health assessment?
```
home environment
education and employment performance
activities
drug and substance use
sexuality
depression and suicide assessment
how safe they feel
```
127
what are risk factors in children for developing a mental health disorder?
genetic predisposition
biochemical imbalances
family problems or environmental conflict
cultural/ethnic issues or assimilation
resiliency level
witnessing or experiencing traumatic events
low socioeconomic level
128
what should the nurse ask older adults when assessing mental health?
```
functional ability
economic and social status
environmental factors
questions from standardized screening tools
substance use
```
129
what should be assessed in relation to adaptation and coping?
```
health status
functional ability
living arrangements
employability
personality
caregiver and family assessments
level of information and knowledge
medications and other services used
```
130
what is milieu therapy?
creating an environment that is supportive, therapeutic, and safe. managing the total environment to create the least amount of stress for the client
131
what are characteristics of the physical setting with milieu therapy?
```
clean
orderly
comfortable
safe
attractive
age-appropriate
space for alone time and opportunity for interaction
```
132
what are the phases of the therapeutic relationship in the mental health setting?
orientation
working phase
termination
133
characteristics of the orientation phase
setting limits
setting goals
introductions and defining rolls
getting informed consent from the patient
134
characteristics of the working phase
```
ongoing assessment
problem solving
learning coping skills
client feeling open and able to share
listening on the part of the nurse
```
135
characteristics of the termination phase
discussing feelings about ending of therapeutic relationship
talk about separation and loss
learn how to integrate coping and other skills into normal life
136
transference
common issue in mental health care where client views the healthcare worker as having characteristics of another significant person in their life
137
countertransference
problem where healthcare worker displaces characteristics of someone in their life or their past onto their current client
138
what are some common activities within the therapeutic milieu?
```
community meetings
individual and group therapy
psychoeducational groups
recreation activities
unstructured free time
```
139
what are focuses and goals of individual therapy?
the needs of one client is the focus, with the goals of good decision making, productive life decisions, and stronger sense of self
140
what is the focus of family therapy?
improving family functioning by addressing family needs and problems
141
what are some goals of family therapy?
effective coping within the family
improved understanding of mental health issues
more positive family interactions
142
what is the focus of group therapy?
individuals developing more functional and satisfying relationships within the group
143
what are goals of group therapy?
discovering commonality among group members and seeing positive behavior changes in regards to social interaction
144
what is a maintenance role in a therapy group?
someone who helps maintain the purpose and process of the group
145
what are task roles in a therapy group?
people who take on tasks within the group process
146
what are individual roles in group therapy settings?
roles taken on by individuals to promote their own agendas, which usually hinders the group goals
147
what is depression?
a mood disorder characterized by depressed mood, sleep disturbances, indecisiveness, suicidal ideation, inability to feel pleasure, and/or weight changes
148
what are common comorbidities with depression?
anxiety and psychotic disorders
substance use
eating and personality disorders
149
what are some different types of depressive disorders?
```
major depressive disorder
seasonal affective disorder
persistent depressive disorder
premenstrual dysphoric disorder
substance-induced depressive disorder
```
150
what are risk factors for depression in children and adolescents?
```
family history
past abuse
homelessness
parental or environmental conflict
bullying
high-risk behaviors
learning disabilities
chronic illness
```
151
what are expected findings with children and teens with depressive disorders?
```
sadness
temper tantrums
loss of appetite
health complaints
isolation
crying
loss of energy
irritability
aggression/risky behavior
suicidal thoughts and actions
```
152
what is depression often associated with in older age?
dementia
153
what are the phases of a major depressive disorder?
acute
continuation
maintenance
154
what are goals for care in an acute phase of depression?
reduction of depressive manifestations. this phase may require hospitalization and suicide monitoring
155
what is the goal of care in a continuation phase of depression?
relapse prevention through education, medications, and psychotherapy
156
what is the goal of care in the maintenance phase of depression?
prevention of future depressive episodes
157
who is at risk for depression?
women
those with a family history
those in early adulthood or over 65
those with neurotransmitter deficiencies
158
what are assessment findings with depression?
