Exam 1 Flashcards
(295 cards)
1
Q
What is mobility?
A
A state or quality of being mobile.
2
Q
What are three alterations in mobility?
A
1) Immobile
2) Impaired physical mobility
3) Deconditioned
3
Q
What are four mobility-related changes in aging?
A
1) Decreased bone density (osteoporosis, fall risk)
2) Decreased elasticity in ligaments
3) Cartilage becomes rigid and fragile
4) Decreased muscle mass and tone (weak, fall prone)
4
Q
What are four factors that impact mobility?
A
1) Acute injury/illness (infection)
2) chronic conditions (COPD)
3) End of life conditions (dementia)
4) mobility specific conditions (neurologic: Parkinson’s; musculoskeletal: arthritis; both: ALS)
5
Q
What percentage of muscle strength does an healthy individual lose per day while immobilized?
A
3%
6
Q
Name the effects related to metabolic complications in mobility:
A
1) Decreased appetite and protein breakdown lead to weight loss, muscles mass loss, and weakness
2) Calcium resorption (loss) from bones increase Ca2+ in blood leading to osteoporosis and risk of renal calculi
7
Q
Name the assessments for metabolic complications in mobility:
A
1) Nutritional status, serum protein and albumin
2) Any impaired wound healing
3) Intake and output
8
Q
Name two interventions for metabolic complications in mobility:
A
1) Increase calories and proteins
2) Supplementation may be needed, especially vitamin C for skin healing and B for energy metabolism
9
Q
Name the effects related to respiratory complications in mobility:
A
1) Atelectasis: collapse of alveoli d/t less movement and coughing
2) Hypostatic pneumonia: fluid build up in lower lungs d/t immobility allowing bacterial growth from secretion stasis and decreased cough
10
Q
Name the assessment for respiratory complications in mobility:
A
1) Monitor lung sounds and oxygenation Q2H
11
Q
What are the interventions for respiratory complication of immobility:
A
1) HOB to 30 degrees
2) Rotate side to side Q2H
3) Incentive spirometry 10x/Q1H while awake by slowly inhaling
4) Early ambulation
5) Fluids to thin mucus
12
Q
What integumentary complication is related to immobility:
A
1) skin injury + pressure injuries
13
Q
What integumentary assessments should be done related to immobility:
A
1) Check bony prominances Q2H
2) Check for moisture
3) Braden Scale
14
Q
What integumentary inteventions are needed in immobility:
A
1) Turn/off-load boy prominences Q2H**
2) Specialty mattress
3) Boots
4) Limit chair time to 1 hour
5) Good nutrition
6) Remove moisture
15
Q
What elimination complications are associated with immobility:
A
1) Decreased GI motility leading to constipation and impaction
2) Urinary stasis (less gravity) and reduced oral intake increases UTI and calculi risk
16
Q
What elimination assessments need to be done in immobility:
A
1) I/O’s
2) Urine /BM characteristics and frequency
3) Auscultate bowel sounds
17
Q
What elimination intervetions need to be done in immobility:
A
1) GI: Hydration, sit up for BM, fiber, stool softener
2) GU: fluids, sit up, pour warm water, catheterization
3) Early mobilization, walking
18
Q
What musculoskeletal complication are related to immobility:
A
1) Protein breakdown causing decreased muscle mass leading to atrophy, impaired balance, and increased fall risk
2) Joint contractions, foot drop
3) Ca2+ reabsorption = diuse osteoporosis
19
Q
What muscoloskeletal assessments should be done in immobility:
A
1) Range of motion, muscle tone and strength
2) Ca2+ intake levels
3) Assistive device use
4) Joint mobility
20
Q
What are musculoskeletal interventions during immobility:
A
1) Range of Motion 3x/day (active + passive)
2) Turn Q2H
3) PT/OT consult
21
Q
What cardiovascular complications as associated with immobility:
A
1) Alteration of blood flow (pooling) leading to clots and vessel damage and possible DVT
2) Orthostatic BP
3) Decreased cardiac muscle effectiveness = increases workload = increases oxygen consumption
22
Q
What cardiovascular assessments are needed during immobility:
A
1) Orthostatic BP, dizziness
2) Edema, color, temperature of extremities
3) Leg DVT = hot, red, swollen, unilateral pain, SOB, headache
23
Q
What cardiovascular interventions are needed during immobility:
A
1) Ambulate ASAP (walk, bed exercises like foot pumps)
2) Slow position changes
3) Stockings or sequential compression devices
4) Blood thinner prophylaxis
24
Q
What psychosocial complications are related to immobility:
A
1) Sensory alterations
2) Social isolation and loneliness
3) Altered self-concept
25
What psychosocial assessments are needed in immobility:
1) mental, emotional, and sleep-wake status
2) involvement in social activities
26
What psychosocial interventions are needed in immobility:
1) Routine socialization
2) Involve family and friends
3) Cluster cares to avoid interrupting sleep
4) Coping strategies
5) Increase daytime stimulation, reduce nighttime stimulation
6) Social work, psychologist, Chaplin consult
27
What are some fall prevention considerations:
1) Medications
2) IV placement
3) Mental status
4) Clutter free home
5) Bright lights
6) Assistive devices
28
What is tissue integrity?
Structurally intact and functioning epithelial tissue and mucus membranes
29
What are four age-related changes in tissue integrity:
1) Thinning
2) Decreased strength, moisture, and elasticity
3) Decreased blood flow to tissues = slow healing
4) Drier skin
30
What is each stage of the tissue healing process?
1) Inflammatory: 3-6 days, vasoconstrict, clot formation, deliver nutrients and O2, WBC and macrophages fight microorganisms
2) Proliferation: 3-24 days, replace lost tissue with connective/granulation tissue and collagen, resurface new endothelium
3) Maturation and remodeling: 21 days - 1 year (long in patients with chronic issues), strengthening collagen scar
31
What is primary heaing?
- Also known as primary intention, it is when a wound if closed with adhesives or sutures creating fast healing
- Ex: surgical incision, laceration w/ closure
32
What is secondary healing?
- Also known as secondary intention, is when the wound is left open to heal allowing granulation tissue to fill in the wound from bottom to top.
- It's slow, which increases the risk for infection
- Ex: pressure injury
33
What is delayed primary closure?
- A combination of both primary and secondary healing when an unclean wound is left open (secondary) and then closed to reduce infection. Tertiary intention.
- Ex: abdominal surgery
34
What are four effects of impaired tissue integrity?
1) Impaired thermoregulation (burns)
2) Fluid and electrolyte imbalance (burns, weeping/draining wounds)
3) Infection risk
4) Impaired body image
35
How do nurses assess impaired tissue integrity?
1) Risk factors: age, Braden Scale
2) Assess history, skin color, integrity, wounds, pressure areas (bony prominences, medical-devices
36
How should you examine darker skin tones with possible impaired tissue integrity?
1) Indirect light
2) No visible blanching
3) Compare area to unaffected areas (warm, texture, color, pain)
4) Shiny, taught, edematous
37
How can nurses help prevent impaired tissue integrity?
1) Reduce moisture
2) Nutrition (vitamins A+C, zinc)
3) Reduce sun exposure (hats, long sleeves, sunscreen)
4) Burn prevention (turn down water heater)
38
What kinds of interventions do you avoid in impaired tissue?
1) No massaging area (friction and tears)
2) Hot water and soap (burns)
3) Cornstarch (promotes bacterial growth)
4) Briefs (holds moisture)
39
What are the four pressure ulcer stages? What is unstageable and suspected deep tissue injury?
Stage 1: **nonblanchable** redness, **intact skin**, sensation changes
Stage 2: partial-thickness skin loss, **dermis exposed, pink, moist, red**
Stage 3: full-thickness skin loss,** fat visible**, slough/eschar possible, granulation tissue
Stage 4: Full-thickness skin loss, **exposed, muscle, tendon, and bone** slough/eschar, tunneling, undermining
Unstageable: obscured full-thickness skin loss by eschar/slough
Suspected deep tissue injury: nonblanchable, deep red/maroon, skin intact or open
40
What are risk factors for pressure injuries?
1) Immobility
2) Decreased sensation/perception
3) Poor nutrition
4) Diabetes or peripheral vascular disease
5) Moisture/incontinence
41
How can nurses prevent pressure injuries?
1) Monitor albumin and proterin serum
2) Good nutrition
3) Check perfusion
4) Turn Q2H
42
What is the maximum degree for the head of the bed when trying to manage pressure injuries?
HoB should not be higher than 30 degrees
43
What lab should you monitor in pressure injury?
Serum albumin
44
How are pressure injuries treated?
1) Pain management
2) Dress wound
3) Relieve pressure
45
Can you massage or place cold packs on pressure injuries?
No
46
How high should the HOB be when eating to prevent aspiration?
45 degrees (High Fowler's)
47
What is arthritis?
Inflammation of the joints
48
What is osteoarthritis?
- Progressive deterioration and loss of articulating joint cartilage, bone, and connective tissue
- Synovial fluid declines = decreased lubrication and nutrition
- Associated with pain w/ mobility
- Most common in older adults
49
What is the brief pathophysiology of osteoarthritis?
1) Enzymes break down articular matrix eroding cartilage and bone
2) Inflammation sets in calcifying, thinning, and ulcerating tissue
3) Cartilage disintegrates causing it to float, creates crepitus (noises)
50
What is crepitus?
Grating sound in osteoarthritic joints d/t loosened bone and cartilage in the joint
51
The causes of osteoarthritis have primary and secondary types, what are they?
1) Primary OA: age and genetics (mechanical weardown)
2) Secondary OA: joint injury, obesity
52
What contributes to osteoarthritis?
1) Manual occupations
2) Excessive use
3) Trauma
4) Joint disease
5) Athletics
6) Metabolic diseases
7) Blood disorders (hemophilia)
53
Is osteoarthritis more common in men or women and at what age? What about military personnel?
