237 Study Cards Flashcards
1
Q
Define atelectasis.
A
closure or collapse of alveoli
2
Q
What is the most common type of atelectasis?
A
acute atelectasis
3
Q
What are common causes of atelectasis?
A
- post operation
- immobilization with shallow, monotonous breathing pattern
- excess secretions or mucus plug
- chronic airway obstruction (e.g. lung cancer)
4
Q
What are the clinical manifestations of atelectasis?
A
- Usually insidious
- Cough, sputum production, and increasing dyspnea
- Tachycardia, tachypnea, pleural pain and central cyanosis may be anticipated
- Difficulty breathing in supine position and is anxious
5
Q
What steps can you take to prevent atelectasis?
A
- Frequent turning
- Early mobilization
- Strategies to expand lungs and manage secretions
- Deep breathing every 2 hours
- Incentive spirometry
- Directed cough
- Suctioning
- Aerosol nebulizer treatment followed by chest physical therapy
- Bronchoscopy
6
Q
What are the components of the ICOUGH program?
A
I - incentive spirometry
C- coughing and deep breathing
O - oral care (brushing teeth and mouth wash twice daily)
U - understanding (patient and staff education)
G- getting out of bed at least 3x daily
H - head-of-bed elevation
7
Q
What is the pathophysiology of atelectasis?
A
- reduced alveolar ventilation or any type of blockage that impedes the passage of air to and from the alveoli
- Monotonous low tidal breathing pattern may cause airway closure and alveolar collapse. Can be caused by anesthesia or analgesic agents, supine positioning, splinting of chest wall because of pain, abdominal distension
- Impaired cough mechanism
- Excessive pressure on the lung tissue
8
Q
What is involved in the assessment and diagnostics for atelectasis?
A
- Increase work of breathing and hypoxemia
- Decreased breath sounds and crackles
- Chest x-ray, SpO2-low saturation (<90%) or lower PaO2
9
Q
What risk factors are there for atelectasis?
A
- Post op patients are at a high risk due to the effects of anesthesia or analgesic agents (surgical procedures: upper abdominal, thoracic, or open-heart surgery).
- Immobilized
- People with shallow, monotonous breathing patterns
- Those in a supine position
- Patients with impaired cough mechanisms
- Excessive pressure on the lungs
- Airway obstruction (cancer, mucus)
- Pain can impair the cough reflex
- Increased abdominal pressure/distension
- Age
- Exposure to pollutants
10
Q
What are signs and symptoms of infection with chronic atelectasis?
A
- Chest pain
- Sputum production with yellow/green colored expectorant
- Pain on deep breathing
- Pain on exhalation, inhalation or both
- Fever
11
Q
What assessments and assessment outcomes are involved with identifying atelectasis?
A
- Monitor vital signs (RR higher, temp, SpO2)
- Do a respiratory assessment (thorax and lungs)
- Monitor change in behaviour, mental status, and LOC
- Increased work of breathing (tachypnea, use of accessory muscles, tripod position breathing)
- Hypoxemia (check skin, nails, lips color)
- Increased respiratory rate
- Decreased breath sounds
- Crackles over affected areas
- Chest X-ray (revealing patchy infiltrates or consolidation areas)
- V/Q Scan
- Pulse Oximetry (SpO2) lower than 90%
- Low PaO2
- Physical assessment of dependent (lower part), basilar, and posterior areas of lung
12
Q
What lab values are relevant with atelectasis?
A
- Less than 90% SpO2 (Sa02)or lower than normal PaO2 (normal PaO2 is 80 - 100 mm Hg)
- Blood gasses- low PA02 (partial pressure of arterial oxygen).
- Using a spirometer airflow values greater than 80% is normal.
- WBC if query infection, Sputum culture
- Difference between alveolar and arterial o2- normal value is less than 10 mm Hg (torr)– Atelectasis Increased A-a O2 gradient
- L/S ratio: 2:1 concentration of lecithin rapidly increases-sphingomyelin concentration decreases
- Decreased Po2 and o2 content
13
Q
What diagnostic findings are associated with atelectasis?
A
- Chest X-ray would reveal patchy infiltrates or consolidated areas (MOST COMMON)
- Thoracentesis is done to remove fluid from the pleura
- Bronchoscopy, CT, imaging tests can confirm a diagnosis.
- Sp02 may be lower (less than 90%)
- Lower partial pressure of oxygen (Pa02)
- V/Q scan
14
Q
How is atelectasis managed using pharmacological agents?
A
- Nebulizer or MDI (metered dose inhaler) treatments with a bronchodilator medication or sodium bicarbonate to assist with the expectoration of secretions
- Expectorants (such as guaifenesin) to thin and aid in removal of secretions or mucous plugs
- Use of oxygen therapy titrated to keep 02 saturations within acceptable range
- Antibiotics, antivirals to assist with the removal of infections
- If it is due to obstruction caused by lung cancer, various pharmacological interventions (Eg. chemotherapy & radiation) can be directed at shrinking the tumor to open airways and provide ventilation to the collapsed area
- Analgesics may be used if hypoventilation is caused by pain
15
Q
What are some treatments for atelectasis?
A
- Frequent turning
- Early ambulation
- Lung volume expansion maneuvers (deep-breathing exercises, incentive spirometry)
- Positive end-expiratory pressure (PEEP) therapy (simple mask and one-way valve system)
- Continuous or intermittent positive pressure breathing
- Chest percussion and postural drainage
- Bronchoscopy
- Endotracheal intubation and mechanical ventilation
- Coughing/suctioning secretions
- Chest physical therapy to loosen secretions
- Radiation to shrink size of neoplasms causing compression of lung tissue
16
Q
What is a pleural effusion?
A
- Collection of fluid in the pleural space
- Usually secondary to another disease
17
Q
What are common causes of a pleural effusion?
A
- Heart failure (most common cause)
- Bacterial pneumonia
- Lung cancer
- Pulmonary embolism
- Pulmonary infection (often viral)
- Radiation therapy to the chest
- Nephrotic syndrome
- Hypothyroidism
- Liver disease
- Connective tissue disease
- Tuberculosis
- Infection
- Smoking
18
Q
What are clinical manifestations of a pleural effusion?
A
- Those caused by the underlying disease process (eg. pneumonia, lung diseases) ; size of the effusion can affect severity of symptoms
- Severity of symptoms relates to the size of the effusion, speed of formation, and underlying lung disease
- May include:
- Fever
- Dyspnea
- Chest pain- increased with breathing and coughing (pleuritic pain)
- Small (dyspnea minimal) vs large effusion (shortness of breath present, lots of pressure on lungs from fluid)
- Asymmetrical chest expansion
- Decreased tactile fremitus
- Orthopnea (difficulty breathing unless sitting up or standing)
- Shallow, rapid breathing– crackles
- Fatigue, Loss of appetite, LOC
19
Q
What is the pathophysiology of a pleural effusion?
A
- Typically secondary to other disease processes such as pneumonia, malignant effusions
- Abnormal volume of fluid accumulates into pleural space. Fluid has pathological significance. Can be serous, purulent, or sanguineous.
- Clear fluid may be transudate - which is filtrate of plasma moving through capillary tissues = occurring when there is an imbalance in hydrostatic or oncotic pressures - not diseased
- This can indicate that the pleural membranes are NOT diseased - in this case HF is the most common cause
- Or it can be exudate -which is leakage of blood, lymph or other fluid into tissues/cavities= which usually results from bacteria or tumors within the pleural surfaces
20
Q
What is involved in the assessment of a pleural effusion?
A
- VS - increased Resp rate, shallow resps, tachycardia, decreased Sp 02, Increased HR and BP
- Respiratory assessment-
- Decreased or absent breath sounds over lung field
- Decreased tactile fremitus
- dull flat sound on percussion.
