Exam 1 Flashcards
Med-Surg Nursing
Provides nursing care in variety of inpatient and outpatient settings from adolescents to end-of-life care
Rehabilitation Nursing
Focuses on returning patients to optimal functionality through a holistic approach to care that is based on scientific evidence
* Disability: considered severe if the person cannot perform one or more activities, receives federal benefits because of an inability to work, uses an assistive device for mobility, or needs help from another person to accomplish basic activities.
* Assistive technology: to incorporate devices to improve the functional capabilities of people with disability; these may include any item, piece of equipment, or product system that may be acquired commercially, off the shelf, modified, or customized
Rehab Goals
- Identify, reach and maintain optimal physical, sensory, intellectual, psychological, and social functional levels
- Focus on existing abilities to facilitate independence, self-determination, and social integration
- Goal is to assist patient to attain and maintain optimum health as defined by patient
- Maximize independence and prevend secondary disability, promote quality of life acceptable to patient
Health Promotion
- do not neglect health promotion issues
- healthy diet
- exercise
- social interaction
- preventive health screening
Chronic Illness
Conditions that last 1 year or more and require ongoing medical attention or limit activities of daily living or both
* Leading cause of death and disability in US
* Irreversible, having prolonged course, and unlikely to resolve spontaneously - learn to live with it
* Medical conditions or health problems with associated symptoms that require long-term (3 mo. or longer) management
Causes
* lifestyle factors - tobacco, alcohol
* obesity
* longer lifespans
* improved screening, diagnostic procedures
Challenges
* managing symptoms, including psychological
* return to satisfactory way of life after acute debilitating episode or reactivation of chronic condition
* carry out regimens as prescribed
Nursing Process
* Identify specific problems, trajectory phase
* Focus on: Regimens to control symptoms, avoid complications and psychosocial issues that affect quality of life
* Assessing status, managing meds, lots of education for regimen, have access to resources
* more interconnected care with other healthcare providers
Acute Illness
Generally develop suddenly and last a short time, often only a few days or weeks - less than 6 months
Pain
- unpleasant sensory, emotional experience with actual or potential tissue damage
- personal or subjective experience
- patient is more reliable indicator of pain
- most common reason to seek healthcare
Assessing Pain for Specific Populations
- The Hierarchy of Pain Measures - nonverbal patient
- FLACC - young children
- PAINAD - patients with advanced dementia
- CPOT - patients in critical care units
Pain Scales
- Numeric Rating
- Wong-Baker
- Faces Pain Scale
- Verbal Descriptor
- Visual Analog
Numeric Rating Scale
Horizontal 0- to 10-point scale, with word anchors of “no pain” at one end of the scale, “moderate pain” in the middle of the scale, and “worst possible pain” at the end of the scale
Wong-Baker Faces
Six cartoon faces with word descriptors, ranging from a smiling face on the left for “no pain (or hurt)” to a frowning, tearful face on the right for “worst pain (or hurt).
Faces Pain Scale
Six faces to make it consistent with other scales using the 0 to 10 metric. Preferred by both patients who are cognitively intact and older adults who are cognitively impaired, and by minority populations
Verbal Descriptor Scale
Uses different words or phrases to describe the intensity of pain, such as “no pain, mild pain, moderate pain, severe pain, very severe pain, and worst possible pain.”
Visual Analog Scale
A horizontal (sometimes vertical) 10-cm line with word anchors at the extremes, such as “no pain” on one end and “pain as bad as it could be” or “worst possible pain” on the other end. Patients are asked to make a mark on the line to indicate intensity of pain, and the length of the mark from “no pain” is measured and recorded in centimeters or millimeters
Types of Pain
- Acute: Short duration, usually resolves with treatment; result of tissue damage, surgery, or trauma
- Chronic: Can be time limited or last a lifetime
- Breakthrough: Chronic pain with acute exacerbations
Pharmaclogic Treatments for Pain
Nonopioid
* acetaminophen
* NSAIDS: ibuprofen, naproxen, celecoxib
Opioid
* Mu agonist: morphine, hydromorphone, fentanyl, oxycodone
* Agonist-antagonist: buprenorphine, nalbuphine, butorphanol
Adjunctive Analgesics for Pain
- local anesthetics: lidocaine patch
- anticonvulsants: gabapentin, pregabaliin
- antidepressants: TCAs and SNRIs
- ketamine
Nonpharm Pain Management
- physical modalities: TENS, hot and cold, massage, acupuncture, chiropractor, PT
- CBT: relaxation, distraction, music, imagery, humor, pet therapy, prayer, meditation, hypnosis
- movement: yoga, tai chi
- biological based therapies: herbs, vitamins, proteins, aromatherapy, diet
- energy: therapeutic touch, reiki
- gate control theory
Goals of Pain Management
- effective and safe analgesia
- optimal relief
- comfort function goal
- pharmacologic therapy is multimodal: combines medications with different underlying mechanisms, along with nonpharmacologic interventions, which allows for lower doses of each of the medications in the treatment plan, reducing the potential for adverse effects
Breakthrough Pain Management
Chronic pain with acute exacerbations
A short-acting opioid that is 5 to 20 percent of the dose you normally take to manage chronic pain - rescue med
* prevent pain by using nonpharm methods
Managing a Patient with Epidural
A more invasive method used to manage pain is accomplished using neuraxial analgesia
* Epidural analgesia is administered by clinician-given bolus, continuous infusion (basal rate), and patient-controlled epidural analgesia (PCEA).
