Ch. 3 Flashcards by Kelsey Klipfel

Poisoning
Med conditions: COPD, uncontrolled DM (esp T1DM), chronic kidney disease
Excessive emesis
Prolonged diarrhea
Hyperventilation
Electrolyte imbalances, esp K

Common risk factors - Acid - base imbalance

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Compensation occurs
Kidneys and lungs - balance out the imbalance if have health lungs and kidneys

Physiologic consequences - Acid - base imbalance

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Health hx for chronic illness: DM/COPD; past experiences of acid-base imbalance
s&s that could predispose to imbalances: excessive vomiting/diarrhea
current/recent use meds
ABG monitoring

Assessment - Acid - base balance

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Living healthy lifestyle
Regular exercise
Healthy diet
Control BG in diabetics
At risk for acute/chronic vomiting/diarrhea - monitored carefully by PCP

Health promotion - Acid - base balance

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Diagnose and treat underlying causes of imbalance

Interventions - Acid - base balance

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Older age (55+ with sig potential abnormal cell development at 70+)
Smoking
Poor nutrition
Physical inactivity
Environmental pollutants (air, water, soil)
Radiation
Selected meds (chemo)
Genetic predisposition/risk

Common risk factors - Cellular regulation

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benign/malignant cell growth

Physiologic consequences - Cellular regulation

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Thorough pt hx, fam hx, psychosocial hx
Thorough and detail phys exam - visible/palpable masses, pain, difficulty breathing
Diagnostic tests - identify location of masses
Invasive tests - visualize masses (colonoscopy/EGD)
Lab tests - overall health pt and comp of mass
Grading and staging extent and severity growth necessary for diagnosis, treatment, prognosis

Assessment - Cellular regulation

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Primary prevention: minimizing risk developing impaired cellular regulation
Secondary prevention: proper and regular screening identify any risks/hazards present

Health promotion - Cellular regulation

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Surgery
Radiation therapy
Chemo
Hormonal therapy
Targeted therapy
Biologic therapy
Bone marrow/hematopoietic stem cell transplants
Type and course management depends on type and severe cellular regulation impairment

Interventions - Cellular regulation

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Increased clotting:
Decreased clotting

Common risk factors - impaired clotting

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Immobility
Polycythemia
Smoking
DM
Atrial fibrillation
Aging
Venous stasis

Increased clotting:

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Inadequate number circulating platelets = thrombocytopenia
Chemotherapeutic drugs; corticosteroids - bone marrow suppression
Cirrhosis of liver
Recessive sex-linked hemophilia A and B - defective clotting factor increasing risk for bleeding

Decreased clotting

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increased/excessive clotting
Decreased ability clot

Physiologic consequences - impaired clotting

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venous/arterial blood vessels
Venous thrombosis - most often in legs when deep
If dislodged can travel to brain/lungs

increased/excessive clotting

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Prolonged internal (systemic)/external (localized) bleeding may occur
Internal - brain (hemorrhagic stroke), GI tract (frank/occult blood in stool), UT (hematuria), skin (purpura)
External - expistaxis (nose bleeds)/prolonged bleeding at site of soft tissue trauma

Decreased ability clot

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Decreased clotting
Excessive clotting
Labs to measure clotting factors and bleeding times

Assessment - clotting

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Observe pts for s&s of decreased clotting esp hemorrhagic lesions
Check urine and stool
Observe gums and nose

Decreased clotting

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s&s venous thrombosis

Excessive clotting

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Decreased: report unusual bleeding/bruising immediately
Increased: drink adequate fluids, avoid crossing legs, ambulate frequently and avoid prolonged sitting, smoking cessation, call PCP of experience s&s of VTE

Health promotion - impaired clotting

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Increased risk for clotting: anticoags/antiplatelet drugs - need be in desired range
Direct thrombin inhibitors: decrease risk stroke for afib pts
Monitor for signs bleeding
Continued bleeding can lead to anemia/hemorrhage

Interventions - impaired clotting

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Adv age: dementia not norm change of aging
Brain trauma at any age
disease/disorder such as brain tumor/hypoxia/stroke (infarction)
Enviornmental exposure to toxins such as lead
Substance use disorder
Genetic diseases: Down syndrome
Depression
Opiods, steroids, psychoactive drugs, gen anesthesia, esp in older adults
Fluid and electroly imbalances