- Asymmetrical chest expansion - delayed or diminished expansion on side of effusion
- Patient may appear in respiratory distress on observation evidenced by:
- increased work of breathing
- Tachypnea
- use of accessory muscles, or
- have orthopnea when lying supine.
- Neurological assessment
- Pt may appear confused
- Reduced level of consciousness
- Tracheal deviation may be noted away from the affected side (rare).
21
Q
What lab values are associated with a pleural effusion?
A
- Pleural fluid analyzed by:
- Bacterial culture
- Gram stain
- Acid-fast bacillus stain (for TB)
- Interferon-gamma concentrations
- Red and white blood cell counts
- Chemistry studies (glucose, amylase, dehydrogenase, protein)
- Cytology analysis for malignant cells
- pH (different pH results can be indicative of the type of effusion)
- CBC
- Increased white blood cells count
- Sputum culture
- Blood gases
22
Q
What diagnostic tests are involved in diagnosing a pleural effusion?
A
- Chest X-ray, chest CT scan, and thoracentesis used to confirm the presence of fluid (in the pleural space)
- In some cases, lateral decubitus X-ray is obtained (have patient lay on affected side in side-lying position, which allows for layering out of fluid, producing a visible air-fluid line)
- Pleural biopsy (to look for cancer, infection, or other condition)
23
Q
What is involved in the pharmacological management of a pleural effusion?
A
- Objective is to treat the underlying cause in order to prevent the re-accumulation of fluid
- Use of chemical pleurodesis to ensure recurrence of fluid build up does not occur (prevents fluid accumulation) → Chemical irritating agents are installed into the pleural space (bleomycin or talc)
- Chemotherapy to treat cancer (cancer can cause pleural effusion)
- Pain management
- Antibiotics to treat underlying infections
- If pleural effusion is a result of treatment of conditions, such as HF, diuretics may be used
- Bronchodilators
24
Q
What are the treatment modalities for a pleural effusion?
A
- Prevent re-accumulation of fluids:
-
Thoracentesis to remove fluid (specimen analysis, relief of dyspnea and respiratory compromise)
- Prepare and position patient for thoracentesis, offering support throughout.
- Record thoracentesis fluid amount and send for appropriate lab testing
-
Thoracentesis to remove fluid (specimen analysis, relief of dyspnea and respiratory compromise)
- Tube Thoracostomy (chest drainage using a large diameter intercostal tube)
- Pain management of test tube and least painful positioning
- Chemical pleurodesis (for malignant effusions, obliterates the pleural space to prevent re-accumulation of fluid)
- Surgical pleurectomy, insertion of a drainage catheter, implantation of a pleuroperitoneal shunt
- Patient education of drainage system and care of catheters if outpatient
25
What is anemia?
Condition in which the hemoglobin concentration is lower than normal and reflects the presence of fewer than the normal number of erythrocytes within circulation. As a result, O2 delivered to body tissues is decreased. **By far the most common hematologic condition.**
26
What are the different classifications of anemia?
* Hypoproliferative: caused by a defect in their production (marrow cannot produce adequate #s of erythrocytes
* Hemolytic: By destruction of erythrocytes
* Bleeding: by the loss of erythrocytes
27
What are some complications of anemia?
* Heart failure
* Paresthesias
* Delirium
28
What are risk factors associated with anemia?
* A **diet lacking** in certain vitamins and minerals (such as iron, vitamin B12, folate, and iron)
* **Family history**
* **Excessive blood loss** due to injury, surgery, heavy menstruation
* Age - **people over 65** are at risk
* Chronic conditions (IBD, HIV/AIDS, cancer, autoimmune diseases, and **chronic kidney disease**)
* **Mediterranean** origin
* **Medications inhibiting effective absorption** of nutrients
* **Alcoholism** affecting production of RBCs
29
What is the pathophysiology associated with anemia?
* The **level of hemoglobin is lower than normal** in the circulation causing **less oxygen being delivered to the body tissues**
* Many different types that can affect the reason as to why there is low hemoglobin:
* Decreased erythrocyte (RBC) production due to **bone marrow damage** either due to medications, chemicals or lack of factors needed for RBC formation = hypoproliferative anemia
* **Premature RBC destruction** -\> causing hemoglobin to be released into plasma -\> which is then converted into bilirubin causing the concentration within the blood to increase-\> leading to tissue hypoxia = known as **hemolytic anemia**
* **Bleeding** causing a loss of RBCs
30
What are the clinical manifestations of anemia?
* The **more rapid** the anemia develops the **more severe** the symptoms.
* A **healthy person** can **tolerate** as much as **50% gradual reduction**, where as the r**apid reduction can be tolerated to \>30%**. **30% rapid loss can cause vascular collapse**.
* **Tachypnea** on exertion and **fatigue (most common)**
* Those who are more active will have more significant symptoms.
* Nausea, vomiting, malena
* Neuro symptoms; weakness, ataxia, muscle pain
* **Fatigue**
* Jaundice with hemolytic anemia
* General malaise
* Tongue (smooth and red with iron deficiency anemia and beefy red and sore with megaloblastic anemia)
* Cheilosis
* Iron-deficiency may crave ice, starch, or dirt (pica)
* Nails can become brittle, ridged, and concave
31
What assessments are involved in identifying anemia?
* History/Genetics of Anemia in family:
* Sickle cell anemia
* Appearance:
* Pallor in hands, mouth, conjunctiva
* Condition of nails
* History of menstrual cycles for female patients
* Vital signs: low BP, high HR (if related to bleeding), decreased Sp02
* Respiratory: dyspnea, tachypnea
* Nutritional assessment
* Looking for potential deficiency in iron, vitamin B12, and folic acid
* Certain dietary approaches are at higher risk (e.g. strict vegetarians)
* Health History
* Medications (some can depress bone marrow activity, induce hemolysis, interfere with folate metabolism)
* Alcohol use
* Cardiovascular:
* Distended neck veins, edema, chest pain on exertion, murmurs, gallops
* Hypotension (below baseline)
* Hypertension (above baseline)
* GI system
* Stool assessment for occult blood
* Neurologic
* Assess for peripheral numbness and paresthesias
* Ataxia
* Poor coordination
* Confusion
* Possibility of delirium
32
What lab values are associated with anemia?
* Depends on the type of anemia (note: MCV measures the size and volume of red blood cells).
* **Hypoproliferative**
* Iron deficiency: decreased MCV, decreased reticulocytes
* Vitamin b12: increased MCV
* Folate deficiency: increased MCV
* **Bleeding (RBC loss)**
* Bleeding: decreased Hgb, Hct, and MCV
* Increased reticulocytes
* **Hemolytic**
* Altered erythropoiesis: decreased MCV, increased reticulocytes
* Drug induced anemia and autoimmune anemia: increased presence of spherocytes
* Serum iron levels, total iron binding capacity. Vitamin B12 and folate levels. Haptoglobin and erythropoietin levels.
33
What diagnostic findings are related to anemia?
* Hemoglobin
* Hematocrit
* Reticulocyte count
* RBC indices - mean corpuscular volume and red cell distribution width
* Iron studies
* Serum B12 and folate levels
* Haptoglobin
* Erythropoietin levels
* Bone marrow aspiration
* Endoscopy - GI Bleed??
34
What pharmacological management is involved in the treatment of anemia?
* Transfusion of packed RBCs
* Supplemental iron, vitamin B12, folic acid
* Transfusions or IV fluid replacement to increase blood volume
* Erythropoesis Stimulating Agents (
* O2 therapy
* IV fluids
35
What are the treatment modalities for anemia?
* Managing **fatigue** (MOST COMMON SYMPTOM)
* Maintaining **adequate nutrition** (iron, B12, folic acid, and protein)
* Maintaining **adequate perfusion** - replacing lost volume with transfusions or IV fluids. Supplemental O2
* Promoting **adherence with prescribed therapy** - Educate on purpose of med, how to take, over what time, and manage side effects. Consequences of stopping meds (corticosteroids)
* Education on **taking iron on an empty stomach unless GI upset**
* Taking a stool supplement
* **Blood transfusion**
* Monitoring for **signs and symptoms** of **heart failure**
36
For post care of thoracentesis, what should you monitor for?
