final Flashcards
(250 cards)
1
Q
pancreas hormones
A
- insulin
- glucagon
2
Q
target cells of insulin
A
cells of body to lower blood glucose levels by moving insulin into cells
3
Q
glucagon target cells
A
- liver and muscles
- promotes glycogenolysis by increasing blood glucose levels by conversion of glycogen to glucose
4
Q
exocrine function
A
secretion of pancreatic juices into the small intestine that aid in digestion
5
Q
endocrine function
A
blood glucose control by the islet cells; insulin (beta cells) and glucagon (alpha cells)
6
Q
when blood glucose gets high…
A
the pancreas releases insulin to stimulate the liver to convert glucose into glycogen for storage to LOWER blood glucose levels
7
Q
if blood glucose is too low…
A
glucagon causes liver to turn stored glycogen back into glucose and release it to INCREASE blood glucose levels
8
Q
risk factors of diabetes
A
- age >30 years for type 2 and <30 years for type 1
- elevated HDL and triglyceride levels
- hx of gestational diabetes or delivery of baby >9lb
HTN - family hx of diabetes
- obesity
- previously impaired fasting glucose test
- african americans, hispanics, native americans, asians, pacific islanders
9
Q
pre-diabetes
A
- impaired fasting glucose, impaired glucose tolerance
- warning for development to type 2 DM
10
Q
fasting blood glucose pre-diabetes
A
100-125 mg/dL
11
Q
a1c prediabetic
A
5.7-6.4%
12
Q
oral glucose tolerance test prediabetic
A
140-199mg/dL
13
Q
type I DM
A
- autoimmune disorder causing beta cells of pancreas to be destroyed resulting in no insulin production
- children and young adults
- total insulin deficiency occurring within 1 year
- lifelong insulin therapy needed
- surgery induced diabetes
14
Q
type II DM
A
- insulin resistance: body tissues do not respond to insulin’s action due to unresponsiveness or insufficient numbers of insulin receptors
- inadequate insulin secretion: cell of pancreas become fatigued and so insulin production is decreased
15
Q
diagnosing diabetes
A
- fasting blood glucose >126
- A1C >6.5%
- oral glucose tolerance test >200mg/dL
- random glucose test >200mg/dL
testing must be repeated before diagnosis
16
Q
clinical manifestations of diabetes
A
- polyuria (increased urination)
- polydipsia (increased thirst)
- polyphagia (increased hunger)
- glucosuria
- fatigue
- unexplained weight loss (type I)
17
Q
medical management of diabetes
A
maintenance of glycemic levels and prevention of complications
18
Q
type I medical management
A
- glucose monitoring
- insulin
- diet
- patient education
- disease management
19
Q
type II medical management
A
- glucose monitoring
- medications
- diet
- exercise
- weight loss
- patient education
- disease management
20
Q
assessing glycemic control
A
- self monitoring w/ finger stick (before meals and at bed time)
- continuous glucose monitor (skin impant or close loop system, insulin pump)
- Hgb A1C (2x/year q3 months if targets haven’t been met)
21
Q
diet for diabetics
A
- weight, meds, activity, and comorbidities should be taken into account
- consistency in times for meals
- carb counting
- incorporate diet individually
22
Q
exercise for diabetics
A
- exercise lowers glucose levels and encourage weight loss as well as many other health benefits
- dietary adjustments
- if glucose >250 and urinary ketones are present, do NOT exercise until levels are normal
- try to exercise at same time each day
- insulin shouldn’t be injected in area that will be worked out
- monitor levels before, during, and after workout
23
Q
insulin therapy
A
- regular insulin
- lispro
- glargine
- determir
24
Q
regular insulin
A
use of this insullin increases change of hypoglycemia if give 3-4x/day due to action overlap
25
lispro (humalog) and aspart (Novolog)
should be held if patient is NPO or unable to tolerate food or caloric intake
26
glargine (lantus) and detemir (levemir)
basal insulins administered daily and given regardless of nutritional intake and not held if glucose levels are within normal limits
27
rapid-acting and short-acting insulin should be taken
at mealtimes to cover incoming carbs
28
correction insulin is determined by
random glucose stick prior to eating
29
prandial and correctional insulins are administered
prior to eating
30
insulin administration
- subq
- insulin pump or patch
31
insulin injection sites
- abdomen
- arm
- thighs
- hips
32
insulin injections
- rapidly absorbs in subq layer of stomach
- systemic rotation to prevent lipodystrophy
- injection should be 1-1.5in apart
- heat, massage, and exercise of injected area to increase absorption
- hypoglycemia may occur
33
storing insulin
- avoid extreme temps
- do not freeze or keep in direct sunlight
- before injection, insulin should be room temp
- if vial of insulin will be used in 1 month ,it may be kept at room temp but if not it needs to be refrigerated
34
complications of insulin admin
- allergic reactions (redness, swelling, tenderness, induration)
- insulin lipodystrophy (fibrous fatty massess at injection site caused by repeated use of an injection site)
- dawn phenomenon (high BS in am)
- somogyi effect (low glucose overnight, high glucose in am)
35
meds for type II diabetes
- biguanides
- sulfonylureas
- meglitindes
- thiazolidineodiones
- a-glucosidase inhibitors
- dipeptidyl peptidase-4 inhibitors
- sglt2 inhibitors
- glp-1 receptor agonist
- insulin
36
biguanides
metformin
most effective med for type II
cannot be used if KF, liver disease, or HF
37
metformin must be withheld when?