Common risk factors - inadequate cognition

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Common s&s
Loss ST and LT memory
Disorientation to person, place, and/or time
Impaired reasoning and decision-making ability
Impaired language skills
uncontrollable/inappropriate emotions: severe agitation and aggression
Delusions and hallucinations
Result in pt safety and communication issues
Communication may not be possible

Physiologic consequences - inadequate cognition

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Thorough hx from either pt/fam essential to determine potential/actual cognitive impairment
Mental status assessment
Diagnostic testing: MRI (determine presence brain abnormalities)
Neuropsychological testing: psychologist

Assessment - cognition

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Avoid risk factors such as substance use and lifestyle behaviors Older adults stimualte intelluctual part of brain learning new activities

Health promotion - inadequate cognition

Safety prevent injury and foster communication With deliurm/mild/early-stage dementia: orientation to person, place, time Mild-to-moderate dementia, esp Alzheimer’s disease: cholnesterase inhibitors prescribed to maintain func for undetermined period of time Collab with interprofessional heathcare team to determine underlying cause of delerium moderate/severe dementia cannot be oriented Psychoactive drug therapy for psychotic behaviors with specific cognitive disorders

Interventions - inadequate cognition

acute/chronic Physical and emotional/psychosocial causes

Common risk factors - decreased comfort

Phys causes: pain, nausea, dyspnea, itching - emotional stress and discomfort fight/flight - cope with source and manifestations of discomfort; not helpful may have persistent pain and anxiety

Physiologic consequences - decreased comfort

Ask pts if comfy If pain source discomfort - assess pain level and plan interventions Emotional stress source - help pt describe nature and cause of stress Once underlying cause(s) identified, coordinate with interprofessional team to treat/remove if possible

Assessment - comfort

Pain and emotional stress most common sources decreased comfort Prevent sensations anticipate which pt may experience them and provide pre-planned interventions

Health promotion - decreased comfort

Alleviate discomfort assessed Collab care with membors of interprofessional team/qualified mental health professional to manage stress Consult with PCP to manage acute and persistent pain, dyspnea, and other sources of impaired comfort

Interventions - decreased comfort

Incontinence occur as result of agining when pelvic muscle floors become weaker As a result neurologic disorders Excessive use laxatives Chronic inflammatory bowel diseases Urinary retention - BPH Retention of stool/obstipation: older adults; lack of fiber and fluids; lack of exercise; certain meds; diuretics; psychoactive drugs; SCI; brain injury Renal and urinary health probs - CKD

Common risk factors - changes in elimination

Risk damage to tissue integrity - skin irritation, fungal infection, skin breakdown Lead to depression and anxiety embarrassed/humiliated Fluid and electrolyte imbalances - dehydration and hypokalemia Buildup of toxins and waste products Rupture of bladder UTI Bowel impaction and partial/total intestinal obstruction - can be life threatening

Physiologic consequences - consequences of changes in elimination

Pt hx Assess perineal area and buttocks for breakdown, redness, fungal infection Frequency, amount, consistency, characteristics urine and stool BS in all 4 quads Palpate bowel and bladder for distention Lab testing of urine/stool Radiologic testing and US - stones/structural abnormalities Bladder scanning - urinary retention - results in UTI Stool culture and sensitivity - suspected C. diff

Assessment - elimination

Adequate nutrition and hydration High in fiber and 8-12 glasses water each day Promptly toilet/void when urge occurs Exercise frequently

Health promotion - changes in elimination

s&s fluid and electrolyte imbalances Stool softeners, bulk-forming agents, and/or mild laxatives; enemas Frequent toileting Straight urinary catheterizations

Interventions - changes in elimination

Acute illnesses: v&d Severe burns Serious injury/trauma CKD Major surgery Poor nutritonal intake Older adults

Common risk factors - Fluid and electrolyte imbalance

Fluid deficit Fluid excess Electrolyte deficit/excess

Physiologic consequences - Fluid and electrolyte imbalance

Result poor perfusion and O2 delivery Hypotension Tachycardia Peripheral pulses weak and treaty Severe dehydration - fever due to inadequate body water Older - delirium Not managed, kidney func diminishes AEB decreased urinary output

Fluid deficit

HTN Peripheral pulses strong and bounding Peripheral edema Third spacing

Fluid excess

Depends on electrolyte

Electrolyte deficit/excess

Complete health hx and any risk factors Any current episodes n/v/d Current use meds Monitor VS: changes weight best indicator fluid volume Assess skin and mucous membranes Lab tests

