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NUR 356 2022 > Final > Flashcards

Final Flashcards

1
Q

Nursing Process:

A

A-assess- gather info about the pts condition
4Ps- pain, personal needs, position, possessions
D- diagnose (analyze)- identify pts problems, causes, symptoms
P-plan- set goals of care and desires outcomes and identify appropriate nursing actions
ABCs, safety, maslow
I- implement- perform the nursing actions identified in planning
bases on clinical judgment and knowledge
types of interventions: nurse initiated, HCP initiated, collaborative
E- evaluate- determine if goals and expected outcomes are achieved

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2
Q

Exogenous

A

Outside the body

Ex: C-Diff, UTI

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3
Q

Endogenous

A

Overgrowth of Flora

Ex) Candida (yeast), Thrush

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4
Q

Iatrogenic

A

HAI from health care staff

Procedures, breaking sterile field, poor hand hygiene

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5
Q

Hypertonic

A

-Get rid of excess volume,
Before fluids given S/S: Hyponatremia
Fluids given: 3% NS, D10 w/ NS,
After fluids given Monitor: Pulmonary Edema, elevated BP, lungs sounds (crackles), hypernatremia,

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6
Q

Isotonic

A

Replacement
Dehydration, Nausea, Vomiting
Fluids given: 0.9% NS, Lactaded ringers (ER and OR)

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7
Q

Hypotonic

A

Before fluids: Hypernatremia

Fluids given: D5 in water, 0.45% NS

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8
Q

Hypovolemia

A

Na+ and H20 loss

Causes: fever, low fluid intake, burns (intravascular to interstitial), hemorrhage

Assess: thirst, cold and clammy, decrease skin turgor, cap refill >3 sec, concentrated urine, decrease urine output, weight loss, elevated Hr & RR, elevated BUN, decreased GFR, increase sodium, weak pulse.

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9
Q

Hypervolemia

A

Na+ and H20 Gain

Causes: excess fluid intake, abnormal fluid retention (HF & Kidney disease), excess sodium, interstitial to intravascular.

Assess: Edema peripheral & pulmonary, JVD, crackles, high BP, bounding pulse, weight gain, decreased BUN, elevated BNP, excess urination, clear urine, daily weight, I/O,

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10
Q

Hyponatremia

A

<135

Assess: Neuro- headache, confusion, irritability, seizures, nausea, vomiting, weakness, abdominal cramps (Hyperactive bowls), cold and clammy, hypotension.

Implementation: 3% NS, D10 w/ NS, 0.9% NS, monitor sodium, strict I/O

Causes: Burns, Diuretics, N/V/D, low sodium intake

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11
Q

Hypernatremia

A

> 145

Assess: altered mental status, Neuro -twitching, confusion, seizures, thirst, fatigue, tired, restlessness, coma.

Implementation: 0.45% NS, D5 in H20, Monitor sodium

Causes: Hypertonic fluids, dehydration, heat stroke, burns, osmotic diuretic, fever.

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12
Q

Hypokalemia

A

<3.5

Assess: changes in cardiac (PVC), brady, irregular HR, weakness, fatigue.

Implementation: Foods high in potassium, K+ IV infusion, EKG, Vitals, urine output.

Causes: Diuretics, low K+ intake, insulin, N/V/D

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13
Q

Hyperkalemia

A

> 5.0

Assess: Cardiac arrhythmias, peaked T-waves, cardiac arrest.

Implementation: Insulin w/ D50, EKG, >7.0 start dialysis, diuretics, kayexalate- K+ exits in stool need good GI.

Causes: Renal failure, high K+ intake, Ace inhibitors -pril

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14
Q

Prerenal

A

Above Kidneys- Heart/Circulation

Causes:

  • decreased cardiac output
  • Severe dehydration
  • HF
  • deceases renovascular blood flow
  • emboli, thrombosis (blood clot)
  • Hemmhorage
  • Hypovolemia
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15
Q

Intrarenal

A

Direct kidney injury

Causes:

  • NSAIDs
  • Ace Inhibitors
  • acute tubular necrosis (tissue in kidney dying)
  • antibiotics (aminoglycosides)
  • acute pylelonephritis (bacterial)
  • Epstein-Barr (viral)
  • Candidiasis (fungal)
  • chemical exposure
  • Kidney Injury (crush injury)
  • hemolytic transfusion reactions
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16
Q

Postrenal

A

-Bladder/obstruction

Causes:

  • BPH
  • Caliculi formation (kidney stones)
  • back/pelvis trauma
  • prostate cancer
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17
Q

Cranial Nerves
PERRLA
Swallow

A

PERRLA: 3, 4, 6/ III, IV, VI
Swallow: 9 &10/ IX, X

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18
Q

Oliguric

A

Assess: decreased urine output, fluid overload, JVD, crackles, high BP, bounding pulse, edema, <400mL/day, last 1-7 after injury.