before and for 48hrs after having radiology studies done due to increased risk of lactic acidosis with dye
38
sulgonylureas
glyburide, glipizide
39
meglitinides
repaglinide, nateglinide
40
thiazolidineodioens
rosiglitazone, pioglitazone
41
a-glucosidase inhibitors
acarbose, miglitol
42
depeptidyl peptidase4 inhibitors
sitagliptin, linagliptin, saxagliptin
43
sodium glucose co-transporter 2 (SGLT2) inhibtors
dapagliflozin, empaglioflozin
44
GLP1 receptor agonists
semaglutide
liraglutide
45
nursing management for diabetes
- vitals
- glucose monitoring
- I&Os
- carb intake at meals
- labs: K, WBC, BUN/Creatinine
- perform neuro assessment
- skin assessment
- assess perfusion
- administer insulin/meds
- administer IV fluids
- dietician referral
- diabetic educator referral
- assess ability to manage diabetes at home
46
nursing interventions (teaching) for diabetes
- signs of hypoglycemia and hyperglycemia
- complications (DKA, HHS)
- insulin admin
- med education
- blood glucose moitoring
- a1c monitoring
- health lifestyle
- medical alert
- sick days
- foot care
- eye exams
- annual physical
47
diabetics during illness
- take insulin or antidiabetics as prescribed
- determine blood glucose levels and ketones q3-4hrs
- if meals cannot be followed, substitute soft foods 6-8x/day
- if vomiting, diarrhea, or fever consume liquids q30-60min
- notify HCP of illness and if levels are >250-300 or when ketonuria is present >24hrs or unable to ingest food
48
diabetic foot care
- provide proper care
- inspect feet daily
- notify HCP if break in skin occurs
- avoid thermal injuries
- wash feet with warm water
- avoid treating blisters
- do not cross legs or restrict blood flow
- apply moisture
- prevent accumulation of moisture between toes
- wear clean gloves and socks
- avoid wearing same shoes
- avoid smoking
49
complications of diabetes
- vascular damage
- nerve damage
- hyperglycemia
- hypoglycemia
- diabetic ketoacidosis
- hyperosmolar hyperglycemic state
50
vascular damage from diabetes
- atherosclerosis causing decreased circulation/perfusion causing inschemia leading to ulcers, amputation, poor wound healing, increase risk of infection and organ damage or disease
51
vascular damage secondary to diabetes can lead to
- nephropathy (KF)
- retinopathy (blindness)
- carotid artery disease (stroke)
- coronary artery disease (myocardial infarction)
- hypertension (cardiomyopathy and HF)
52
hyperglycemia in hospitalized patient
- changes in usual treatment
- meds
- IV dextrose
- overly vigorous treatment for hypoglycemia
- inappropriate witholding or use of sliding scales
- mismatched timing of meals and insulin
53
hypoglycemia
- acute or life-threatening emergency
- blood glucose levels fall below <65mg/dL or drops rapidly from elevated level
- caused by too much insulin, too little food, excessive activity
- more circulating insulin than is needed to handle amount of circulating glucose
54
signs of hypoglycemia
- shaking or trembling
- tachycardia
- extreme hunger
- sweating
- confusion/difficulty concentrating
- dizziness
55
mild hypoglycemia
awake and alert
glucose <70
56
moderate hypoglycemia
client shows s/s of worsening hypoglycemia
blood glucose <40
57
severe hypoglycemia
showing neuroglycopenic s/s
glucose <20
58
mild s/s
hunger
nervousness
palpitations
sweating
tachycardia
tremor
59
moderate s/s
confusion
double vision
drowsy
emotional changes
headache
impaired coordination
inability to concentrate
irrational or combative behavior
light-headed
numbness of lips and tongue
slurred speech
60
severe s/s
difficult to arouse
disoriented behavior
loss of consciousness
seizures
61
carbs to treat hypoglycemia
- 6-10 lifesavers
- 4tsp of sugar
- 4 sugar cubes
- 1tsp of honey or syrup
- 1/2 cup fruit juice
- 8oz of low fat milk
- saltine crackers (6)
- 3 graham crackers
62
diabetic ketoacidosis causes
- intentional or unintentional missed or reduced dose of insulin
- inadequate insulin due to increased insulin needs secondary to stress, infection, illness, trauma
- new onset of type 1 diabetes
63
s/s of DKA
- blood glucose >250
- acidosis (pH <7.35)
- kussmaul respirations
- ketosis (fruity smelling breath)
- ketonuria
- hyperkalemia
- dehydration
- hypotension
- tachycardia
64
treatment for DKA
- fluid replacement and electrolytes
- correct hyperglycemia (IV insulin)
- treat electrolyte imbalances (K+, cardiac monitor)
- monitor neuro status (increased ICP- cerebelar edema)
65
hyperosmolar hyperglycemic syndrome cause
- extreme hyperglycemia and dehydration occur without ketosis or acidosis
- blood glucose >600
66
s/s of HHS
- glucose >600
- negative ketones
- glycosuria
- profound dehdyration
- altered LOC
- increased BUN/Creatinine
67
treatment of HHS
- ID and treat cause
- fluid replacement
- insulin admin (if hyperglycemia not correct by fluid replacement)
- correction of imbalances
- monitor neuro status
68
DKA occurs more in
type 1
69
HHS occurs more in
type 2
70
main funciton of urinary system
- eliminate of waste
- fluid and electrolyte balance (blood volume, blood pressure, increase or decrease in electrolytes)
- acid base balance
71
kidneys are the primary
organs responsible for maintaining water balance in the body
volume in = volume out
72
with low intake, dehydration or hypovolemia...
