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Krystan: Semester Two Nursing School > 2800 Exam Four > Flashcards

2800 Exam Four Flashcards

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1
Q

Total blindness

A

absence of all sight

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2
Q

legal blindness

A

central visual acuity of 20/200 or less in better eye with correction
OR very narrow peripheral vision field (20 degrees or less)

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3
Q

severe visual impairment

A

being unable to read newsprint even with correction

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4
Q

what is almost all blindness in the US caused by?

A

common eye diseases like cataracts, glaucoma, diabetic retinopathy, or age related macular degeneration

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5
Q

what are nursing interventions to protect vision?

A 
regular hand washing
screening and early detection
sunglasses
regular eye exams for diabetics 
proper nutrition
eye protection during hazardous activities
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6
Q

what is the “sighted guide technique”?

A

the guiding person stands to the side and slightly in front of the visually impaired person, who is holding onto the guide’s elbow

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7
Q

what are some ways to help clients adjust to decreased vision?

A 
have corrective devices clean and available
use large print books or magazines 
provide good lighting
uncluttered/safe environment 
have things within reach
introduce yourself
speak before touching the client 
describe things and explain sounds
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8
Q

what can vision problems lead to in older adults?

A

loss of freedom, functional ability, or self esteem
disorientation
confusion
social isolation

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9
Q

what is conductive hearing loss?

A

hearing loss caused by problems in the outer or middle ear

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10
Q

what are some common causes of conductive hearing loss?

A

otitis media
earwax accumulation
foreign bodies in the ear

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11
Q

what is sensorineural hearing loss?

A

impairment of inner ear function or vestibulocochlear nerve damage

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12
Q

what are some common causes of sensorineural hearing loss?

A 
noise
genetics
nerve damage 
ototoxicity 
tympanic membrane trauma
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13
Q

what are some assessment findings/manifestations for hearing loss?

A 
not responding when spoken to
answering questions inappropriately 
asking people to speak up/repeat things
reading lips
straining to hear 
impacted social/familial relationships
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14
Q

what are some nursing interventions to prevent hearing loss?

A 
control environmental noise 
use ear protection 
MMR immunization 
avoidance/proper use of ototoxic medications (chemo, loop diuretics, mercury) 
hearing screenings
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15
Q

what are some good practices when communicating with a hearing impaired client?

A 
use hand movements 
have face in good light
speak into patient's good ear 
lower tone of voice 
minimize distractions
speak normally and slowly 
dont over-enunciate
write out hard words 
rephrase if necessary
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16
Q

how can the nurse help a client adapt to using a hearing aid?

A

make sure it’s properly fitted
determine the patient’s readiness to use it
educate on care and use
have them start using it in a quiet environment to get used to it

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17
Q

how do we care for hearing aids?

A 
clean ear and hearing aid regularly 
make sure battery works
protect it from heat and chemicals
store in a cool dry place
disconnect battery when hearing aid not in ear
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18
Q

what intervention will help if a whistling or ringing is coming from the hearing aid?

A

reposition in the patient’s ear and adjust the volume level

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19
Q

what is dementia?

A

a neurocognitive disorder characterized by dysfunction or loss of memory, orientation, language, judgment, and reasoning

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20
Q

what is the most common type of dementia?

A

alzheimers

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21
Q

what are general assessment findings with any type of dementia?

A 
memory loss
disorientation
problems with words and numbers
decreased judgment
mood and behavior changes 
personality changes
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22
Q

what is alzheimers disease?

A

the most common form of dementia. it’s a chronic, progressive neurodegenerative brain disease

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23
Q

what are some early manifestations of Alzheimer’s?

A 
getting lost in familiar areas
memory loss
time and place disorientation 
problems with calculations 
problems with familiar tasks 
language issues 
behavior/personality changes
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24
Q

How do memory issues often manifest in alzheimers?

A

short term memory problems first

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25
Q

what are some later stage manifestations/complications of Alzheimers?

A 
incontinence 
delusions
wandering
all cognitive functions impaired
immobility
inability to speak or understand 
need for complete care (loss of functional ability)
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26
Q

what is apraxia?

A

inability to manipulate objects or perform purposeful actions

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27
Q

what is visual agnosia?

A

inability to recognize objects by sight

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28
Q

what is dysgraphia?

A

difficulty communicating by writing or recognizing written language

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29
Q

what is retrogenesis?

A

process in alzheimer’s disease where degenerative changes occur in reverse order in which they were acquired (person becomes more like an infant as disease progresses)

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30
Q

what is the top choice for a cognitive tool to screen for alzheimers and monitor disease progression?

A

Mini-mental status examination (MMSE or mini-mental)

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31
Q

what other diagnosis should be screened for and ruled out when alzheimer’s is suspected?

A

depression

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32
Q

why is early recognition and treatment important in Alzheimers?

A

in order to monitor disease progression and maximize functional ability at every stage, as well as ensure patient safety

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33
Q

what are some measures that may help prevent alzheimers?

A 
regular exercise
challenging your mind
staying socially active 
avoiding harmful substances 
avoiding brain trauma (like repeat concussions)
treat depression early
sleep
healthy diet
diabetes and cardiovascular health management
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34
Q

what are some nursing interventions to prevent behavioral problems in Alzheimers?