```
sadness
blunted affect
poor grooming/hygiene
psychomotor retardation and agitation
social isolation
slowed speech and delayed response
anergia
anhedonia
```
159
what are vegetative findings in depression?
changes in eating patterns
changes in bowel patterns (usually constipation)
changes in sexual activity and sleep habits
somatic complaints
160
remember there are several types of depression screening scales!
use the correct one for the correct population group
161
what is included in milieu therapy for patients with depression?
```
suicide risk assessment
self-care assessment
communication with patient and IDT
maintaining safe environment
counseling
```
162
what are some alternative therapies for depression?
light therapy
St. John's wort
exercise and good nutrition
163
what are important patient teaching points for depression?
manifestations of depression
effects and adverse effects of medications
benefits/importance of treatment adherence
importance of regular exercise
how to prevent relapse
164
what is electroconvulsive therapy (ECT)?
using electrical currents to induce a brief seizure while client is sedated
165
what are nursing considerations during ECT treatment?
obtaining informed consent
med management and side effects
client education
understanding normal and desired patient responses
166
what indicates the need for ECT in a major depressive disorder?
unresponsive to pharmacological interventions
when risks outweigh benefits for other treatments
suicidal/homicidal clients who need rapid intervention
those experiencing psychotic manifestations
167
what meds will be given to a client undergoing ECT?
muscle relaxant to prevent injury
| anticholinergics to counteract secretions and prevent aspiration
168
how long does a course of ECT last?
2-3 times per week for a total of 6-12 treatments
169
what should the nurse monitor before, during, and after ECT?
BP
ECG
oxygen saturation
170
what are potential complications of ECT?
memory loss and confusion
anasthesia reaction
cardiovascular changes
relapse of depression
171
what are nursing actions to be taken to prevent/counteract complications of ECT?
frequent orientation and safety focus after treatment
monitoring during and after treatment for anesthesia reaction
monitor vitals and cardiac rhythm
encourage maintenance ECT to prevent relapse q
172
what is transcranial magnetic stimulation?
using MRI strength magnetic pulsations to stimulate the cerebral cortex
173
what are indications for use of TMS?
major depressive disorder when pharmacological intervention doesnt work
174
what is bipolar disorder?
mood disorder with recurrent episodes of depression and mania that usually emerges in early adulthood
175
what is the acute phase of bipolar?
acute mania, where patient might need hospitalization and extra safety measures
176
what is the continuation phase of bipolar?
remission of manifestations, with a focus on treatment and relapse prevention techniques
177
what is the maintenance phase of bipolar?
increased ability to function with the goal of preventing future manic episodes
178
what is mania?
abnormally elevated mood (irritable, expansive) lasting at least one week
179
what is hypomania?
less severe episode of mania lasting at least 4 days with 3 or more manic characteristics. less severe, hospitalization may not be needed
180
what is rapid cycling?
four or more episodes of mania or hypomania in one year
181
what are manic characteristics in bipolar?
```
euphoria
agitation/irritability
restlessness
intolerance of criticism
flight of ideas
impulsivity and poor judgment
attention seeking behaviors
decreased sleep
ADL neglect
delusions and hallucinations
rapid speech
```
182
what are depressive characteristics in bipolar?
```
blunted affect
crying
lack of energy
anhedonia
pain
poor focus
self-destructive behavior
decrease in hygiene
disturbed sleeping and eating
psychomotor retardation
```
183
what populations are at risk for bipolar?
those with genetic predisposition
those with environmental stress
those with neurobiologic and neuroendocrine disorders
184
what are collaborative therapies for those with bipolar?
electroconvulsive therapy
| medications
185
what are nursing considerations in acute manic episodes?
```
safety
suicide assessment
decrease stimulation
supervision
rest and physical activity
nutrition support
protection from impulsivity and poor judgment
```
186
what are important teaching points for clients with bipolar?
```
follow up care
benefits of therapy adherence
psychotherapy reference
long-term/lifelong treatment
regular sleep and eating schedule
med adherence
indicators and precipitating factors for relapse
```
187
what are some criteria for substance use disorders?
```
impaired control of substance intake
social impairment due to use
risky use of substance
dependence on substance
taking substance for longer than intended or failing to quit using
```
188
addiction
psychological and physical inability to stop consuming something despite it's negative impacts
189
intoxication
clinically significant behavioral or psychological changes following the use of a substance
190
tolerance
reduced reaction to a drug or substance following repeated use
191
withdrawal
physical/psychological manifestations experienced when a patient discontinues a med or drug to which they are addicted
192
who is at risk for substance use disorder?