- thirst is stimulated
- ADH is released increasing water reabsorption and decreasing urine output
- these processes increase solutes in urine
73
increased intake, fluid overload, and hypervolemia
- lowers ADH release to increase urine output and fluid release
- this decreases solute in urine
74
anuria
less than 100mL urine output in 24hrs
75
dysuria
painful urination
76
enuresis
involuntary urination at night
77
frequency
increase in incidence of voiding, usually only small amounts
78
hematuria
blood in urine
79
hesistancy
difficulty starting flow of urine
80
nocturia
frequent urination at night
81
oliguria
decreased urine output
<400mL/24hrs
82
polyuria
increased urine output >2,000mL/24hrs
83
renal colic
pain radiating to perineal or groin area
84
retention
inability to completely empty bladder
85
urgency
sudden onset of urge to void
86
normal UA findings
- color: pale yellow
- turbidity: clear
- odor: faint ammonia smell
- specific gravity: 1.005-1.030
- osmolality: 250-900
- pH: 4.5-8
- protein: 30-150
- glucose: -
- ketones: -
- bilirubin: -
- RBC: 0-4
- WBC: 0-5
- casts: few or none
- bacteria: <1000
87
renal function tests
- renal concentration (specific gravity (1.005-1.030) and urine osmolality (300-900mOsm))
- 24hr Creatinine Clearance (M=55-146, F=52-134)
- creatinine level (M=0.5-1.2, F=0.4-1.0)
- BUN (8-20mg/dL)
- BUN/creatinine ratio (10:1)
88
cytoscopy
- cystoscope inserted through urethra into the bladder
- preop: educate, informed consent, assess allergies to contrast, iodine, shellfish, if done under anesthesia, NPO @ midnight
- postop: monitor urine output, monitor s/s of infection, expect pink tinged urine and frequency, educate on signs and symptoms of infection and adequate output, when to call
89
red flags for GU
- decerasing urine output
- pain in bladder or flank
- difficult or painful urination
- burning w/ urination
- felling like bladder is not emptying
- hematuria
- elevated BUN/Cr
- elevated K+
- EKG changes related to K+ (tall T waves, ST segement depresion)
90
acute kidney failure
sudden short term loss of kidney function
if not stopped and reversed, can lead to chronic renal failure
91
chronic kidney failure
long term chronic damage to kidneys, year of destruction leading to permanent damage
92
stage 1 CKD
90%+ of normal kidney function
93
stage 2 CKD
60-89% normal kidney function
94
stage 3 CKD
30-59% of normal kidney function
95
stage 4 CKD
15-29%
kidney function low and treatment for kidney failure may be needed soon
96
stage 5 CKD
<15% normal kidney function
no longer removing wastes effectively leading to renal failure, end stage kidney disease or renal disease
97
CKD causes
- long-term disease or medical comborbities like HTN, DM, untreated AKI
- poorly managed or untreated AKI
- reduces independence shortnes life, and decreases quality of life
98
diagnosis of CKD
- low GFR (ESRD <15mL/min)
- low urine output (may be anuric)
- increased BUN/creatinine
- ultrasound shows scarring/damage
99
clinical manigestation of renal failure
- neurological weakness and fatigue
- increased BP
- pitting edema
- periorbital edema
- increased CVP
- preicarditis
- SOB
- depressed cough
- thick sputum
- ammonia odor to breath
- metallic taste
- mouth/gum ulcers
- anorexia
- weight loss
- n/v
- anemia
- bleeding tendencies
- increased K+
- dry flaky skin
- uremic frost
- weight related to fluid retention
- cramps
100
medical managment of CKD
- anemia: epoetin alfa (synthetic EPO)
- hyperkalemia: monitor K+, tele, K+ lowering meds (Kayexalate, insulin and dextrose)
- hyperphosphatemia: phosphate binders to lower phosphorous levels
- hypocalcemia: calcium carb, vit D
- HTN: antihypertensives, diuretics, diet
- diet: low protein, K+, Na+, PO34, fluid restriction
- dialysis
- transplant
- weight loss and exercise
- smoking cessation
- avoid NSAIDs and aspirin
101
nursing management for CKD
- daily weights
- I&Os
- monitor electrolytes
- fluid, protein, na, k, phos restriction
- assess peripheral nerve function
- meds
- pep for dialysis
- protect dialysis access site
- end of life care
- patient education: diet restrictions, dialysis, daily weights, s/s to report (SOB, CP, severe itching, weight >2lbs/day or 5/week)
102
hemodialysis complications
- hypotension/hypovolemic shock
- air emoblism
- hemorrhage from site
- systemic infection
103
medication precautions for hemodialysis
- hold antihypertensives and meds that drop BP
- hold meds that will be removed from dialysis
104
nursing priroties for hemodialysis
- monitor vitals and EKG closely
- monitor labs
- weight client before and after to estimate fluid loss (1kg=1L)
- assess for bleeding from site
105
vascular access sites
- fistula
- graft
- external dialysis catheter
106
vascular access info
- do not use dialysis access catheters for anything other than dialysis
- no IV or BP on extermity with graft or fistula
- assess pulses and cap refill in extremity
- monitor for clots in fistula or graft (bruit (swooshing), thrill (feel vibrations), if absent call HCP)
- protect access
107
peritoneal dialysis
- peritoneum acts as semipermeable membrane for dialysis
- can be coninuous or intermittent
- contraindications: peritonitis, abdominal surgery
- risk: cloudy outflow is sign of peritonitis and should be reports, avoid infection via strict sterile technique
108
AKI prerenal causes
- disruption in BP or blood flow to kidneys
- blood loss
- dehydration
- HF
- sepsis
- vascular occlusion
109
intrarenal/intrinsic casuses of AKI
- direct injury to kidney
- acute tubular necrosis: drugs, toxins, prolonged hypotension
- glomerulonephritis
- infection
- small vessel vasculitis
110
postrenal causes of AKI
- sudden osbtruction of urine flow due to enlarge prostate, stones, or bladdery injruy
- BPH
- cervical cancer
- meatal stenosis
- retroperitoneal fibrosis
- prostate cancer
- urinary caliculi
111
medical management of AKI
- restore normal chemical balance and prevent complications until renal tissue and function return
- eliminate cause
112
stages of AKI
1. initiation (onset)
2. oliguric
3. diuretic
4. recovery
113
medical management of oliguric phase of AKI
- restrict fluid
- diuretics
114
diuretic phase medical management
- replace fluids and electrolytes
- reduce med doses
- diet
- dialysis
115
oliguric s/s
- <400 mL/day
- UA: casts, RBCs, WBCs, specific gravity @1.010
- metabolic acidosis
- hyperkalemia and hyponatremia
- elevated BUN/CR
- fatigue and malaise
116
diuretic s/s
- increase in urine output (1-3L/day, can reach 3-5)
- hypovolemia, dehydration
- hypotension
- BUN/Cr levels begin to normalize
117
recovery AKI
- beings when GFR increases
- BUN and creatinine levels plaeau then decrease
118
nursing management for AKI
- monitor labs: increased BUN/Cr, low GFR, increased K+, low sodium, high phosphate, low calcium, metabolic acidosis
- monitor urine output (decreased = oliguric phase, increased = diuretic phase)
- daily weights, strict I&Os
- signs of FVO: edema, JVD, crackles, SOB
- assess for lethargy or stupor
- assess for s/s of UTI
- replace electrolytes as needed
- treat hypokalemia
- fluid restriction during oliguric phase
- diuretics
- prep for dialysis if needed
119
polycystic kidney disease s/s
- HTN
- hematuria
- flank, low back pain, abdomen
- headaches
- renal caliculi
- UTIs
- increasing abdominal girth
- enlarged palpable kidneys
120
polycystic kidney disease treatment
- manage UTIs and cyst infections w/ antibiotics
- manage pain (acetaminophen, morphine, nephrectomy (severe pain - palliative)
- manage HTN (ACE, ARBs)
- manage complications: UTIs, calculi, cyst rupture
- end stage needs dialysis
- transplant
- diet (low sodium and fat, no alcohol)
- exercise
- smoking cessation
121
nursing assessments for PKD
- vitals
- o2
- daily weight
- monitor labs (H/H, BUN/Cr, Na, K, Ca, Phos)
- UA and cultures
122
nursing actions and teaching for PKD
- diet modification
- fluid restriction
- administer meds
- report s/s of infection
- medication education
- following diet restrictions
123
diagnostic subjective questions for neuro
- sudden onset or slowly increase
- how long
- any other symptoms along w/ headache
- pre-existing auras
- recent infections or traveling
- any previous trauma
124
if sudden onset think...
