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Adult Health Nursing II > Exam 2 > Flashcards

Exam 2 Flashcards

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1
Q

Cognition

A

Integration of mental processes and intellectual function

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2
Q

Cognition is necessary for…

A

Reasoning, learning, memory, personality

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3
Q

S/S of Impaired Cognition

A

Loss of short/long term memory

Disorientation to person, place, time, and/or situation

Impaired reasoning/decision making

Impaired language skills

Emotionally labile

Delusions and hallucinations

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4
Q

Risk Factors for Impaired Cognition

A 
Advanced age
Brain trauma, disorder, or disease
Toxins
Substance use disorder
Genetic diseases
Depression
Fluid/Electrolyte imbalances
Opioids, steroids, psychoactive drugs, and general anesthesia
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5
Q

Health History for Impaired Cognition

A

Onset, signs/symptoms

Comorbidities such as diabetes, cardiovascular disease, hypertension, cancer, post-op, pain, hypothyroidism, end of life

Mini-Mental Status Examination

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6
Q

Delirium

A

An acute confused state, may become fearful or anxious, often secondary to another problem

May be caused by lack of sensory stimulation, alcohol withdrawal, dehydration, lack of environmental cues

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7
Q

Dementia

A

A chronic confused state

Onset is subtle

Slowly progressive and organic

Problems with confusion and disorientation, personality changes, impaired judgment

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8
Q

Delayed Intellectual Functions

A

Have more to do with children

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9
Q

Amnesia

A

Occurs as a result of a head trauma

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10
Q

Primary Prevention of Impaired Cognition

A

Avoid substance use

Safety measures such as helmets, prevention of head injuries, monitoring for lead in the water

Stimulate intellect

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11
Q

Nursing Interventions for Impaired Cognition

A

Focus on safety

Communication aids such as eye glasses, hearing aides

Orientation on a regular basis

Identify and treat causes

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12
Q

Nursing Interventions for the Prevention of Delirium

A

Provide therapeutic activities

Early mobilization

Control pain

Minimize use of psychoactive drugs

Prevent sleep deprivation

Maintain oxygen levels and fluid/electrolyte balance

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13
Q

Nursing Interventions for Delirium

A

Identify and treat cause

Safety

Nonessential medications should be stopped (with a Doctor’s order)

Nutrition and fluid should be supervised

Environment should be quiet and calm, contain familiar environmental cues, encourage visits from family and friends

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14
Q

Most Common Types of Dementia

A

Alzheimer’s Disease

Vascular or Multi-Infarct Dementia

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15
Q

Alzheimer’s Disease

A

Chronic, progressive, irreversible disease process

Caused by the degeneration of the brain that leads to impaired intellectual function

Plaques in the cortex, neurofibril tangles

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16
Q

Risk Reduction for Alzheimer’s Disease

A

Engage in activity, change diet, exercise

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17
Q

Diagnostics for Alzheimer’s Disease

A

CT scan would show smaller brain

Acetylcholine levels

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18
Q

Early Stage of Alzheimer’s Disease

A

Mild memory lapses, difficulty in work or social activities

Able to compensate for loss and function independently

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19
Q

Further Progression of Alzheimer’s Disease

A

Obvious memory lapses, confabulating

Problem to recognize familiar faces, word finding problems

May get lost in familiar places

Sundowning, wandering

Speaking skills deteriorate, ADL problems

Disorientation with delusions and hallucinations

Apraxia, Visual Agnosia, Dysgraphia

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20
Q

Apraxia

A

Inability to carry out sequential movements on command

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21
Q

Visual Agnosia

A

Inability to recognize objects by sight

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22
Q

Dysgraphia

A

Difficulty writing

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23
Q

Terminal Stage of Alzheimer’s Disease

A

Severe mental and physical deterioration

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24
Q

Alzheimer’s Disease Treatments

A

Goal is to manage cognitive and behavioral symptoms

Aricept and Namenda used to enhance acetylcholine uptake into the brain, which enables patient to maintain memory over time

Ativan to help with anxiety and stress

HALOPERIDOL–antipsychotic

Anti-depressants

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25
Q

Nursing Interventions for Alzheimer’s Disease

A

Support cognitive function by cuing, guidance, providing a calm predictable environment, clear simple explanations, memory aids

Safety measures such as removing all hazards, putting in hand rails, providing adequate lighting, prohibiting driving, smoking only with supervision, avoiding restraints

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26
Q

Vascular Dementia

A

Associated with cerebrovascular disease, same risk factors as cardiovascular disease

Abrupt onset, caused by clot in a small vessel, multiple infarcts or strokes

Uneven, stepwise downward decline

Impairments dependent on what area of the brain is affected

Associated with HTN, CVD, hypercholesterolemia, smoking, diabetes

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27
Q

Opthalmologist

A

Physician that specializes in diagnosing and treating eye diseases and prescribes lenses

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28
Q

Optometrist

A

Professional in eye assessment, vision and vision problems

Does not treat eye diseases

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29
Q

Optician

A

Grinds and fits lenses, according to prescriptions

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30
Q

Eye Assessment History

A

Complaint, pain, discharge, onset/duration/recurrent, precipitating/relieving factors, effects on ADLs, history (diabetes, macular degeneration, surgeries)

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31
Q

Optic Nerve

A

Cranial Nerve II

Important to realize any damage to this will affect vision

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32
Q

Occipital Lobe

A

Visual center of the cerebral cortex

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33
Q

Entropion

A

Eyelid that folds inward

Related to atrophy, congenital conditions, muscle spasms

Need to monitor this, help with any self-care issues, observe for infection/inflammation