1) Men under 55 y/o
2) Women over 55 y/o
3) Veterans are 2x more likely to be diagnosed at age 40
54
Is osteoarthritis systemic or localized? Unilateral or bilateral?
Localized, unilateral
55
What are ways to prevent osteoarthritis?
1) Avoid injury
2) Take breaks at work, especially if it is repetitive tasks
3) Proper nutrition to prevent obesity
56
What should nurses assess in osteoarthritis?
1) Pain location and quality
2) Joint stiffness
3) Any swelling
4) Disruption of ADLs
5) Age, gender, work, veteran, weight
57
What are the signs and symptoms of osteoarthritis?
1) Stiffness w/ 30 minutes of no activity
2) Severe joint pain that worsens with activity
3) Crepitus
4) Nodules on hands
58
In osteoarthritis is pain relieved with activity or rest/sleep?
Pain is relieved by rest/sleep
59
How is osteoarthritis diagnosed?
1) MRI
2) Erythrocyte sedimentation rate (ESR)
3) X-ray
60
What are the nursing priorities in osteoarthritis?
1) Pain management
2) Decreased mobility d/t pain and atrophy
61
What drug therapy can be used in osteoarthritis?
1) NSAIDs like Diclofenac 1% cream = topical NSAID, 2 weeks before effective, avoid heat to area
2) Acetaminophen = 4000mg/day max, **use only 3000mg** d/t liver damage
3) Celecoxib = cox 2 inhibitor; watch out for edema, SOB, dark-tarry stool; not for those with hypertension, kidney disease, or cardio history
4) Corticosteroid injection = reduced inflammation (suppresses immune system, decrease bone density, increase blood sugar, weight gain)
5) Hyaluranic acid = increase lubrication
62
What should you monitor for in NSAID use?
Kidney damage, GI bleed (dark-tarry stools), dehydration
63
Can NSAIDs be taken with a history of stroke or cardiac history?
No
64
What nonpharmacological methods can be used for osteoarthritis treatment?
1) Rest and exercise
2) Hot and cold packs
3) Aquatic exercises
4) Topical capsacin (modified substance P)
5) Glucosamine supplement (reduced inflammation)
6) Proper lifting and posture
65
What is the surgical management for osteoarthritis and what are its contraindcations?
1) Total join arthroplasty: total join replacement of all functional parts with a prosthesis (Ex: hip, knee, shoulder, ankle)
2) Contraindications: infection anywhere in the body, hypertension, uncontrolled diabetes, progressive inflammation
66
What are postoperative care consideration for osteoarthritis?
1) KEEP LEGS ABDUCTED
2) On surgery day, ambulate them
3) Night after surgery = weight bearing ambulation, 1 week later = full weight bearing
4) VTE prevention = heparin, ambulation 3x/day, heel push, leg extensions, knee pushes
67
How does a patient improve osteoarthritis?
1) Exercise after heat is applied
2) Exercise on good and bad days
3) Respect pain
4) Active exercise is best
68
What is rheumatoid arthritis, the etiology, and what is it characterized by?
1) A chronic, progressive, and systemic inflammatory autoimmune disease affecting primarily synovial joints;
2) Etiology: environment and genes, stress, infection, but affects women more d/t reproductive hormones
3) Characterized by exacerbations and remissions
69
What gender and race does rheumatoid arthritis mainly affect?
2-3x more women than men; mainly white individuals
70
What are early versus late signs of rheumatoid arthritis?
1) Early: joint inflammation, low-grade fever, fatigue, weakness, parathesias
2) Late: deformities join joint (swan neck, ulnar deviation), **morning stiffness that lasts longer than 30 minutes**, moderate-severe pain, fatigue, subcutaneous nodules, dry eyes/mouth/vagina
71
What are the effects of rheumatoid arthritis?
1) Pain
2) Decreased mobility
3) Decreased self-image
72
How is rheumatoid arthritis diangosed?
1) Rheumatic factor
2) HsCRP
3) Anti-CCP
4) Antinuclear antibody
5) Erythrocyte sedemendation rate
73
What are the treatments for rheumatoid arthritis?
1) Total joint arthroplasty
2) NSAIDs
3) Disease-modifying antirheumatic drugs (methotrexate and hydroxychloroquine)
4) Biological response modifiers = inhibit inflammatory cytokines
5) Ice + heat application
6) Wax dips
74
How do DMARDs help in RA? When in the disease process should they be used?
1) DMARDs: they slow the progression of RA by reducing joint pain and inflammation.
2) Use: Earlier in the disease process = more effective
75
Methotrexate: what is it, how often is it taken, length before effectiveness, adverse effects?
What is it: immunosuppressing drug that works by reducing pain and swelling
Taken: once per week
Length: Work best earlier in disease course, takes 4-6 weeks before seeing inflammation control
Effects: Decrease in WBC or platelets d/t bone marrow suppression, elevated liver enzymes and serum creatinine. Lymph node tumor. Pneumonitis. Mouth sores. Dyspnea.
76
What patient education is needed for RA patients taking Methotrexate?
1) Increased infection risk = avoid large crowds and those who are ill
2) Avoid alcoholic beverages becuase of possible liver toxicity
3) Report adverse effects like mouth sores and acute dyspnea
4) Taking folic acid can help decrease side effects
5) Methotrexate use can cuase birth defects, therefore patients who can become pregnant should be on strict birth control. It must be stopped 3 months before pregnancy and cannot be used while breastfeeding.
77
Hydroxychloroquine: what is it, what stage of RA does it work best in, side effects, and contraindications?
1) What is it: It is an antimalarial drug that helps suppress the immune response to decrease joint and muscle pain.
2) Stage: Works best in mild RA
3) Side effects: Lightheadedness, stomach discomfort, headache
4) Contraindications: Do not use if present cardiac disease or dysrhythmias
78
What are some mobility interventions that can be given for those with rheumatoid arthritis?
1) Find alternatives for ADLs
2) Replace heavy cup lids and difficult handles
3) Long-handled brushes
4) Shoe horn
5) Handles + grip bars
6) OT consult
79
What is the brief pathophysiology of rhuematoid arthritis?
1) Antibodies (rhuematoic factors) attack healthy synovium causing inflammation
2) Inflammation and immunity factors cause cartilage damage alongside cytokine + WBC attraction
3) Synovium thickens, fluid accumulates in joints, bone fuses and calcifies
80
What are risk factors for Parkinson's disease?
**1)** 50 +
**2)** Male
**3)** Genetic
**4)** Toxin or chemical exposure
**5)** Chronic use of antipsychotics
81
What are expected findings in Parkinson's Disease?
**1)** Bradykinesia: slowness of movements
**2)** Akinesia: difficulty intiating movement
**3)** Tremor (pill-rolling)
**4)** Gait (Shuffling, festinating)
**5)** Muscle rigidity
**6)** Stooped posture
**7)** Masklike expression
**8)** ANS difficulties (swallowing, chewing, mood)
82
What are some nursing interventions in Parkinson's Disease?
**1)** Administer meds
**2)** Monitor intake (aspiration risk, nutrition)
**3)** Sit upright while eating, smaller meals, thickened liquids
**4)** OT consult
**5)** Exercise
**6)** Safe area/fall prevention
83
What are possible treatments for Parkinson's Disease?
**1) Dopaminergic agents:** increase dopamine in BG (Cabidopa prevents levodopa from being broken down)
**2) Dopamine agonists:** activate release of dopamine (Bromocriptine, ropinirole) - monitor for orthostatis hypotension
**3) Anticholinergics:** block Ach controlling tremor and rigidity (Benztropine) - very drying - mouth, GI, GU
84
What are some complications of Parkinson's Disease?
**1)** Aspiration pneumonia
**2)** Altered cognition
**3)** UTI
**4)** Depression
**5)** Skin breakdown
85
What is pain?
An unpleasant sensory and emotional experience associated w/ actual or potential tissue damage.
86
What is the most common reason individuals seek care?
Pain
87
What is protective versus pathologic pain?
Protective: tells us something is wrong to correct in the moment
Pathologic: pain associated with a disease process
88
Is pain a conscious or unconscious experience?
It is a conscious experience requiring an intact CNS
89
What is the physiologic process of pain?
1) Nociception: cells of free nerve endings detect injury
2) Transduction: stimulus is converted into electrical impulse
3) Transmission: signal travels along axons to send AP/NXT release
4) Perception: signal is received and interpreted by the brain
5) Modulation: brain releases endogenous opioids and serotonin
90
Is pain a normal part of again?
It is not a normal part of aging, pain is also considered an indication that something is wrong.
91
How long must pain last to be considered chronic?
3 months
92
What is nociceptive, visceral, and somatic pain?
Nociceptive: Normal pain tramission (Ex: aching, cramping, throbbing)
Visceral: Pain within a body or cavity
Somatic: localized and sharp
93
What is neuropathic pain?
Pain that is indicative of the somatosensory system, pathologic (Ex: burning, shotting, sharp)
94
What are the physiologic consequences of pain?
1) Initiates metabolic proceses (weight loss, tachycardia, increased RR)
2) Higher rates of infection d/t higher cortisol levels
3) Unrelieved pain can lead to pneumonia (shallow breathing) and hypercoagulation leading to MI/stroke.
4) Increased heart rate and blood pressure in acute pain
5) Impaired mobility
95
What pain levels should each analgesic be used for?
1) Nonopoids - mild to moderate nociceptive pain (NSAIDs, acetaminophen)
2) Opioids - moderate to severe pain (Oxycodone, hydrocodone, morphine)
3) Adjuvants - anticonvulsants/antidepressants for neuropathic pain
96
What kind of pain can antidepressants help with? What should you monitor for?
Nerve-related pain, monitor for sedation and suicidal ideation.