- CSF leak
- stroke
- meningitis
- brain tumor
- cerebral aneurysm
125
if gradual onset think
- sinusitis
- opiate withdrawl
- caffeine withdrawl
- OTC meds
126
diagnostics for neuro
- blood work to evaluate infection of inflammation (CBC, blood cultures, CRP, ESR)
- CSF testing
- CT or MRI
- EEG and sleep studies
127
seizures
- uncontrolled, sudden, excessive discharge of electrical activity
- various types; cryptogenic, epilepsy, partial vs generalized, nonepileptic seizures s/p other disorders, febrile seizures
- no conclusive pathophysiological explanation for most seizures
- may be due to genetic malformations, developmental malformations, hyperexcitability of neurons
128
focal onset seizure
one part of brain is affected so s/s are more specific to one side of the body
129
generalized onset seizure
entire/both sides of brain are effected causing bilateral s/s
130
clinical manifestations of a seizure
preictal phase: smelling odors, seeing unpleasant visualizations/hallucinations, butterflies in stomach, sense of deja vu
ictal phase: acute seizure phase, MSK jerksin, zoning out, stiffening, incontinence, epileptic cry, arched back
postictal phase: typically an altered state of consciousness, may be drowsy, can expierence hypoxia, headaches, nausea, or migraine depending on severity and duration of seizure
131
diagnosis of seizures
- iamging studies and lab workup
- diagnsotic EEG
- patient interview of symtpoms
132
age related considerations for seizures
- difficult to diagnose in older adult
- new onset seizures in older adult generally due to other caustive factors
- altered clearance of medications
133
meds for seizures
- antiepileptic drugs and anticonvulsants
- combination therapy
134
status epilepticus
- seizure lasting >5 minutes (MEDICAL EMERGENCY)
- seizure lasting >30min can lead to respiratory failure, brain damage, and death
- caused by head trauma, hydrocephalus, acute/drug/alcohol withdrawl, metabolic disturbances, or abrupt withdrawl of AEDs
- airway breathing and circulation itnerventions necessary (intubation, ABGs, benzos, loading-doses, sedating agents)
- close CV monitoring and continuous EEG
- ANOXIC brain injury is largest problem related to seizures
135
assessment of seizures
- clinical manifestations vary (eval movements, LOC, aura presentation, and motor tone)
- vitals
- presence of seizures or aura
- neurologic assessments
- airway management
136
nursing interventions for seizures
- initiate seizure precautions
- proper documentation of seizure activity or neuro changes
- patient teaching for meds, alert bracelets, driving restrictions
- suction and O2 at bedside
- paddding on side rails
- fall risk
- gently lower to ground if seizing
- if seizing in chair, keep them there
- check vitals after seizure, try and get O2 during seizure
137
evaluating outcomes for seizures
- imrpoved QOL
- compliance with meds and lifestyle changes
- social and emotional support
138
increased intracranial pressure
- something in the brain that shouldn't be there like a tumor, mass, lesion, bleeding, or blockage is causing decreased CSF output causing edema leading to increased pressure
- cerebral herniation will occur if not resolved
- patient goes to ICU immediately
139
external ventricular drain has a high risk for
infection!