Labs: hyponatremia (dilution) , high K+, elevated hydrogen, low bigarb, high Bun and Creat, low GFR.

Restrict fluids

19
Q

Diuretic

A

Assess: Extreme urination, sudden increase in urination, true hyponatremia, and hypokalemia, dehydration, notify provider,

20
Q

Recovery

A

Assess: GFR increases, BUN and CREAT decrease, major improvements in first few weeks, longer than 12 mos is considered early stages of chronic kidney failure

21
Q

4 Reasons to start Dialysis

A
  • BUN over 120
  • K+ over 7
  • cerebral changes due to hyponatremia
  • severe metabolic acidosis
22
Q

Pneumonia

A

Assess:

  • cough, fever, chills
  • fine or course crackles
  • green/yellow/rust colored sputum
  • pleuretic chest pain
  • tachycardia
  • SOB
  • Dyspnea
  • Tachypnea
  • Altered mental status (eldery)
  • elevated HR

Implementations

  • incentive spirometry
  • deep breathing
  • early ambulation
  • CXR
  • Elevated WBC
  • blood and sputum culture
  • give lots a fluid to break up the sputum
  • corticoid steroids
  • bronchodilators
  • Antibiotics (after sputum culture)
  • Nasal canula 1-6
  • Humidity >4
  • Small frequent high protein meals
  • antipyretics (tylenol)
23
Q

COPD

A

-Air gets trapped in lungs, pursed lips to breath with air already in their lungs

Assess:

  • Dyspnea
  • SOB
  • Chronic cough
  • weight loss
  • Finger clubbing
  • trouble sleeping
  • hx smoking
  • barrel chest
  • Wheezing
  • NO fever/chills
  • early dyspnea on exertion
  • use of accessory muscles
  • fatigue

Diagnostics:

  • spirometry test
  • fEV/FVC <70% (measure of forced volume lower the sicker)
  • Chest X-Ray
  • 6 min walk test

Causes of exacerbation:

  • cold, flu
  • pneumonia

Implementations:

  • pursed lips and huff cough
  • Smoking cessation
  • bronchodilators
  • 02 therapy
  • corticosteroids
  • antibiotics
  • no cure for COPD just control of symptoms
  • small frequent high calorie soft diet, rest 30 min before, give bronchodilator 1 hr before and after before meals
  • start oxygen low and slowly titrate up
  • Oxygen 88-90% (respiratory drive goes down and they become dependent)
24
Q

Fine Crackles

A 
Fluid overload
Pneumonia
Clear w/cough
Incentive spirometer
Left sided HF
Pulmonary edema
Hear at the end of inhalation
Diuretics
25
Q

Course Crackles

A 
Excess fluid
Pneumonia
Do no clear w/ cough
Sounds like bubbles popping
Hear upon inspiration and expiration
COPD
Diuretics
Long low pitched
26
Q

Wheezes

A 
COPD
Pneumonia
Asthma
High fowler's
Tripod
High pitched and continuous
27
Q

Left sided HF

A

Assess:

  • crackles
  • decreased
  • dyspnea
  • Increase in heart rate
  • S3 S4
  • Neuro: mental status, restlessness, confusion
  • shallow respirations
  • fast respiratory rate
  • dry hacking cough
  • frothy, pink tinged sputum
  • nocturia (supine position when sleeping at night)
  • orthopnea (difficulty breathing)
  • HTN
  • lower cardiac output
  • how many pillows they use when sleeping at night (connor says 4 pillows)

Causes:

  • HTN** (most common)
  • CAD**
  • MI
  • PAD (pulmonary artery disease)
  • DM
  • tobacco use, older age
  • higher incidence in males

Diagnostics

  • Chest x-ray
  • Echocardiogram
  • EKG
  • Exercise stress test
  • heart catheterization
  • 6 minute walk test
  • BNP (brain natriuretic peptide) > 100

Interventions

  • circulatory assist devices
  • sodium restricted diet (< 1500 mg)
  • semi-fowler’s
  • beta blockers
  • weight at same day/time/naked
  • I&Os
  • Digoxin
28
Q

Right sided HF

A

Assess:

  • JVD
  • dependent edema
  • weight gain
  • abdominal distention
  • increased heart rate, murmurs
  • nausea, anorexia
  • RUQ pain (liver pain)
  • hepatomegaly (enlarged liver)
  • fatigue

Causes:

  • Left sided HF
  • COPD
  • pulmonary
  • right ventricular MI

Diagnostics

  • Chest x-ray
  • Echocardiogram
  • EKG
  • Exercise stress test
  • heart catheterization
  • 6 minute walk test
  • BNP (brain natriuretic peptide) > 100