97
What is fluid balance?
the process of regulating the ECF volume and body fluid osmolality
98
What is the optimal osmolality of ECF?
285-295 Osm
99
Why are older adults at risk for dehydration?
1) Low percent body weight as water
2) Decreased thirst response
3) Decreased kidney function
100
What is clinical dehydration?
Loss of water w/o loss of sodium increasing osmolality and decreasing volume
101
What is fluid volume deficit?
Loss of both water and electrolytes equally decreasing volume
102
What is fluid volume excess?
Too much isotonic fluid increasing volume
103
What causes clinical dehydration?
1) Lack of water intake
2) Lack of thirst response (coma, tube feeding w/o water)
3) GI losses (vomiting, diarrhea)
4) Diabetes insipidous (no ADH = large urine output)
5) Excessive sweating
6) Wound drainage
104
What are symptoms of clinical dehydration?
1) sudden weight loss (1kg (2.2lbs)/day =1L of water lost)
2) dry oral mucosa
3) Low BP
4) High HR
5) High RR
6) Flat veins
7) Oliguria (minimal urine output, dark, less than 500mL/day or 30mL/hour)
8) LOC
9) seizures
**10) Na+ increased (>145)**
11) High sodium, high hematocrit, high BUN, high urine specific gravity, high creatinine
105
What are the causes of fluid volume deficit?
1) blood loss
2) GI losses (nausea, vomiting)
3) diuretic treatment
4) lack of aldosterone
5) Altered intake (impaired swallowing)
6) prolonged NPO
7) confusion
106
What are the symptoms of fluid volume deficit?
1) sudden weight loss
2) Low BP
3) High HR
4) Dry mucosa
5) Oliguria
107
What is different between clinical dehydration and fluid volume deficit?
There is no sodium loss in fluid volume deficit
108
What is a consequence of fluid volume deficit and dehydration?
Decreased tissue perfusion leading to low O2 to tissues, shock
109
What is a consequence of fluid volume overload?
Impaired tissue perfusion d/t edema (generalized, pulmonary edema) because capillaries are pushed farther away from cells
110
What is a consequence of clinical dehydration?
Na+ shifts fluid away from cells causing them to shrink leading to LOC, confusion, shock
111
How is clinical dehydration treated?
Isotonic Na+ solution (sodium included to prevent seizures from rapid shifting) and extra water, fall prevention
112
How is fluid volume deficit treated?
Isotonic Na+ solution, monitor, fall prevention
113
What are the causes of fluid volume excess?
1) Excess Na+ isotonic solutions
2) high oral intake of sodium and water
3) Oliguria (CKD)
4) Heart failure
5) IV overload
114
What are the symptoms of fluid volume excess?
1) Sudden weight gain (1kg (2.2lbs)/day)
2) Edema
3) Bounding pulse
4) Dyspnea/SOB
5) Pulmonary edema
6) Distended veins
7) Increased RR and BP
8) decreased Hct, Hgb
9) pale, cool skin
10) lung crackles
115
How is fluid volume excess treated?
1) Fluid/Na+ restriction
2) Elevate HOB
3) Administer O2
4) **Diuretics (Furosemide)**
5) Aquaretics
6) Dialysis
116
Furosemide (Lasix):
1) Type
2) Oral vs. IV
3) Adverse effects
4) Patient teaching
1) Type: It is a loop diuretic that removes water, sodium, and electrolytes (K+)
2) *Oral* onset is 60 minutes and duration is 8 hours; *IV* onset is 5 minutes and duration is 2 hours (rapid intervention)
3) Adverse effects: Ototoxicity (hearing damage), excess Na+/K+/water loss, hypotension
4) Teaching: Slow position changes and eat foods high in potassium or supplement
117
What is gastroenteritis?
Inflammation of the mucus membrane of the stomach and intestines
118
Is gastroenteritis viral or bacterial?
It is both bacterial and viral, but most commonly viral
119
Which part of the GI is often infected in gastroenteritis?
The small intestine.
120
What are symptoms of gastroenteritis?
Nausea, vomiting, diarrhea, distended/tender abdomen, hyperactive BS, dehydration, increased HR
121
What lab is looked at in gastroenteritis?
Low K+, hypokalemia
122
What aspect of the stool do you monitor in gastroenteritis?
Amount of stool
123
What is the most common cause of gastroenteritis?
Norovirus especially in cold months becuase it can survive at low temperatures and as long viral shedding
124
How long does gastroenteritis last?
Around 3 days and is self-limiting
125
How can you prevent gastroenteritis?
1) Proper handwashing and sanitizing of surfaces
2) Proper food and beverage preparation and storage
126
What population is of concern in gastroenteritis?
Older adults due to hypovolemia and hypokalemia
127
How do you treat gastroenteritis?
1) Oral fluid replacement (water, sports drinks, pedialyte)
2) Antibiotics only in bacterial (Ciprofloxacin or azithromycin)
3) Wash and gently cleanse buttocks, keep dry, use barrier cream
128
Can medication be used in viral gastroenteritis?
No, supportive therapy only
129
Can motility limiting drugs (anti diarrheal drugs) be used in gastroenteritis?
No, b/c it can prevent infection removal if motility is stopped
130
What foods are risk factors for gastroenteritis?
Raw spinach, oysters, sprouts, sushi
131
What is clostridium difficile?
It is a anaerobic bacteria that can cause infection
132
What are risk factors for c. diff?
1) Antibiotic use (especially fluoroquinolones, cephalosporins, and clindamycin)
2) GI surgery
3) Immunocompromised
4) Old age
133
How is c. diff transmitted?
fecal to fomite (surface)
134
What are symptoms of c. diff?
1) Watery diarrhea
2) fever
3) Loss of appetite
4) nausea
5) abdominal pain
135
How is c. diff diagnosed?
By clinical symptoms and positive culture test
136
What is colonization versus infection in c. diff?
Colonization is being infected with c. diff, but no current symptoms while infection is both positive c. diff with symptoms present
137
What is the treatment for c. diff?
1) Isolation precautions
2) Contact precautions
3) Antibiotics: oral vancomycin or fidaxomicin
138
What are complications of c. diff?
1) Sepsis
2) Colitis
3) Toxic megacolon
4) Colon perforations
139
What are the three main causes of electrolyte imbalances?
**1)** Output is greater than intake
**2)** Output is less than intake
**3)** Altered elecrolyte distribution (i.e., potassium moving into ECF and H+ moving into ICF during acidosis, calcitonin increasing ECF Ca2+ )
140
What are age-related issues in fluid balance regarding skin, kidney, musclar, neurologic, and endocrine?
1) Skin: poor turgor, dry skin
2) Kidney: decreased GFR means less excretion and decreased concentrating capacity increasing water loss
3) Muscular: less muscle mass = less total body water
4) Neurologic: decreased thirst reflex = less fluid intake
5) Endocrine: adrenal atrophy = poor Na+ and K+ balance (low for both)
141
What is obligatory urine output? How much is it?
Obligatory urine output: The minimum output per day to remove toxic waste.
Amount: 400-600mL/day
142
What is insensible water loss? How much is typically lost?
Insensible water loss: lost fluid b/c no mechanism controls it (Ex: salivation, perspiration, lung vapor, fistulas, drains, GI suction
Amount: 500-1000mL/day
143
What is normal fluid intake per day (mL)?
~2300mL/day
144
What is the stimulus and function of aldosterone?
Stimulus: It is secreted by the adrenal cortex when Na+ ECF levels are low, renin signals release
Function: Acts on the kidneys to prevent and Na+ and water excretion by increasing reabsorption
145
What is the stimulus and function of antidiueretic hormone?
Stimulus: Secreted by the hypothalamus and stored in the PP for release when blood osmolarity is too high
Function: Inserts aquaporins into the collecting ducts to reabsorb water
146
What is the stimulus and function of natriuretic peptide hormone (NPH)?
Stimulus: Released from the heart atria and ventricles in response to increased blood volume and blood pressure
Function: Inhibits Na+ and water reabsorption at the kidneys (works in contract to aldosterone)
147
What are the functions of angiotensin 2?