* Assess insertion site for bleeding and/or drainage
* Monitor for :
* *Increased chest tightness*
* *Uncontrollable cough*
* *Blood tinged, frothy mucous*
* *Sudden, uncontrollable pain*
* *Signs of hypoxemia: increased respiratory rate, rapid pulse, anxiety, restlessness*
* Nursing Assessments:
* *Vital signs*
* *Respiratory assessment (note any diminished breath sounds near the insertion site)*
* Interventions:
* *Oxygen, notify physician*
37
What are interventions to ensure adequate perfusion related to anemia?
* *Monitor hemoglobin and ferritin levels*
* *Vital signs to assess for hypoxemia*
* *Supplemental oxygen and medications*
38
What are interventions to address fatigue that is related to anemia?
* *Prioritize activities and develop schedule with periods of activities balanced with rest*
* *At least daily physical activity/exercise as tolerated*
39
What interventions address ensuring adequate nutrition related to anemia?
* *Supplements: iron, folic acid, Vitamin B12*
* *Protein rich diet – not tea and toast*
* *Limit alcohol – inhibits absorption of nutrients and diminishes appetite*
40
What interventions can address a patient with anemia adhering to prescribed therapy once discharged?
* *Assess ability to maintain healthy diet once home – need family support? Meals on Wheels?*
* *Affordability of supplements – need assistance?*
* *Strategies to manage side effects of supplements (constipation with iron therapy)*
41
What principles are involved in setting priorities?
1. Make sure you **have the big picture** of all the **patient’s problems**.
2. Determine the **relationship among the problems**.
3. Setting priorities is a **dynamic, changing process**.
4. Develop a **multidisciplinary problem list**, and **refer to it frequently**.
42
What are the steps involved in setting priorities?
1. Ensure patient and caregiver safety and prevent infection transmission.
2. Assign high priority to first-level priority problems.
3. Attend to second-level priority problems.
4. Address third-level priority problems.
43
Define clinical judgment.
The definition of clinical judgment used for this concept presentation is “an interpretation or conclusion about a patient’s needs, concerns, or health problems, and/or the decision to take action (or not), use or modify standard approaches, or improvise new ones as deemed appropriate by the patient’s response.
44
What two ways is priority setting defined?
1. Differentiating between problems needing immediate attention and those requiring subsequent action
2. Deciding what problems must be addressed in the patient records
45
What are some methods of assigning priorities to patient needs?
* ABC method
* In emergency departments: life, limbs, and vision
* Maslow's Hierarchy of Needs
46
What are the priority levels within Maslow's Hierarchy of Needs?
Priority 1: Physiological needs - life threatening problems
Priority 2: Safety and security
Priority 3: Love and belonging
Priority 4: Self-esteem
Priority 5: Personal goals
47
When thinking about first-level priority problems, what does “ABCs plus V and L” represent?
**_A_**irway problems
**_B_**reathing problems
**_C**_ardiac and _**c_**irculation problems
+
**_V_**ital signs concerns (e.g., fever, hypertension, hypotension)
**_L_**ab values that are life-threatening (e.g, low blood sugar)
48
What are considered second-level priority problems?
* Mental status change (e.g., confusion, decreased alertness)
* Medical problems requiring immediate attention (e.g., a diabetic who hasn't had insulin)
* Pain
* Urinary elimination problems
49
By what process do nurses arrive at clinical decisions? Think of Tanner's model.
50
Using an interpretivist view of clinical judgment, what attiributes are associated with it?
* Holistic view of the patient situation
* Process orientation
* Reasoning and interpretation
* Ethical comportment
51
What does reflecting in action and reflecting on action refer to?
**Reflection-in-action** refers to the nurse’s understanding of patient responses to nursing actions **while care is occurring**. **Reflection-on-action** is consideration of the situation **after the patient care occurs**. In reflection-on-action, the nurse contemplates a situation and considers what was successful and what was unsuccessful.
52
What are casts used for?
* Immobilize a reduced fracture
* Correct a deformity
* Apply uniform pressure to underlying soft tissue
* Support and stabilize weakened joints
* Materials: nonplaster (polyurethane), plaster
53
What are some of the teaching needs associated with having a cast?
* Cast care: keep dry; do not cover with plastic
* Positioning: elevation of extremity; use of slings
* Hygiene
* Activity and mobility
* Report the following signs and symptoms: pain not relieved by elevating cast limb or by analgesics; changes in sensation, movement, skin colour, or temperature; and signs of infection or pressure areas
* Monitor neurovascular status and the potential for complications
54
What nursing interventions are there for patients with casts or immobilizers?
* Assess and maintain adequate neurovascular status:
* Assess circulation, sensation, and movement
* Five P’s (pain, paresthesia, pallor, pulse, paralysis)
* Notify physician at once of signs of compromise
* Elevate extremity to heart level
* Encourage movement of fingers or toes
55
What is traction?
* The application of pulling force to a part of the body
* Promotes and maintains alignment of the injured part of the body
* Surgical procedures such as open reduction with internal fixation (ORIF) have largely replaced the use of most forms of traction
56
What are the principles of effective traction?
* Traction must be continuous to be effective
* Weights are not removed unless intermittent traction is prescribed
* The patient must be in good body alignment in the centre of the bed
* Weights must hang freely and not rest on the bed or floor
* Prevent complications such as skin breakdown (repositioning), nerve damage, infection, circulatory impairment
57
What is an external fixator?
Used to manage open fractures with soft-tissue damage
Provide support for complicated or comminuted fractures
58
What nursing care is related to external fixators?
* Reassure patient concerned by appearance of device
* Discomfort is usually minimal, and early mobility may be anticipated with these devices
* Elevate to reduce edema
* Monitor for signs and symptoms of complications, including infection
* Provide pin care
59
Define immobility.
Inability to move about freely.
60
What are some metabolic hazards of immobility?
* Slowed wound healing, abnormal labs, muscle atrophy, decreased subcutaneous fat
* endocrine metabolism, calcium resorption, gastrointestinal function (constipation), negative nitrogen balance
61
What are some respiratory hazards of immobility?
atelectasis, hypostatic pneumonia, dyspnea, increased respiratory rate, crackles, wheezes, decreased air entry
62
What are some cardiovascular hazards of immobility?
* orthostatic hypotension
* thrombus
* embolus
* pulmonary emboli
* deep vein thrombosis (DVT)
63
What are some musculoskeletal hazards of immobility?
* loss of endurance, strength, and muscle mass;
* decreased stability and balance,
* osteoporosis,
* joint contracture
64
What are some urinary elimination hazards of immobility?
* urinary stasis
* urinary tract infection
* urinary retention
* decreased bowel movements
* distended bladder or abdomen
* decreased bowel sounds
* constipation
* anorexia, decreased appetite
* renal calculi, urinary tract infections
65
What are some integumentary hazards of immobility?
* ischemia
* pressure ulcers
66
What are some of the psychosocial effects of immobility?
* Decreased social interaction
* Social isolation
* Sensory deprivation
* Loss of independence
* Role changes
* Worry
* Depression
67
What are some risk factors for immobility?
* older adults due to physiological changes
* acute and chronic conditions
* chronic
* injury/trauma
68
Why is immobility especially concerning in children?
May interfere with their growth and development and intellectual and psychomotor functioning
69
What are the different materials used for casts?
* plaster
* non-plaster
* aircast
* half slab
* polyurethane (lighter)
70
What are some complications of casts?
* Compartment syndrome
* Pressure injuries
* Disuse syndrome
71
What does CSM stand for relative to patients in a cast?
