EXAM THREE Flashcards
(51 cards)
1
Q
How do you speak to someone with IMPAIRED HEARING?
A
auditory interventions:
- encouraging hearing tests
- avoid putting things in ears
- protective ear devices
speaking to someone:
- can use WRITTEN INSTRUCTIONS
- can use more HEARING AID CARE
- speak more SLOWLY and CLEARLY - keep one’s face VISIBLE
- have a QUIET ENVIRONMENT
- can use other aids like GESTURING and BODY LANGUAGE
- be more PATIENT + allow EXTRA TIME
- can communicate through ASL interpreter
2
Q
what is the PRIORITY for VISION LOSS PATIENTS? **any interventions?
A
- leading cause of blindness > derives from MACULAR DEGENERATION
- main PRIORITY; helping MAXIMIZE remaining vision + QUALITY OF LIFE
- can suggest some ALTERNATIVES *more large-print books, public transportation, other community resources/adaptive aids
- ensure PROPER LIGHTING
3
Q
what is OSTEOPOROSIS?
A
- type of bone disease known for LOW BONE MASS, MICROARCHITECTURAL DISRUPTION, and SKELETAL FRAGILITY
- causes more DECREASED BONE STRENGTH + INCREASES RISK for FRAGILITY FRACTURES
- most commonly affects the WRISTS and the HIPS
4
Q
dietary risk factors for OSTEOPOROSIS
A
if patient’s diet consist of LOW:
- phosphorus
- vitamin D
- calcium
- proteins
*drinking a LOT of caffeine or alcohol
dietary needs:
- milk
- dairy products
- leafy greens
- salmon, sardines
- nuts
5
Q
what nursing internvetions would be implemented if a bone density scan indicates OSTEOPOROSIS?
A
- discussion of TREATMENT OPTIONS: meds to increase BONE DENSITY
- increase in WEIGHT-BEARING EXERCISES
- fall preventions
- lifestyle changes - Xsmoking, Xalcohol
- regular follow-up bone scans
- increased dietary (calcium, protein, vitamin D) diets
6
Q
describe DEXA bone scan scores
A
T-score is:–1 or higher, your bone is healthy.
–1 to –2.5, you have osteopenia (low bone density)
–2.5 or lower, you might have osteoporosis
7
Q
lifestyle changes - osteoporosis
A
- smoking & alcohol cessation/reduction
- increase calcium & vitamin
- regular weight-bearing exercises
8
Q
common risk factors - osteoporosis
A
- female sex
- older age
- lower BMI
- family history
- lack of estrogen, calcium
- sedentary lifestyles
- long-term use of steroids
9
Q
most common drug for treatment of osteoporosis
A
- ORAL BISPHOSPHONATES *works by slowing down the rate of bone loss
10
Q
what is OSTEOARTHRITIS?
A
- the PROGRESSIVE DETERIORATION & LOSS of ARTICULAR CARTILAGE and bone in one or more joints
11
Q
what are the BIGGEST CONCERNS for OSTEOARTHRITIS patients?
A
- chronic joint pain & stiffness > decreased ADLs & decreased mobility *pain is relieved with rest, intensifies after activity / persistent pain
- can have a LOSS OF INDEPENDENCE and SELF-CARE
- is a big cause of DISABILITY - 5th most common cause
- want to achieve a PAIN INTENSITY LEVEL that is ACCEPTABLE to the PATIENT
12
Q
describe the differences between OSTEOARTHRITIS vs. RHEUMATOID ARTHRITIS
A
OA:
- degenerative dz
- has morning stiffness
- involves more CARTILAGE LOSS
- can be asymmetrical *HERBERDENS NODES
RA:
- autoimmune dz
- increased morning stiffness
- involves more INFLAMTED SYNOVIUM
- mainly symmetrical *involves more extra-articular movements
13
Q
RA
A
- symmetric, INFLAMMATORY PERIPHERAL POLYARTHRITIS of unknown etiology
- causes EROSION of CARTILAGE AND BONE
14
Q
s/s of SEPTIC JOINT - with an RA PATIENT
A
- severe & worsening joint pain & swelling
- fevers/chills
- increased REDNESS and WARMTH over the affected joint
- inability to move/bear weight on the joint
- increased fatigue
15
Q
non-pharmacological interventions for JOINT PAIN
A
- exercising
- weight loss exercises
- usage of HEAT/COLD therapies
- TENS *transcutaneous electrical nerve stimulation
- use of braces or canes
- PT or OT
- meditation or deep breathing
16
Q
what is PAD?