A 
assess physical status and for pain
assess environment
assess for infection frequently
redirect and distract 
maintain familiar routines
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35
Q

what is sundowning?

A

patient getting more confused, disoriented, and combative in late afternoon and evening

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36
Q

what can be done to prevent sundowning?

A

calm environment, maximum exposure to sunlight, limit naps and caffeine, drug treatment if necessary

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37
Q

what are some good communication techniques for alzheimers patients?

A 
don't rush them
minimize distractions
don't argue 
ask simple questions 
don't tell them no or ask why
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38
Q

what would some other signs of pain be in Alzheimer’s patients if they cannot say they have pain?

A

agitation
withdrawal
increased vocalization

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39
Q

what nursing interventions can help with eating and swallowing difficulties in Alzheimers?

A 
pureed food and thickened liquids
nutrition supplements 
finger foods
moist foods
bite sized pieces 
quiet and unhurried environment
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40
Q

what are oral care considerations for Alzheimers?

A

ensure good oral care (either by patient or by nurse)

regular mouth inspection for pocketed food

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41
Q

how can nurses help support caregivers of those with Alzheimers?

A

assess stressors and coping strategies
assess caregiver expectations
support groups
teaching based on disease stage

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42
Q

what are top goals for patients with Alzheimers?

A

maintain safety and maximize remaining social and functional ability

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43
Q

what are autism spectrum disorders?

A

group of complex neurodevelopmental disorders

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44
Q

what are basic clinical manifestations in autism spectrum disorders?

A

core deficits in social interaction, communication, and behavior

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45
Q

what is seen in relation to social interaction with ASD?

A

less interest in socializing
abnormal eye contact
decreased imitation
decreased response to their own name

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46
Q

what is seen in relation to communication in ASD?

A

absent or delayed speech

not meeting speech milestones

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47
Q

what does echolalia mean?

A

unsolicited, meaningless repetition of vocalizations made by another person (often seen in ASD)

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48
Q

what can improve prognosis for children with ASD?

A

early detection and intense early intervention

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49
Q

what is seen in terms of behavioral patterns with ASD?

A

unusual fixations, preferences, or repetitive behaviors

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50
Q

what are important interventions/actions when a child with ASD is hospitalized?

A

parent staying with child and being involved in planning
individualized assessment and treatment
decreased stimulation
presence of comfort items
as much structure and routine as possible

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51
Q

what should the nurse keep in mind in relation to physical contact for patients with ASD?

A

minimal holding and eye contact

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52
Q

what should the nurse keep in mind in relation to feeding and eating for patients with ASD?

A

may be fussy eaters
may gag or willfully starve themselves
may hoard food or swallow non-food items
may refuse food and end up with nutrient deficiencies

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53
Q

how should children with ASD be introduced to new things?

A

slowly and cautiously

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54
Q

what are good approaches in terms of communicating with patients with ASD?

A

tell them directly what to do
be brief and concrete
be appropriate to developmental level
reward desired behavior

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55
Q

how can the nurse support the family of a child with ASD?

A

educate the parent and make sure they know the autism is not their fault
direct them to expert counseling and resources
encourage care by the family as much/as long as possible
use creative approaches to managing child’s care and behavior

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56
Q

an undesired change or removal of a valued person, object, or situation is..

A

loss

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57
Q

how is grief defined?

A

the physical, psychological, and spiritual responses to a loss

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58
Q

actual loss

A

a tangible, physical loss (loved one, loss of limb, etc)

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59
Q

perceived loss

A

a loss felt only by the person, such as loss of freedom, future, relationship, etc

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60
Q

what are some things that impact coping?

A

family and support system
spirituality
developmental stage

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61
Q

what is bereavement?

A

the process of mourning and the period of adjustment after a loss

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62
Q

what are some major factors that affect grief?

A 
significance of the loss
support systems available
unresolved conflict
circumstances of the loss 
other recent losses
spiritual beliefs and practices 
time circumstances of the loss
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63
Q

how do infants and toddlers view death?

A

they cannot comprehend the absence of life and dont know how to accept permanence of death

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64
Q

how will infants and toddlers react to death of a loved one?

A

changes in eating and sleeping

anxiety and sadness often caused by changes in routines and sadness of those around them

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65
Q

how do preschoolers understand death?

A

they struggle with the permanence of death
believe their thoughts can cause death (may struggle with guilt and shame)
may distance themselves from loss and grief

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66
Q

how do school aged children understand death?

A

guilt is an issue, but have a more concrete understanding of death
may be fascinated by death
fear unknown quality of death

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67
Q

how do adolescents understand and cope with death?

A

they understand it but struggle with guilt and shame

have the most difficulty coping with death and may feel very alone in their grief

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68
Q

when do adults start to accept their own mortality?

A

usually between the ages of 45 and 65

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69
Q

why might coping with death be challenging for older adults?