C - circulation
S - sensation
M - movement
72
What is compartment syndrome?
**Limb-threatening** complication that occurs when **perfusion pressure** falls **below tissue pressure** within a closed anatomic compartment.
Involves a s**udden and severe decrease in blood flow** to the tissues **distal** to an area of injury that results in **ischemic necrosis** if prompt, decisive intervention does not occur
73
What are the 5 Ps of neurovascular function to assess after a fracture?
* Pain
* Paresthesia
* Pallor
* Paralysis
* Pulselessness
74
What interventions can you undertake to address compartment syndrome?
* Reduce pressure by bivalving cast if full cast
* posterior cast with tensor
* fasciotomy
75
Though use of traction has reduced, what type traction is still common?
Halo traction
76
When are external fixators used with fractures?
* Manage open fractures with soft tissue damage
* Provide support for complicated or comminuted fractures
77
Nursing care of fracture with external fixator.
* Discomfort is usually minimal
* Elevate the limb to reduce edema
* Provide pin care
* Monitor for signs and symptoms of complications
78
What are early complications of fracture healing?
* Shock
* Fat embolism syndrome (signs include: hypoxemia, neurologic compromise, petechial rash)
* Acute compartment syndrome (MOST IMPORTANT sign is severe, unrelenting pain) - often occurs within 12 -24 hours
* DVT and PE
79
What are delayed complications of fracture healing?
* Delayed union and nonunion
* Avascular necrosis
* Reaction to internal fixation devices
* Complex regional pain syndrome
* Hetertrophic ossification
80
What are some factors that enhance healing?
* Immobilization of fracture fragments
* Max fragment contact
* Sufficient blood supply
* Proper nutrition
* Exercise: weight bearing for long bones
* Hormones: growth hormone, thyroid, calcitonin, anabolic steroids
* Electric potential across fracture
81
What factors can inhibit healing?
* Over 40 years old
* Bone loss
* Avascular necrosis
* Smoking
* Comorbidities
* Corticosteroids, NSAIDS
* Extensive local trauma
* Inadequate immobilization
* Infection
* Local malignancy
* Malalignment of fracture fragments
82
What are some causes of amputation?
* progressive peripheral arterial disease (MOST COMMON REASON)
* fulminating gas gangrene
* trauma
* congenital deformities
* chronic osteomyelitis
* malignant tumour
83
What are some complications of amputations?
* Hemorrhage
* infection
* skin breakdown
* phantom limb pain
* joint contracture
84
What nursing interventions are associated with amputations?
* Managing pain
* Minimizing altered sensory perception
* Promoting wound healing
* Enhancing body image
* Helping the patient resolve grieving
* Promoting independent self-care
* Helping the patient achieve physical mobility
* Monitoring and managing potential complications
* Promoting home, community-based, and transitional care
85
What teaching is critical to re-iterate with hip replacement patients?
* Mobility limitations for life
* No adduction (no crossing legs, use pillow to keep knees apart)
* Hip cannot go below the knee
* Use pillow between knees
* No twisting so the hip does not dislocate
86
After fracture, who most frequently experiences a fat embolism?
adults younger than 40 and men; also those with multiple fractures
87
What are some of the signs of a fat embolism?
* Respiratory signs including PAO2 less than 60 mm Hg, cough
* Neuro changes
* Cardio: techy, **chest xray shows snowstorm infiltrate**
* Skin: pale, **petechial rash** occurs 2-3 days after symptoms begin
* Critical assessment is in first 12-72 hours
* **fever** greater than 39.5
* May find **fat in urine**
88
When assessing neurovascular compromise in cases of fracture, what element of assessment is important?
Check bilaterally and compare!
89
How often should you reposition someone to prevent skin breakdown if they cannot move themselves?
Every 2 hours
90
The nurse teaches which intervention to avoid hip dislocation after replacement surgery?
Never cross the affected leg when seated
91
Define teaching and learning.
✘Teaching is an **interactive process** that promotes learning.
✘Teaching and learning begin when a **person identifies a knowledge or skill deficit.**
✘Teaching is **most effective** when it addresses the **learner’s needs**, learning **style**, and **capacity.**
✘With successful teaching, **patients can learn new skills** or **change existing attitudes**.
92
What is the role of the nurse in teaching and learning?
* In patient education
* **Create an environment** to facilitate learning.
* Use a **patient-centered** approach *(include patient's perspective*)
* Assess the **learning needs** of the patient (*what they know versus what I need them to know*)
* Use the **most appropriate educational strategy**.
* To be taught: information **needed by the patient and family** to make **informed decisions** regarding their care
93
What are the three learning domains?
Cognitive, affective, psychomotor
94
Define the cognitive domain of learning.
Includes all intellectual behaviors and requires thinking.
95
Define the affective domain of learning.
Expression of feelings and acceptance of attitudes, opinions, or values
96
Define the psychomotor domain of learning.
Involves acquiring skills that require integration of mental and muscular activity
97
List the key basic learning principles.
* Learning environment
* Ability to learn
* Emotional capability
* Intellectual capability
* Physical capability
* Developmental stage
* Learning in children
* Adult learning
98
What is an important consideration for emotional capacility?
Timing is important. Must consider anxiety.
99
What are important elements to include in a discharge summary?
* Use **clear, concise descriptions** in the patient's **own language**
* Provide **step-by-step instructions** for how to perform any procedure that the **patient or family** will be doing **independently**; reinforce explanation with **printed instructions**
* **Identify precautions** to follow when performing self-care or administering medications
* Review **signs and symptoms of complications** that a patient or family member needs to **report to a health care practitioner**
* **List names and phone numbers** of **health care providers** and **community resources** that the patient or family member can contact
* Identify any **unresolved problem**, including **plans for follow up** and **continuous treatment**
* List **actual time of discharge**, **mode of transportation**, and **who accompanies** the patient
100
When does discharge planning happen?
Begins at admission.
101
What are some of the motivational factors for learning?
* Social motives
* Task mastery motives
* Physical motives
* Motivation and social learning theory
* Motivation and transtheoretical model of change
* A patient-centered approach to patient education
102
What are the goals of patient education?
* Maintaining and promoting health and preventing illness
* Restoring health
* Coping with impaired functioning
103
What physical attributes should be considered for learning psychomotor skills?
* Size (height and weight)
* Strength
* Coordination
* Sensory acuity
* Any physical condition (such as pain, fatigue, hunger) that depletes energy also impairs the ability to learn
104
When teaching adult learners, what approaches generally work well?
* They can be independent, self-directed learners, but become dependent in new situations
* Helps when they are encouraged to draw on past experiences to solve problems
* Also good to collaborate with them on educational topics and goals
* Address needs or issues that are important to the adult early on
105
Define motivation.
A person's willingness or desire to learn; influences a person's behaviour.
106
What are the stages of the transtheoretical model of change.
* Precontemplation
* Contemplation
* Preparation
* Action
* Maintenance
107
What is involved in the L.E.A.R.N.S model?
L - Listen to patient needs
E - Establish therapeutic relationship
A- Adopt an intentional approach to every learning encounter
R - Reinforce health literacy
N - Name new knowledge via teach-back
S - Strengthen self-management
108
What is involved in the assessment phase of patient education?
* Learning needs
* Ability to learn
* Health literacy
* Motivation to learn
* Teaching environment
* Resources for learning
109
Define health literacy.
* Definition: a patient’s ability to find, access, read, and understand reliable health information to make informed decisions about their health
* Depending on their health literacy, patients can either be well informed or misinformed
* In addition, patient information needs to be presented clearly, avoiding medical terminology, jargon, and acronyms
110
What are some examples of patient education related nursing diagnoses?
* *Deficient knowledge*
* *Health maintenance*
* *Health-seeking behaviours*
* *Health self-management*
* *Mastery of health-related skill*
* When health care problems can be managed through education, the foci of patient education are *knowledge* and *skills.*
111
What activities are involved in the planning phase of patient education?