Interventions

  • circulatory assist devices
  • sodium restricted diet (< 1500 mg)
  • semi-fowler’s
  • beta blockers
  • weight at same day/time/naked
  • I&Os
  • Digoxin
  • Diuretics
29
Q

Acute Decompensated HF

A

Assess

  • mild increased RR
  • decrease in PaO2
  • Decreased cardiac output
  • manifest pulmonary edema (L and R combined)
  • edema
  • dyspnea
  • JVD
  • sudden onset of HF symptoms
  • S3S4
  • crackles and wheezes
  • Elevated BP initially than decreased BP as worsens

Causes:

  • Left-sided HF
  • Uncontrolled HF

Interventions:

  • Urinary output
  • High-fowlers
  • Positive pressure ventilation
  • Oxygen therapy
  • I/O
  • Diuretics
  • Vasodilators (HR up & BP down)
  • Morphine (lower dose than what used for pain)
  • Sodium restriction
30
Q

EKG

A

PR: 0.12-0.20 sec
QRS: 0.06-0.11
QT: 0.36-0.44

P Wave: impulse across the atria
PR Interval: Beginning of P wave to beginning of QRS
QRS Complex: Impulse through bundle branches & into Purkinje fibers, ventricular depolarization
ST Segment: From end of QRS to beginning of T wave
T Wave: ventricular depolarization, rounded, larger than P wave
QR interval: Measures from beginning of QRS to end of the T wave.

31
Q

7 steps to Rhythm Interpretation

A
  1. Identify P wave, QRS complex, & T wave.
    - Is there a P for every QRS?
    - Are all the complexes consistent?
  2. Determine if rhythm is regular or irregular?
  3. What is the rate?
    - 6 second method: count number of complexes and multiply by 10= HR in bpm
    - Can be used for regular and irregular rhythms
  4. Measure the PR interval.
    - Normal PR 0.12-0.20 seconds (3-5 small boxes)
  5. Measure the QRS complex.
    - Normal QRS is less than 0.12 seconds (less than 3 small boxes)
  6. Measure the QT interval
    - Normal QT is 0.36 – 0.44 seconds
  7. Name the rhythm.
    - Where is the impulse generated? Sinus, Atrial, Junctional, Ventricular
    - What is the rate? Normal, Brady-, Accelerated, Tachy-
    - Are there any additional abnormal characteristics noted?
32
Q

Hypertension

A
33
Q

Hepatitis

A

Asess:

  • fever
  • vomiting
  • clay colored stools
  • jaundice
  • dark colored urine
  • pruritus
  • spider angiomas
  • fatigue
  • anorexia
  • malaise
  • decreased sense of taste of smell
  • hepatomegaly
  • splenomegaly
  • asterixis (loss of motor control)
  • High bilirubin
  • Low platelets
  • Bleeding abnormalities

interventions:

  • Hep C- antiviral pegases
  • Avoid alcohol, acetaminophen (tylenol)
  • rest
  • High calorie, high crab, moderate protein and fat
  • Vitamin supplements (E)
34
Q

AST

A

5-40

35
Q

ALT

A

7-56

36
Q

Bilirubin

A

<1

37
Q

Platelets

A

150,000-400,000

38
Q

Pruritus (jaundice)

A

Interventions:

  • Trim nails and scratch w/ knuckles
  • antihistamines
  • oatmeal bath
  • lotion
  • soft, old linens
  • atarax (itching)
  • control temp
  • baking soda
39
Q

Cirrhosis

A

Assess:

  • jaundice
  • edema
  • ascites -causes SOB
  • Fever
  • portal hypertension
  • cachexia
  • petechiae
  • ecchymoses
  • spider angiomas
  • Shallow, rapid respirations

Labs:

  • ALT/AST elevated
  • decreased albumin
  • high bilirubin
  • high ammonia

Interventions:

  • albumin
  • diuretics
  • Diuretics (spiralactolone)
  • nonselective beta blockers
  • parasynthesis (ascites) -pee before, high fowler, girth, hypovolemia, electrolyte imbalances.
  • Avoid alcohol and NSAIDS
  • elevated ammonia - mental status change
  • lactulose
  • fluid restriction
  • Liver biopsy

Nutrition:

  • High carb
  • high calorie
  • moderate fat
  • low protein if encephalopathy (high ammonia)
40
Q

Airborne Precautions

A

Measles, tuberculosis, varicella- private room, negative airflow (6-12)- I wear N95, pt wears mask outside of room, full face if splashing or spraying possible

41
Q

Mild Dementia

A

short term memory impairment (especially for new learning)

42
Q

Moderate Dementia

A

lack of judgment and wandering, has more trouble organizing, planning, and following directions

43
Q

Severe Dementia

A

unable to perform self-care activities

NUR 356 2022 (2 decks)

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