```
chronically stressed
genetically predisposed
trauma history
low self esteem
isolation
risk takers
alaska natives
native americans
older adults
those facing peer presusre
```
193
what are some manifestations/findings with substance use disorders?
```
fatigue
insomnia
headache
seizures
mood changes
anorexia
looking aged/unkempt
sexual dysfunction
DWI
defensive or evasive behaviors or actions
life function issues
```
194
what are assessment findings of intoxication with stimulants?
```
palpitations and dysrhythmias
increased BP and HR
MI
impending doom feelings
euphoria
agitation
seizures
combativeness
paranoia
confusion
fever
```
195
what are signs of withdrawal from stimulants?
```
fatigue
depression
excess sleeping
vivid dreams
irritability
increased appetite
disorientation
craving the drug
```
196
what are findings for intoxication with depressants?
```
aggression
agitation
confusion
lethargy
hallucinations
slurred speech
pinpoint pupils
seizures
weak pulse and dysrhythmias
decreased BP
respiratory depression
```
197
what are signs of withdrawal from sedative hypnotics?
```
weakness
anxiety
insomnia
fever
orthostatic hypotension
disorientation
delirium
seizures
respiratory and cardiac arrect
```
198
what are signs of opioid withdrawal?
```
cravings
diaphoresis
GI issues
restlessness
fever
insomnia
tremors
aches
runny nose
```
199
what are some priority care measures for clients with substance abuse disorders?
```
airway/ABCs
IV access and fluids
ECG monitoring
drugs for dysrhythmias, HTN, angina, seizures, and psychotic manifestations
vitals
LOC
cooling measures
info about drugs and amounts taken
antidotes/gastric lavage
```
200
what are gerentologic considerations for substance use disorders?
hard to recognize
can be mistaken for a medical condition
greater risk for medical issues caused by substance use
201
what is ADHD?
inability to control behaviors requiring sustained attention
202
what is inattention?
difficulty paying attention, listening, and focusing
203
what is hyperactivity?
fidgeting, inability to sit still, excess talking, problems playing quietly, excess running and climbing
204
what is impulsivity?
interrupting, impatience, or acting without considering the consequences
205
what are clinical manifestations of ADHD?
```
distractibility
immaturity
selective attention
risk taking
lack of regard for consequences
hyperactivity
inappropriate social behaviors
```
206
what is necessary for a patient to be diagnosed with ADHD?
associated behaviors must be present before age 12 and in more than one setting
207
what are the three main treatment plans for children with ADHD?
behavior therapy
environmental manipulation
classroom placement
208
what does behavior therapy for ADHD consist of?
rewarding good behavior and preventing undesired behavior by using contingencies, rewards, and organizational charts
209
what does environmental manipulation consist of for clients with ADHD?
consistency in expectations and discipline and structure between school and home
having the child take responsibility for actions and choices
decreasing environmental distractions
210
what is important for classroom placement for children with ADHD?
orderly, predictable, consistent classroom with clear and consistent rules
interspersed breaks
bulk of learning in the morning
intersperse activities of high and low levels of interest
211
what is the goal for children with ADHD?
help them identify areas of weakness and compensate for them, and promote healthy interventions and adaptation
212
what are the rights of a patient with a voluntary mental health admission?
right to refuse medication and treatment
213
what is a temporary emergency admission?
receiving emergent mental health care due to being unable to make decisions regarding care
214
what is an involuntary admission?
client enters mental health facility against their will for an indefinite time period
215
what is the length of time to which an involuntary admission is limited?
60 days
216
how long are long-term involuntary admissions?
60-180 days
217
what are the three categories of restraints?
physical
chemical
environmental
218
what potential unmet physiologic or psychosocial needs could result in disruptive behaviors by an older adult?
need for toileting or not being able to speak
219
what are some restraint alternatives that should be considered?
```
low beds
body props
bed/chair alarms
distractions/mentally stimulating activities
floor mats
family visits
safety assistants or direct observation
```
220
what must occur for use of seclusion or restraints?
less restrictive measures must fail
doctor's order must be written
time limit
frequent assessment and documentation
221
what documentation needs to be completed in relation to restraints?