A

because they are preparing for/thinking of their own deaths, and often have experienced lots of cumulative losses

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70
Q

uncomplicated/normal grief

A

natural response to a loss, with intense emotions that gradually diminish. person can still take care of themselves during grief process

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71
Q

complicated grief

A

prolonged acute grief that lasts for longer than 6 months with maladaptive and overwhelming grief responses

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72
Q

how do we distinguish whether a person’s grief is complicated or normal?

A

by evaluating their functional/self-care abilities

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73
Q

definition of death

A

irreversible cessation of all functions of the brain and brainstem

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74
Q

higher brain death

A

irreversible cessation of higher brain function even if the brainstem still works (respiration and cardiac activity might continue)

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75
Q

what are the stages of grief?

A 
denial
anger
bargaining
depression 
acceptance
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76
Q

what are some goals of palliative care?

A 
regard dying as a normal process
provide pain relief 
not hastening death or postponing it 
enhance quality of life 
support patient to live as actively as possibly until death 
support patient's family
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77
Q

what is the difference between palliative care and hospice?

A

palliative care allows for both curative and comfort cares, while hospice is only comfort cares

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78
Q

what are the two criteria for admission to a hospice program?

A

patient must desire the service and agree to only hospice care (not curative care)
patient must be considered eligible with 2 physicians saying they probably only have 6 months or less to live

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79
Q

why is spiritual assessment important in the dying and grieving process?

A

Because spirituality shapes how people view death and cope with it, as well as the rituals people have surrounding death

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80
Q

what are some characteristics of spiritual distress?

A

anger towards God
changes in mood or behavior
desire for spiritual assistance
displaced anger towards clergy

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81
Q

what are some ways that culture affects reactions to death?

A

culture impacts rituals around death, how grief is expressed, and how families find comfort

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82
Q

what is the nurses role in regards to spiritual and cultural practices surrounding death?

A

facilitate and support these practices

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83
Q

who makes the decision to donate organs?

A

the patient before death or the family after death

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84
Q

who on the healthcare team makes organ donation requests?

A

specially trained professional for that specific role

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85
Q

what are advanced directives?

A

document signed by a competent individual regarding the patient’s wishes about care and their designated medical spokesperson

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86
Q

what is a living will?

A

document in lay terms giving specific directions about future care and life sustaining measures

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87
Q

what is a durable power of attorney for healthcare?

A

a document stating who makes your healthcare decisions if you cannot (and if the living will is not clear on an issue)

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88
Q

what does DNR mean?

A

do not resuscitate (take comfort measures only, but no CPR or intubation)

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89
Q

describe AND (allow natural death)

A

pain control and symptom management are allowed and done, but natural progression to death is not hindered

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90
Q

why do opioids not hasten death at the end of life?

A

because pain is the counteracting agent to opioid-induced respiratory depression, so the opioids given for comfort will not depress respirations fatally

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91
Q

what happens to our senses at the end of life?

A 
hearing is the last to go
decreased sensation and pain perception
blurred vision
glazed eyes
absent blink reflexes 
eyes half open
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92
Q

what are cardiovascular manifestations at the end of life?

A

increased HR, then decreased
irregular heart rhythm
decreased BP
delayed drug absorption

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93
Q

respiratory manifestations at end of life

A

increased respirations

inability to clear secretions

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94
Q

death rattle

A

noisy, congested breathing due to not being able to clear secretions

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95
Q

cheyne stokes respirations

A

alternating periods of apnea and deep, rapid breathing

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96
Q

urinary manifestations at the end of life

A

decreased urinary output or anuria

incontinence

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97
Q

GI manifestations at the end of life

A 
slowed/stopped GI processes
gas accumulation
nausea
incontinence
bowel movement right before or at time of death
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98
Q

musculoskeletal manifestations at the end of life

A

loss of ability to move
loss of muscle tone and gag reflex
difficulty speaking and swallowing
jaw sagging

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99
Q

integumentary manifestations at the end of life

A

mottling
cold/clammy skin
cyanosis
wax-like appearance

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100
Q

psychosocial manifestations at the end of life

A 
altered decision making
anxiety/restlessness
fear 
decreased socialization 
life review
peacefulness
saying goodbye 
unusual communication or vision-like experiences
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101
Q

what are some psychosocial nursing interventions for end of life care?

A 
converse with the patient
encourage family to talk to them whether conscious or not
affirm dying person's experience 
allow privacy 
assess spiritual needs
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102
Q

what are four specific fears associated with death?

A

pain
shortness of breath
loneliness/abandonment
meaninglessness

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103
Q

how can nurses help alleviate the fear of pain?

A

prompt pain assessment and management

management of drug side effects

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104
Q

how can nurses alleviate fear of shortness of breath for the dying patient?

A

use of opioids, bronchodilators, oxygen, and anti-anxiety meds

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105
Q

how can nurses alleviate the fear of loneliness in dying patients?

A

hold their hands and use touch
listen
be present and have loved ones present too

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106
Q

how can nurses help alleviate the fear of meaninglessness for the dying patient?

A

facilitate life review process and listen

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107
Q

how can nurses help children deal with loss?

A 
dont force them to go to the funeral
spend as much time with them as possible 
use play therapy 
care for the whole family
reassure child that it's not their fault
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108
Q

how can nurses manage end of life dehydration?