A
known as PERIPHERAL ARTERIAL DISEASE (PAD)
- considered to be an ATHEROSCLEROTIC DISEASE - leads to peripheral artery obstructions
- causes an alteration in the NATURAL BLOOD FLOW in our peripheral circulation
17
Q
what is PVD?
A
- circulatory disease that affects the veins - lack of BF due to peripheral defective valves or not enough pumping ability
- can also be THROMBUS formation
18
Q
primary HTN
A
- most common type of HTN
- can cause DAMAGE to one’s vital organs
- causes more MEDIAL HYPERPLASIA/thickening of the ARTERIOLES
19
Q
common risk factors for HTN
A
- obesity
- smoking
- stress
- family history
- diet; high sodium
20
Q
secondary HTN
A
- HTN caused by a specific disease state or drugs
- ex. renal diseases/tumors
21
Q
PAD s/s
A
- hair loss/no hair growth
- dry/scaly/pale/mottled skin
- thicker toenails
- INTERMITTENT CLAUDICATION
- dependent RUBOR
- cold/gray-blue extremity
- muscular atrophy
22
Q
PAD interventions
A
- proper exercising & positioning
- want to PROMOTE more VASODILATION
- always want to assess the feet DAILY
- want to avoid wearing SANDALS/FLIP FLOPS
- feet should be maintained as DRY and avoiding moisture/hot water
- use lotion to AVOID CRACKS
- can also use ANTICOAGULANTS and ANTIPLATELET AGENTS
23
Q
post op interventions for POST-OP BYPASS
A
- comprehensive cardiac assessments
- taking vitals & pulses, color of skin, & cap refill
- want to monitor for GRAFT OCCULSION, COMPARTMENT SYNDROME, and INFECTION
24
Q
s/s of OCCULSION - bypass patients
A
- severe pain below level of occlusion
- severe cramping
- numbness or weakness to limb
- absent pulses/pale or cool feet
- confusion or LOC
- chest pain/angina/SOB
25
what are the SIX P's of ARTERIAL INSUFFICIENCY?
- pain
- pallor
- pulselessness
- paresthesia
- paralysis
- poikilothermia (coolness)
26
what is COMPARTMENT SYNDROME?
- increased pressure within the MUSCLE COMPARTMENT - causes COMPROMISE to the circulation & function of tissues
27
compartment syndrome s/s
- pain OUT OF PROPORTION to the apparent injury
- persistent deep ACHES or BURNING PAIN
- PARESTHESIA *can suggest ischemic nerve dysfxn
- pain with passive stretch of muscles
- TENSE/WOOD-LIKE feeling
- PALLOR
- diminished sensations
- muscle weakness *seen in around 2 - 4 hours
- PARALYSIS *late finding
28
s/s of PVD
- pain
- edema
- ulcerations
- throbbing
- itching
- skin discoloration
29
if a bypass occlusion is suspected, what are the PRIORITY INTERVENTIONS?
- notifying the HCP
- administering supp. O2
- obtaining VS/monitoring
- potential emergency thrombectomy/graft revisions
- anticoagulant meds
- monitoring of limb for ischemia
30
PAD & PVD - patient teaching
- want to PROMOTE VASODILATION in both of these conditions
- want to manage stress/smoking cessation
- Inspection of FEET DAILY for any cuts/wearing closed shoes
- avoiding ELEVATION of AFFECTED LIMBS
- diet; low-fat, high protein
31
PVD nursing internvetions
- assessing affected extremities for changes in pulse or temp
- increased position changes/limb exercises
- providing good foot & skin care
- applying warm compresses/reducing restrictive clothing
- use of assistive devices
- education of smoking cessation/exercising/diet
32
ischemia
- insufficient oxygen supplied to meet requirements
33
infarction
- NECROSIS or cell death due to severe and prolonged ischemia - decreases perfusion, causes IRREVERSIBLE DAMAGE to tissue
34
CSA - chronic stable angina pectoris
chest discomfort that occurs with moderate to prolonged exertion in familiar pattern
35
stable vs. unstable angina
stable angina:
- more often is PREDICATBLE with one's exertion or stress
- symptoms are RELIEVED with rest or nitroglycerin
- don't typically have EXACERBATION of heart disease
- often due to FIXED PLAQUE limiting BF
unstable angina
- is more NEW and is SEVERE, UNPREDICTABLE CHEST PAIN
- seen with only MINIMAL ACTIVITY or at rest
- more INTENSE/PROLONGED
- potential progression of CAD/has higher risk of MI
36
MI vs. unstable angina
- all comes down to the presence of MYOCARDIAL INJURY/NECROSIS
- MI: have ACTUAL DAMAGE and NECROSIS to the heart due to prolonged BF **more SERIOUS
- UNSTABLE ANGINA: more TRANSIENT DECREASE in BF/ does NOT have permanent muscle damage
37
what causes UNSTABLE ANGINA?