**Functions:**
**1)** constricts ateries and veins to increase total peripheral resistance
**2)** Constricts afferent arterioles to decrease GFR and urine output
**3)** Stimulates aldosterone output to increase Na+ and water reabsorption
148
Provide the normal value range for sodium, potassium, calcium, magnesium, and typical serum osmolarity:
**Sodium:** 136-145 mEq/L
**Potassium:** 3.5-5.0 mEq/L
**Calcium:** 9.0-10.5 mg/dL
**Magnesium:** 1.3-2.1 mEq/L
**Osmolarity:** 270-300 mOsm
149
Hyponatremia: lab value, key issue, causes, symptoms, nurse role, treatment
**Lab value:** <136mEq/L
**Key issue:** decreased membrane excitability (need high ECF Na+ to excite) and **cellular swelling**
**Causes:** prolonged diuresis, excessive water intake, kidney failure, GI fluid loss, burns
**Sx:** *normal volume* = increased HR; *hypovolemic* = thready, weak pulse, rapid HR, hypertension; *hypervolemic* = rapid, bounding pulse, BP normal or elevated
-> *cerebral changes (behavioral)* = **LoC, confusion, seizure**, headache
-> *Neuromuscular* = weakness, hyporeflexia
-> *Intestional* = increased GI motility, nausea, diarrhea
**Nursing role:** monitor LoC, extremity strength/reflex, slow position changes, monitor patient's respons to therpy, prevent hypernatremia and fluid overload,
**Tx:** IV saline (if deficit), reduce dieuretic dose, **increase Na+ intake**, **hypertonic solution if ECF is low osmolairty**, lithium for SIADH
150
Hypernatremia: lab value, key issue, causes, symptoms, treatment, and nurse role
**Lab value:** >145 mEq/L
**Key issue:** increase tissue excitability (Na+ moves more easily into cells), **cells shrink and stop responding**
**Causes:** kidney failure, hyperaldosteronemia, dehydration, excessive Na+ intake, IV fluids, steroids, diabetes insipidous
**Sx:** *nervous* = altered mental status, **irritable, agitated**, short attention span; *skeletal muscle* = twiching, contractions, weakness + hyporeflexia in severe; *CV*= **edema**, decreased contractility; **other** = skin flushed and dry, thirsty
**Nurse:** assess muscle strength with hand grip/arm flexion
**Tx:** Restrict Na+ intake, **furosemide** diuretic, **isotonic saline w/ dextrose 5% in .45% sodium to correct imbalance without rapid shifting into cells**
151
Hypokalemia: lab value, key issue, causes, symptoms, treatment, and nurse role
**Lab value:** <3.5 mEq/L
**Key issue:** decreased excitability causing nerve and musces cells to be less responsive
**Causes:** diuretics (loop + thiazide), corticosteroids, high aldosterone, vomiting, diarrhea, alkalosis, hyperinsulinism
**Sx:** respiratory = shallow, **weak respirations** ; skeletal muscle = hyporeflexia, weak grip; CV = weak, thready pulse, orthostatic hypotension; neuro = irritable, anxious, confused; GI = decreased peristalsis, N/V, constipation
-> ECG Findings: **Prominent U-wave** , ST depression, inverted T wave
**Nurse role:** **Ensure good urine output,** PO K+ with food d/t N/V, adequate gas exchange **(assess respiratory status and heart Q2H)**, prevent K+ admin injury
**Tx:** K+ supplements, IV K+ (**DO NOT PUSH, DILUTE INSTEAD; 5-10 mEq/hour)**, self intake (bananas, citrus, raisins, meat), switch to potassium sparing diuretics like **Spironolactone**
152
Can you IV push K+? Can it be given IM or SubQ?
HELL NO. It should be administed via IV infusion, diluted with saline, and administered slowly at 5-10mEq/hour.
It cannot be given IM/SubQ.
153
What type of PO K+ can be crushed?
Effer-K can be dissolved in liquid for PO admin
154
Hyperkalemia: lab value, key issue, causes, symptoms, nursing role, and treatment
**Lab value:** >5.0 mEq/L
**Key issue:** increases cell excitability causing less response to stimuli, **especially conduction to the heart**
**Causes:** high K+ intake (supplements,** salt substitutes**), IV infusion, whole blood transfusions, acidosis, kidney failure, **potassium-sparing diuretics (Spironolactone), ACE Inhibitors (lisinopril - 'prils)** , acidosis
**Sx:** *CV=* bradycardia, hypotension, ectopic beats, heart block, asystole, ventricular fibrilation; *neuromuscular=* twitching, **contracting/cramps**, **numbness/tingling of hands/feet/mouth**, weakness starting at extremities; *GI=* increased motility, diarrhea, hyperactive BS
-> *ECG:* **Peaked T waves**, prolonged PR, wide QRS
**Nurse role**: **assess for any cardiac complications** with continuous monitoring , decrease potassium intake, prevent falls,
**Tx:** Patiromer/Kayexelate = bind K+ decreaseing GI absorption, low K+ foods, no supplements, **potassium-excreting diuretics (loop=furosemide or thiazide = hydrochlorothiazide)**; insulin w/ dextrose, dialysis
155
Hypocalcemia: lab value, key issue, causes, symptoms, nursing role, and treatment
**Lab value:** <9.0 mg/dL
**Key issue:** Inceased Na+ movement across excitable membranes when there is low Ca2+ = increased depolarization
**Causes:** Decreased Ca2+ intake, lactose intolerance, malabsorption syndromes (Chron's/Celiac), low vitamin D intake, diarrhea, alkalosis, CKD, wound drainage, decreased parathyroid hormone
**Sx:** *neuromuscular=* muscle twitching, **painful cramps/spasms in thigh/calf,** N/T of hands/feet/lips, **positive Troussea's sign, positive Chvostek** sign; *CV=* **weak respirations** weak, thready pulse, decreased HR and BP; *ECG=* **prolonged QT intervals** ; *GI=* increased bowel sounds, cramping, diarrhea; *skeletal=* osteoporosis
**Nursing role:** **decrease environmental stimuli, have emergency trachestomy equipment on standby (d/t laryngospasm)**, careful lifting/moving d/t brittle bones, proper body mechanics
**Tx:** Dietary (spinach, kale)/IV Ca2+ replacement, vitamin D
156
Hypercalcemia: lab value, key issue, causes, symptoms, nursing role, and treatment
**Lab values:** >10.5 mg/dL
**Key issue:** High Ca2+ causes excitable tissue to be less sensitive = cells needs a stronger stimulus to depolarize
**Causes:** Excess Ca2+ intake, excess vitamin D intake, hyperparathyroidism, CKD, thiazide diuretics, immobiltiy
**Sx:** *CV=* increased HR and BP in mild and decreased in severe, increased clotting in legs and pelvis, edema; *ECG=* short QT, wide T; *neuromuscular=* weakness, **hyporeflexia**, confusion; *GI=* constipation, decreased bowel sounds, vomiting, **excessive urination**
**Nursing role:** **monitor cardiac function,** rehydration with normal saline
**Tx:** Stop Ca2+ intake, use normal fluids, **phosphorus/calcitonin/biphosphonates/NSAIDs** to keep Ca2+ in bone, stop/change diuretics **(stop thiazide, start loop)**
157
Hypomagnesemia: lab value, key issue, causes, symptoms, nursing role, and treatment
**Lab value:** <1.3 mEq/L
**Key issue:** Increased membrane excitability (magnesium at normal levels helps inhibit) - also **low Mg2+ means low K+ and Ca2+**
**Causes:** decreased absorption of dietary Mg2+ (proton pump inhibitors - stop acid = no magnesium chelation, Celiacs/Chron's), Thiazide and loop diuretics, diarrhea
**Sx:** CV= **tachycardia, hypertension**, dysrthymias (a. fib, v. fib, long QT); neuromuscular= **hyperreflexia**, N/T, irritability, **positive Troussea's, positive Chvostek, seizures;** GI = nasuea, constipation
**Nursing Role:** **monitor cardiac activity,** assess DTR in IV Mg2+ replacement, seizure precuations
**Tx:** discontinue diuretics (loop + thiazide), aminoglycosides, magnesium sulfate, IV therapy
158
Hypermagnesemia: lab value, key issue, causes, symptoms, nursing role, and treatment
**Lab value:** >2.1 mEq/L
**Key issue:** high Mg2+ causes extreme inhibition and decreased depolarization
**Causes:** mangesium-containing antacids/laxitives, IV replacement, CKD/kidney failure
**Sx:** **CV = bradycardia, peripheral vasodilation, hypotension, cardiac arrest, respiratory depression**; ECG = wide QRS, prolonged PR; neuromuscular = **absent or reduced DTR**, muscle weakness
**Nursing Role:** **monitor cardiac function**, monitor DTR
**Tx:** calcium gluconate, stop all Mg2+ products, **loop (furosemide/lasix)**, Mg2+ free fluids
159
What is cell proliferation?
When the body has a physiological needs for more cells (Ex: more WBCs during infection) or after apoptosis
160
What is cell differentiation?
When cells go from immaturity to maturity for a specific function
161
What is contact inhibition? Do cancer cells have contact inhibition?
It is what prevents cells from growing outside their territory.
Cancer cells do not have contact inhibition.
162
What are proto-oncogenes and tumor suppressor genes? How do cancer cells benefit from mutations on these?
Proto-oncogenes: regulate and promote cell growth
Tumor supressor genes: regulat and suppress cell growth
Cancer cells benefit becuase mutations will either inactive tumor suppressor genes or overactivate proto-oncogenes.
163
What is a cancer or malignancy?
Abnormal cell growth which new tissues grow unregulated harming normal cell function
164
What are the three steps to cell transformation to cancer?
1) Initiaion: lose regulation, irreversible
2) Promotion: enhanced growth by endogenous hormones or other substances
3) Progression: increased growth and can be detected, **has own blood supply**
165
What is cancer grading?
How similar cancer cells look like parent cells
166
What is cancer staging?
How progressed is the cancer? Informes prognosis, tx, and options. Tumor-node metastasis (TNM):
1) Location
2) Size
3) Lymph spread
4) Spread to distant points
167
What cancers have the highest death rate and higest incidence?
**Death:** Lung + Bronchus
**Incidence:** Prostate (men), breast (women)
168
What are the three main cancer risks? What accounts for the most causes?
1) Carcinogen exposure = responsible for 90% of cancer
2) Genetics
3) Immunity (reduced immunity d/t **age**, infection, transplant, medications) - age is a risk because exposure accumulates
169
What is cachexia?
Cachexia: malnutrition and extreme body wasting caused by cancer becuase it steals nutrients that cells need
170
Describe the following cancer treatment modalities:
* Prophylactic
* Diagnostic
* Curative
* Debulking
* Palliative
* Reconstructive
1) **Prophylactic:** tissue removal to prevent cancer (i.e. mastectomy)
2) **Diagnostic:** removal of all or part of lesion to test
3) **Curative:** remove all cancerous tissue, cure
4) **Debulking:** partial tumor removal to improve symptoms, improve other treatment, and increase survival time
5) **Palliative:** symptom relief and impove quality of life
6) **Reconstructive:** increase function and/or appearance
171
What treamtent strategies are used in cancer?
1) **Monotherapy:** single treatment modality used
2) **Combination:** two or more treatments used together
3) **Maintenance:** continued treatment to prevent cancer recurrence and progression
4) **Experimental:** clinical trials for a new treatment
172
What is radiation therapy and where does it affect tissue?
