AH II Exam I Flashcards
What does the acronym SPICES stand for?
Sleep disorders Problems with eating and feeding Incontinence Evidence of falls Skin breakdown
What 2 assessments do we use to observe changes from the baseline in older adults?
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
What happens to each body system as we age?
kidney function, thirst and fluid status all decrease
If an older adult is having problems with swallowing/chewing, what do we want to give them?
THICKENED liquids
for example: a shake instead of a lemonade to reduce the risk of aspiration
What is a high risk BRADEN scale? What does it mean? How should a nurse intervene?
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.
What is a high risk MORSE scale? What does it mean? How should the nurse intervene?
a score over 50 indicates a high risk for falls
Nursing Action: get rid of environmental hazards, assess for muscle weakness.
When assessing an older adult’s AAOX3, are they oriented if they are off by just one day?
NO- the nurse should be reorienting the patient daily.
What is the “triple S” associated with chronic illness?
Sedentary lifestyle
Smoking
Stress
What defines a chronic illness?
it is permanent, and caused by a non-reversible pathological alteration.
it has a remission-exacerbation cycle.
What is the difference between the NIC and the NOC?
NIC- provides standardized patient interventions
NOC- provides standardized patient outcomes
What are 3 isotonic fluids? When are they indicated? When are they contraindicated?
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
What are 3 HYPOtonic fluids? When are they indicated? When are they contraindicated?
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
What are 3 HYPERtonic fluids? When are they indicated? When are they contraindicated?
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
What is the pressure called that PULLS (absorbs) fluid from the interstitial space?
colloid oncotic pressure
What are the 4 routes too edema?
- increased capillary permeability r/t burns, allergies, inflammatory reactions, etc.
- decreased capillary oncotic pressure r/t loss of plasma proteins
- increased capillary hydrostatic pressure r/t vein obstruction, salt/water retention and heart failure
What are the 4 routes too edema?
- increased capillary permeability
- decreased capillary oncotic pressure
- increased capillary hydrostatic pressure
- lymphatic obstruction
How do decreased blood volume and decreased blood pressure affect osmolarity?
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)
What are the three things that cause the body to increase its ADH production and consequently decrease its osmolarity? (yes. do the big list)
- decreased blood volume/blood pressure
- too high an increase in osmolarity (sensed by the hypothalamus)
- extrinsic factors such as:
HAANNSS
Heat
Anesthetics
Antineoplastics (chemo)
Narcotics
Nicotine
Surgery
Stress
Describe the RAAS cycle.
- Triggered by low BP
- Kidneys release renin which travels to the liver
- Renin converts angiotensin to angiotensin I
- Angiotensin I travels to the lungs to be converted by ACE into angiotensin II
- Angiotensin II powerfully vasoconstricts vessels and increases BP
What is the best indicator of fluid status?
daily weight
What are the 2 most important things to monitor during rehydration?
HR
urine output
Dilution of which two electrolytes can lead to seizures, coma and death?
sodium and potassium
Urine output below _____ for a kidney patient is cause for concern?
500mL/day
or
1lb/day
What is the most common type of fluid loss problem?
isotonic dehydration
A patient with acute kidney injury or chronic kidney disease is at risk for fluid volume _____
excess
What are the 5 clinical signs of HYPOvolemia?
sudden weight loss flat neck veins HYPOtension tachycardia weak, thready pulse
What are the 4 clinical LABS for HYPOvolemia?
Increased hematocrit
Increased BUN (>25)
Increased urine specific gravity (> 1.03)
Increased serum sodium
What are the 3 clinical signs of HYPERvolemia?
sudden weight gain
distended neck veins
lung crackles
What are the 4 clinical LABS for HYPERvolemia?