* Nursing care for patients receiving epidural analgesia focuses on safely administering analgesia, achieving optimal pain control, and identifying and managing adverse reactions or complications.
* Closely monitor patients receiving epidural analgesia, including vital signs, pain intensity rating, sedation score, and degree of motor and sensory block
* Assess the patient for signs and symptoms of complications associated with the use of epidural analgesia including hypotension, nausea and vomiting, urinary retention, and motor block.
Disability Nursing Management
- assistance with carrying out ADLs
- effective communication strategies for those with hearing/vision loss
- people-first language
- Ramps, grab bars, and raised and padded toilet seats
Older Adult and Changes in Functional Decline
under-nutrition and dehydration, decreased mobility and loss of independence, accelerated bone loss, delirium and depression, pressure ulcers and skin tears and incontinence
Body Changes in Older Adults
- lose lean muscle
- atrophy in organs
- bones become less dense
- body fat increases, towards center of body
- stiffer joints
- cells unable to replace themselves, accumulate lipofuscin
- tisses become stiffer and less elastic with degradation of elastin and collagen
- increasing anemia
Cardiovascular System and Aging
- heart disease - leading cause of death
- reduced efficiency and decreased compliance
- myocardial hypertrophy, increased fibrosis and calcified tissues
- heart valves become thicker and stiffer, and the heart muscle and arteries lose their elasticity, resulting in a reduced stroke volume
- Ca and fat in arterial walls and veins - hypertension and increase workload
- dyspnea or neurologic symptoms associated with heart disease
Respiratory System and Older Adults
Problems
* increase in residual lung volume
* decrease in muscle strength, endurance, and vital capacity
* decreased gas exchange and diffusing capacity
* decreased cough efficiency, difficult coughing excretions
NC
* Exercise regularly; avoid smoking; take adequate fluids to liquefy secretions; receive yearly influenza immunization and pneumonia vaccine at 65 years of age; avoid exposure to upper respiratory tract infections
Integumentary System and Older Adults
Problems
* Decreased subcutaneous fat, interstitial fluid, muscle tone, glandular activity, and sensory receptors, resulting in atrophy
* decreased protection against trauma, sun exposure, and temperature extremes
* diminished secretion of natural oils and perspiration
* capillary fragility
NC
* Limit sun exposure to 10–15 min daily for vitamin D (use protective clothing and sunscreen); dress appropriately for temperature; stay hydrated; maintain a safe indoor temperature; take shower rather than hot tub bath if possible; lubricate skin with lotions that contain petroleum or mineral oil
Reproductive System and Older Adults
- Vaginal narrowing and decreased elasticity; decreased vaginal secretions
- Gradual decline in fertility, less firm testes, and decreased sperm production
Musculoskeletal System and Older Adults
- Loss of bone density; loss of muscle strength and size; degenerated joint cartilage
- Height loss; prone to fractures; kyphosis; back pain; loss of strength, flexibility, and endurance; joint pain
Gastrointestinal System and Older Adults
- Difficulties with chewing and swallowing are generally associated with lack of teeth and diseases
- Gastric motility appears to slow modestly, which results in delayed emptying of stomach contents and early satiety (feeling of fullness)
- Dysphagia increases
- Constipation common
Genitourinary System and Older Adults
- Urinary retention; irritative voiding symptoms including frequency, feeling of incomplete bladder emptying, multiple nighttime voiding
- Male: Benign prostatic hyperplasia
- Female: Relaxed perineal muscles; detrusor instability leads to urge incontinence; urethral dysfunction (stress urinary incontinence)
Nervous System and Older Adults
- Slower to respond and react
- learning may take longer