* Develops a teaching plan
* Sets goals and expected outcomes
* Works with the patient to select a teaching method
* Developing learning objectives
* Setting priorities
* Timing
* Organizing teaching material
* Maintaining attention and promoting participation
* Building on existing knowledge
* Selecting teaching methods
* Selecting resources
* Writing teaching plans
112
What are teaching approaches during the implementation phased of patient education?
Teaching approaches
* Telling
* Selling
* Participating
* Entrusting
* Reinforcing
113
List some of the different teaching methods that nurses can use.
* One-on-one discussion
* Demonstrations
* Role playing
* Simulation
114
What are some key aspects to consider when selecting the best teaching method?
* Paying attention to learning barriers
* Illiteracy and learning disabilities
* Health literacy
* Sensory alterations
* Language
* Cultural diversity
* Needs of patients with severe illness
115
What is involved in the evaluation phase of patient education?
* It is necessary to determine whether the patient has learned the material.
* Demonstration of skill taught
* Teach back of information learned
* This helps to reinforce correct behaviour and change an incorrect behaviour.
* May need to modify approach if further patient teaching is needed.
116
What are the elements to include in the documentation of patient education?
* **Purpose** of teaching session
* Patient **engagement**
* **Evaluation of patient learning**
* Any **reinforcement** required
117
What is involved in the teaching approach ‘Telling’?
* Useful when there is limited information to be taught. Nurse outlines the task and fives instructions. No real opportunity for feedback.
118
What are the major cations?
* Sodium
* Potassium
* Calcium
* Magnesium
* Hydrogen ions
119
What are the major anions?
oChlorideo Bicarbonateo Phosphateo Sulfateo Proteinate ions
120
What are the main causes of hyponatremia?
* adrenal insufficiency
* water intoxication
* SIADH, and
* losses by vomiting, diarrhea, sweating, and diuretics and other certain medications
121
What are the signs of hyponatremia?
* poor skin turgor
* dry mucosa
* headache
* decreased salivation
* decreased BP (orthostatic)
* nausea
* abdominal cramping
* and neurologic changes
122
What medical management is involved in hyponatremia?
* water restriction
* sodium replacement
* AVP receptor antagonists
123
What is the nursing management of hyponatremia?
* assessment and prevention
* monitoring of dietary sodium and fluid intake
* identification and monitoring of at-risk patients and the effects of medications (diuretics and lithium)
124
What are the causes of hypernatremia?
* excess water loss
* excess sodium administration
* diabetes insipidus
* heat stroke
* near-drowning in sea water
* and hypertonic IV solutions
125
What are the manifestations of hypernatremia?
* thirst
* elevated temperature
* dry, swollen tongue
* sticky mucosa
* neurologic symptoms
* restlessness; and weakness
* Thirst may be impaired in the older adult or ill
126
What is the medical management of hypernatremia?
: hypotonic sodium solution or D5W (only if water needs to be replaced and not sodium)
127
What is the nursing management of hypernatremia?
* assessment and prevention
* assess for over-the-counter (OTC) sources of sodium
* offer and encourage fluids to meet patient needs
* and provide sufficient water with tube feedings
128
What are causes of hypokalemia?
GI losses, medications, alterations of acid--base balance, hyperaldosteronism, and poor dietary intake
129
What are the manifestations of hypokalemia?
fatigue, anorexia, nausea, vomiting, dysrhythmias, hypotension, muscle weakness, leg cramps, paresthesias, glucose intolerance, decreased muscle strength, and deep tendon reflexes (DTRs)
130
What is the medical management of hypokalemia?
increased dietary potassium, potassium replacement, and IV for severe deficit
131
What is the nursing management of hypokalemia?
assessment (severe hypokalemia is life-threatening), monitoring of electrocardiogram (ECG), arterial blood gases (ABGs), I&O, and dietary potassium, and providing nursing care related to IV potassium administration
132
What are the causes of hyperkalemia?
usually treatment-related, decreased renal excretion of potassium, rapid administration, and movement from ICF to ECF
133
What are the manifestations of hyperkalemia?
cardiac changes and dysrhythmias, muscle weakness with potential respiratory and speech impairment, paresthesias, anxiety, and GI manifestations
134
What is the medical management of hyperkalemia?
monitor ECG, cation exchange resin (Kayexalate), IV sodium bicarbonate, IV calcium gluconate, regular insulin and hypertonic dextrose IV, and b2-agonists; limit dietary potassium; and perform dialysis
135
What is the nursing management for hyperkalemia?
assess serum potassium levels, mix well IVs containing K+, monitor medication effects, and initiate dietary potassium restriction and dietary teaching for patients at risk
136
What level is hypocalcemia?
vSerum calcium lower than 2.18 mmol/L
137
What are the causes of hypocalcemia?
hypoparathyroidism, malabsorption, pancreatitis, alkalosis, massive transfusion of citrated blood, kidney injury, medications, other
138
What are the manifestations of hypocalcemia?
: tetany, **circumoral numbness**, paresthesias, hyperactive DTRs, **Trousseau’s** sign, **Chovstek's sign**, seizures, respiratory symptoms of dyspnea and laryngospasm, abnormal clotting, and anxiety
139
What is the medical management of hypocalcemia?
IV of calcium gluconate, calcium and vitamin D supplements, diet
140
What nursing management is involved in hypocalcemia?
assessment as severe hypocalcemia is life-threatening, weight-bearing exercises to decrease bone calcium loss, patient teaching related to diet and medications, and nursing care related to IV calcium administration
141
At what serum level is hypercalcemia?
2.6 mmol/L
142
What are the causes of hypercalcemia?
malignancy and hyperparathyroidism, bone loss related to immobility
143
What are the manifestations of hypercalcemia?
muscle weakness, confusion, incoordination, anorexia, constipation, nausea and vomiting, abdominal and bone pain, polyuria, thirst, ECG changes, and dysrhythmias
144
What is the medical management of hypercalcemia?
treat underlying cause, administer fluids, furosemide, phosphates, calcitonin, and bisphosphonates
145
What nursing management is involved in hypercalcemia?
assessment as hypercalcemic crisis has high mortality, encourage ambulation, fluids of 2.8 to 3.8 L/day, provide fluids containing sodium unless contraindicated and fibre for constipation, and ensure safety
146
At what level is hypomagnesemia?
vSerum magnesium level less than 0.75 mmol/L
147
What are the causes of hypermagnesemia?
alcoholism, GI losses, enteral or parenteral feeding deficient in magnesium, medications, rapid administration of citrated blood; contributing causes include diabetic ketoacidosis, sepsis, burns, and hypothermia
148
What are the manifestations of hypomagnesemia?
neuromuscular irritability, muscle weakness, tremors, athetoid movements, ECG changes and dysrhythmias, and alterations in mood and level of consciousness
149
What is the medical management of hypomegnesemia?
diet, oral magnesium, and magnesium sulfate IV
150
What nursing management is associated with hypomagnesemia?
assessment, ensure safety, patient teaching related to diet, medications, alcohol use, and nursing care related to IV magnesium sulfate
151
What often accompanies hypomagnesemia?
Hypocalcemia
152
What other condition is common in magnesium-depleted patients?
Dysphagia
153
What serum level is hypermagnesemia?
Greater than 0.95 mmol/L
154
Define metastasis.
vThe abnormal cells have invasive characteristics and infiltrate other tissues. This phenomenon is **metastasis** – most commonly through lymphatic circulation
155
What is involved in the malignant process?
* Cell proliferation: uncontrolled growth, with the ability to metastasize, destroy tissue, and cause death
* Cell characteristics: presence of tumour-specific antigens, altered shape, structure, and metabolism
* Metastasis:
* Lymphatic spread (most common)
* Hematogenous spread
* Angiogenesis
* Carcinogenesis
156
Define sepsis.
