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AH II Exam I Flashcards

1
Q

What does the acronym SPICES stand for?

A 
Sleep disorders
Problems with eating and feeding
Incontinence 
Evidence of falls
Skin breakdown
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2
Q

What 2 assessments do we use to observe changes from the baseline in older adults?

A 
ACES
Assess function and expectations for ADLs 
Coordinate and manage care
use Evolving knowledge
makeSituational decisions

-used to Advance Care for the Excellence of Seniors

SPICES
assesses changes to their normal ADLs

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3
Q

What happens to each body system as we age?

A

kidney function, thirst and fluid status all decrease

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4
Q

If an older adult is having problems with swallowing/chewing, what do we want to give them?

A

THICKENED liquids

for example: a shake instead of a lemonade to reduce the risk of aspiration

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5
Q

What is a high risk BRADEN scale? What does it mean? How should a nurse intervene?

A

a low Braden score indicates a high risk for pressure ulcers

the highest risk score you can get is 6

no risk for ulcers is 23

Nursing Action: turn the patient every 2 hours. It only takes 20 minutes for an ulcer to begin developing.

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6
Q

What is a high risk MORSE scale? What does it mean? How should the nurse intervene?

A

a score over 50 indicates a high risk for falls

Nursing Action: get rid of environmental hazards, assess for muscle weakness.

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7
Q

When assessing an older adult’s AAOX3, are they oriented if they are off by just one day?

A

NO- the nurse should be reorienting the patient daily.

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8
Q

What is the “triple S” associated with chronic illness?

A

Sedentary lifestyle
Smoking
Stress

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9
Q

What defines a chronic illness?

A

it is permanent, and caused by a non-reversible pathological alteration.
it has a remission-exacerbation cycle.

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10
Q

What is the difference between the NIC and the NOC?

A

NIC- provides standardized patient interventions

NOC- provides standardized patient outcomes

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11
Q

What are 3 isotonic fluids? When are they indicated? When are they contraindicated?

A

0.9% Normal Saline
D 5% W
Lactated Ringers

Indicated: to increase intravascular volume
can be used in conjunction with blood products

Contraindicated: volume overload
do NOT gives lactated ringers when patient is alkylotic or in liver failure

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12
Q

What are 3 HYPOtonic fluids? When are they indicated? When are they contraindicated?

A

0.45% (half) normal saline
33% (one third) normal saline
2.5% (half) dextrose

Indicated: to draw water into the cell

Contraindicated: anasarca, cerebral edema, HYPOtension

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13
Q

What are 3 HYPERtonic fluids? When are they indicated? When are they contraindicated?

A

D 5% W in 0.45% NS
D 5% W in 0.9% NS
D 5% W in lactated ringers

Indicated: to draw water into the vessels

Contraindicated: heart failure, DKA

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14
Q

What is the pressure called that PULLS (absorbs) fluid from the interstitial space?

A

colloid oncotic pressure

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15
Q

What are the 4 routes too edema?

A
  1. increased capillary permeability r/t burns, allergies, inflammatory reactions, etc.
  2. decreased capillary oncotic pressure r/t loss of plasma proteins
  3. increased capillary hydrostatic pressure r/t vein obstruction, salt/water retention and heart failure
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16
Q

What are the 4 routes too edema?

A
  1. increased capillary permeability
  2. decreased capillary oncotic pressure
  3. increased capillary hydrostatic pressure
  4. lymphatic obstruction
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17
Q

How do decreased blood volume and decreased blood pressure affect osmolarity?

A

They both lead to a decrease in osmolarity.
They tell the atria and great veins that they need more fluid.
That sets off an increase in ADH.
ADH increase causes reabsorption of water into the vessels which decreases the concentration of electrolytes there (decreases osmolarity)

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18
Q

What are the three things that cause the body to increase its ADH production and consequently decrease its osmolarity? (yes. do the big list)

A
  1. decreased blood volume/blood pressure
  2. too high an increase in osmolarity (sensed by the hypothalamus)
  3. extrinsic factors such as:
    HAANNSS
    Heat
    Anesthetics
    Antineoplastics (chemo)
    Narcotics
    Nicotine
    Surgery
    Stress
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19
Q

Describe the RAAS cycle.