Assessment - Fluid and electrolyte balance

Drink adequate fluids: 8+ glasses water Older adults not feel thirsty - imp still drink Well-balanced diet

Health promotion - Fluid and electrolyte imbalance

Maintain safety and comfort Fluid deficit - primary collab intervention is fluid replacement - orally/parenterally Fluid overload - fluid restriction; diuretic therapy Interprofessional collab for electrolyte imbalance depends on electrolyte messed up; electrolyte deficits increased and excesses restricted

Interventions - Fluid and electrolyte imbalance

acute/chronic probs affect CNS, norm diaphragm func, adequate skeletal muscle contractility, and chest thorax can cause decreased ventilation Age - alveoli lose elasticity Health probs affect lung functioning Prolonged immobility

Common risk factors - decreased Gas exchange

Inadequate transport O2 to body cells and organs and/or retention of CO2 Inadequate O2: cell dysfunc (ischemia) and possible cell death (necrosis/infartion) Excessive buildup CO2 combines with water to produce carbonic acid: lowers pH of blood

Physiologic consequences - decreased Gas exchange

Complete health hx; focused resp assessment current/hx lung disease/trauma Assess breathing effort, O2 sat, cap refill, thoracic expansion, lung sounds antiorly and posteriorly Lab results CXR, CT, V/Q scan may be performed - presence and severity disease Bronchoscopy - direct visualization of bronchus and extending structures

Assessment - Gas exchange

Infection control Smoking cessation Immunizations Aware exposure to specific resp conditions

Health promotion - decreased Gas exchange

Finding underlying cause and treating it; often with drug therapy Chest expansion improved when sitting/semi-Fowlers position Need for deep breathing and coughing for further enhance lung expansion and breathing effort Correctly use IS and inhalers Admin O2 and pulse ox

Interventions - decreased Gas exchange

Older adults Low socioeconomic groups (inability obtain proper immunizations) Nonimmunized adults Adults with chronic illnesses that weaken the immune sys Adults taking chronic drug therapy such as corticosteroids and chemotherapeutic agents Adults experiencing substance use disorder Adults not prac healthy lifestyle Adults genetic risk for decreased/excessive immunity

Common risk factors - changes in Immunity

Decreased immune response susceptible to multiple types of infection Excessive response: allergies/autoimmune rxns/diseases

Physiologic consequences - changes in Immunity

Thorough hx of indiv and fam necessary determine previous risks Identify pt allergies, current meds, hx environmental exposures Ask about immunization hx Assess weight, adequate wound healing, cognition, allergic responses, potential/acutal organ dysfunc Monitor lab tests: CBC, CRP, ESR, allergy testing Complete immune panel Specific tests - see if HIV antibodies present

Assessment - Immunity

Avoid infection Frequent handwashing Immunizations Healthy lifestyle Reg phys exams Avoid environmental hazards

Health promotion - changes in Immunity

Decreased immune sys: avoid large crowds/someone who is sick; wash hands frequently Excessive immune sys: interprofessional collab; EO: decrease symp and promote quality of life; remission of health prob can occur but not a cure

Interventions - changes in Immunity

Immunocomprosed by disease: HIV/treatment: chemo (aka opportunistic infections) Have chronic illnesses: COPD/DM Adv age Live in crowded/unsanitary environment Ingest contaminated food/water Impaired tissue integrity Exposed to indivs who have highly contagious infections Experience continuous/frequent stress

Common risk factors - Infection

Localized: inflammation; does not respond to treatment; may spread and affect body leading to systemic infection Systemic: affects entire body; fever and increased WBC (leukocytosis); if not treated or not improved = sepsis and get hypotension and organ failure

Physiologic consequences - Infection

Thorough hx determine risk and exposure Observe for s&s of infection’ Ask about changes in elimination Monitor lab results: elevated WBC count with differential (esp lymphocytes and neutrophils); increased ESR; increased CRP; + culture and sensitivity

Assessment - Infection

Primary prevention: prevent infection Secondary prevetnion: screening for existing infections

Health promotion - Infection

Sometimes need medical, nursing, and collab interventions including: antimicrobial drug therapy, increased fluids and electrolytes, sufficient rest, adequate nutrition

Interventions - Infection

Anyone at risk because norm rxn to injury Pts at risk for allergy/chronic inflammatory diseases more suscpetible to chronic inflammation