Radiation therapy is using high-energy radiation to kill cancer cells for curative or palliative treatment.
Effects are only seen in the target area.
173
What are protective measures nurses should do when workin with radiation therapy?
1) Reduce time in field
2) Increase distance from field
3) Use shielding (lead apron/shield)
4) Use dosimeter
174
What are the two types of radiation therapy?
1) External beam: radiation is outside of patient, they are not radioactive (IMRT, stereotactic, radiosurgery)
2) Brachytherapy: internal radiation, object placed direct in contact with tumor or ingested giving a higher dose. Patient is only radioactive while the seed is still in
175
What are some symptoms of radiation therapy?
1) Radiation dermatitis: redness pigmentation, desquamation
2) systemic: fatigue, altered taste, bone marrow suppression
3) Fibrosis and scarring
4) Secondary malignancies
5) N/V
6) Photosensitive skin
176
Why should radiation patients stay out of the sun?
Because their skin becomes photosenitive increasing sunburn risk. They should avoid sun during and 1 year after radiation is complete.
177
What should nurses educate patients about their skin during radiation?
1) Wash area with mild soap and water
2) **No scrubbing**
3) Do **not** remove ink tattoo until radiation therapy is complete
178
What is systemic cancer therapy? What is important to know about the systemic aspect?
The use of antineoplastic (chemo) or immunotherapy drugs to kill cancer and disrupt regulation of cancer cells.
It kills both healthy and cancerous cells.
Types: Chemo, immunotherapy, hormone (endocrine), and targeted therapy
179
What is immunotherapy in cancer?
Therapy that works to activate the immune system to attack cancer cells
180
What is neoadjuvant chemo?
Chemo used **before** surgery/radiation to debulk or shrink the tumor
181
What is adjuvant chemo?
Chemo used **after** radiation/surgery
182
Is treatment of metastatic cancer curative?
No, but it can help increase survival time
183
Why should the nurse emphasize proper adherence to the chemo/immunotherapy schedule?
The schedule must be followed to achieve the best dose in order for the best response
184
Chemo drugs are considered vesicants. What is a vesicant and what should you assess/do?
Vesicant: medication that is damaging to tissue on direct contact
Assess IV site and stop infusion if s/s appear.
185
Are oral chemotherapy drugs as toxic as IV drugs?
Yes
186
Can oral chemotherapy drugs be crushed, split, or broke?
No
187
Are patients allowed to touch oral chemotherapy medications with their bare hands?
No, they should use a glove.
188
What should a patient do if they miss their chemotherapy dose?
Do not double up, take the next dose when scheduled
189
What are symptoms of chemo?
1) Cardiac muscle damage
2) Decreased bone density
3) Anemia
4) Reduced immunity
5) Neutropenia
6) Thrombocytopenia
7) Reduced clotting
8) N/V
9) Mucositis
10) Alopecia
190
What is the greatest dose-limiting symptoms/effect of chemo?
Bone marrow suppression d/t concern of reduced immunity
191
What are some neutropenic precuations?
1. Handwashing or alcohol-based rubs before contact
2. Clean their room and bathroom 1x/day
3. Place patient in private room
4. Vitals Q4H
5. Monitor IV sites
6. Inspect mucus membranes and skin
7. Restrict sick visitors
8. Change wound dressings daily
9. Notify provider of any possible infection
10. Keep equipment in patients room
11. Monitor WBC daily
12. Avoid catheter use
13. Avoid potted plants/flowers in the room
192
What are low WBC precuations for patients?
1) Avoid crowds
2) no sharing toiletries
3) bathe daily
4) use antimicrobial soap
5) do not drink standing liquids
6) do not clean up after pets
193
What is an emetogenic?
Vomit inducing substance/agent
194
When are antiemetics given for chemo to work best?
Before chemo is best but can also be given at first s/s
195
Describe the following types of chemotherapy-induced N/V:
* Anticipatory
* Acute
* Delayed
* Breakthrough
* Anticipatory: before receiving chemo, triggered by thoughts, sights, sounds
* Acute: w/in 24 hours of receiving chemo (i.e. Decarbazine)
* Delayed: after first 24 hours (Cisplatin)
* Breakthrough: intermittent
196
Ondansetron (Zofran): Use, MoA, route, when to use, side effects
Use: Treat nasuea and vomiting, antiemetic
MoA: serotonin antagonist blocking the H-HT3 receptors in brain and GI.
Route: Oral or IV
When: 1-2 hours before chemo
Side effects: headache, orthostatic hypotension, bradycardia, vertigo, constipation, porlonged QT interval
197
Prochlorperazine (Compazine): Use, MoA, route, side effects
Use: Nasuea and vomiting, antiemetic
MoA: dopamine (D2) antagonist in the brain
Route: Oral
Side effects: drowsiness, extrapyramidal reactions, difficulty cooling body
198
What is mucositis and how can it allieved?
Mucositis: inflammation of the oral and GI mucosa
Relieved: gentle flossing, non-alcoholic rinses, brush every 8 hours, drink 2L of water daily, avoid spicy and acidic food
199
What is alopecia and how should you protect your scalp?
Alopecia: hair loss
Protection: use sunscreen and coverings
200
How soon after chemotherapy does hair regrow?
Hair regrowth begins ~1month after stopping chemotherapy
201
What is "chemo brain"
Decline in concentration and memory during chemo
202
What is chemo-induced peripheral neuropathy?
It is peripheral neuropathy caused by damage to the nerves in extremities, especially lower extremities cuasing gait and balance issues, loss of sensation in hands and feet, orthostatic hypotension, erectile dysfunction, pain, constipation, and reduced taste
203
What is time toxicity in chemotherapy?
The time and energy one spends on everything cancer-related: treatment, managing care, driving, waiting, fatigue and side effects of treatment
204
What is immunotherapy and its symptoms? Why may it be preferred to chemo?
Immunotherapy: medication used to activate the body's own immune system to detect and attack cancer cells.
Sx: fatigue, rash, increased infection risk
Preference: It may be preferred over chemo because there are less cytotoxic effects.
205
What is immune-related adverse effects of immunotherapy and how is it treated?
Immune-related adverse events: It is when the immune system stimulation affects healthy cells too causing systemic inflammation (hepatitis, pancreatitis, colitis, etc.)
Tx: corticosteroids
206
What is targeted therapy in cancer treatment and what are the symptoms?
Targeted therapy: The use of medications to block growth and spead by interfering with growth and regulatory pathways. For instance, blocking VEG-F acting directly on cancer cell
Sx: GI disturbance, decreased immunity, skin rash, hypotension
207
What happens if cancer cells do not express the protein or mutation when undergoing targeted therapy?
The therapy will not work if the protein or mutation is not expressed.
208
What is endocrine therapy and associated symptoms in cancer treatment?
Endocrine therapy: aromatase inhibitors, GRH analogs, antiandrogens, and antiestrogens to prevent cancer cells from receiving growth stimulation
Sx: fatigue, orthalgia (joint pain), bone pain, hot flashes, sexual dysfunction, osteoporosis, thrombosis
209
What is the second most deadly type of cancer?
Colorectal cancer
210
Where is colorectal cancer found most often and what is the most common metastasis site?
Found: Rectosigmoid area
Metastasis: Most often spreads to the liver
211
What are colorectal risk factors?
1) 50 y/o
2) Genetic predisposition or family history
3) First degree relative = 2-3x risk
4) Familial adenomatous polyposis (FAP) = polyp have 100% chance of becoming cancerous
5) Inflammatory GI issues = Chron's, Ulcerative colitis
6) Personal factors (smoking, alcohol use, physical inactivity, high red meat intake)
212
When is colorectal cancer screening recommended? What kinds of tests?
Age: Beginning at age 45
Tests: stool-based testing, fecal-occult blood testing, multi-targeted stool DNA, colonoscopy, sigmoidoscopy
213
What are ways to prevent colorectal cancer?
1) Increase fiber intake
2) Decrease fat intake
3) Increase vegetables
4) Reduce smoking and drinking
214
What are signs of colorectal cancer?
1) Rectal bleeding
2) Anemia
3) Change in stool consistency
4) Change in stool shape
215
What is the definitive diagnostic test for colorectal cancer?
Colonocopy: viewing entire large bowel
216
What are some nonsurgical interventions in colorectal cancer treatment?
1) Rectal radiation
2) Palliative radiation
3) Adjuvant chemo
4) Bevacizumab: angiogenesis inhibitor, blocks VEG-F
5) Intrahepatic chemo: with 5-fluororacil for liver metastasis
217
What are the two surgical options for colorectal cancer treatment?
1) Colon resection: removal of part of the colon and surrounding lymph nodes
2) Abdominoperineal resection: remove part of the sigmoid colon, rectum, and anus via abdominal + perineal incisions
218
What are some colostomy management recommendations/education?
1) Begins functioning 2-3 days post-op
2) Empty at 1/3-1/2 full
3) Avoid flatus foods
4) Cleans stoma before appliance
5) Should be pink, moist, and 1-3cm tall
219
What are pain management recommendations after colorectal surgery?