A
  1. Triggered by low BP
  2. Kidneys release renin which travels to the liver
  3. Renin converts angiotensin to angiotensin I
  4. Angiotensin I travels to the lungs to be converted by ACE into angiotensin II
  5. Angiotensin II powerfully vasoconstricts vessels and increases BP
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20
Q

What is the best indicator of fluid status?

A

daily weight

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21
Q

What are the 2 most important things to monitor during rehydration?

A

HR

urine output

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22
Q

Dilution of which two electrolytes can lead to seizures, coma and death?

A

sodium and potassium

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23
Q

Urine output below _____ for a kidney patient is cause for concern?

A

500mL/day
or
1lb/day

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24
Q

What is the most common type of fluid loss problem?

A

isotonic dehydration

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25
A patient with acute kidney injury or chronic kidney disease is at risk for fluid volume _____
excess
26
What are the 5 clinical signs of HYPOvolemia?
``` sudden weight loss flat neck veins HYPOtension tachycardia weak, thready pulse ```
27
What are the 4 clinical LABS for HYPOvolemia?
Increased hematocrit Increased BUN (>25) Increased urine specific gravity (> 1.03) Increased serum sodium
28
What are the 3 clinical signs of HYPERvolemia?
sudden weight gain distended neck veins lung crackles
29
What are the 4 clinical LABS for HYPERvolemia?
Decreased hematocrit Decreased BUN (< 10) Decreased urine specific gravity Decreased serum sodium
30
What are 3 nursing management options for HYPOvolemia?
check urine output monitor for bounding pulse/difficulty breathing when rehydrating give ~100mL/hr PO fluid replacement
31
What are 4 nursing management options for HYPERvolemia?
prevent skin breakdown from edema/oxygen therapy administer diuretics restrict fluid restrict sodium to 2-4g/day
32
Sodium Range:
135-145
33
HYPOnatremia neuromuscular:
decreased mm contraction that leads to shallow respirations
34
How does the nurse fix HYPOnatremia?
if related to excess fluid intake, restrict fluids and administer diuretics if related to decreased sodium intake, replace with hypertonic solution like 3-5% normal saline
35
Common causes of HYPOnatremia:
``` excessive sweating wound drainage diuretics HYPOtonic fluids HYPERglycemia ```
36
Potassium LOSS can be caused by an INCREASE in what hormone?
aldosterone
37
Shifting potassium into cells via what condition can cause HYPOkalemia? Shifting potassium OUT of the cells via what condition can cause HYPERkalemia?
HYPO: metabolic ALKalosis treatment of DKA (b/c it may lead to an alkylotic state) HYPER: metabolic ACIDosis trauma
38
Potassium Range:
3.5-5
39
What the early and late neuromuscular sign of HYPERnatremia?
early: Increased mm contraction late: Decreased mm contraction
40
How should the nurse treat HYPERnatremia?
restrict sodium intake and drink fluids | give 0.9% normal saline to rehydrate AND dextrose 5% in 1/2 normal saline
41
What is HYPERnatremia commonly caused by?
Cushing's | HYPERtonic fluid administration
42
mental status for HYPOkalemia versus HYPERkalemia:
HYPO: lethargic coma HYPER: irritable
43
Respiratory for HYPOkalemia
shallow respirations
44
What is the #1 cause of death in patients with HYPOkalemia?
respiratory arrest
45
HYPOkalemia cardiac vs. HYPERkalemia cardiac
``` HYPO: Peaked P Prolonged PR Normal QRS Depressed ST Shallow T Prominent U ``` ``` HYPER: Absent P Prolonged PR (even more than HYPOkalemia) Widened QRS Depressed ST Tall T No U ```
46
HYPOkalemia GI vs. HYPERkalemia GI
HYPO: constipation HYPER: diarrhea
47
What is the earliest sign of HYPERkalemia? Late sign?
early: irritability late: flaccid paralysis
48
HYPOkalemia neuromuscular vs. HYPERkalemia neuromuscular
HYPO: mm weakness, diminished DTRs and flaccid paralysis HYPER: early- paresthesias, cramps, mm twitches late-flaccid paralysis