Common risk factors - Inflammation

Closely r/t immune func s/s: redness, warmth, swelling, pain/discomfort widespread/severe: Loss func of affected part(s) of body may occur Func of organs/parts body also decrease/impaired

Physiologic consequences - Inflammation

Localized: s/s: redness, warmth, swelling, pain/discomfort Inflammation not observable - confined to inside body - monitor for s/s of organ dysfunc Serum tests - measure WBC with differential, CRP, ESR indicate presence inflammation Direct visualization via endoscopy allows observe s&s and extent inflammation

Assessment - Inflammation

Avoid injury

Health promotion - Inflammation

RICE: Rest, ice, compression, elevation Check distal circ in affect extremity to ensure perfusion Swelling impair circ leading to ischemia Systemic inflammation: NSAIDS, antipuretics, corticosteroids, biologic response modifiers Allergic symp: antihistamines, decongestants

Interventions - Inflammation

Dysfun of MS/NS at risk Severe brain/SCI Bedridden or prolonged bed rest

Common risk factors - decreased Mobility

Decreases in mobility/total immobility for few days = serious and life-threatening comps

Physiologic consequences - decreased Mobility

Observe pts to determine mobility level Sev fxnal assessment tools available to measure level performance of ADLs Assess muscle strength and ROM

Assessment - Mobility

Assess who are most at risk for decreased mobility Teach do active ROM q2h; assess and manage pain to promote more comfy movement Teach heel pump activities and drink adequate fluids to prevent VTE Collab with OT to eval ablity ADL Eval need for ambulatory aid; encourage ambulate; talk with PT

Health promotion - decreased Mobility

Passive ROM immobile Turn and reposition pts q1-2hrs PRN; assess skin redness and intactness Keep pt’s skin clean and dry Use pressure-relieving and pressure-reducing devices Ensure adequate nutrition Eat high-Ca foods; avoid high-cal foods Encourage deep-breathing and coughing; teach how and when use IS Need adequate hydration to prevent renal calculi and constipation Report s&s comps of immobility Collab with PT to ambulate pt with mobility aids

Interventions - decreased Mobility

Older adults - acute and chronic diseases, poor oral health, social isolation Lack of money to purchase health food and substance use Adults with anorexia and bulimia nervosa

Common risk factors - decreased Nutrition

Whether indiv has generalized malnutrition/lack specific nutritnets Deficit - bone demineralization Adults - not eat meat or other sources iron: iron-deficiency anemia Low serum protein: esp albumin and prealbumin: generalized edema: exert osmotic pull; when decrease get third spacing

Physiologic consequences - decreased Nutrition

Complete pt and fam hx of risk factors current/recent GI symp Obtain height, weight, calc BMI Assess skin, hair, nails Serum lab - prealbumin and albumin measurement

Assessment - Nutrition

Healthy lifestyle: regular exercise and adequate nutrients inadequate/decreased nutrition: collab with interprofessional team to implement appropriate interventions team to implement appropriate interventions

Health promotion - decreased Nutrition

Weight loss/low weight: high-protein oral supplements, enteral supplements, parenteral nutrition; collab with nutritionist regarding enteral feedings and consult with pharmacist on parenteral nutrition; drug therapy: iron/vit D replace selected nutritents must be given; weigh once/week; same scale, same time of day (before breakfast) Obesity: drug therapy to lose weight; bariatric surgical procedures needed restrict volume food can be ingested and/or decrease absorptive area for nutrients

Interventions - decreased Nutrition

Acute trauma Chronic diseases

Common risk factors - Pain

Acute: 1+ SNS s&s: vomiting, nausea, sweating, HTN, RR, pulse, dilated pupils Persistent pain - not cause fight/flight of acute; can cause psychosocial issues: anxiety and depression

Physiologic consequences - Pain

Lcoation of pain and whether radiates/referred to other areas of body Intensity of pain using one of several valid and reliable pain assessment tools Quality of pain Onset and duration pain Aggravating and precipitating factors that cause pain Effects of pain on QOL and daily func Psychosocial effects of pain

Assessment - Pain

Avoid high-risk activities help prevent trauma from accidental injury and prevent severe acute pain

Health promotion - Pain

Pharmacologic: analgesics: nonopioid and opioid Nonpharmacologic: depends on pt preferences