only used in ICU
140
cerebral herniation
- medical emergency caused by increased ICP
- brain tissue beigns to palce pressure on vital organs of brain altering functions causing many poor symptoms
141
signs of increased ICP
- decreased LOC
- behavior changes; restlessness, irriability, confusion
- headache
- n/v
- aphasia or changes in speech
- changes in sensory motor status; pupil changes
- abnormal posturing (decorticate or decebrate
- late sign: cushing's triad
142
cushing's triad
- decerased HR (as low as the 30s)
- irregular respiration (rate can be normal but rhythym is irregular
- widened pulse pressure (>systolic/low diastolic)
143
care of unconscious client
- assess airway
- monitor BP, pulse, and heart sounds
- monitor respiratory and circulatory status
- don't leave unattended
- maintain airway and ventilation
- assess lung sounds
- monitor neuro status (pupils, LOC)
- semi-fowler's
- side rails unless contraindicated
- assess dehydration
- monitor I&Os
- monitor bowel sounds
- turn q2hrs
- seizure precautions if necessary
144
medical management of ICP
- goal is to decrease volume of water, blood, or CSF in brain and make room in the skull
- close neurologic monitoring
- radiographic imaging; CT scans, MRI, EEG
- lab testing and ABGs
- increase HOB and keep neck in straight alignment
- surgical management: craniotomy or craniectomy
145
nursing care postop for craniotomy or craniectomy
- HOB up
- neck aligned straight
- if head turns to side, they can pinch vertebral arteries impacting BF
- roll towel under body
- dont lay on surgical site
- vitals
- sedatives
- educate on meds
- helmet on at all times
146
assessment for increased ICP
- frequent neuro and vitals (q1hr)
- O2, ventilation, and hemodynamic monitoring
- ICP monitoring q1hr
- cardiac rythm monitoring (tele)
- lab values
- I&Os
147
nursing interventions for increased ICP
- HOB >30
- ensure craniectomy site is elevated
- perform oral care and oxygenation
- admin sedatives and diuretics
- monitor vitals and ensure pt remains afebrile
- educate about meds and devices
- safety (helmet at all times)
- importance of calm and quiet environments
148
stroke
- general term to describe disruption of BF to brain
- ischemic = lack of bloow flow due to vessel blockage
- hemorrhagic = bleeding in brain
- transient ischemic attack.= temporary stroke s/s that self-resolve
149
pathophysiology of ischemic stroke
- plaque deposits in artery can disrupt blood flow but blood can flow around it for the most part
- as the plaque grows, teh pressure causes a rupture of the plaque causing a blood clot to form around it
- this blocks the blood vessel from allowing blood to pass through
150
MCA stroke
- detremental
- s/s on opposite sides of body
- inattention or neglect of one side like they don't know its there
- decreased sensation
- loss of vision in one eyes
- difficulty speaking
151
basilar artery syndrome
- life altering but less severe
- dizziness
- ataxia
- tinnitus
- n/v
- weakness on one side of body
- decerased sensation
- difficulty articulating speech
- difficult swallowing and managing oral secretions
152
pathophys of ischemic strokes from small intracranial vessels
- lacunar strokes
- vary in degree of functional deficit
- obstruction of small vessels or group of small vessels
- typically from a blood clot that travels from another site of body
- common w/ patent formen ovale
- a-fib is common cause
153
diagnosis of stroke
- CT and MRI (ct for workup, mri for specifics)
- clinical presentation and symptoms
- carotid duplex scan
- echocardiogram
- lab tests: CBC, platelets, electrolytes, kidney function, cholesterol
154
meds/procedural management of ischemic strokes
- IV tPA for clot (exclusion criteria)
- intra-arterial retrieval of clot through IR procedure
- antihypertensives, anti-platelets, anticoagulants
155
tPA criteria
- cannot receive tPA after 4.5hrs of symptoms onset
- blood on CT scan
- surgery in past 14 days
- high BP
- age >80
- on anticoags or if INR is normal
- prior hx of stroke and diabetes
156
life-threatening acute phase of ischemic stroke
- hemorrhagic transofrmation (hemorrhage into infarcted area) most common w/ tPA use
- cytotoxic edema
- cerebral herniation
- aspiration risk
157
life-altering long term changes after ischemic stroke
- weakness or paralysis of extermities
- agnosia
- visual field disturbances
- alteration in speech and swallowing
- apraxia
- depression and anxiety
158
hemorrhagic stroke
- bleeding in brain
- subarachnoid, intracerebral, intraventricular
159
which hemorrhagic stroke is most critcal
subarachnoid
160
medical and surgical managment of hemorrhagic stroke
- goal to prevent complications such as rebleeding or vasospasm
- aneurysm clipping or coiling
- BP management
- hematoma evacuation
- ICP monitoring devices and CSF draings
161
vasospasms
- narrowing of vessel segments temporariliy decerasing BF to brain
- specific to subarachnoid hemorrhage
- vessels irriated and spasms close BF off
162
complications of hemorrhagic stroke
- neurologic and systemic problems (ischemic stroke, cerebral edema, pulmonary edema, myocardial ischemia)
- delayed cerebral ischemia often secondary to vasospasm (confusion, altered LOC, new focal muscle weakness, waxing and waning pattern of s/s)
- hyponatremia r/t SIADH or cerebral salt-wasting syndrome
163
ischemic vs hemorrhagic stroke and ICP
elevated ICP from dead tissue w/ ischemic
elevated ICP from bleeding in brain w/ hemorrhagic
164
nursing assessments for stroke
- neuro assessment q1-2hrs
- vitals q1-2hrs
- neurovascular assessment
- post-angio monitoring of puncture sites
- blood glucose w/ neuro changes
- ECG and cardiac enzyme monitoring
- electrolyte monitoring
- close I&Os
165
nursing interventions for strokes
- admin meds
- perform swallow eval
- elevate HOB
- follow post-angio procedures for positioning
- manage NGT placed
- implement aspiration precautions
- bleeding precuations
- reposition q2hr
- educate on stroke, s/s, when to call EMS, risks, smoking cessation, med adherance, prevention
166
xray
- positioning, can be painful
- remove proper clothing or jewlry
- proper shielding with lead apron on ovaries, testes, thyroid gland
- pregnancy
167
ct scan
- patient education
- contrast safety
- pregnancy
168
MRI
- patient education (loud, NPO (if needed), ride home if sedated)
- safety assessment: claustraphobia, metal, pacemakers, medicated patches
169
arthogram
- patient education about procedure and postop care
- taking anticoagulants or ASA
- perform time out
170
bone mineral density
- DEXA scan
- low bone density (presence of osteoporosis and increased fracture risk)
- patient education regarding test and results
- notify HCP of recent test using contract
- feet placed on padded box