49
How should the nurse fix HYPOkalemia?
give IV potassium always diluted 1mEq potassium to 10mL solution
50
When administering supplemental potassium, what are the rules?
NEVER IV push/IM/subQ infusion should never exceed 20mEq/hour if the infusion exceeds 10mEq/hour we have to monitor respiratory and cardiac
51
How should the nurse fix HYPERkalemia?
Patiromer - decreases potassium absorption Sorbitol- laxative that draws. potassium out Potassium wasting (loop) diuretics. Dialysis
52
What is the emergency treatment for HYPERkalemia?
IV fluids with 10-20% glucose and 10-20 units insulin | monitor cardiac
53
Foods high in potassium:
``` Avocado Banana Broccoli Cantaloupe Carrots Dairy Dried fruit Kiwi Mushrooms Oranges Organ meats Potatoes Pork, beef, veal Seaweed Spinach ```
54
What drug do we need to be careful with when a patient is in a HYPOkalemic state?
Digoxin - it worsens the hypokalemia and therefore the dysrhythmias
55
Calcium Range:
9.0-10.5
56
HYPOcalcemia vs. | HYPERcalcemia bones:
BOTH: osteoporosis fractures HYPO: calcium deposits throughout the body b/c bones give it away when they sense low l levels throughout the body
57
HYPOcalcemia vs. | HYPERcalcemia cardiac:
Both: dysrhythmias/arrest HYPER: long QT and ST, HYPOtension HYPO: short QT, HYPERtension, increased HR that progresses to decreased HR
58
HYPOcalcemia vs. | HYPERcalcemia GI
HYPO: diarrhea HYPER: constipation
59
HYPOcalcemia vs. | HYPERcalcemia Neuromuscular:
HYPO: tetany, (+) Trousseau's, (+) Chvostek's HYPER: decreased DTR, lethargy, coma
60
How does the nurse fix HYPOcalcemia?
IV 10% calcium gluconate (NEVER push) Slow IV chloride vitamin D replacement Reduce stimulation (lights, voice volume)
61
What is the most important nursing consideration with a patient who has HYPOcalcemia?
fall prevention
62
How should the nurse fix HYPERcalcemia?
increase isotonic fluids corticosteroids switch diuretics to Furosemide
63
What is the most important nursing consideration with a patient who has HYPERcalcemia?
watch for calcium-containing antacids (AlOH) | assess for poor perfusion
64
Foods high in calcium:
``` cheese collard greens milk rhubarb sardines spinach tofu yogurt ```
65
Which vitamin increases with calcium increase?
D
66
Which electrolyte increase leads to a decrease in calcium absorption?
magnesium | since magnesium and calcium go together, having more magnesium absorbed leaves "less room" for calcium.
67
Magnesium Levels:
1.8-2.6
68
HYPOmagnesemia vs. HYPERmagnesemia cerebral:
HYPO: agitation HYPER: drowsiness, coma
69
HYPOmagnesemia vs. HYPERmagnesemia cardiac:
``` HYPO: tachycardia HYPERtension atherosclerosis Long QT left ventricle hypertrophy ``` ``` HYPER: bradycardia HYPOtension (vasodilation) increased PR shortened QT T wave changes ```
70
HYPOmagnesemia vs. HYPERmagnesemia neuromuscular:
HYPO: tetany (+) Trousseau's (+) Chvostek's HYPER: decreased DTR lethargy coma
71
How does the nurse treat HYPOmagnesemia vs HYPERmagnesemia?
HYPO: IV magnesium replacement HYPER: diuretics Dialysis Calcium Gluconate
72
Nursing action for HYPOmagnesemia:
ask if the patient is taking Digoxin or if they drink
73
What is the largest concern for patients with HYPERcalcemia and HYPERmagnesemia?
respiratory arrest | when levels are high, nerves and muscles slow down
74
Nursing actions for HYPERmagnesemia:
give phosphate
75
Foods high in magnesium:
``` avocado canned tuna cauliflower green leafy veggies oatmeal peanut butter peas pork potatoes soy beans raisins yogurt ```
76
What do you do if the patient gets air emboli related to a catheter?
place them in Trendelenburg
77
What should the nurse assess for after an IV placement?
``` redness swelling tenderness blood return integrity of dressing color ```
78
When should IV tubing be replaced?
72-96 hours
79
IV dressings must be:
dry intact occlusive
80
What is infiltration vs. extravasation?
Infiltration: leakage of NON-vesicant IV solution into the tissues Extraversion: leakage of vesicant IV solution into the. tissues