A

assess mucous membranes often
know that dying patient might be comfortable being dehydrated
moist swabs in mouth
don’t force them to eat or drink

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109
Q

how can nurses manage end of life dyspnea?

A 
elevate head
fan or air conditioning 
pursed lip breathing 
expectorants
opioids
suction
oxygen
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110
Q

how can nurses manage end of life skin breakdown?

A

control drainage
dress wounds properly
manage incontinence
use blankets (not heat) for warmth

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111
Q

how can nurses manage end of life bowel patterns?

A 
assess function
assess for impaction
use laxatives as needed for comfort 
watch for constipation
fiber/fluids/movement as wanted and tolerated
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112
Q

what is involved in post-mortem care?

A 
close eyes
replace dentures
wash the body 
remove tubes and dressings 
straighten body and prop up head
allow family time and privacy with the body
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113
Q

how do we support families and caregivers after a death?

A 
recognize their stress and grief 
watch for abnormal grieving and those dealing with concurrent crises
keep them informed 
refer to counseling
encourage use of support systems
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114
Q

what is included in an assessment of mental health?

A 
physical assessment 
psychosocial history
stress level
coping ability
spiritual/religious/cultural beliefs
mental status
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115
Q

what are stigmas that exist in relation to mental health?

A

belief that it is taboo or not real
belief that you are crazy
belief that it’s all a spiritual influence/possession

116
Q

what is included in a mental status examination?

A

level of consciousness
physical appearance
behavior
cognitive and intellectual abilities

117
Q

what are the four stages of mental status/alertness?

A

alert
lethargic
stuporous
comatose

118
Q

alert

A

patient is responsive and responds appropriately

119
Q

lethargic

A

patient can open eyes and respond but is drowsy and falls asleep easily

120
Q

stuporous

A

vigorous or painful stimuli is necessary to elicit even a brief response in the patient

121
Q

comatose

A

unconscious, with no response to painful stimuli

122
Q

what is the difference between mood and affect?

A

mood is the emotion the client is feeling

affect is the objective expression of the mood (flat, blunted, smiling, crying, etc)

123
Q

what are some elements of cognitive and intellectual ability that the nurse should note?

A 
orientation
memory
level of knowledge about illness and perception of illness
ability to calculate 
abstract thinking 
judgment
rate and volume of speech
124
Q

what are some standardized screening tools used in screening mental status?

A

mini mental state examination (MMSE)

pain assessment

125
Q

what are some questions included in a mini-mental?

A

orientation
attention span
registration and recall of objects
language abilities

126
Q

what should the nurse ask children/adolescents in a mental health assessment?

A 
home environment
education and employment performance 
activities
drug and substance use
sexuality
depression and suicide assessment 
how safe they feel
127
Q

what are risk factors in children for developing a mental health disorder?

A

genetic predisposition
biochemical imbalances
family problems or environmental conflict
cultural/ethnic issues or assimilation
resiliency level
witnessing or experiencing traumatic events
low socioeconomic level

128
Q

what should the nurse ask older adults when assessing mental health?

A 
functional ability 
economic and social status 
environmental factors 
questions from standardized screening tools
substance use
129
Q

what should be assessed in relation to adaptation and coping?

A 
health status
functional ability
living arrangements 
employability 
personality
caregiver and family assessments
level of information and knowledge 
medications and other services used
130
Q

what is milieu therapy?

A

creating an environment that is supportive, therapeutic, and safe. managing the total environment to create the least amount of stress for the client

131
Q

what are characteristics of the physical setting with milieu therapy?

A 
clean
orderly
comfortable
safe 
attractive
age-appropriate
space for alone time and opportunity for interaction
132
Q

what are the phases of the therapeutic relationship in the mental health setting?

A

orientation
working phase
termination

133
Q

characteristics of the orientation phase

A

setting limits
setting goals
introductions and defining rolls
getting informed consent from the patient

134
Q

characteristics of the working phase

A 
ongoing assessment
problem solving
learning coping skills
client feeling open and able to share 
listening on the part of the nurse
135
Q

characteristics of the termination phase

A

discussing feelings about ending of therapeutic relationship
talk about separation and loss
learn how to integrate coping and other skills into normal life

136
Q

transference

A

common issue in mental health care where client views the healthcare worker as having characteristics of another significant person in their life

137
Q

countertransference

A

problem where healthcare worker displaces characteristics of someone in their life or their past onto their current client

138
Q

what are some common activities within the therapeutic milieu?

A 
community meetings
individual and group therapy
psychoeducational groups
recreation activities
unstructured free time
139
Q

what are focuses and goals of individual therapy?

A

the needs of one client is the focus, with the goals of good decision making, productive life decisions, and stronger sense of self

140
Q

what is the focus of family therapy?

A

improving family functioning by addressing family needs and problems

141
Q

what are some goals of family therapy?

A

effective coping within the family
improved understanding of mental health issues
more positive family interactions

142
Q

what is the focus of group therapy?

A

individuals developing more functional and satisfying relationships within the group

143
Q

what are goals of group therapy?

A

discovering commonality among group members and seeing positive behavior changes in regards to social interaction

144
Q

what is a maintenance role in a therapy group?