1) NO straining
2) soak in sitz bath for 10-20 minutes 3-4x/day
3) analgesics
4) side-lying
5) avoid sittin for long periods and use foam pads
6) avoid using air rings and rubber donuts
220
Acidosis risk factors:
1) older adults
2) Those with breathing dificiluties (COPD, asthma)
3) Kdiney failure
4) Diabetes melitus
5) Diarrhea (bicarb loss)
6) Pancreatitis (bicarb loss)
7) Fever
8) Heavy exercise
221
Metabolic Acidosis: Labs, symptoms, nurse role, treatment
**Labs: ph less than 7.35;** PaO2 (80-100mmHg), PaC02 (35-40mmHg), **HCO3 (less than 15-20)**
**Sx:** cardiac = tachy and increased CO early on, **hypotensive and brady later** with wide QRS complex; **CNS = depression of CNS function, lethargy, confusion**; neuromuscular = hyporeflexia, flaccid paralysis; respiratory = **Kussmal respirations**; integumentary = warm, flush, dry skin
- cognitive changes may be first seen
**Nurse role:** akways **assess CV system first d/t hyperkalemia risk** (H+ ions are exchanged into ICF for K+ into ECF)
**Tx:** hydrate low and slow to avoid edema, bicarbonate, antidiarrheals, insulin for DKA
222
Respiratory Acidosis: Labs, symptoms, nurse role, treatment
**Labs:** **pH less than 7.35**; PaO2 (less than 90mmHg); **PaCO2 (>50mmHg);** HCO3- (21-28+)
**Sx:** CV= Tachy and high CO early, hypotension and bradycardia with wide QRS complex later on; CNS= depression of CNS w/ **lethargy and confusion**; neuromuscular= hyporeflexia; **integumentary= pale to cyanotic skin**
**Nurse role**: always **assess CV system first d/t hyperkalemia risk,** monitor accessory muscle use, breath sounds, cyanosis, monitor lung sounds
**Tx:** oxygenation = bronchodilators, antiinflammatories, mucolytics, O2 therapy, mechanical venitlation
223
Causes of metabolic alkalosis?
**1) Increased bases**: Antacid use, blood transfusion, sodium barb, TPN
**2) Decreased acids:** vomiting, NG suction, hypercortisolism, hyperaldosteronism, thiaizde diuretics
224
Causes of respiratory alkalosis?
**1) Excess CO2 loss:** hyperventilation, mechanical ventilation, salicylate overuse (too much aspirin stimulating medulla), high altitude
225
Nursing interventions for respiratory alkalosis?
1) Breathe into paper bag
2) Calm reassurance if hyperventalation is due to panic or fear
3) Supplemental O2 as needed
226
Nursing interventions for metabolic alkalosis?
1) Administer fluids as prescribed
2) Administer electrolyte replacement if prescribed
227
What are the symptoms of respiratory/metabolic alkalosis?
Think of hypokalemia and hypocalcemia symptoms!
**CNS:**diziness, agitation, confusion, hyporeflexia, N/T in hands/feet/mouth, positive Trousseau's and Chvostek signs
**Neuromuscular:** cramps, twitches, "charlie horse", tetany
**CV:** tachycardic, thready pulse, digoxin sensitivity
**Respiratory:** hyperventilation (respiratory), decreased RR effort (metabolic)
228
Treatment for alkalosis?
1) Redhydrate w/ IV electrolytes
2) Stop suctioning
3) Stop loop/thiazide dieuretics
4) Antiemetics
229
What are some differences between acidosis and alkalosis?
**Acidosis:** hyperkalemia, hyporeflexia, muscle weakness/paralysis,
**Alkalosis**: hypokalemia, hyperreflexia, muscle cramps/twitching
230
Hyperthyroidism: what is it, lab levels, symptoms, nursing interventions
**1) What is it:** a hypermetabolic state related to increased T3 and T4 hormones
**2) Labs:** High T3+T4, low TSH
**3) Sx:** tachycardia, hypertension, hyperglycemia, warm, sweaty, heat intolerance, exopthalmos (bulging eyes), goiter (bulging of thyroid gland), irritable, nervous, fine/soft hair
**4) Nursing interventions:** promote calm environment, encourage rest, I/O's and weight, monitor nutrition, decrease room temp, cool showers, report any 1 degree increases in temperature, montior for thyroid storm, monitor vitals, monitor mental status
231
What is thyroid storm?
It is a severe and life-threatening complication of hyperthyroidism where heart rate increase and temperature spikes dramatically, which may lead to coma and possibly death
232
Are you able to palpate a goiter?
No, you should not palpate goiter as it can lead to thyroid storm.
233
Methimazole: what is it, what is it used for, monitor for, patient education
**1) What is it:** it is an drug that blocks iodine from binding in the thyroid gland reducing T3+T4 release
**2) Used for:** It is used to treat hyperthyroidism
**3) Monitor for:** liver toxicity, hypothyroidism
**4) Patient education:** It can suppress your immune system and increase your risk for infection = avoid crowds and those who are ill; symptoms such as weight gain, cold intolerance, and slow heart rate may indicate hypothyroidism indicating the dose needs to be lowered; lastly, women who become pregnant should stop taking this drug and contact their provider d/t birth defect risks
234
Hypothyroidism: what is it, lab levels, symptoms, nursing interventions
**1) What is it:** inadequate thyroid hormone decrease metabolic system activity
**2) Lab levels:** low T3+T4, high TSH
**3) Sx:** Fatigue, excess sleeping (up to 16 hours and still feeling tired), cold intolerance, constipation, weight gain w/o calorie increase, pallor, brittle nails, depression, bradycardia, hypotension, hair loss, dry ksin, myxedema, hoarseness
**4) Nursing interventions:** vital signs and **chest pain**, monitor weight, **monitor mental status changes**, increase activity slowly, avoid laxatives which may interfere with meds, hypothyroidsm decrease medication metabolism = be careful with meds becoming toxic, **monitor respiratory status,** increase room temp/extra blankets
235
Levothyroxine: what is it, what is it used for, monitor for, patient education
**1) What is it:** it is a thyroid replacement medication becuase it acts as a T4 analog
**2) Used for:** hypothyroidism
**3) Monitor for:** chest pain, dyspnea, hyperthyroidism
**4) Patient education:** take 1 hour before meals with water on an empty stomach; avoid taking iron, calcium, and antacids within 4 hours of taking levothyroxine as they decrease absorption; may increase insulin needs and other meds
236
Hypercortisolism (Cushing's): What is it, symptoms, nursing role
**1) What is it:** excess adrenal hormones like cortisol, aldosterone, androgens, and estrogens
**2) Sx:** weakness, fatigue, join pain, decreased libido, thin/fragile skin, increased HR and BP, weight gain, increased appetite, bone pain (fracture risk), hyperglycemia, extreme muscle wasting, truncal obesity, buffalo hump, moon face, hypernatremia, hypokalemia, hypocalcemia
**3) Nursing actions:** I/O's and weight daily, hypervolemia s/s (edema, SoB, high BP/HR), safe environment d/t fracture risk, meticulous skin care, handwashing, antiseptic dressing changes
237
Hypocortisolism (Addison's): What is it, symptoms, nursing role
**1) What is it:** adrenal insufficiency lacking in cortisol and aldosterone creating a rapid and acute crisis
**2) Sx:** salt craving, weight loss, hyperpigmentation of skin (bronzing), N/V, anorexia, low BP, hypovolemia, hyponatremia, hypoglycemia, hyperkalemia, hypercalcemia
**3) Nursing role:** prevent circulatory shock, monitor fluids and electrolytes, saline infusions to restore volume, hydrocortisone IV bolus + continuous infusion, monitor and treat hyperkalemia, hypoglycemic management, safe environment
238
What is the risk in an Addisonian crisis?
Priority is to assess for circulatory shock (low BP, LoC down)
239
What is the normal range for fasting glucose?
74-106 mg/dL
240
What is the diagnosis for diabetes (A1C, fasting BG, GTT, random BG)
**1) A1C:** greater than 6.5% OR
**2) Fasting BG:** greater than 126 mg/dL OR
**3) 2-hour GTT:** greater than 200 mg/dL OR
**4) Random BG:** greater than 200 mg/dL WITH hyperglycemis symptoms
241
What are the classic symptoms of hyperglycemia?
**1) Polyuria** = osmotic diuresis d/t high glucose
**2) Polydipsia** = thirst d/t fluid loss and high osmolatiry
**3) Polyphagia** = increased hunger as body struggles to use glucose
**4) Fatigue** = d/t inadequate glucose utilization and energy production
242
What is the recommended amount of exercise for primary prevention of diabetes?
150 minutes of aerobic exercise per week
243
Type **1** diabetes: what is it, cause, risk factors, symptoms, treatment
**1) What is it:** autoimmune destruction of beta cells of pancreas creating a lack of insulin causing the body to be unable to move glucose into its cells (thinks it's starving)
**2) Cause:** autoimmune
**3) Risk factors:** family history, age (kids, teens, young adults)
**4) Sx:** polyuria, polydipsia, polyphagia - abrupt onset of these
**5) Tx:** lifelong insulin use
244
Type **2** diabetes: what is it, cause, risk factors, symptoms, treatment
**1) What is it:** peripheral tissue insulin resistance with impaired insulin secretion d/t beta cell exhaustion
**2) Cause:** unknown, genetic
**3) Risk factors:** obesity, poor diet, physicaly inactivity, family history, medications, environment
**4) Sx:** polydipsia, fatigue, blurred vision, dry/warm skin
245
What are the symptoms of hypoglycemia? How is hypoglcyemia managed (treatment and nursing role)?
**1) Sx of hypoglycemia:** weakness, fatigue, sweaty (clammy), tremulous/shaky, anxious, decreased/loss of consciousness, cold
**2) Treatment:**
**A.** If BG is less than 70 mg/dL, give 15g of **fast acting simple carbs**; if below 50 mg/dL give 30g of fast acting simple carbs.
-> **if conscious:** 4oz juice/soda, tbsp of honey, 3-4 glucose tabs, 5 hard candies
-> **if unconscious: nothing by mouth**, IM glucagon, IV dextrose
**B.** After carbs given, recheck BG in 15 minutes. If still hypoglycemia, repeat simple carbs.
**C.** Once BG is above 70 mg/dL and no s/s of hypoglycemia present, provide a snack of **complex carbs**
**3) Nursing role:** obtain IV access, provide O2 (only if below 90%), no oral anything if they are unconscious/altered, recheck BG every 15 minutes, check neuro status
246
What is glucagon?