Sepsis is defined as **life-threatening organ dysfunction** caused by a **dysregulated host response** to **infection**.
157
Define septic shock.
Septic shock is a subset of sepsis with **circulatory and cellular/metabolic dysfunction** associated with a **higher risk of mortality**
158
What are the element of the quickSOFA relative to sepsis?
The qSOFA provides simple bedside criteria to quickly identify adult patients with suspected infection who are likely to have poor outcomes.
This screening tool is positive in those with suspected infection and at least 2 of the following criteria:
* Respiratory rate ≥ 22/min
* Altered mental status
* Systolic blood pressure ≤ 100 mmHg
Positive screening should prompt further work-up for organ dysfunction and infection (if not already identified), and escalation of therapy or level of care
159
What is the management of sepsis?
The Surviving Sepsis Campaign (SSC) Bundle (Levy, Evans, & Rhodes, 2018)
Initiate promptly upon recognition of sepsis/septic shock.
Prioritize resuscitation, diagnosis, and treatment by instituting the following interventions:
* Measure lactate level (repeat lactate if initial lactate elevated [\>2mmol/L]).
* Obtain blood cultures before administering antibiotics.
* Administer broad-spectrum antibiotics.
* Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate 4mmol/L.
* Give vasopressors if hypotensive during or after fluid resuscitation, to maintain mean arterial pressure 65mm Hg
160
What is the most common type of distributive shock?
septic shock
161
What are the risk factors for septic shock?
•Risk factors include patients with immunosuppression, extremes of age \< 1 and \> 65, malnourishment, chronic illness, invasive procedures, and emergent and/or multiple surgeries
162
What are common precursors to septic shock?
Bacteremia, pneumonia, and urosepsis
163
What kind of bacteria most commonly causes septic shock?
gram-negative bacteria
164
What is a central component of treating septic shock?
antibiotic treatment
165
What are the four stages of sepsis?
* SIRS- systemic inflammatory response syndrome
* Sepsis
* Septic Shock
* MODS- multi organ dysfunction syndrome
166
What are the clinical signs of SIRS?
Must meet 2 of the 4 criteria plus have clinical suggestion of possible SIRS
* Temperature•\> 38•\< 36
* Heart Rate•\> 90
* Respiratory Rate•\> 20 or PaC02 \<32
* WBC\> 12,000 or \< 4,000 •\> 10% band cells
* Acutely Altered Mental Status
167
How is sepsis diagnosed?
* Blood cultures
* Urinalysis and urine cultures
* Wound culture
* Sputum sample
* Labs: CBC,PT, PTT, albumin, ALP, ALT, Bilirubin, Calcium, Urea, Creatinine, Electrolytes, Glucose, Lactate, Lipase, Magnesium
* Chest x-ray SIRS criteria met plus a confirmed infection
168
What are some characteristics of septic shock?
* Sepsis
* Decreased blood pressure
* We fluid challenge the patient to increase the BP
* Decreased organ function that is reversible
169
What are some characteristics of Multi-organ dysfunction syndrome (MODS)?
* Severe septic shock with organ failure
* Liver failure
* Other **organ failure** that is **not reversible**
170
What is the first line of treatment for sepsis?
* Oxygen therapy
* Fluids - IV 30mL/kg
* Vasopressors
* Antibiotics
171
What is the second line of treatment for sepsis?
* Corticosteroids
* Insulin therapy
* Dialysis
* Mechanical ventilation
* Blood transfusions
172
What should MAP minimally be for organ perfusion?
60-65 mmHg
173
What medications are used to increase blood pressure in sepsis?
* Vasopressors
* Vasoconstriction to elevate MAP through increasing the SVR
* Stimulate alpha-1, beta-1, and beta-2 receptors in the body
* Norepinephrine, epinephrine, vasopressin
* Inotropes
* Increase cardiac contractility (through increasing intracellular calcium)
* Dopamine, dobutamine
174
What is the most commonly identified agent in _antibiotic-associated diarrhea_ in the hospital?
Clostridium difficile
175
When do signs and symptoms of c-diff start?
•Signs and symptoms usually occur 5-10 days after starting antibiotics, but may occur as soon as the first day or up to two months later
176
Who does c.diff commonly affect?
•Commonly affects older adults and individuals in hospitals and LTC
177
How is c. diff diagnosed?
•Diagnosed with a stool test
178
What are the manifestations of a severe infection with c. diff?
* Watery diarrhea 10 to 15 times a day
* Abdominal cramping and pain, which may be severe
* Rapid heart rate
* Fever
* Blood or pus in the stool
* Nausea
* Dehydration
* Loss of appetite
* Weight loss
* Swollen abdomen
* Kidney failure
* Increased white blood cell count
179
What treatments are available for c. diff?
* Stop taking the antibiotic when possible
* Other antibiotics: vancomycin (Vancocin HCL, Firvanq) or fidaxomicin (Dificid). Metronidazole (Flagyl) may be rarely used if vancomycin or fidaxomicin aren't available.
* Surgery
* Fecal transplant
* Probiotics – may be controversial
180
What complications are associated with c. diff?
* Fluid and electrolyte imbalances
* Dehydration
* Cardiac dysrhythmias
* Skin breakdown
181
List three types of shock.
1. Distributive
2. Hypovolemic
3. Cardiogenic
182
What are two critical actions by the nurse in preventing death from sepsis?
* Early recognition; know when your patient is deteriorating
* Do not wait to give antibiotics; even if pharmacy is closed, find a way
183
What kind of isolation precautions are needed with c. diff?
contact precautions
184
How should you perform hand hygiene when caring for patients with c. diff?
Soap and water (alcohol-based hand sanitizers are not as effective)
185
Organ failure associated with MODS usually begins in:
a) kidneys
b) lungs
c) liver
d) brain
b) lungs
It goes, lung, liver, GI system, kidneys
186
What pulse pressure indicates shock?
A narrowed or decrease pulse pressure e.g. 90/70 (20, so less than 40 mm Hg)
187
What is a notable difference between Crohn's and ulcerative colitis?
Crohn's is more systemic and can affect many other parts of the body.
188
What diagnostic tests are typically involved in diagnosing Inflammatory Bowel Disease?
lab values, intestinal biopsies, CT scan, and barium studies
189
What is involved in the assessment of a patient with IBD?
* Perform health history to identify onset, duration, and characteristics of pain, diarrhea, urgency, tenesmus (cramping rectal pain), nausea, anorexia, weight loss, bleeding, and family history
* Discuss dietary patterns, alcohol, caffeine, and nicotine use
* Assess bowel elimination patterns and stool
* Perform abdominal assessment
190
What are some of the common diagnosis related to IBD?
* Diarrhea
* Acute pain
* Deficient fluid
* Imbalanced nutrition
* Activity intolerance
* Anxiety
* Ineffective coping
* Risk for impaired skin integrity
* Risk for ineffective therapeutic regimen management
191
What are some potential complications of IBD?
* Electrolyte imbalance
* Cardiac dysrhythmias related to electrolyte imbalances
* GI bleeding with fluid volume loss
* Perforation of the bowel
* Intraperitoneal infection
* Complete large bowel obstruction
* Peritonitis, abscess, and sepsis
192
What are major goals in the nursing planning phase for a patient with IBD?
* Attainment of normal bowel elimination patterns
* relief of abdominal pain and cramping
* prevention of fluid volume deficit
* maintenance of optimal nutrition and weight
* avoidance of fatigue
* reduction of anxiety
* promotion of effective coping
* absence of skin breakdown
* increased knowledge of disease process and therapeutic regimen, and
* avoidance of complications
* Emotional support from the family is critical post discharge
193
What are some strategies for maintaining normal elimination patterns?