A

someone who helps maintain the purpose and process of the group

145
Q

what are task roles in a therapy group?

A

people who take on tasks within the group process

146
Q

what are individual roles in group therapy settings?

A

roles taken on by individuals to promote their own agendas, which usually hinders the group goals

147
Q

what is depression?

A

a mood disorder characterized by depressed mood, sleep disturbances, indecisiveness, suicidal ideation, inability to feel pleasure, and/or weight changes

148
Q

what are common comorbidities with depression?

A

anxiety and psychotic disorders
substance use
eating and personality disorders

149
Q

what are some different types of depressive disorders?

A 
major depressive disorder
seasonal affective disorder 
persistent depressive disorder
premenstrual dysphoric disorder 
substance-induced depressive disorder
150
Q

what are risk factors for depression in children and adolescents?

A 
family history
past abuse
homelessness
parental or environmental conflict
bullying
high-risk behaviors
learning disabilities 
chronic illness
151
Q

what are expected findings with children and teens with depressive disorders?

A 
sadness
temper tantrums
loss of appetite 
health complaints 
isolation
crying
loss of energy
irritability 
aggression/risky behavior
suicidal thoughts and actions
152
Q

what is depression often associated with in older age?

A

dementia

153
Q

what are the phases of a major depressive disorder?

A

acute
continuation
maintenance

154
Q

what are goals for care in an acute phase of depression?

A

reduction of depressive manifestations. this phase may require hospitalization and suicide monitoring

155
Q

what is the goal of care in a continuation phase of depression?

A

relapse prevention through education, medications, and psychotherapy

156
Q

what is the goal of care in the maintenance phase of depression?

A

prevention of future depressive episodes

157
Q

who is at risk for depression?

A

women
those with a family history
those in early adulthood or over 65
those with neurotransmitter deficiencies

158
Q

what are assessment findings with depression?

A 
sadness
blunted affect 
poor grooming/hygiene 
psychomotor retardation and agitation 
social isolation
slowed speech and delayed response 
anergia
anhedonia
159
Q

what are vegetative findings in depression?

A

changes in eating patterns
changes in bowel patterns (usually constipation)
changes in sexual activity and sleep habits
somatic complaints

160
Q

remember there are several types of depression screening scales!

A

use the correct one for the correct population group

161
Q

what is included in milieu therapy for patients with depression?

A 
suicide risk assessment
self-care assessment
communication with patient and IDT
maintaining safe environment 
counseling
162
Q

what are some alternative therapies for depression?

A

light therapy
St. John’s wort
exercise and good nutrition

163
Q

what are important patient teaching points for depression?

A

manifestations of depression
effects and adverse effects of medications
benefits/importance of treatment adherence
importance of regular exercise
how to prevent relapse

164
Q

what is electroconvulsive therapy (ECT)?

A

using electrical currents to induce a brief seizure while client is sedated

165
Q

what are nursing considerations during ECT treatment?

A

obtaining informed consent
med management and side effects
client education
understanding normal and desired patient responses

166
Q

what indicates the need for ECT in a major depressive disorder?

A

unresponsive to pharmacological interventions
when risks outweigh benefits for other treatments
suicidal/homicidal clients who need rapid intervention
those experiencing psychotic manifestations

167
Q

what meds will be given to a client undergoing ECT?

A

muscle relaxant to prevent injury

anticholinergics to counteract secretions and prevent aspiration

168
Q

how long does a course of ECT last?

A

2-3 times per week for a total of 6-12 treatments

169
Q

what should the nurse monitor before, during, and after ECT?

A

BP
ECG
oxygen saturation

170
Q

what are potential complications of ECT?

A

memory loss and confusion
anasthesia reaction
cardiovascular changes
relapse of depression

171
Q

what are nursing actions to be taken to prevent/counteract complications of ECT?

A

frequent orientation and safety focus after treatment
monitoring during and after treatment for anesthesia reaction
monitor vitals and cardiac rhythm
encourage maintenance ECT to prevent relapse q

172
Q

what is transcranial magnetic stimulation?

A

using MRI strength magnetic pulsations to stimulate the cerebral cortex

173
Q

what are indications for use of TMS?

A

major depressive disorder when pharmacological intervention doesnt work

174
Q

what is bipolar disorder?

A

mood disorder with recurrent episodes of depression and mania that usually emerges in early adulthood

175
Q

what is the acute phase of bipolar?

A

acute mania, where patient might need hospitalization and extra safety measures

176
Q

what is the continuation phase of bipolar?

A

remission of manifestations, with a focus on treatment and relapse prevention techniques

177
Q

what is the maintenance phase of bipolar?

A

increased ability to function with the goal of preventing future manic episodes

178
Q

what is mania?

A

abnormally elevated mood (irritable, expansive) lasting at least one week

179
Q

what is hypomania?

A

less severe episode of mania lasting at least 4 days with 3 or more manic characteristics. less severe, hospitalization may not be needed

180
Q

what is rapid cycling?

A

four or more episodes of mania or hypomania in one year

181
Q

what are manic characteristics in bipolar?