```
events leading up to restraint measures
alternatives attempted
time restraint began and ended
current behavior
vitals
food and fluid offered
skin assessment
meds administered
```
222
how often does restraint documentation need to be completed?
every 15-30 minutes (facility dependent)
223
what is a tort?
a civil wrong-doing in which money can potentially be collected and awarded
224
false imprisonment
confining a client physically, verbally, or by using chemical restraint when not part of the treatment plan
225
assault
making a threat to the client's person
226
battery
harmful or offensive touch
227
what documentation needs to be completed in relation to violent or unusual episodes?
record of client behavior in a clear and objective manner
staff response with timelines and extent of responses
time nurse notified provider
prescriptions/orders received
228
what are arterial ulcers?
ulcers caused by arterial insufficiency in the extremities
229
what are causes/reasons that arterial ulcers develop?
inadequate circulation of oxygenated blood, leading to ischemia and tissue damage
230
what are characteristics of arterial ulcers?
```
"punched out" appearance
small and round
smooth borders
pale base
usually on lower extremity
surrounding skin thin/shiny/cool/dry
loss of hair
delayed capillary refill and delayed or absent pedal pulses
pain that increases with activity
```
231
what are venous stasis ulcers?
ulcers caused by venous insufficiency or issues
232
what causes venous ulcers?
incompetent venous valves, deep vein obstruction, or inadequate calf muscle function
233
how will venous insufficiency manifest in the leg?
venous pooling
edema
impaired microcirculation
234
what are characteristics of venous stasis ulcers?
located on lower calf or inner ankle usually
surrounding skin is red, brown, or edemateous
shallow with irregular margins
beefy/granular/red wound bed
moderate to heavy drainage
pain when legs are in dependent position
235
what is considered a chronic wound?
a wound that exceeds expected length of recovery and has trouble healing
236
what are diabetic food ulcers?
ulcers that occur due to narrowing of arteries, which decreases oxygenation and blood to feet
237
what about diabetes increases the risk of foot ulcer development?
neuropathy (patient wont necessarily feel a wound)
238
are diabetic foot ulcers arterial or venous ulcers?
arterial
239
what labs would need to be done for a patient with chronic wounds?
```
albumin
culture and sensitivity
CBC
glucose
thyroid
iron
coagulation
```
240
what are three chronic complications of wound healing?
adhesions
fistulas
keloids
241
what is an adhesion?
band of scar tissue forming between or around organs
242
what is a fistula?
abnormal passage between organs or between a hollow organ and the skin
243
what are keloids?
protrusions of scar tissue that extend beyond wound edges in a healing/healed wound
244
what are some other factors that delay wound healing?
```
nutrient deficiencies
inadequate blood supply
steroid use
infection
smoking
friction
age
obesity
diabetes
poor health
anemia
```
245
what is negative pressure wound therapy?
a vacuum source being used to create negative pressure in the wound to remove fluid, exudate, and infectious materials. helps prepare the wound for healing and closure
246
what should the nurse monitor in patients with negative pressure wound therapy?
serum protein
fluid and electrolyte balance
platelets
PT and PTT
247
What are nutrition considerations for patients with chronic wounds?
high fluid intake needed
undernutrition is a risk for poor healing
protein/carbs/fat are crucial
vitamin C and A are crucial
248
what are psychological implications for patients with wounds?
fear of scarring and disfigurement
drainage or odor can cause alarm
may want to understand the healing process
249
what are assessment considerations for dark skinned patients with wounds?
```
look for color changes in the skin
use natural or halogen light (not fluorescent)
assess skin temperature
touch to feel skin consistency
ask about pain and itching
```
250
what is a pressure ulcer?
localized injury caused by pressure on an area of tissue
251
where are the most common sites of presusre injuries?
heels
elbows
sacrum
scapulae
252
what are intrensic/internal risk factors for pressure ulcer development?