171
bone scan
- patient education (breastfeeding, use formula, discard breastmilk for 48hrs)
- insert IV
- verify consent
- very pt has not had bismuth in last 72hrs
- increase fluids post-test to remove radioactive tracer
- cold spots show darkened areas of blackened tissue
172
imaging safety alert
- assess pregnancy status
- allergies
- consent
- assess kidney function before administering dye
- ensure IV is placed
- verify if taking metformin
- encourage fluids after exam
173
bone scan interventions
- food and fluids may be withheld before the procedure
- informed consent
- remove all jewlry and metal object
- follow injection of radioisotope to promote filtering
- void before scan
- need to lie supine during procedure
- monitor injection site
- encourage oral fluids after procedure
174
electromyography
- patient education: slight pain on needle insertion and bruising, shower before test, do not apply lotions, do not eat or drink caffeine 2-3hrs pre-test
- verify meds
- assess pain during and after testing
175
arthroscopy
- patient education
- follow pre-op proedures
- verify consent
- assess for anticoags and ASA
- ensure NPO
- perform time out
- no arthogram in previous days on affected joint (can cause inflammation and diffiuculty visualizing joint)
- post-op apply ice 1-2 days, elevate leg, follow providers orders; weight bearing
- ensure someone can drive individual home
176
arthocentesis
- patient education
- patient positioning
- assess for anticoags and asa
- perform time out
- apply ice 24hrs
177
electromyography interventions
- informed consent
- needle insertion is uncomfortable
- no stimulants or sedatives for 24hrs
- inform client slight bruising may occur
- mild analgesics
178
arthroscopy interventions
- instruct client to fast for 8-12hrs
- ensure informed consent was obtained
- admin pain meds
- assess neurovascular status
- elastic compression bandage worn postop for 2-4 days
- weight bearing after sensation returns
- elevate as often as possible for 24hrs
- call HCP if fever or increased knee pain, redness around incision, drainage for >3days, edema >3days
179
arthrocentesis interventions
- informed consent
- elastic compression bandage
- post-op ice and pain meds
- may increase blood glucose levels
- rest joint for 8-24hrs
- call HCP if feveror swelling of joint occurs
180
fractures
a break in the continuity of a bone caused by trauma, twisting, bone decalcifcation or disease resulting in osteopenia
181
closed fracture
skin remains intact
182
compound or open fracture
bone exposed through break in skin, soft tissue injury and infection are common
183
care of fractures
- immobilize affected extremity with cast or splint
- if compound fracture exists, splint extremity and cover wound with sterile dressing
- assess neurovascular status of extremity
- reduction (closed or open)
- fixation
- traction
- casts
184
reduction
- restores bone to proper alignment
- closed reduction is a nonsurgical intervention performed via manual manipulation
- may be performed under local or general anesthesia
- cast may be applied after reduction
- open reduction is a surgical intervention and may be treated with internal fixation devices
185
fixation
- internal fixation follows an open reduction providing immediate bone stabilization (application of screws, plates, pins, wires, or rods to hold bone and may involve removal of damage bone
- external fixation is the use of an external frame to stabilize a fracture by attaching skeletal pins through bone providing more freedom than traction
- monitor pins for stability and provide pin care to decrease infection
186
traction
- exertion of a pulling force applied in 2 directions to reduce and immobilize a fracture
- provides proper bone alignment and reduces muscle spasms
- maintain proper body alignment
- ensure weights hang freely and don't touch the floor
- do not remove or life weights without an order or only if coding
- ensure pulleys are not obstructed and that ropes move freely
- place knots in ropes to prevent slipping
- check ropes for fraying
187
skeletal traction
- applied mechanically to bone with pins, wires, or tongs
- neurovascular checks (color, motion, sensation)
- monitor insertion sites for redness swelling drainage or increased pain
- provide insertion site care
188
skin traction
- applied using elastic bandages or adhesive, foam boot or sling
- be cautios to avoid excessive pressure on skin that could result in a pressure injury or skin breakdown
- wrapping too tight can increase risk of compartment syndrome
189
buck's traction (extension)
- alleviates muscle spasms and immobilizes lower limb
- boot appliance attached to traction
- weights attached to a pulley; allow the weights to hang freely over edge of bed
- no more than 8-10lbs as prescribed
- elevate foot of bed
190
casts
- plaster, fiberglass, or air casts to immobilize bones and joints into correct alignment
- keep cast and extremity elevated
- allow wet plaster cast 24-72hrs to dry
- handle wet plaster cast with plams, not fingertips
- turn extremity q1-2hrs
- hair dryer on cool setting
- monitor for circulatory impairment
- call provider to perp for bivlaving if needed for pain, swelling, discoloration, tingling, numbness, coolness, or diminished pulse
- petal cast or apply moleskin to edges to protect client's skin
- monitor for infection (increased temp, hot spots, foul odor, change in pain)
- open drainage can exist
- don't stick objects in the cast
- teach client to keep cast clean and dry
- exercises to prevent muscle atrophy
191
fracture assessment
- vitals
- pain in involved area
- decrease or loss of muscular strength or function
- obvious deformity of affected area
- crepitation, erythema, edema or bruising
- muscle spasm and neurovascular impairment
- verfiy proper positioning, application, and stability of traction/splinting/immobilization
192
nursing interventions for fractures
- pain management
- pulmonary hygeine
- admin antibiotics
- admin anticoags
- wound and pin care
- elevate extremity if appropriate
- apply ice
- reposition
- hydration and nutrition
- consume adequate cals and vitamins to promote healing, pain management, wound care, activity, proper use of sligns, pslints, casts and traction
193
complications of fractures
- fat embolism
- compartment syndrome
- avascular necrosis
- infection/osteomyelitis
194
fat emoblism
- fat droplets from broken bones enter blood stream and travel to lungs
- s/s: petechiae on chest, upper arms, or neck, restlessness, confusion, decreased LOC, tachypnea, sudden onset of dyspnea, chest pain, cough, hemoptysis, hypoexmia, or crackles
195
fat emoblism interventions
- notify HCP
- admin O2
- admin IVF and anticoags
- monitor vitals and R status