A 
euphoria
agitation/irritability
restlessness
intolerance of criticism
flight of ideas
impulsivity and poor judgment
attention seeking behaviors
decreased sleep
ADL neglect
delusions and hallucinations
rapid speech
182
Q

what are depressive characteristics in bipolar?

A 
blunted affect
crying
lack of energy
anhedonia
pain
poor focus
self-destructive behavior
decrease in hygiene
disturbed sleeping and eating
psychomotor retardation
183
Q

what populations are at risk for bipolar?

A

those with genetic predisposition
those with environmental stress
those with neurobiologic and neuroendocrine disorders

184
Q

what are collaborative therapies for those with bipolar?

A

electroconvulsive therapy

medications

185
Q

what are nursing considerations in acute manic episodes?

A 
safety
suicide assessment
decrease stimulation
supervision
rest and physical activity 
nutrition support 
protection from impulsivity and poor judgment
186
Q

what are important teaching points for clients with bipolar?

A 
follow up care
benefits of therapy adherence
psychotherapy reference 
long-term/lifelong treatment 
regular sleep and eating schedule 
med adherence 
indicators and precipitating factors for relapse
187
Q

what are some criteria for substance use disorders?

A 
impaired control of substance intake
social impairment due to use 
risky use of substance 
dependence on substance 
taking substance for longer than intended or failing to quit using
188
Q

addiction

A

psychological and physical inability to stop consuming something despite it’s negative impacts

189
Q

intoxication

A

clinically significant behavioral or psychological changes following the use of a substance

190
Q

tolerance

A

reduced reaction to a drug or substance following repeated use

191
Q

withdrawal

A

physical/psychological manifestations experienced when a patient discontinues a med or drug to which they are addicted

192
Q

who is at risk for substance use disorder?

A 
chronically stressed 
genetically predisposed 
trauma history
low self esteem
isolation
risk takers
alaska natives
native americans 
older adults
those facing peer presusre
193
Q

what are some manifestations/findings with substance use disorders?

A 
fatigue
insomnia
headache
seizures
mood changes 
anorexia
looking aged/unkempt 
sexual dysfunction
DWI
defensive or evasive behaviors or actions 
life function issues
194
Q

what are assessment findings of intoxication with stimulants?

A 
palpitations and dysrhythmias
increased BP and HR
MI
impending doom feelings 
euphoria
agitation 
seizures
combativeness
paranoia
confusion
fever
195
Q

what are signs of withdrawal from stimulants?

A 
fatigue
depression
excess sleeping
vivid dreams
irritability
increased appetite 
disorientation
craving the drug
196
Q

what are findings for intoxication with depressants?

A 
aggression
agitation 
confusion
lethargy 
hallucinations 
slurred speech
pinpoint pupils
seizures
weak pulse and dysrhythmias 
decreased BP
respiratory depression
197
Q

what are signs of withdrawal from sedative hypnotics?

A 
weakness
anxiety
insomnia
fever
orthostatic hypotension
disorientation 
delirium 
seizures
respiratory and cardiac arrect
198
Q

what are signs of opioid withdrawal?

A 
cravings
diaphoresis
GI issues
restlessness
fever
insomnia
tremors 
aches
runny nose
199
Q

what are some priority care measures for clients with substance abuse disorders?

A 
airway/ABCs
IV access and fluids
ECG monitoring 
drugs for dysrhythmias, HTN, angina, seizures, and psychotic manifestations
vitals 
LOC
cooling measures
info about drugs and amounts taken
antidotes/gastric lavage
200
Q

what are gerentologic considerations for substance use disorders?

A

hard to recognize
can be mistaken for a medical condition
greater risk for medical issues caused by substance use

201
Q

what is ADHD?

A

inability to control behaviors requiring sustained attention

202
Q

what is inattention?

A

difficulty paying attention, listening, and focusing

203
Q

what is hyperactivity?

A

fidgeting, inability to sit still, excess talking, problems playing quietly, excess running and climbing

204
Q

what is impulsivity?

A

interrupting, impatience, or acting without considering the consequences

205
Q

what are clinical manifestations of ADHD?

A 
distractibility
immaturity
selective attention
risk taking
lack of regard for consequences 
hyperactivity 
inappropriate social behaviors
206
Q

what is necessary for a patient to be diagnosed with ADHD?

A

associated behaviors must be present before age 12 and in more than one setting

207
Q

what are the three main treatment plans for children with ADHD?

A

behavior therapy
environmental manipulation
classroom placement

208
Q

what does behavior therapy for ADHD consist of?

A

rewarding good behavior and preventing undesired behavior by using contingencies, rewards, and organizational charts

209
Q

what does environmental manipulation consist of for clients with ADHD?

A

consistency in expectations and discipline and structure between school and home
having the child take responsibility for actions and choices
decreasing environmental distractions

210
Q

what is important for classroom placement for children with ADHD?

A

orderly, predictable, consistent classroom with clear and consistent rules
interspersed breaks
bulk of learning in the morning
intersperse activities of high and low levels of interest

211
Q

what is the goal for children with ADHD?

A

help them identify areas of weakness and compensate for them, and promote healthy interventions and adaptation

212
Q

what are the rights of a patient with a voluntary mental health admission?