```
immobility
impaired sensation or circulation
poor nutrition
edema
aging
fever
mental deterioration
diabetes
moisture/incontinence
```
253
what are extrensic/external risk factors for pressure ulcers?
friction
shearing
moisture
compression
254
what are shearing forces?
epidermal layer sliding over the dermis, damaging the vascular bed
example: sliding down in bed
255
what is friction?
the epidermis sliding against another surface
256
stage I pressure ulcer findings
intact skin
non-blanchable redness
usually over a bony prominence
257
stage II pressure ulcer
partial thickness loss of dermis
shallow open ulcer with red/pink wound bed
no slough
can look like an open blister
258
stage III pressure ulcer
full thickness tissue loss
subcutaneous fat may be visible
slough present but doesnt obscure depth
possible undermining/tunneling
259
stage IV pressure ulcer
full thickness tissue loss with exposed or palpable bone, tendon, or muscle
slough and eschar possible
260
unstagable pressure ulcer
depth of ulcer is obscured by slough or eschar, but will either be a stage III or IV ulcer
261
why is reverse staging of pressure ulcers inaccurate?
because while the wound is getting more shallow, the lost bone/muscle/tissue is not being replaced, it's just being filled with granular tissue. Once it's a certain stage, its always that stage
262
how do you document a healing ulcer?
by writing "healing stage __ ulcer"
263
what is a common tool for assessing pressure ulcers?
PUSH tool
264
how often should patients be assessed for pressure ulcer risk?
upon admission (very thoroughly), then every 48-72 hours or according to policy
265
with the Braden scale, is a high or low score good?
a high score is good (indicates low risk)
266
what should we remember about turning patients every 2 hours?
its not evidence based. patients may need to be turned more often, or maybe not as often depending on individualized risk
267
what interventions will likely be used in care of the pressure ulcer?
```
debridement
wound cleaning
dressing application
pressure relief (float heels, padding, special mattresses or chairs)
moisture management
good documentation
```
268
what will be needed for pressure ulcers with necrotic tissue or eschar?
tissue removal by debridement
269
what are important patient/caregiver teachings related to pressure ulcer wound care?
```
risk factors
how to manage incontinence
correct positioning and repositioning
put a clean dressing over the sterile dressing
daily skin inspection
good nutrition
```
270
what is peripheral arterial disease?
progressive narrowing of arteries in upper and lower limbs
271
how is peripheral arterial disease different from venous diseases?
PAD has no peripheral pulses, capillary refill greater than 3 seconds, thick nails, thin shiny skin, cool skin, and no edema
272
what are assessment findings in PAD?
intermittent claudication
numbness and tingling
reactive hyperemia
pain at night
273
what is intermittent claudication?
ischemic muscle pain caused by exercise
274
how should patients with intermittent claudication be instructed to exercise?
exercise, then rest when pain begins, and resume exercise when pain subsides
275
what are potential complications of PAD?
```
skin/muscle atrophy
delayed healing
infection
necrosis
possible amputation
```
276
what are modifiable risk factors for PAD?
```
tobacco use
blood pressure
exercise/weight
diet
glucose control/diabetes management
lipid control
```
277
what diet is recommended for PAD?
dash diet
278
what are exercise therapy recommendations for PAD?
supervised exercise program consisting of 30-45 minutes/day, 3 or more days a week, for at least 3 months
279
what are nutritional considerations for PAD?
reduced calories and salt
| keep waist circumference at healthy level
280
what nursing interventions should be considered for home/ambulatory care for PAD?
```
long term antiplatelets
supervised exercise
foot assessment and care
proper shoes
diet modification
```
281
what is chronic venous insufficiency?
functional abnormalities of the venous system in the legs
282
what are assessment findings of chronic venous insufficiency?
```
leathery brownish skin
edema
eczema
itching
venous ulcers (often above medial maleolus)
pain
```
283
what are potential complications of chronic venous insufficiency?
osteomyelitis
malignant changes
venous stasis ulcers
284
what does interprofessional care and nursing management for chronic venous insufficiency consist of?
compression therapy
| nutrition therapy
285
what are skin care considerations for chronic venous insufficiency?
```
compression
moist environment for wounds
dressings
frequent assessment
moisturizing skin
educate patient on how to put on compression stockings
```
286
what are nutrition recommendations for chronic venous insufficiency?
high protein, vitamin C, and zinc
287
what are activity and rest recommendations for chronic venous insufficiency?
avoid standing or sitting for long periods of time
elevate legs frequently
begin daily walking once ulcers heal
avoid leg trauma