* Identify **relationship** between **diarrhea** and **food, activities, or emotional stressors**
* Provide **ready access** to bathroom or commode
* Encourage **bed rest** to **reduce peristalsis**
* Administer **medications as prescribed**
* Record **frequency, consistency, character, and amounts of stools**
194
What are some key topics for patient teaching for patients with IBD?
* Understanding of disease process
* Nutrition and diet (high protein, low residue, bland, high vitamin, etc.)
* Medications
195
What is benign prostatic hyperplasia (BPH)?
Enlarged prostate
196
This is one of the most common pathologic conditions in men older than 50 years of age.
Benign prostatic hyperplasia (BPH)
197
Crohn's Disease is a condition of malabsorption caused by which pathophysiological process?
a) disaccharide deficiency
b) Gastric resection
c) Inflammation of all layers of intestinal mucosa
d) Infection disease
c) inflammation of all layers of intestinal mucosa
198
The presence of mucus and pus in the stool is indicative of what disease?
a) Intestinal malabsorption
b) Disorders of the colon
c) Ulcerative colitis
d) small bowel disease
c) ulcerative colitis
199
What is a true statement regarding regional enteritis (Crohn's disease)?
a) The lesions are in continuous contact with one another.
b) The clusters of ulcers take on a cobblestone appearance.
c) It is characterized by pain in the left abdominal quadrant?
d) It has a progressive disease pattern.
b) The clusters of ulcers take on a cobblestone appearance.
200
Clients with irritable bowel disease are at significant risk for which condition?
a) Hypotension
b) DVT
c) Pneumonia
d) Osteoporosis
d) osteoporosis
201
What is the most prominent sign of IBD?
a) Intermittent pain
b) Hyperactive sounds
c) Increased peristalsis
d) Abdominal distension
a) Intermittent pain
202
What are manifestations of BPH?
feelings of urgency, urinary obstruction, urinary retention, and urinary tract infections
203
What treatments are there for BPH?
* Pharmacologic: alpha-adrenergic blockers, alpha- adrenergic antagonists or a combination of both, and antiandrogen agents
* Catheterization if unable to void
* Prostate surgery
204
What are potential complications of prostate surgery?
* **Hemorrhage** and **shock** – monitor catheter drainage system, monitor vital signs, administer fluids and blood
* **Infection** – catheter care, antibiotic cream
* **DVT**- compression stockings, encourage mobilization, assess leg circumference
* **Catheter obstruction** – monitor catheter drainage system, irrigate the catheter
205
What is the most common type of prostate surgery?
Transurethral resection of the prostate (TURP)
206
What are the risk factors for renal failure?
diabetes, hypertension, heart failure, acute dehydration
207
What are the leading causes of chronic kidney failure in Canada?
Diabetes and hypertension
208
What are the clinical manifestations and lab evidence of renal failure?
* Fluid volume loss or excess
* Anemia
* Elevated serum creatinine, BUN, and decreased GFR (see stages page 1285)
* Electrolyte abnormalities – most common hyperkalemia
* Metabolic acidosis
* Proteinuria
209
What is acute kidney failure?
When the kidneys cannot remove wastes or perform regulatory functions
210
What are the four phases of acute kidney failure?
1. initiation
2. oliguria
3. diuresis
4. recovery (may take 3 - 12 months)
211
True or false: acute kidney injury is sometimes reversible?
True
212
What is the most accurate indicator of fluid loss or gain in an acutely ill patient?
Weight
1-kg weight gain is equal to 1,000 mL of retained fluid
213
What are the major categories of acute kidney injury?
* Prerenal (hypoperfusion of the kidney)
* Intrarenal (actual damage to kidney tissue)
* Postrenal (obstruction to urine flow)
214
What is azotemia?
abnormal concentration of nitrogenous wastes in the blood
215
What are some of the causes of acute kidney injury?
* Hypovolemia
* Hypotension
* Reduced cardiac output and heart failure
* Obstruction of the kidney or lower urinary tract
* Bilateral obstruction of renal arteries or veins
216
What are treatment options for renal failure?
* Hemodialysis
* Peritoneal dialysis (PD)
* Continuous renal replacement therapies (CRRTs)
217
What is the nursing care for excess fluid volume?
* Assess for signs and symptoms of fluid volume excess; keep accurate I&O and daily weight records
* Limit fluid to prescribed amounts
* Identify sources of fluid
* Explain to patient and family the rationale for the restriction
* Assist patient in coping with the fluid restriction
* Provide or encourage frequent oral hygiene
218
What are some medication considerations relative to hemodialysis?
* Depending on the time of hemodialysis will need to modify medication regimen as many medications are dialyzed out by the dialyzer.
* You also need to **hold antihypertensives** before all dialysis as removing fluid causes **hypotension**
219
What is a characteristic of the intrarenal category of acute renal failure?
Increased BUN
220
What is involved in family-centered care?
* Involves both patient and family members
* Considers the impact of illness on family, as well as patient
* Provides a context for patient teaching and need for services
221
True or false:
Negative family responses have been associated with negative patient outcomes, while supportive positive family responses are associated with positive patient outcomes
222
When gathering information about families, what should nurses ask about?
* Cultural identity
* Rituals
* Values
* Level of involvement
* Decision making
* Spiritual beliefs
* Traditional behaviors
* Past medical experiences
* Concurrent family stressors
* Expectations for treatment
*
223
What are some family related considerations to prevent short term caregiver burden?
* **Open visitation** policies but **need for respite**
* **Educating the family** along with the patient
* Helping families **access services**, **support groups**, and **natural support networks**
* **Supporting** the **caregiver r/t discharge planning** (referrals to home care, community resources)
* **Validating** and **normalizing emotions**
* **Managing criticism** and **advice** from **less involved family members**
224
What are some technology options for enhancing communication?
* Cellular phones
* Skype, FaceTime
* Twitter, Facebook, other social media
* Caring Bridge
* World wide web
* YouTube
* Informational videos
225
What are some common diagnoses regarding family dynamics and caregiving?
* Compromised family coping
* Ineffective family therapeutic regimen management
* Readiness for enhanced family processes
* Readiness for enhanced relationship
226
What is involved in the planning phase of nursing care for families?
* Family involvement increases likelihood of successful adaptation.
* Development of appropriate nursing actions should be based on **mutually established goals**.
* **Interventive questioning** sets up a sense of **ownership** and **self-efficacy** for families.
227
What is involved in the Implementation phase for nursing care related to family dynamics?
* Validating emotional responses
* Summarizing each person’s viewpoint
* Offering information – consequences of not following a healthy diet
* Collaboration about possible solutions
* Compromise: Healthy options that meet both their needs
228
What are some pitfalls for the nurse to avoid in family-centered care?
* Not considering the context of the family situation (resources, distance, health state)
* Taking sides – act as a mediator
* Giving too much advice prematurely – gather as much information beforehand
229
Define family dynamics.
the term family dynamics is defined as **interrelationships between** and **among** individual family members or “the **forces at work** within a family that **produce particular behaviors or symptoms**
230
What is the Calgary Family Assessment Model (CFAM)?
The CFAM6 is widely used by nurses to assess families.
The model is used to ask family members questions about themselves to gain understanding of the ***structure, development, and function*** at a point in time. Not all questions within the subcategories are asked at the first interview, and not all questions are appropriate for all families.
231
What are some of the needs of families of critically ill patients?
* Fell there is **hope**
* Feel that hospital **personnel care** about the patient
* Have a **waiting room near the patient**
* Be **called at home about changes** in the patient's condition
* Know the **prognosis**
* Have questions **answered honestly**
* **Receive info** about the patient **at least once per day**
* Have explanations in **understandable terms**
* Be allowed to **see the patient frequently**
232
Care of the dying should include a comprehensive approach that addresses what components?
* Respecting the patient’s goals, preferences, and choices
* Attending to the medical, emotional, social, and spiritual needs
* Using the strengths of interdisciplinary resources
* Acknowledging and addressing caregiver concerns
* Building mechanisms and systems of support
233
What are the characteristics of palliative care?