A

right to refuse medication and treatment

213
Q

what is a temporary emergency admission?

A

receiving emergent mental health care due to being unable to make decisions regarding care

214
Q

what is an involuntary admission?

A

client enters mental health facility against their will for an indefinite time period

215
Q

what is the length of time to which an involuntary admission is limited?

A

60 days

216
Q

how long are long-term involuntary admissions?

A

60-180 days

217
Q

what are the three categories of restraints?

A

physical
chemical
environmental

218
Q

what potential unmet physiologic or psychosocial needs could result in disruptive behaviors by an older adult?

A

need for toileting or not being able to speak

219
Q

what are some restraint alternatives that should be considered?

A 
low beds
body props
bed/chair alarms
distractions/mentally stimulating activities 
floor mats
family visits
safety assistants or direct observation
220
Q

what must occur for use of seclusion or restraints?

A

less restrictive measures must fail
doctor’s order must be written
time limit
frequent assessment and documentation

221
Q

what documentation needs to be completed in relation to restraints?

A 
events leading up to restraint measures
alternatives attempted 
time restraint began and ended
current behavior
vitals
food and fluid offered
skin assessment
meds administered
222
Q

how often does restraint documentation need to be completed?

A

every 15-30 minutes (facility dependent)

223
Q

what is a tort?

A

a civil wrong-doing in which money can potentially be collected and awarded

224
Q

false imprisonment

A

confining a client physically, verbally, or by using chemical restraint when not part of the treatment plan

225
Q

assault

A

making a threat to the client’s person

226
Q

battery

A

harmful or offensive touch

227
Q

what documentation needs to be completed in relation to violent or unusual episodes?

A

record of client behavior in a clear and objective manner
staff response with timelines and extent of responses
time nurse notified provider
prescriptions/orders received

228
Q

what are arterial ulcers?

A

ulcers caused by arterial insufficiency in the extremities

229
Q

what are causes/reasons that arterial ulcers develop?

A

inadequate circulation of oxygenated blood, leading to ischemia and tissue damage

230
Q

what are characteristics of arterial ulcers?

A 
"punched out" appearance 
small and round
smooth borders
pale base
usually on lower extremity 
surrounding skin thin/shiny/cool/dry
loss of hair
delayed capillary refill and delayed or absent pedal pulses
pain that increases with activity
231
Q

what are venous stasis ulcers?

A

ulcers caused by venous insufficiency or issues

232
Q

what causes venous ulcers?

A

incompetent venous valves, deep vein obstruction, or inadequate calf muscle function

233
Q

how will venous insufficiency manifest in the leg?

A

venous pooling
edema
impaired microcirculation

234
Q

what are characteristics of venous stasis ulcers?

A

located on lower calf or inner ankle usually
surrounding skin is red, brown, or edemateous
shallow with irregular margins
beefy/granular/red wound bed
moderate to heavy drainage
pain when legs are in dependent position

235
Q

what is considered a chronic wound?

A

a wound that exceeds expected length of recovery and has trouble healing

236
Q

what are diabetic food ulcers?

A

ulcers that occur due to narrowing of arteries, which decreases oxygenation and blood to feet

237
Q

what about diabetes increases the risk of foot ulcer development?

A

neuropathy (patient wont necessarily feel a wound)

238
Q

are diabetic foot ulcers arterial or venous ulcers?

A

arterial

239
Q

what labs would need to be done for a patient with chronic wounds?

A 
albumin
culture and sensitivity 
CBC
glucose 
thyroid 
iron
coagulation
240
Q

what are three chronic complications of wound healing?

A

adhesions
fistulas
keloids

241
Q

what is an adhesion?

A

band of scar tissue forming between or around organs

242
Q

what is a fistula?

A

abnormal passage between organs or between a hollow organ and the skin

243
Q

what are keloids?

A

protrusions of scar tissue that extend beyond wound edges in a healing/healed wound

244
Q

what are some other factors that delay wound healing?

A 
nutrient deficiencies
inadequate blood supply
steroid use
infection
smoking
friction
age
obesity
diabetes
poor health
anemia
245
Q

what is negative pressure wound therapy?

A

a vacuum source being used to create negative pressure in the wound to remove fluid, exudate, and infectious materials. helps prepare the wound for healing and closure

246
Q

what should the nurse monitor in patients with negative pressure wound therapy?

A

serum protein
fluid and electrolyte balance
platelets
PT and PTT

247
Q

What are nutrition considerations for patients with chronic wounds?

A

high fluid intake needed
undernutrition is a risk for poor healing
protein/carbs/fat are crucial
vitamin C and A are crucial

248
Q

what are psychological implications for patients with wounds?

A

fear of scarring and disfigurement
drainage or odor can cause alarm
may want to understand the healing process

249
Q

what are assessment considerations for dark skinned patients with wounds?

A 
look for color changes in the skin
use natural or halogen light (not fluorescent) 
assess skin temperature 
touch to feel skin consistency 
ask about pain and itching
250
Q

what is a pressure ulcer?

A

localized injury caused by pressure on an area of tissue

251
Q

where are the most common sites of presusre injuries?

