Ch. 3 Flashcards
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
Compensation occurs
Kidneys and lungs - balance out the imbalance if have health lungs and kidneys
Physiologic consequences - Acid - base imbalance
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
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
Diagnose and treat underlying causes of imbalance
Interventions - Acid - base balance
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
benign/malignant cell growth
Physiologic consequences - Cellular regulation
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
Primary prevention: minimizing risk developing impaired cellular regulation
Secondary prevention: proper and regular screening identify any risks/hazards present
Health promotion - Cellular regulation
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
Increased clotting:
Decreased clotting
Common risk factors - impaired clotting
Immobility
Polycythemia
Smoking
DM
Atrial fibrillation
Aging
Venous stasis
Increased clotting:
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
increased/excessive clotting
Decreased ability clot
Physiologic consequences - impaired clotting
venous/arterial blood vessels
Venous thrombosis - most often in legs when deep
If dislodged can travel to brain/lungs
increased/excessive clotting
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
Decreased clotting
Excessive clotting
Labs to measure clotting factors and bleeding times
Assessment - clotting
Observe pts for s&s of decreased clotting esp hemorrhagic lesions
Check urine and stool
Observe gums and nose
Decreased clotting
s&s venous thrombosis
Excessive clotting
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
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
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
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
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
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
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
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
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