- follow up on x-ray or CT scan
- prep for intubation and mechanical ventilation
- document event, actions, and response
196
compartment syndrome
- serious medical condition occuring when excess pressure builds up within closed muscle leading to reduced BF to muscles and nerves
- if untreated can lead to tissue damage, muscle and nerve injury, and permanent disability
- severe cases can cause loss of lumb function or even loss of limb itself
- treatment: immediate fasciotomy to relieve perssure
197
signs of compartment syndrome
- severe pain out of proportion to injury unrelived by pain meds
- pulselessness
- numbness or tingling, loss of sensation (paresthesia)
- pallor or dusky skin color
- swelling and tightness in affected limb
- weakness or difficulty moving limb
198
interventions for compartment syndrome
- call HCP
- loosen dressings or bivalved cast
- assist with fasciotomy
199
avascular necrosis
- occurs when fracture interupts blood supply to section of bone leading to bone death
- increased pain and decreased sensation
- interventions: notify HCP if pain or numbness occurs
- prep for surgical intervention to remove infection or necrotic tissue
200
infection/osteomyelitis
- caused by intro of organisms into bones leading to localized bone infection
- s/s: tachycardia, fever, erythema and pain, leukocytosis and elevated ESR, confirmed infection via xray, mri, or bone scan
201
interventions for infection or osteomyelitis
- notify HCP
- prep for aggressive long term IV antibiotics, central line likely
- surgery
- hyperbaric o2 therapy is used
202
fractured hip
- intracapsular (femoral head is broken within joint capsule) where skin traction is applied preop to reduce fracture and decrease muscle spasms, treatment is hip replacemnt or open reduction internal fixation
- extracapsular (fracture outside joint capsule) where balanced suspension or skin traction is used with surgical treatment of ORIF with nail plate and intramedullary fixation
203
indications for THA/TKA
- osteoarthritis
- rheumatoid arthritis
- previous injury or surgery to joint
- previous childhood hip disease
- avascular necorsis of femoral haed
- intracapsular fractured neck of femur
- ankylosing spondylitis
204
medical management of joint replacement
- begin w/ conservative care like weight management, activity modification, NSAIDs, and joint supplements like glucosamine and chondroitin
- if unsuccesfful, surgical plan developed
205
complications of joint replacement
- bleeding
- hypotension
- hypovolemia
- infection
- dislocation
- subluxation
- DVT
- PE
206
hip replacement approaches
- posterior (more severe)
- lateral
- anterior
207
postop hip replacement interventions
- assess vitals
- pain meds and muscle relaxants as needed
- assess surgical site for bleeding and infection
- DVT prevention (coags, ambulation, scd's, leg exercises)
- maintain leg and hip in alignment, prevent internal or external rotation, abductor pillow
- avoid extreme hip flexion >90 degrees for 2-3months, avoid low chairs, use raised toilet seats
- assist client to ambulate as prescribed (20-30min 2-3x/day)
- turn and reposition
- avoid weight bearing on affected leg as ordered
- avoid crossing legs or bending over
- remove throw rugs, nonslip socks and shoes
- admin antibiotics
- neurovascular assessment of affected extremity (color, pulse, cap refill, movement, sensation)
208
amputation
- surgical removal of limb or part of limb
- can be traumatic or elective
- traumatic amputations have large risk for hemorrhaging so place pressure banadage or tourniquet, obtain cbc and type and x match for blood transfusion and prep for surgery
209
post-op amputation interventions
- maintain large bore IV
- assess vitals
- monitor for s/s of complications (marked bleeding and drainage)
- admin IVF and transfuse blood prn
- pain management
- first 24hrs: eelevate foot of bed to reduce edema, keep bed flat to prevent hip flexion contractures
- after 24-48hrs, position prone ot stretch muscles and prevent contractions
- maintain I&Os and nutritional status
- maintain surgical dressing, compression wrap, or elastic stump shrinker or reduce swelling, minimize pain, mold residual limg in prep for prosthesis
- eval for phantom limb sensation and pain
- don't elevate limb on pillow
- wash limb with mild soap and water and ddry completely
- massage skin toward suture line to mobilize scar tissue and prevent adherance
- prep for prosthesis and isntruct resistive techniques
- verabilizationregarding loss of body part
210
below knee amputation interventions
- prevent edema
- don't allow limb to hang over edge of bed
- discourage long periods of sitting to lessen complications of knee flexion
- place client in prone position throughout day
211
above knee amputation interventions
- prevent iternal or external rotation of limb
- place sandbag, rolled towel, or trochanter roll along outside of thigh to prevent external rotation
- palce client in prone position throughout day
212
rehab for ampuation
- instruct licnet to use mobility aid
- prep for prosthesis
- prep for fitting of residual limb for prosthesis
- maintain ROM and upper body strength
213
pneumonia
- inflammation and infection of lung parenchyma (functional lung tissue) resulting from bacterial, viral, or fungal infection
- fluid and exudates fill alveoli, impairing exchange of o2 and co2 causing hypoexmia
- localized or diffuse
- bacteria can enter bloodstream causing septicemia and shock
214
risk factors of pneumonai
- advanced age
- long term care residence
- smoking
- chronic respiratory disease (COPD, asthma)
- immune system malfunctions (aids, cancer)
- altered mental status
- prolonged immobility
- aspiration
- NPO status
- diminished cough, gag, and swallow reflexes
- exposure to air pollutants, gases, or inhalants
- hospitalization for longer than 48hrs
215
classifications of pneumonia
- hospital acquired
- community acquired
- healthcare-associated
216
s/s of pneumonia
- fever
- tachypnea/dyspnea
- tachycardia
- chills
- rhonchi and wheezing
- use of accessory muscles
- cough, productive or nonproductive
- pleuritic chest pain
- fatigue
- mental status changes
- myalgia/arthralgia
- purulent blood-streaked sputum
- hypotension
- dysrythmias
217
diagnosis of pneumonia
- lab studies (elevated WBC, CRP, abgs showing respiratory alkalosis (tachypnea) changing into respiratory acidosis with hypoexmia, and sputum cultures
- imaging studies
- CXR
- CT scan
218
medical treatment of pneumonia
- depends on type
- supportive
- hospitalization
- treat hypoxia
- bronchodilators
- O2
- support CV satus and thin secretions
219
complications of pneumonia
- necrotizing pneumonia
- meningitis
- empyema
- pulmonary fibrosis
- pulmonary HTN