A

heels
elbows
sacrum
scapulae

252
Q

what are intrensic/internal risk factors for pressure ulcer development?

A 
immobility
impaired sensation or circulation
poor nutrition
edema
aging
fever 
mental deterioration
diabetes
moisture/incontinence
253
Q

what are extrensic/external risk factors for pressure ulcers?

A

friction
shearing
moisture
compression

254
Q

what are shearing forces?

A

epidermal layer sliding over the dermis, damaging the vascular bed
example: sliding down in bed

255
Q

what is friction?

A

the epidermis sliding against another surface

256
Q

stage I pressure ulcer findings

A

intact skin
non-blanchable redness
usually over a bony prominence

257
Q

stage II pressure ulcer

A

partial thickness loss of dermis
shallow open ulcer with red/pink wound bed
no slough
can look like an open blister

258
Q

stage III pressure ulcer

A

full thickness tissue loss
subcutaneous fat may be visible
slough present but doesnt obscure depth
possible undermining/tunneling

259
Q

stage IV pressure ulcer

A

full thickness tissue loss with exposed or palpable bone, tendon, or muscle
slough and eschar possible

260
Q

unstagable pressure ulcer

A

depth of ulcer is obscured by slough or eschar, but will either be a stage III or IV ulcer

261
Q

why is reverse staging of pressure ulcers inaccurate?

A

because while the wound is getting more shallow, the lost bone/muscle/tissue is not being replaced, it’s just being filled with granular tissue. Once it’s a certain stage, its always that stage

262
Q

how do you document a healing ulcer?

A

by writing “healing stage __ ulcer”

263
Q

what is a common tool for assessing pressure ulcers?

A

PUSH tool

264
Q

how often should patients be assessed for pressure ulcer risk?

A

upon admission (very thoroughly), then every 48-72 hours or according to policy

265
Q

with the Braden scale, is a high or low score good?

A

a high score is good (indicates low risk)

266
Q

what should we remember about turning patients every 2 hours?

A

its not evidence based. patients may need to be turned more often, or maybe not as often depending on individualized risk

267
Q

what interventions will likely be used in care of the pressure ulcer?

A 
debridement
wound cleaning
dressing application
pressure relief (float heels, padding, special mattresses or chairs)
moisture management 
good documentation
268
Q

what will be needed for pressure ulcers with necrotic tissue or eschar?

A

tissue removal by debridement

269
Q

what are important patient/caregiver teachings related to pressure ulcer wound care?

A 
risk factors
how to manage incontinence 
correct positioning and repositioning 
put a clean dressing over the sterile dressing 
daily skin inspection
good nutrition
270
Q

what is peripheral arterial disease?

A

progressive narrowing of arteries in upper and lower limbs

271
Q

how is peripheral arterial disease different from venous diseases?

A

PAD has no peripheral pulses, capillary refill greater than 3 seconds, thick nails, thin shiny skin, cool skin, and no edema

272
Q

what are assessment findings in PAD?

A

intermittent claudication
numbness and tingling
reactive hyperemia
pain at night

273
Q

what is intermittent claudication?

A

ischemic muscle pain caused by exercise

274
Q

how should patients with intermittent claudication be instructed to exercise?

A

exercise, then rest when pain begins, and resume exercise when pain subsides

275
Q

what are potential complications of PAD?

A 
skin/muscle atrophy
delayed healing 
infection
necrosis 
possible amputation
276
Q

what are modifiable risk factors for PAD?

A 
tobacco use
blood pressure 
exercise/weight 
diet
glucose control/diabetes management 
lipid control
277
Q

what diet is recommended for PAD?

A

dash diet

278
Q

what are exercise therapy recommendations for PAD?

A

supervised exercise program consisting of 30-45 minutes/day, 3 or more days a week, for at least 3 months

279
Q

what are nutritional considerations for PAD?

A

reduced calories and salt

keep waist circumference at healthy level

280
Q

what nursing interventions should be considered for home/ambulatory care for PAD?

A 
long term antiplatelets 
supervised exercise
foot assessment and care
proper shoes
diet modification
281
Q

what is chronic venous insufficiency?

A

functional abnormalities of the venous system in the legs

282
Q

what are assessment findings of chronic venous insufficiency?

A 
leathery brownish skin
edema
eczema 
itching
venous ulcers (often above medial maleolus) 
pain
283
Q

what are potential complications of chronic venous insufficiency?

A

osteomyelitis
malignant changes
venous stasis ulcers

284
Q

what does interprofessional care and nursing management for chronic venous insufficiency consist of?

A

compression therapy

nutrition therapy

285
Q

what are skin care considerations for chronic venous insufficiency?

A 
compression
moist environment for wounds 
dressings
frequent assessment 
moisturizing skin
educate patient on how to put on compression stockings
286
Q

what are nutrition recommendations for chronic venous insufficiency?

A

high protein, vitamin C, and zinc

287
Q

what are activity and rest recommendations for chronic venous insufficiency?

A

avoid standing or sitting for long periods of time
elevate legs frequently
begin daily walking once ulcers heal
avoid leg trauma

Krystan: Semester Two Nursing School (13 decks)

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