Interventions - Pain

Modifiable: smoking, lack phys activity, obesity, hyperlipidemia, DM, peripheral vascular disease, atherosclerosis Nonmodifiable: age, gender, fam hx

Common risk factors - decreased Perfusion

Distal legs become cool and pale/cyanotic Pedal pulses - diminished/absent - may get skin ulcers/cell death Central perfusion: life-threatening systemic events like MI, stroke, shock

Physiologic consequences - decreased Perfusion

Conduct pt and fam hx and existing probs with perfusion Assess s&s central: dyspnea, dizziness/syncope, chest pain, decreased CO Peripheral: decreased hair distribution, nonlocalized and diffuse pain/discomfort, coolness, pallor and/or cyanosis of extremities Doc presence and quality of distal peripheral pulses - severe impaired can lead to absent to arterial occlusion

Assessment - Perfusion

Identify modifiable risk factors Teach importance heart-health lifestyle Encourage obtain frequent screening, monitor BP, relevant lab work

Health promotion - decreased Perfusion

Vasodilating drugs promote blood flow Vascular intervention to open occluded/narrowed artery

Interventions - decreased Perfusion

Age Chronic diseases: DM, HTN direct/mechanical trauma, genetic risk, cranial nerve II damage, drug therapy (antihistamines and antihypertensives) Hearing: direct phys trauma, cranial nerve VIII damage, occupation factors, genetic risk, drugs ototoxic

Common risk factors - Sensory perception

Visual and hearing acuity loss not corrected at risk for phys injury - not able perform ADLs or ambulate independently Hearing - not able rely on verbal communication Visually - not able use written communication

Physiologic consequences - Sensory perception

Thorough pt and fam hx About use eyeglasses/contacts/magnifiers - if used determine effectiveness Ask if uses hearing aids - if used determine effectiveness Ask read form written text - assess ability read before requesting screen Whisper test

Assessment - Sensory perception

Primary: avoiding risk factors; use protective devices; health lifestyle Secondary: screening and diagnostic tests for early detection

Health promotion - Sensory perception

Glaucoma: drug therapy (local/systemic) decrease IOP and prevent loss vision Corrective lenses/LASIK improve refractory vision Glasses and contact lenses Hearing aids Guide dogs and/or braille Deaf - CC, assistive listening devices, sign language Assess self-image, anxiety; consult to qualified member

Interventions - Sensory perception

Poor sexual health/lack sex Menopause - more + sexuality/vaginal atrophy and moodiness leading to - experience Men with issues with erection or prostate probs have poor self-concept Get older risk for ED increases Drug therapy (antihypertensives), chronic diseases (DM), decreased testosterone contribute to ED

Common risk factors - changes in sexuality

May not be physiologic May be do to poor self-image and self-concept Sexual intimacy imp

Physiologic consequences - changes in sexuality

Ask pts about perception of sexuality including sexual activity and intimacy behaviors Detemrine if have sex and/or intimacy with 1+ partners Ask about protection methods and hx STIs/probs during sex

Assessment - sexuality

STI screening; phys exams determine any phys cause changes in sexuality Assess for self-concept r/t issues/other intimacy concerns

Health promotion - changes in sexuality

ED/STIs - drug therapy and other measures emotional/psychological factors - PCP

Interventions - changes in sexuality

Occur at any age; older adults increased risk Malnutrition Neurologic disorders DM Peripheral vascular disease Urinary and bowel incompetence Immune suppression

Common risk factors - changes in Tissue integrity

Localized (cellulitis)/systemic (sepsis) infection

Physiologic consequences - changes in Tissue integrity

Thorough health hx of previous and current health probs and current meds Assess change in skin color, moles/lesions, excessive skin dryness, bruising, hair loss/brittle nails Risk for pressure injury = Braden scale Document existing tissue impairment Monitor serum albumin and prealbumin - adequate protein for healing

Assessment - Tissue integrity

Proper hygiene and nutrition Inspect skin every day Keep skin clean and dry Moisturize skin to avoid dryness Confined to bed/chair change position q1-2h Lie on pressure reducing surface Wear wide-brim hats, long- sleeves, long pants Wear sunscreen to prevent cancer Sunglasses protect eyes

Health promotion - changes in Tissue integrity

Preventative interventions Ensure adequate diet and nutritional supplements for healing Protein and vit C esp imp for preventing skin breakdown and promoting healing of existing wounds Drug therapy Chem and surgical debridement

Interventions - changes in Tissue integrity