- increased vulnerability to delirium with illness, anesthesia, even changes in environmental cues such as a room change
- increased risk of fainting and falls
Special Senses and Older Adults
Vision
* diminished ability to focus on close objects; decreased ability to tolerate glare; pupils become more rigid and lenses more opaque; decreased contrast sensitivity; decrease in aqueous humor
Hearing
* decreased ability to hear high-frequency sounds; tympanic membrane thinning and loss of resiliency; difficulty with sound discrimination especially in noisy environment
Taste and Smell
* Decreased recognition of familiar smells including recognizing spoiled food or a gas stove left on; decreased enjoyment of food; uses excessive sugar and salt
Geriatric Syndromes: Risk Factors/Risks
- impaired mobility: causes include strokes, Parkinson’s disease, diabetic neuropathy, cardiovascular compromise, osteoarthritis, osteoporosis, and sensory deficits. - should stay as active as possible
- dizziness: inability to differentiate between true dizziness and vertigo
- falls and falling: Mobility difficulties, polypharmacy, medication effects, foot problems or unsafe footwear, orthostatic hypotension, visual problems, and tripping hazards
- urinary incontinence: Transient causes may be attributed to delirium and dehydration; restricted mobility; inflammation, infection, and impaction; and pharmaceuticals and polyuria
- increased susceptibility to infection: Blunted response of host defenses caused by a reduction in both cell-mediated and humoral immunity
- atypical responses: The response to pain in older adults may be lessened because of reduced acuity of touch, alterations in neural pathways, and diminished processing of sensory data.
- altered emotional impack: Older adults admitted to the hospital are at high risk for disorientation, confusion, change in level of consciousness, and other symptoms of delirium, as well as anxiety and fear.
- altered systemic response: Older adults may be unable to respond effectively to an acute illness or, if a chronic health condition is present, they may be unable to sustain appropriate responses over a long period.
Pathological Aging: AD
- Forgetfulness is manifested in many daily actions; patients may lose their ability to recognize familiar faces, places, and objects and they may become lost in a familiar environment.
- Primary goal is to help maintain mental function as well as manage the cognitive and behavioral symptoms, and slow down the symptoms of the disease.
- Promoting the patient’s physical safety, promoting independence in self-care activities, reducing anxiety and agitation, improving communication, providing for socialization and intimacy, promoting adequate nutrition, promoting balanced activity and rest, and supporting and educating family caregivers.
Physical Assessments
- general observations: posture, nutritional status, body movements, speech patterns
- vital signs
- focused assessment of all body systems
- inspection, auscultation, palpation, percussion
Nutritional Assessment
BMI: Ratio based on body weight and height
* Less than 18.5: risk of problems associated with poor nutrition
* Between 25-29.9: considered overweight
* 30 or more: obese
Weight Circumference: High waist circ puts patients at risk for diabetes, dyslipidemia, HTN, heart attack, and stroke
* males: more than 40 in
* females: more than 35 in
Biochemical Measurements
* Serum prealbumin and albumin, Serum transferrin and retinol-binding protein, CBC, electrolytes, urine test
Indicators of nutritional status
* general height/appearance, skin/hair/nails, mouth: teeth/tongue/gums, thyroid, musculoskeltal, abdomen
Dietary data
* 24 hr food recall
Cultural Assessment
A systematic appraisal or examination of individuals, families, groups, and communities in terms of their cultural beliefs, values, and practices, cultual assessment tool
* communication
* space
* social organization
* time
* environmental control
* biological variations
CBC
WBC
* Immunity - the defense system of the body to fight infection.