Decreased hematocrit
Decreased BUN (< 10)
Decreased urine specific gravity
Decreased serum sodium
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
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
Sodium Range:
135-145
HYPOnatremia neuromuscular:
decreased mm contraction that leads to shallow respirations
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
Common causes of HYPOnatremia:
excessive sweating wound drainage diuretics HYPOtonic fluids HYPERglycemia
Potassium LOSS can be caused by an INCREASE in what hormone?
aldosterone
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
Potassium Range:
3.5-5
What the early and late neuromuscular sign of HYPERnatremia?
early: Increased mm contraction
late: Decreased mm contraction
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
What is HYPERnatremia commonly caused by?
Cushing’s
HYPERtonic fluid administration
mental status for HYPOkalemia versus HYPERkalemia:
HYPO:
lethargic
coma
HYPER:
irritable
Respiratory for HYPOkalemia
shallow respirations
What is the #1 cause of death in patients with HYPOkalemia?
respiratory arrest
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
HYPOkalemia GI
vs.
HYPERkalemia GI
HYPO: constipation
HYPER: diarrhea
What is the earliest sign of HYPERkalemia? Late sign?
early: irritability
late: flaccid paralysis
HYPOkalemia neuromuscular vs. HYPERkalemia neuromuscular
HYPO: mm weakness, diminished DTRs and flaccid paralysis
HYPER: early- paresthesias, cramps, mm twitches
late-flaccid paralysis
How should the nurse fix HYPOkalemia?
give IV potassium
always diluted
1mEq potassium to 10mL solution
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
How should the nurse fix HYPERkalemia?
Patiromer - decreases potassium absorption
Sorbitol- laxative that draws. potassium out
Potassium wasting (loop) diuretics.
Dialysis
What is the emergency treatment for HYPERkalemia?
IV fluids with 10-20% glucose and 10-20 units insulin
monitor cardiac
Foods high in potassium:
Avocado Banana Broccoli Cantaloupe Carrots Dairy Dried fruit Kiwi Mushrooms Oranges Organ meats Potatoes Pork, beef, veal Seaweed Spinach
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
Calcium Range:
9.0-10.5
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
HYPOcalcemia vs.
HYPERcalcemia cardiac:
Both: dysrhythmias/arrest
HYPER: long QT and ST, HYPOtension
HYPO: short QT, HYPERtension, increased HR that progresses to decreased HR
HYPOcalcemia vs.
HYPERcalcemia GI
HYPO: diarrhea
HYPER: constipation
HYPOcalcemia vs.
HYPERcalcemia Neuromuscular:
HYPO: tetany, (+) Trousseau’s, (+) Chvostek’s
HYPER: decreased DTR, lethargy, coma
How does the nurse fix HYPOcalcemia?
IV 10% calcium gluconate (NEVER push)
Slow IV chloride
vitamin D replacement
Reduce stimulation (lights, voice volume)
What is the most important nursing consideration with a patient who has HYPOcalcemia?
fall prevention
How should the nurse fix HYPERcalcemia?
increase isotonic fluids
corticosteroids
switch diuretics to Furosemide
What is the most important nursing consideration with a patient who has HYPERcalcemia?
watch for calcium-containing antacids (AlOH)
assess for poor perfusion
Foods high in calcium:
cheese collard greens milk rhubarb sardines spinach tofu yogurt
Which vitamin increases with calcium increase?
D
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.
Magnesium Levels:
1.8-2.6
HYPOmagnesemia vs. HYPERmagnesemia cerebral:
HYPO: agitation
HYPER: drowsiness, coma
HYPOmagnesemia vs. HYPERmagnesemia cardiac:
HYPO: tachycardia HYPERtension atherosclerosis Long QT left ventricle hypertrophy
HYPER: bradycardia HYPOtension (vasodilation) increased PR shortened QT T wave changes
HYPOmagnesemia vs. HYPERmagnesemia neuromuscular:
HYPO:
tetany
(+) Trousseau’s
(+) Chvostek’s
HYPER:
decreased DTR
lethargy
coma
How does the nurse treat HYPOmagnesemia vs HYPERmagnesemia?