81
S&S of infiltration and extravasation:
cool, tight, blanched skin | numbness and pain
82
Treatment of infiltration:
STOP and remove elevate apply warm OR cool compress document
83
Treatment of extravasation:
STOP and remove disconnect tubing aspirate the medication out document
84
What is phlebitis? S&S? Tx?
venous inflammation S&S: veins are hard and cordlike pain, redness, inflammation can occur 2-4 days p extubation Treatment: STOP. and remove apply warm compress document
85
What could cause phlebitis?
mechanical trauma or bacterial infection
86
Which catheters can NOT take vesicant medications?
Peripheral IV | Midline
87
What are considerations with a PICC line?
No heavy lifting No wheelchairs No crutches X ray confirms placement
88
What are considerations with a non-tunneled CVC?
assess for blood return | watch for air emboli
89
Which catheter needs a Huber needle to access it?
Implanted ports
90
You can't give anything via IV at the same time as ______.
Blood or heparin
91
What is the only thing you can give with TPN?
lipids and insulin
92
How should the nurse prevent infection during IV catheter administration?
wear a mask and have the patient look away
93
If a patient is allergic to_________, they have a high probability of a latex allergy
ABS Avocado Banana Strawberry
94
-rrhapy
repair
95
Surgical Timing:
Green: Elective- planned but unessential Yellow: Urgent- unplanned, requires timely intervention Red: Emergent- immediate to preserve life/limb
96
What herb is important to note in a preoperative assessment? Why?
Ginkgo: impacts clotting
97
Which medications should be noted in a preoperative assessment?
``` NSAIDs: anti-platelet Steroids: infection risk Antihypertensives Diuretics Metformin Opioids: higher tolerance MAOIs: interactions - stop 13 days before surgery ```
98
What are the 4 risk factors for pulmonary complications post-op?
Smoking COPD Respiratory infection Skeletal deformities that impair ventilation
99
A patient should be NPO _______ hours before surgery.
6-8 hours
100
Should patients take prescribed medication before surgery?
Yes-unless told otherwise
101
Why would a bowel/intestinal prep be conducted before surgery?
it reduces the number of intestinal bacteria
102
Describe how how to use an incentive spirometer (5 steps).
1. sit upright 2. put in mouth 3. raise the ball between the 600-900 mark 4. hold a full breath for 5 seconds before breathing out 5. repeat 10 times/hour
103
What does using the incentive spirometer prevent?
atelectasis
104
What is a non-pharmacological intervention we can use when using the incentive spirometer?
splinting
105
When should antibiotics be administered pre-op?
30 minutes
106
What medications can be given pre-op?
``` the -pams Glycopyrrolate Hyoscine Hydrobromide PPIs Rubinol Supolamine ```
107
Scrubbing in:
3-5 minutes elbows to fingertips water should drip FROM elbows TO fingertips solution used is broad spectrum and antimicrobial
108
What is malignant hyperthermia?
``` a common complication of general anesthesia that causes: mm rigidity of the jaw/chest rapid breathing HYPOtension CO2 levels rising respiratory and metabolic acidosis late sign: pt temp into 112F ```
109
What is the treatment of malignant hyperthermia?
Dantrolene
110
What level should you check when patient is getting Heparin?
PTT | goal: 45-70
111
What should you do if a patient's PTT is high (>70)?
STOP, they're taking too long to clot
112
What should you do if a patient's PTT is low (<45)?
prepare to give more heparin, they're clotting too quickly
113
The _________ gauge catheter should be chosen that suits the prescribed therapy.
smallest
114
_________ gauge peripheral catheters increase risk of phlebitis
large
115
How many times can you attempt to put in a catheter?
each clinician can try 2X | max of 4X
116
What is the max flow rate fora Power PICC?
5mL/sec
117
What is the most serious complication of a PICC?
thrombophlebitis

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