- acute obstruction of the CORONARY ARTERY W/O MI
38
unstable angina s/s
- chest pain w/o dyspnea
- nausea
- diaphoresis
*often diagnosed via ECG/presence or absence of biomarkers
39
unstable angina treatment
- antiplatelets
- anticoagulants
- nitrates
- statins
- beta-blockers
- usage of coronary angiography or bypass surgery
40
what happens if the telemetry monitor is showing up as ABNORMAL? what do you do?
- want to reassess condition & VS
- notify HCP/code team
- reviewing telemetry strip & document dysrthyhmias
- prep EMERGENCY INTERVENTIONS - CPR, defib, meds
- possible readjustment of leads
41
what arteries do we assess/palpate?
- carotid arteries (neck) *one at a time
- brachial arteries (antecubital)
- radial arteries (wrist - thumb side)
- femoral arteries
- popliteal arteries
- dorsalis pedis
- posterior tibial
[grading between 0 - 4]
42
how to prevent DVT?
- early AMBULATION & LEG EXERCISES
- applying anti-embolism stockings
- anticoagulant medications
- monitor for PAIN, SWELLING, WARMTH
- proper skin care/repositioning
43
Anticoagulant education for patients
- teach name, purpose, dosages, and side effects
side effects: bleeding increase, thrombocytopenia, renal impairment, warfarin skin necrosis
- want to PREVENT BLEEDING - avoid trauma/rough activities
- limit VITAMIN K INTAKE on warfarin
- proper adherence to meds
44
abnormal potassium levels
range: 3.5 - 5.0
HYPO:
- monitor ECG for changes in cardiac rhythm
- potassium supplements
- increased K diet; bananas, oranges, tomatoes
- I & Os
- mg levels decrease as well
HYPER:
- monitor ECG/cardiac rhythms
- RESTRICT dietary K intake
- potential neuromuscular changes
- dialysis if severe
45
atypical angina
- indigestion
- shoulder pain (b/w)
- aching haw
- choking sensations
46
what are the COMPLICATIONS that can occur with IV INFUSION THERAPY?
INFILTRATION
PHLEBITIS
THROMBOSIS
47
infiltration
where IV fluids begin LEAKING into the SURROUNDING TISSUES vs. entering the actual vein
SIGNS;
- swelling
- redness
- coolness
- buldging
- pain
*can cause tissue damage/necrosis
PREVENTION;
- monitoring site closely
- ensuring proper placement
TREATMENT;
- STOP INFUSION
- ELEVATE AREA
- APPLY WARM COMPRESS
- notify HCP/guidelines
48
phlebitis
the INFLAMMATION of the VEIN due to irritation of the IV CATHETER or SOLUTIONS
SIGNS;
- palpable vein at site
- pain, swelling, redness, warmth
- can progress to THROMBOSIS if not treated
PREVENTION;
- change/rotate IV sites
- avoid irritant solutions
- assess site frequent;y
- proper IV insertion
TREATMENT;
- WARM COMPRESS
- ELEVATION
- restarting IV or removal
49
acute pancreatitis s/s
severe abd. pain (mid-epigastric/LUQ)
jaundice
cullen’s sign **blue-gray discoloration **ecchymosis around periumbilical area
bleeding *pancreatic ecchymosis
hypoactive bowel sounds
increased HR + temp/decreased BP
tender abdomen
50
cholecystitis - definition and s/s
obstruction & inflammation of the gallbladder ; often due to presence of cholelithiasis/gallstones
abdominal pain (RUQ) & radiating pain towards right shoulder/scapula
N & V
bloating
jaundice
loss of appetite
51
common risk factors for pressure ulcers + nursing interventions
RISK FACTORS:
- immobility
- incontience/moisture
- impaired nutrition
- altered sensory perception
- shearing forces
NURSING INTERVENTIONS:
- repositioning
- skin inspection & hygiene &bony prominences
- proper NUTRITION & HYDRATION status
- minimizing shear & friction
- braden scale assessments
- proper positioning aid & devices
- patient education and caregivers