It is a hormone that prevents hypoglycemia by triggering the release of glucose from storage in liver and skeletal muscle. It has the opposite action of insulin.
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What is the first-line treatment for hypoglycemic patients who are unconscious? Why are they turned on their side? When should glucagon be readministered?
**1)** IV/nasal glucagon
**2)** They are turned on their side b/c it can induce vomiting
**3)** Readminister if the patient is still unconscious after 10 minutes
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What are ways to prevent hypoglycemic episodes?
**1)** Check insulin before administering (miscalculation)
**2)** Keep regular timing of food intake
**3)** Do not exercise while insulin is peaking
**4)** Monitor exercise/activity as it can cause BG drop even hours later
**5)** Do not exercise if ketones are present (indicates insulin is insufficient, raise BG above 100 mg/dL)
**5)** Avoid alcohol - it inhibits liver glucose production causing hypoglycemia. If you want to drink, drink with meals.
249
What are diabetic complications? Describe them.
**1) Eye + vision problems like retinopathy** d/t vessel blockage, leakage, and retinal hypoxia and edema increasing pressure in the eye. This causes glaucoma too.
**2) Peripheral neuropathy causing burning, tingling, pain, loss of sensation** d/t hyperglycemia reducing O2 and nutrient delivery leading to nerve hypoxia and decreased transmission
**3) Diabetic autonomic neuropathy** d/t hyperglycemia affecting the SNS and PSNS causing orthostatic hypotension, gastroporesis and constipation, N/V, heartburn, early satiety, and urinary urgency and incontinence
**4) Diabetic nepropathy** d/t hyperglycemia and hypertension harming nephrons causing albuminuria and decreased GFR later on
**5) Sexual dysfunction** such as ED, retrograde ejaculation, decreased lubrication, and painful intercourse
**6) Cognitive dysfunction** d/t hyperglycemia harming neurons leading to atrophy
250
What are three medications used to lower blood glucose in diabetes melitus?
**1)** Biguinides (Metformin)
**2)** GLP-1 agonist (semaglutide - Ozempic)
**3)** Sulfonylureas (Glipizide, Glimepiride)
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Metformin: class of medication, MoA, adverse effects
**1) Class:** Biguinides
**2) MoA:** lowers blood glucose by inhibitng liver glucose production (also reduces intestinal absorption and increase insulin sensitivity)
**3) Adverse effects:** do not take with alcohol (hypoglycemia and lactic acidosis risk); **hold 24 hours before contrast** and surgery (kidney damage risk); GI upset like **diarrhea (most common)** and N/V - take it with food to reduce GI discomfort
252
Semaglutide (Ozempic): class of medication, MoA, adverse effects
**1) Class:** GLP-1 agonists
**2) MoA:** increase insulin secretion, decreases glucagon secretion, reduces appetite
**3) Adverse effects:** pancreatitis (s/s abdominal pain, nausea)
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Glipizide: class of medication, MoA, adverse effects
**1) Class:** Sulfonylureas
**2) MoA:** lowers BG by triggering release of insulin from beta cells (may also increase insulin sensitivity and decrease hepatic glucose production)
**3) Adverse effects:** Can cause **hypoglycemia (take with meals)**, check with pharmacist before over the counter drug use d/t multiple interactions; **absolutely no drinking (hypoglycemia and disulfide-like reactions = severe vomiting)**
254
Can other insulin be mixed with insulin glargine or detemir?
No, rapid, short/regular, and intermiediate (NPH) should never be mixed with long acting or premixed insulin formulations.
255
How soon before eating should insulin lispro/aspart/glulisine be administered?
How soon before eating should insulin regular/short be administered?
**Rapid acting:** 10 minutes before because it is rapid acting
**Short/regular acting:** 30 minutes before eating
256
Provide the onset, peak, and duration of rapid, short/regular, intermediate (NPH), and long acting insulin.
**Rapid:** 10-30 min onset, .5-3hr peak, 3-6hr duration
**Regular:** 30-60 min onset, 1-5hr peak, 6-10hr duration
**Intermediate:** 1-2hr onset, 6-14hr peak, 16-24hr duration
**Long:** 1-2hr onset, no peak, 12-24hr duration
**Ultra-long:** 30-90min, no peak, 24hr duration
257
What are insulin storage and administration recommendations?
**1)** Only give subQ, preferrably in the abdomen 2cm away from umbilicus
**2)** Refridgerate unopened insulin
**3)** Keep insulin out of direct sunlight
**4)** Keep opened insulin at room temperature, cold insulin hurts to administer
**5)** Wash your hands before testing
**6)** Inspect vials and pens before using, should not be clumpy and only NPH should be cloudy
**7)** Do not reuse strips or lancets
**8)** Use fingertips to test
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What are important points about **foot care** in diabetes melitus to prevent complications?
**1)** Examine feet daily
**2)** Use a mirror to examine sole of foot
**3)** Inspect between toes
**4) Do NOT** treat blister, sores, or infections at home (don't treat anything yourself)
**5)** Do not wear sandals
**6)** Wash feet with water and dry thoroughly
**7)** Wear clean socky daily
**8)** Trim nails straight across
**9)** No moistureizer between toes
**10)** Wear a different pair of shoes daily
**11)** Do not go barefoot
259
What are important points about **nutrition** in diabetes melitus to prevent complications?
**1)** Eat 25g of fiber daily
**2)** Eat legumes, vegetables, fruits, whole grains, dairy in place of empty calories
**3)** If drinking, men should drink 2 drinks and 1 for women, **drink with meals**
**4)** 1 unit of rapid acting insulin for 15g of carbohydrates
**5)** 10-15g of carbohydrates per hour of moderate to intense physical activity
**6)** Limit trans fats, saturated fats, cholesterol
**7)** Keep a routine eating schedule with a similar amount of food
**8)** Registered dieticians can help create a personalized meal plan and provide education
260
What are important points about **exercise** in diabetes melitus to prevent complications?
**1)** Avoid intense exercise in retinopathy, autonomic neuropathy, and peripheral neuropathy
**2)** Wear proper footwear and inspect feet daily for peripheral diabetes
**3)** Regular exercise can help prevent T2DM by increasing insulin sensitivity, reducing body weight and glucose intolerance
**4)** Warm up first with low intensity sessions and should have a cool down session too; both 5-10 minutes long
**5)** 150 minutes of aerobic activity per week and avoid going longer than 2 days without any activity
**6)** Do not exercise when urine ketones are high
**7)** Check BG before, at intervals during, and after exercise
**8)** BG shoud be above 100 mg/dL before exercise
**9)** Do not exercise during insulin peaks
261
What are important points about **sick days** in diabetes melitus to prevent complications?
**1)** Monitor blood glucose every 2-4 hours
**2)** Continue taking your insulin or other antidiabetics - **do not omit insulin during illness**
**3)** Drink 8-12 ounces of sugar-free liquids every hour your awake, 2L daily
**4)** Continue to eat meals at regular times
**5)** Notify your health provider that you're ill
**6)** Test your urine for ketones to ensure they're in range, especially if you're vomiting
**7)** Call your provider if you expierience: persistent N/V, hypoglycemia, moderate-high ketones, fever (101.4+), sick for longer than 1-2 days
262
Diabetic Ketoacidosis (DKA): what is it, diagnosis, which type of diabetes most common in, pathology, causes, symptoms, treatment.
**1) What is it:** rapid onset, life-threatening complication of diabetes caused by severe hyperglycemia, ketosis, metabolic acidosis, and a lack of insulin
**2) Diagnosis:** BG = greater than 300 mg/dL, pH = less than 7.35, elevated ketones, elevated BUN/creatinine, low bicarbonate (less than 15 mEq/L)
**3) Most common in:** Type 1 diabetes
**4) Pathology:** infection or insufficient insulin -> hyperglycemia -> osmotic diuresis -> glucose in urine, dehydration, and electrolyte imbalance
**5) Causes:** infection, lack of insulin, stress
**6) Sx:** urine ketosis, acetone/fruity breath, kussmal breathing, respiratory alkalosis, polydipsia, polyuria, polyphagia, N/V, dehydrated, high HR, hyperkalemia, abdominal pain
**7) Tx:** IV fluids, IV insulin, electrolyte replacement, address underlying cause, supportive breathing
263
Hyperglycemic Hyperosmolar Syndrome (HHS): what is it, diagnosis, which type of diabetes most common in, causes, symptoms, treatment.
**1) what is it:** gradual onset which turns into a hyperglycemic emergency characterized by **profound dehydration,** hyperosmolatiry, but **no ketoacidosis** becuase insulin secretion is enough
**2) Diagnosis:** BG = great than 600 mg/dL, serum osmolarity = greater than 320 mOsm, pH = greater than 7.4, higher bicarbonate (above 20), high BUN/creatinine
**3) Most common in:** Type 2 diabetes
**3) Causes:** infection, stress/illness, poor fluid intake
**4) Sx:** hyperglycemia, polyuria, polydipsia, **dry mucus membranes**, high HR, hypotension, **neurologic symptoms like confusion and lethargy into coma**
**5) Tx:** aggressive **rehydration (main priority)**, insulin therapy, electrolyte replacement, address underlying cause
264
What is the priority assessment in HHS and DKA?
Adequate perfusion related to fluid volume deficit d/t osmotic diuresis. Hyperkalemia may take priorty in DKA if there are cardiac problems
265
What is autoregulation in intracranial regulation?
The adjustments in blood flow depending on metabolic needs of the brain or BP changes
266
What is the Monro-Kellie Doctrine? What ICR component is the first to change for compensation?
**MKD:** The sum of all cranial volumes, brain, CSF, and BP should remain constant, but can adapt if one changes.
**CSF is the first to change in order to compensate** becuase we don't want to alter blood flow
267
Who are the main risk populations for dysregulated ICR?