* Normal: 5,000 - 10,000
RBC
* 4 - 6 million
* Low: Anemia, Renal Failure
* High = Dehydration
Hemoglobin
* oxygen carriers on the red blood cells
* Normal: 12-18
* 8-11: Bleeding & Anemia, Malnutrition, Cancers
* Below 7: Pale skin: pallor, dusky skin tones, Cool clammy skin, fatigue and weakness - need blood transfusion
Hematocrit
* Normal: 36 - 54%
* Elevated Hct: Dehydration
* Decreased Hct: bleeding, anemia, malnutrition
Platelets
* Blood clotting proteins that help to stop bleeding by forming scabs, but also creates blood clots
* Normal: 150,000 to 450,000
* Elevated: thrombocytosis and blood clots
* Decreased: thrombocytopenia and bleeding
Metabolic Panel
Measures 14 different substances in your blood
Provides important information about your body’s chemical balance and metabolism
* glucose, calcium, total protein, bilirubin, BUN, creatinine, albumin, sodium, potassium, bicarb, chloride, ALP, ALT, AST
Renal Functioning Labs
H+ Ions: in renal failure will be high or low
* increase: metabolic acidosis
* decrease: metabolic alkalosis
Urea/BUN: biproduct of protein waste
* Normal: 10-20
* Elevated: dehydration
Creatinine: waste product from muscles
* Elevated over 1.3: can clog kidneys - kidney impairment
Urine Specific Gravity
* 1.003-1.030
Urine less than 30mL/hr - bad kidneys
Liver Functioning Labs
- Alanine transaminase (ALT). ALT is an enzyme found in the liver that helps convert proteins into energy for the liver cells. When the liver is damaged, ALT is released into the bloodstream and levels increase.
- Aspartate transaminase (AST). AST is an enzyme that helps metabolize amino acids. Like ALT, AST is normally present in blood at low levels. An increase in AST levels may indicate liver damage, disease or muscle damage.
- Alkaline phosphatase (ALP). ALP is an enzyme found in the liver and bone and is important for breaking down proteins. Higher-than-normal levels of ALP may indicate liver damage or disease, such as a blocked bile duct, or certain bone diseases.
- Albumin and total protein. Albumin is one of several proteins made in the liver. Your body needs these proteins to fight infections and to perform other functions. Lower-than-normal levels of albumin and total protein may indicate liver damage or disease.
- Bilirubin. Bilirubin is a substance produced during the normal breakdown of red blood cells. Bilirubin passes through the liver and is excreted in stool. Elevated levels of bilirubin (jaundice) might indicate liver damage or disease or certain types of anemia.
- Prothrombin time (PT). PT is the time it takes your blood to clot. Increased PT may indicate liver damage but can also be elevated if you’re taking certain blood-thinning drugs, such as warfarin.
Coag Labs
Coagulation tests measure your blood’s ability to clot, and how long it takes to clot.
* APTT (activated partial thromboplastin time) – measures one part of the clotting pathway known as the “intrinsic pathway”
* INR (international normalised ratio) – measures one part of the clotting pathway known as the “extrinsic pathway”
* Fibrinogen – this protein is a precursor to fibrin, which is an essential part of a blood clot.
Glucose Test
Measures the glucose levels in your blood
* High: possible diabetess, hyperthyroidism, pancreas disorder, stress from surgery or trauma
* Low: liver disease, kidney disease, hypothyroidism, alcohol use disorder
Lipid Panel
- Total cholesterol: This is your overall cholesterol level — the combination of LDL-C, VLDL-C and HDL-C.
- Low-density lipoprotein (LDL) cholesterol: This is the type of cholesterol that’s known as “bad cholesterol.” It can collect in your blood vessels and increase your risk of cardiovascular disease.
- Very low-density lipoprotein (VLDL) cholesterol: This is a type of cholesterol that’s usually present in very low amounts when the blood sample is a fasting samples since it’s mostly comes from food you’ve recently eaten. An increase in this type of cholesterol in a fasting sample may be a sign of abnormal lipid metabolism.
- High-density lipoprotein (HDL) cholesterol: This is the type of cholesterol that’s known as “good cholesterol.” It helps decrease the buildup of LDL in your blood vessels.
- Triglycerides: This is a type of fat from the food we eat. Excess amounts of triglycerides in your blood are associated with cardiovascular disease and pancreatic inflammation.
Urine Specific Gravity
Measures the density of urine compared to water. It is a measure of the concentration of solutes in the urine. Assesses kidneys ability to excrete water
* Normal: 1.005-1.030
Homeostatic Mechanisms: Kidneys
Major functions in order to maintain fluid balance
* Regulation of ECF volume and osmolality by selective retention and excretion of body fluids
* Regulates electrolytes and pH
* Excretion of metabolic wastes and toxic substances
Homeostatic Mechanisms: Heart
The pumping action of the heart circulates blood through the kidneys under sufficient pressure to allow for urine formation.