* Comprehensive care for patients whose disease is **not responsive to cure**
* Care also e**xtends to the patient's family**
* Palliative care emphasizes management of **psychological, social, and spiritual problems** as well as **control of pain** and other **physical symptoms**. The goal is to **improve quality of life** for persons who have a **life-limiting illness** that is usually **at an advanced stage**
* This is a **comfort-focused approach** to care that **may be used with cure-focused treatment**
234
What are the principles of palliative care?
* The patient’s total care is best managed by an **interdisciplinary team** whose members **communicate regularly**
* **Pain and other symptoms must be managed**
* The **patient and the family** should be **viewed as a single unit of care**
* Palliative care **may also occur in the home** – have palliative home care teams.
* **Bereavement care must be provided to family members**
235
What are some key communication considerations when working with a patient and their family during end of life care?
* Reflect on your **own experiences and values** concerning illness and death
* **Deliver** and **interpret technical information** without hiding behind medical terminology
* Realize the **best time for the patient** to talk **may be the least convenient for you**
* Be **fully present** during all communications
* Allow the **patient and the family to set the agenda** regarding the **depth** of the conversation
* **Resist the impulse** to **fill “empty space”**
* Allow the patient and family **sufficient time** to reflect and respond
* Prompt gently
* Avoid distractions
* Avoid the impulse to give advice
* Avoid canned responses
* Ask questions
* Assess **understanding**, both **your own and the patient’s**
* Create an **appropriate time and space** for conversation
* Be aware of **body language**
* Enable the **patient or family to lead conversation**
* Explore **what they know** or **their perceptions**
* **Be comfortable with silence**, acknowledge and encourage
* Provide information **at rate and depth** the patient and family are able to grasp
236
What is spirituality in the context of end-of-life care?
* Spirituality includes religion but is n**ot synonymous with religion**
* Addressing spirituality is an important component of the care of the dying patient
* How a person **derives meaning** and **purpose from life**
* One’s **beliefs and faith**
* Sources of **hope**
* **Attitudes towards death**
237
What is the goal of symptom management during end-of-life care?
The goal of symptom management is to completely relieve each symptom or, if this is not possible, to decrease the symptom to a level that the patient can tolerate
238
What are common symptoms at end-of-life that need to be managed?
* Pain
* Dyspnea
* Fatigue
* Anorexia, dehydration, and cachexia
* Delirium and depression
* Nausea
239
When is palliative sedation used?
* To address distressing, intractable symptoms (dyspnea, delirium, seizures, etc.)
* Imperative that preconditions have been met
* Providing psychological support to the family is important
* Provide rationale
* Discuss with the family
240
What are some signs of approaching death?
* Refusal of food and fluids
* Urinary output decreases
* Weakness and sleep
* Confusion and restlessness
* Impaired vision and hearing, seeing things
* Secretions in throat
* Breathing pattern irregular with periods of apnea
* Incontinence
* Decreased temperature control
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What is involved in after death care?
* Determination of death – auscultating breath and heart sounds
* Pronouncement and death certificate
* Body becomes bluish/dusky, mottling, waxen, cool, releasing of body fluids, gasping when turning
* Wrapping the body (shrouding)
* Securing all valuables (try to give to family beforehand)
* Transport to the morgue/pick up by funeral home
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What is a key distinction between palliative sedation and MAID?
Palliative sedation does not hasten dying
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How does the disease process of cancer begin?
A disease process that begins when an abnormal cell is transformed by the genetic mutation of cellular DNA
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What is the most common route of metastasis?
lymph node
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What are some common carcinogenic agents and factors?
* Viruses and bacteria
* Physical factors: ultraviolet rays of the sun, radiation, chronic irritation or inflammation
* Chemical agents: tobacco, asbestos
* Genetic and familial factors
* Diet
* Hormones
* Role of the immune system
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What is primary prevention concerning cancer?
Primary prevention is concerned with reducing cancer risk in healthy people
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What is secondary prevention concerning cancer?
Secondary prevention involves detection and screening to achieve early diagnosis and intervention
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What are actions associated with primary prevention?
* Avoid known carcinogens
* Lifestyle and dietary changes to reduce cancer risk
* Public and patient education
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What are some activities associated with secondary prevention?
* Identification of patients at high cancer risk
* Cancer screening
* Self-breast examination
* Self-testicular examination
* Screening colonoscopy
* Pap test
* Public and patient education
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What are 3 categories of cancer management?
* Cure
* Control
* Palliation
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What are some surgical treatments for cancer?
* Diagnostic surgery
* Biopsy: excisional, incisional, needle
* Tumour removal: wide excision, local excision
* Prophylactic surgery
* Palliative surgery
* Reconstructive surgery
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What is brachytherapy?
Internal readiation
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Are there different types of radiation?
Yes: curative, controlling, and palliative
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What is chemotherapy?
* Agents used to destroy tumour cells by interfering with cellular function and replication
* Curative, control, or palliative
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What are some of the adverse effects of chemotherapy?
* Toxicity
* GI effects: nausea and vomiting, diarrhea, mucositis, and stomatitis
* Hematopoietic effects: myelosuppression
* Renal damage
* Cardiopulmonary system: potential cardiac toxicities
* Reproductive system: potential sterility, potential reproductive cell abnormalities
* Neurologic effects
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What nursing care is delivered for a patient on radiation?
* Patient and family education
* Include restrictions and precautions
* Skin care
* Oral care
* Protection of care providers
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What are some related nursing diagnoses for a patient diagnosed with cancer?
* Risk for infection
* Impaired skin integrity
* Impaired oral mucous membrane
* Impaired tissue integrity
* Imbalanced nutrition
* Fatigue
* Chronic pain
* Anticipatory grieving
* Disturbed body image
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What is bone marrow suppression?
* **Bone marrow suppression** refers to a decrease in the ability of the **bone marrow** to manufacture cells (erythrocytes, leukocytes, thrombocytes) and is common with **chemotherapy.**
* In addition to eliminating cancer cells, **chemotherapy** drugs eliminate normal cells that divide rapidly, such as hair and those in the **bone marrow** that form the different types of blood cells.
* Does not affect already formed blood cells.
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What are some causes of thrombocytopenia?
* Decreased production of platelets within the bone marrow (radiation or chemotherapy),
* increased destruction of platelets (autoimmune disorders such as Immunologic Thrombocytopenic Purpura or Heparin induced Thrombocytopenia),
* increased consumption of platelets (Disseminated Intravascular Coagulation, major bleeding)
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What are clinical manifestations of thrombocytopenia?
* bleeding, petechiae, nasal and gingival bleeding, excessive menstrual bleeding, excessive bleeding after surgery or dental extraction, severe – spontaneous bleeding in the nervous or GI system
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What diagnostic tests identify thrombocytopenia?
CBC and differential, bone marrow biopsy, manual examination of peripheral smear
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What treatments are there for thrombocytopenia?
platelet infusions, safety precautions
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What is the most common chronic sustained dysrhythmia seen in the older adult population and that should be immediately considered if the patient presents with an irregular rhythm?
Atrial fibrillation
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What is atrial fibrillation?
A condition in which the atria are contracting so fast – **greater than 350 bpm** – that they are unable to have adequate filling or contraction
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What is a major risk factor for atrial fibrillation?
Due to inadequate emptying, blood that remains in the atria is prone to forming clots, which increases the risk of thrombotic stroke or pulmonary embolus
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What approach to assessment can detect atrial fibrillation?
listen to apical rate & palpate the radial pulse at the same time - should be equal – if not make physician aware
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What diagnostic tool is used to confirm atrial fibrillation?
12 lead ECG
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What treatments are available for atrial fibrillation?
anticoagulants, beta blockers. Symptomatic: amiodarone, cardioversion