**1)** Older adults (degenerative conditions, falls)
**2)** Young adults and adolescents (risky behavior, MVA)
**3)** Children (falls)
268
What subjective history should you obtain when investigating increased ICP or general intracranial regulation?
**1) Level of consciousness**
**2) Unexplained headaches**
**3)** Other neuro s/s like N/T, dizziness, confusion, **vision changes**
**4)** OLD CARTS (pain assessment)
269
What is the main priority in disrupted intracranial regulation?
Balancing ICP
270
What is the collaborative management for intracranrial regulation (priority assessment, decreasing ICP via medications, surgery, and nursing intervention)?
**1)** Priority one is ongoing assessment
**2)** Decrease ICP if high by having the HOB @30 degrees and proper head+neck alignment.
**3) Pharmacotherapy:** **IV Mannitol** (osmotic diuretic) to pull fluid off, sedatives like **Propofol** to decrease metabolic demand
**4) Surgical:** craniotomy, shunt, drain
271
What is the priority nursing roles in strokes?
**1) Restore perfusion to the brain**
**2)** CT to determine stroke type and cause
**3)** Neuro exam
272
What is stroke prevention (ABCS)?
**A:** Aspirin
**B:** Blood pressure management
**C:** Cholesterol management
**S:** Smoking cessation
273
What heart dysrhythmia can cause emboli?
A. fib
274
Ischemic stroke: what is it, onset, risk factors, level of consciousness, seizure presence, symptoms
**1) What is it:** The occlusion or blockage of a cerebral or carotid artery by thrombus or emboli causing decreased or lack of perfusion
**2) Onset:** gradual (thrombic), sudden (embolic)
**3) Risk factors:** atheroscerolsis, emboli, hypertension, obesity, diabetes melitus, smoking, drug and alcohol abuse, oral contraceptive use
**4) LoC:** awake
**5) Seizure presence:** no seizures
**6) Sx:** dysphasia, muscle weakness, facial drooping, difficulty with walking (gait, balance), slurred speech, headache, trouble seeing
**7) Tx:** fibrinolytic (Alteplase - TPA), craniotomy, shunt
275
Alteplase: what is it, timeframe for use, blood pressure requirement, what to check before administration, checks after administration, other
**1) What is it:** a fibrinolytic, tissue plasminogen activator, that converts plasminogen to plasmin to lyse fibrin and fibrinogen breaking down clots
**2) Timeframe:** 3-4.5 hours (after 3 hours there are special requirements)
**3) BP:** must be below 185/110 - if above, antihypertensives must be given first (IV Labetolol)
**4) Checks before admin:** confirm **onset** and timeframe of symptoms, Blood glucose (hypoglycemia can mimic stroke symptoms), K+ levels (it can lower K+), check pH (acidosis), weight (dosing is by weight), pregnancy (harm to fetus), any surgery within the past 14 days
**5) Checks after admin:** hold anticoagulants (no Heparin, aspirin, etc.) for 24 hours, monitor vitals, monitor BG to prevent stroke complications, consult hematology to increase PT and INR
276
Hemorrhagic stroke: what is it, onset, risk factors, level of consciousness, seizure presence, symptoms, treatments
What is it: The interruption of vessel integirty cuasing bleeding into the brain tissue or subarachnoid space
Onset: abrupt, sudden
Risk factors: hypertension, cochise and alcohol use, obesity, diabetes
LoC: decreased
Seizure: yes
Sx: severe, unrelieving headache, blurry vision, seizure, decreased LoC, difficulty walking, dysphasia
Tx: antihypertensive, craniotomy, shunt
277
What history is necessary in stroke assessment?
**1) Symptom onset (when**)
**2)** Abrupt or slow onset
**3)** Any improvement
**4)** Medications (blood thinner, antihypertensives, contraceptives)
**5)** Social diet (food, alcohol, smoking)
**6)** Drug use (cocaine especially)
278
What is the diagnostic standard in strokes?
CT imaging such as CTP (computerized tomography perfusion) and CTA (computerized tomography angiography)
279
What are important post-stroke considerations?
**1)** They should remain NPO until swallowing can be assessed
**2)** Help with ambulation, they are a fall risk d/t neuro status and blood thinners
**3**) Thickened liquids to prevent aspiration
**4)** High fowlers when eating
**5)** No straws
**6)** Electric razor not straight razor to prevent bleeding
**7)** Have suction available for aspiration
**8)** Discontinue combined birth control
**9)** Oral care continues even if NPO
**10)** Toileting Q2-3H
280
What side do you approach a stroke patient from, but which side do you start interventions with?
Approach from their unaffected side but start with their affected side.
281
Compare left- and right-sided brain damage d/t stroke:
**Left-sided damage:** right-sided paralysis, more cautious, apprehensive, anxious, needs encouragement, impaired speech
**Right-sided damage:** left-sided paralysis and neglect, more impuslive, impaired judgement, tends to deny problems, short attention
282
What is a tonic clonic seizure? Describe tonic and clonic portions.
**Tonic-clonic seizure:** a seizure lasting 2-5 minutes where there is a tonic phase and clonic phase.
**Tonic:** muscle stiffness and loss of consciousness
**Clonic:** rhythmic jerking of all extremities
283
Hydantonins: what is it, meds, education
**1) What is it:** seizure medication that decreases sodium and calcium influx thereby stabilizing cell membranes
**2) Meds:** Phenytoin, Fosphenytoin
**3) Education:** Headache and drowsiness when starting, provide regular oral care and checks becuase it **can cause gingival hyperplasia**, **never give warfarin and phenytoin at the same time**, give IV for status epilecticus by diluting in .9% NS
284
Benzodiazepines: what is it, meds, education
**1) What is it:** GABA agonist allowing Cl- ions in to inhibit neurons
**2) Meds:** Lorazepam, clorazepate
**3) Education:** most often given IV for status epilepticus, clorazepate helps prevent seizures, **monitor for respiratory depression and hypotension**
285
What are seizure precuations (pre-seizure preparation)?
**1)** O2 and suction ready
**2)** IV access on patient
**3)** Side rails with pads up
286
What are priorities during seizures?
**1)** Protect from injury
**2)** Do not place anything in their mouth
**3)** Turn sideways to maintain airway
**4)** Remove any injurious objects
**5)** Suction oral secretions lightly
**6)** Do not restrain, instead guide them
**7)** Loosen restrictive clothing
**8)** Record beginning and end times of seizure
**9)** Remove pillow, raise side rails
287
What should you do after a seizure?
**1)** Take vitals
**2)** Provide O2 if needed
**3)** Check neurologic status
**4)** Keep side lying
**5)** Allow to rest
**6)** Check mouth for blood d/t tongue/cheek bite
288
Status epilecticus: what is it, causes, priority, treatment
**1) What is it:** a medical emergency d/t prolonged seizure lasting longer than 5 minutes or repeated seizures over 30 minutes
**2) Causes:** withdrawl from antiepileptic drugs, infection, acute alcohol withdrawal, TBI, cerebral edema, metabolic disturbances
**3) Priority:** establish airway
**4) Tx:** IV-push lorazepam/diazepam
289
Delirium: what is it, what are the subtypes, risk factors, management/tx, prevention
**1) what is it:** acute, abrupt, fluctuating course of disorientation, inattentiveness, disorganized thinking, altered level of consciousness, and cognition changes
**2) Types:** Hyperactive = restless, agitated, aggressive; Hypoactive = quiet, stares, lethargic, unaware, moves slowly/not alot; mixed = both
**3) Risk factors:** mechanical ventilation, sedation, old adults, alcohol disorders, organ disorders, low 02, UTI, insomnia
**4) Management/tx:** O2 therapy if low, treating underlying cause (i.e. UTI), calm voice, reorient patient, ambulate them, provide comfort object
**5) Prevention:** adequate lighting, clock and calendar in room, promote proper sleep-wake cycle, avoid unecessary meds and interventions, address pain, cluster cares at night
290
What is key to determining delirium?
Need to know their **baseline**
291
Alzheimer's disease: what is it, risk factors, diagnosis
**1) What is it:** specific and progressive cognitive loss affecting functional domains
**2) Risk factors:** female, older adults, down syndrome, TBI, smoking, depression, CVD, excess stress, PTSD
**3) Diagnosis:** mini-mental state exam (MMSE) = lower score, worse dementia, MoCHA, clock drawing test, PET (amyloid plaques), MRI to r/o, CT for structural changes
292
What are the symptoms of early, moderate, and severe stages of Alzheimer's?
**Early:** forgets names, misplaces items, less social, can do ADLs, unable to travel alone to new places
**Moderate:** cannot handle finances well, disoriented to place and time, gets lost while driving, wandering
**Severe:** agnosia, incapacitated, bedridden, cannot do ADLs, loss of mobility
293
What are safety interventions for those with Alzheimer's?
**1)** remove keys
**2)** lock doors
**3)** remove dangerous objects (knives, oven/stove, guns)
**4)** lower bed
**5)** use bed/chair alarm
**6)** grab bars
**7)** motion activated lights
**8)** keep room quiet with TV off unless requested
**9)** To prevent wandering place them close to nurses tation, have frequent checks or a sitter
**10)** Keep away from stairs/elevators
**11)** Consider if lines/drains are needed or camouflage them
**12)** Toilet every 2 hours
294
When should you reorient versus redirect/validate for those with Alzheimer's disease?
Reorient in early stages
Redirect/validate in late stages
295
Donepzil: what is it, what does it treat, what side effects should you monitor for?
**1) What is it:** a cholinesterase inhibitor prevening cholinesterase from breaking down acetylcholine allowing more to remain in the synapse improving ADLs
**2) Treats:** Alzheimer's disease
**3) Monitor:** Decreased heart rate, diziness, and falls d/t bradycardia