Homeostatic Mechanisms: Lungs
Exhalation: removes 300mL of water daily (insensible water loss)
* Decrease breathing rate = more CO2, more acidic
* Increase breathing rate = less CO2, less acidic
Homeostatic Mechanisms: Pituitary
Hypothalamus makes ADH – stored in posterior pituitary and released as needed to conserve water
* ADH - secreted when dehydration or blood loss is present
Homeostatic Mechanisms: Adrenal
Cortisol secreted produces sodium and fluid retention
Aldosterone secreted by zona glomerulosa
* Increased secretion: sodium retention, potassium loss
* Decreased: sodium loss, potassium retention
Homeostatic Mechanisms: Baroreceptors
Respond to changes in blood volume and regulate symp and parapsymp activity
* Decrease in impulses stim SNS -> stim SA node
* Increase HR, conduction, and contractility
* Constricts renal arterioles, triggers renin release and stim of RAAS system
Homeostatic Mechanisms: RAAS
Kidney’s sense low profusion -> secrete renin
II stim adrenal gland to secrete aldosterone -> increases Na and water reabsorption at nephron
* raises blood volume and BP
HM: Antidiuretic Hormone and Thirst
As serum concentration or osmolality increases or blood volume decreases, neurons in the hypothalamus are stimulated by intracellular dehydration; thirst then occurs, and the person increases their intake of oral fluids.
HM: Osmoreceptors
Osmotic pressure increases -> neurons become dehydrated and release impulses to posterior pituitary to release ADH
* This causes reabsorption of water and decreased urine output
HM: Natriuretic Peptide
Affect fluid volume and cardiovascular function through natriuresis (the excretion of sodium), direct vasodilation, and the opposition of the renin–angiotensin–aldosterone system.
Hypovolemia
Patho
* Loss of ECF volume exceeds the intake of fluid
Causes
* abnormal fluid losses from vomiting, diarrhea, GI suctioning, and sweating
* decreased fluid intake
* DI
* adrrenal insufficiency
* osmotic diuresus
* hemorrhage
* coma
Assessment
* HIGH: H&H, serum and urine osmolality and specific gravity, BUN and creatinine (greater than 20:1), urine specific gravity and osmolarity
* LOW: low urine sodium
S/S
* weight loss, decreased skin turgor, oligouria, conc urine, low BP, flattened neck veins, thirst, confusion, high pulse, muscle cramps, high temp, cool/clammy/pale skin
Prevention: Identifies patients at risk and takes measures to minimize fluid losses
NM
* I&Os every 8 hrs, or hourly
* skin and tongue monitored - longitudinal furrows
* mental functioning - decreasing cerebral perfusion
* oral fluids, oral rehydration solutions
Hypervolemia
Patho
* Simple fluid overload or diminished function of the homeostatic mechanisms
Causes
* heart failure
* kidney dysfunction, cirrhosis, excessive salt
S/S
* Edema, distended jugular veins, and crackles (abnormal lung sounds due to interstitial pulmonary fluid)
* high BP, high RR, high urine output
Assessment
* LOW H&H, serum and urine osmolality, urine sodium and specific gravity, BUN
Prevention: sodium-restricted diets
NM
* diuretics
* restrict sodium
* may have increased protein intake
* I&Os, weighed daily
* restore intravascular volume
Hyponatremia
Patho
* less than 135
* imbalance of water
S/S
* Poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping
* Neurologic changes, including altered mental status, status epilepticus, and coma, are related to the cellular swelling and cerebral edema
* Anorexia, muscle cramps, and a feeling of exhaustion
Assessment
* serum osmolality decreased
* Lack of Na ingestion: urinary Na content = less than 20 and specific gravity is low - 1.002 to 1.004
* SIADH: urinary sodium content is greater than 20 mEq/L, urine specific gravity is usually greater than 1.012
NM
* sodium replacement
* water restriction
* monitor I&Os
Hypernatremia
Patho
* more than 145
* Caused by a gain of sodium in excess of water or by a loss of water in excess of sodium.
Causes
* DI: can lead to lack of adequate reabsorption of water into the bloodstream
* heatstroke
* nonfatal drowning in seawater
S/S
* Skin: flushed, edema, low grade fever
* excess thirst
* dry tongue
* N/V
* increased muscle tone
Assessment
* Serum osmolality exceeds 300 mOsm/kg (300 mmol/L)
* The urine specific gravity and urine osmolality are increased as the kidneys attempt to conserve water
NM
* hypotonic solutions
* Observing for changes in neurologic status, such as confusion, disorientation, and possible decreased level of consciousness
* Don’t want rapid reduction – could cause cerebral edema