- septic shock
- acute respiratory failure
- multiple organ failure
220
nursing assessments for pneumonia
- vitals (tachypnea and tachycardia, decreased O2, fever)
- neuro function (agitation, restlessness, anxiety, lethargy)
- breath sounds (wheezing, rhonchi, crackles)
- perfusion showing diminished peripheral pulses, moist, pale skin, peripheral cyanosis
- respiratory secretions (purulent or bloody secretions)
- labs (C&S, ABGs)
- intake and output
221
nursing actions for pneumonia
- humidified O2
- meds (bronchodilators, antibiotics, antipyretics, cough suppresssants)
- pulmonary hygeine (incentive spirometer, TCDB, postural drainage, vibration/precussion, early mobility)
- patient positioning (HOB >30)
- monitor I&Os (3L fluid/day)
- adequate nutrition
- alternate activity w/ rest
222
patient education for pneumonia
- hand hygeine
- respiratory ettiquette
- encourage rest
- take antibiotics if prescribed
- proper nutrition and fluid
- s/s of worsening respiratory status
- pneumonia vacine
223
tuberculosis
- highly communicable respiratory infection caused by organism mycobacterium tub
- transmitted through droplets inhaled from coughing or sneezing
- latent tb, primary tb, primary progressive, drug resistant
224
risks for tb
- homeless
- incarcerated
- live in crowded areas or facilities
- older adults and children <5
- HIV/AIDS or immunosuppressed
- malnutrition
- alcohol or IV drug abuse
- populations living outside US
- low socioeconomic groups
- racial and ethnic minorities
- in contact with untreated/undiagnosed individual
225
signs of tb
- fatigue
- weight loss
- night sweats
- cough w/ rusty colored or blood-streaked sputum
- dyspnea
- orthopnea
- rales
226
diagnosis of tb
- sputum culture
- quantiferon tb
- mantoux tb skin test
- cxr showing gas filled space in lung tissue
227
medical treatment of tb
- cure disease
- minimize transmission
- four drug combo (RIPE) for 9-12months
228
RIPE meds
- rifampin
- isoniazid
- pyrazinamide
- ethambutol
229
tb complications
- respiratory failure
- bronchopleural fistula
- pleural effusions
- extrapulmonary tb (meningitis, lymphadenopathy, bone disease, liver and kidney failure)
230
tb nursing assessment
- oxygenation (decreased)
- temp (fever)
- sputum (blood-tinged rust colored)
- breath sounds (wheezing, rales, rhonchi)
- isolation
231
tb nursing actions
- humidified o2
- airborne (negative pressure room, n95)
- administer antibiotics (RIPE)
- ensure adequate nutrition
232
tb pt education
- skin/blood testing for individuals living with infected persons
- med adherance
- support systems
233
obstructive sleep apnea
- partial or complete obstruction of airway during sleep
- with onset of sleep, the body muscle tone relaxes which includes muscles of upper airway
- causes airway collapse and periods of apnea
- during apnea, no movement of air in or out causing hypoexmia, hypercapnia, and acidosis
234
risk factors for OSA
- a-fib
- nocturnal dysrhythmias
- type 2 DM
- HF
- pulmonary HTN
- male
- obesity
- cigarette and alcohol use
- 40-65
- craniofacial or upper airway soft tissue abnormalities
- menopause
235
s/s of OSA
- loud snoring
- snorting
- witness apnea
- gasping during sleep
- recurrent waking during sleep
- nocturnal restlessness
- choking
- excessive daytime sleepiness
- falling asleep during quiet times
- short and repetitive attention lapses
- mood swings
- intentional naps
236
diagnosis of sleep apnea
- sleep hx, patterns, snoring, daytime sleepiness
- polysomnography (sleep study) - apnea-hypopnea index (AHI) showing # of apneic episodes/hr
237
medical treatment of OSA
- CPAP
- weight management and loss
- sleep in non-supine (HOB raised)
- quit smoking
- no alcohol or sedatives before bed
- oral appliance to hold jaw open
- tongue retaining devices
- surgery to remove excess tissue in upper airway
- inspire (internal OSA device)
- weight reduction surgery (gastric bypass)
238
uvulopalatopharyngoplasty
- perform if conservative theray hasn't worked (weight loss, CPAP, positioning)
- removal of tonsils, adenoids, uvula, and soft palate tissue
- postop: sore for several weeks, stiches in back of throat, humidified o2, raise HOB, avoid strenous activity but stay in motion to prevent clots, clear liquids, avoid irritating foods, food and drinks cold or room temp, rinse mouth after meals
239
complications of OSA
- heart disease (HTN, MI, a-fib, sudden cardiac death)
- pulmonary HTN leading to HF
- stroke
- diabetes
- depression
- weight gain
- chronic fatigue
240
nursing assessment for OSA
- vitals (HTN, dysrythmias)
- height and weight
- sleep, rest, activity hx
- post-op; assess edema, bleeding, respiratory distress
241
nursing actions for OSA
- assist with CPAP education and application
- admin meds (HTN, dysrhythmias, post-op pain, mouth wash)
- diagnostic tests (sleep study, ECG, echo)
- patient education: disease process, meds, CPAP, weight reduction
242
asthma
- chronic lung disease w/ intermittent, reversible airway obstruction
- affects BRONCHIAL airways NOT alevoli
- inflammation of lung's airways and tightening of muscles that surrond airways
- triggered by exposure to irritants, exercise, cold weather, or risk factors
243
asthma risk factors
- race/ethnicity
- family hx
- mold
- dampness
- allergies
- air pollution
- urbanization
- viral infections
- eczema
- exposure to irritants
- obesity
- stress
244
asthma s/s
- wheezing
- dyspnea
- coughing
- increased sputum
- increased respiratory rate
- retractions use of accessory muscles
- cyanosis
- chest tightness
- tachycardia
- elevated BP
- restlessness, change in LOC
- inability to lie flat
- anxiety/panic
- decreased peak flow
- inability to speak in full sentences
- quiet lungs/absent breath sounds = NO AIR MVMNT
245
asthma diagnosis
- detailed hx
- focused phsyical
- pulmonary function tests
- CXR
- pulse ox
- ABGs
- peak expiratory flow
246
asthma medical management
- asthma action plan
- acute attack
- anti-finlammatories
- bronchodilators
- leukotriene modifiers
- control of triggers and enivronment
247
status asthmaticus
- unable to speak
- cyanosis and O2 sat <92%
- silent chest
- use of accessory muscles
- drowsy
- poor respiratory effort
- bradycardia
248
asthma nursing interventions
- vitals
- peak flow
- ABGs
- breath sounds
- LOC
- ability to speak in full sentences
- cough
- use of accessory muscles
- position (tripod, semifowler's)
- dyspnea (visual analog dyspnea scale)
- hx of previous intubation (!!!!!!!!!!!!!!!!)
249
nursing actions for asthma
- iv access
- o2 to maintain sat >90%
- admin meds as ordered
- educate on asthma plan
- pursed lip breathing
- avoidance of triggers and risks
- meds
- proper inhaler technique
- smoking cessation
- peak flow meter
- cleaning of respiratory equpment
250