HYPO: IV magnesium replacement
HYPER: diuretics
Dialysis
Calcium Gluconate
Nursing action for HYPOmagnesemia:
ask if the patient is taking Digoxin or if they drink
What is the largest concern for patients with HYPERcalcemia and HYPERmagnesemia?
respiratory arrest
when levels are high, nerves and muscles slow down
Nursing actions for HYPERmagnesemia:
give phosphate
Foods high in magnesium:
avocado canned tuna cauliflower green leafy veggies oatmeal peanut butter peas pork potatoes soy beans raisins yogurt
What do you do if the patient gets air emboli related to a catheter?
place them in Trendelenburg
What should the nurse assess for after an IV placement?
redness swelling tenderness blood return integrity of dressing color
When should IV tubing be replaced?
72-96 hours
IV dressings must be:
dry
intact
occlusive
What is infiltration vs. extravasation?
Infiltration:
leakage of NON-vesicant IV solution into the tissues
Extraversion:
leakage of vesicant IV solution into the. tissues
S&S of infiltration and extravasation:
cool, tight, blanched skin
numbness and pain
Treatment of infiltration:
STOP and remove
elevate
apply warm OR cool compress
document
Treatment of extravasation:
STOP and remove
disconnect tubing
aspirate the medication out
document
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
What could cause phlebitis?
mechanical trauma or bacterial infection
Which catheters can NOT take vesicant medications?
Peripheral IV
Midline
What are considerations with a PICC line?
No heavy lifting
No wheelchairs
No crutches
X ray confirms placement
What are considerations with a non-tunneled CVC?
assess for blood return
watch for air emboli
Which catheter needs a Huber needle to access it?
Implanted ports
You can’t give anything via IV at the same time as ______.
Blood or heparin
What is the only thing you can give with TPN?
lipids and insulin
How should the nurse prevent infection during IV catheter administration?
wear a mask and have the patient look away
If a patient is allergic to_________, they have a high probability of a latex allergy
ABS
Avocado
Banana
Strawberry
-rrhapy
repair
Surgical Timing:
Green: Elective- planned but unessential
Yellow: Urgent- unplanned, requires timely intervention
Red: Emergent- immediate to preserve life/limb
What herb is important to note in a preoperative assessment? Why?
Ginkgo: impacts clotting
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
What are the 4 risk factors for pulmonary complications post-op?
Smoking
COPD
Respiratory infection
Skeletal deformities that impair ventilation
A patient should be NPO _______ hours before surgery.
6-8 hours
Should patients take prescribed medication before surgery?
Yes-unless told otherwise
Why would a bowel/intestinal prep be conducted before surgery?
it reduces the number of intestinal bacteria
Describe how how to use an incentive spirometer (5 steps).
- sit upright
- put in mouth
- raise the ball between the 600-900 mark
- hold a full breath for 5 seconds before breathing out
- repeat 10 times/hour
What does using the incentive spirometer prevent?
atelectasis
What is a non-pharmacological intervention we can use when using the incentive spirometer?
splinting
When should antibiotics be administered pre-op?
30 minutes
What medications can be given pre-op?
the -pams Glycopyrrolate Hyoscine Hydrobromide PPIs Rubinol Supolamine
Scrubbing in:
3-5 minutes
elbows to fingertips
water should drip FROM elbows TO fingertips
solution used is broad spectrum and antimicrobial
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
What is the treatment of malignant hyperthermia?
Dantrolene
What level should you check when patient is getting Heparin?
PTT
goal: 45-70
What should you do if a patient’s PTT is high (>70)?
STOP, they’re taking too long to clot
What should you do if a patient’s PTT is low (<45)?
prepare to give more heparin, they’re clotting too quickly
The _________ gauge catheter should be chosen that suits the prescribed therapy.
smallest
_________ gauge peripheral catheters increase risk of phlebitis
large
How many times can you attempt to put in a catheter?
each clinician can try 2X
max of 4X
What is the max flow rate fora Power PICC?
5mL/sec
What is the most serious complication of a PICC?
thrombophlebitis