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34
Q

Trichiasis

A

Turning in of the eyelids

Give eyedrops to soothe, monitor for infection/inflammation

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35
Q

Ectropion

A

Outward position of the eyelid with tearing, corneal dryness, red sclera

Can lead to vision loss, tear loss

Topical meds are prescribed around the clock

Can occur from trauma, laceration/burn, paralysis

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36
Q

Ptosis

A

Drooping of the eyelid

Related to congenital factors, stroke, neurological trauma

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37
Q

Nystagmus

A

Involuntary oscillation of eye

Not very common

Caused by drug intoxication, problems with the inner ear

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38
Q

Visual Acuity Tests

A

Snellen chart

Finger count

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39
Q

Slit Lamp Examination

A

Magnification that evaluates inflammation and cataracts

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40
Q

Noncontact Tonometry

A

Looking at intraocular pressure, screening for glaucoma, puff of air in the eye

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41
Q

Goldmann Applanation Tonometry

A

Cone-shaped device used and placed in the eye to detect pressures

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42
Q

Color Vision Diagnostic Exams

A

Check for inherited impairments or acquired impairments (use of Digitalis, cataracts)

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43
Q

Amsler Grid

A

Assesses disturbances in central vision (macular degeneration)

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44
Q

Fluorescein Angiography

A

Dye is injected to check retinal blood flow

Pre-Procedure: consent, check kidney function, allergies to dye/seafood/iodine, hydration, warn about warmth and metallic taste

Post-Procedure: monitor for N/V, watch for gold hue to the skin, urine may turn orange

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45
Q

Automated Perimetry Test

A

Identifies flashes of light as they enter the field of vision

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46
Q

What is the correct procedure for performing an ophthalmoscopic exam on the client’s right retina?

A

From a distance of 8-12 inches and slightly to the side shine a light into the patient’s pupil

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47
Q

Refractory Errors

A

Problems relating to the bending of light that creates vision in the eye

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48
Q

Signs and Symptoms of Refractory Errors

A

Diminished or blurred vision

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49
Q

Treatment of Refractory Errors

A

Corrective lenses

Surgical correction such as LASIK (may cause dry eyes) or Intacs (ring implanted through an incision that reshapes the cornea)

Myopia is the refractive error most commonly corrected by surgery

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50
Q

Myopia

A

Nearsightedness

Can see near, can’t see far

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51
Q

Hyperopia

A

Farsightedness

Can see far, can’t see near

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52
Q

Presbyopia

A

Old-age farsightedness, loss of elasticity of the ciliary muscles

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53
Q

Astigmatism

A

Unequal curve in the shape of the cornea or lens, leads to problems with focusing

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54
Q

Strabismus

A

Inability of the eyes to focus in one direction (cross-eyed)

55
Q

Estropia

A

One or both eyes turn in the direction of the nose

56
Q

Extropia

A

One or both eyes turn away from the nose

57
Q

Absolute Blindness

A

No light perception

No usable vision

20/400 or less

58
Q

Legal Blindness

A

20/200 with corrective eyewear

Visual field of less than 20 degrees

59
Q

Cause of Blindness

A

Birth defects

Acquired problems (diabetic retinopathy, glaucoma, cataracts, infection, tumors, acute trauma)

60
Q

Signs and Symptoms of Blindness

A

Diplopia, blurred vision, pain, floaters or flashes of light, light sensitivity, pruritus, halos

Sense of increased orbital pressure, bulging of the eyes, different appearance in eye structure, psychological concerns

61
Q

Nursing Interventions for Blindness

A

Assess what they can see, how it affects their ADLs

Make referrals for support groups

Use magnifying systems, seeing-eye animals, make sure glasses are clean

Give verbal clues, walk in front of patient holding their elbow

Knock when entering, introduce yourself

Give them the call light, tell them if you remove something

62
Q

OD

A

Right eye

63
Q

OS

A

Left eye

64
Q

OU

A

Both eyes

65
Q

Topical Anesthetic Agents for Eyes

A

Proparacaine, Tetracaine

Give before a diagnostic procedure

Give instructions not to rub their eyes

NOT home medications

Overuse results in softening of the cornea, permanent whitening of the tissue leading to vision loss and scarring

66
Q

Miotics

A

Pupil constrictors

67
Q

Mydriatics

A

Pupil dilators

68
Q

Cycloplegic Agents

A

Paralyze the iris

69
Q

Contraindications for Eye Medications

A

Narrow-angles, anti-depressant use

70
Q

Adverse Effects of Eye Medications

A

Increased blood pressure, tachycardia, dizziness, ataxia, confusion, disorientation, incoherent speech, hallucinations

71
Q

Glaucoma Medications

A

Lower the intraocular pressure, will be taken the rest of their lives

72
Q

Ocular Irrigants/Lubricants

A

Used to clean, maintain a normal pH of the eye related to chemical burns, eliminate debris

DO NOT IRRIGATE if the ocular surface is not intact

73
Q

Nursing Interventions for Eye Medications

A

Educate the patient

Use hand hygiene before and after any medication administration

Eye dropper should never touch any part of the eye

Recap immediately after each use

74
Q

Glaucoma

A

Increased ocular pressure resulting in optic nerve atrophy, causing loss of peripheral vision

Big cause of blindness

75
Q

Risk Factors for Glaucoma

A 
Family history
Migraines
Elderly
Thin cornea
African American
Diabetes/Cardiovascular issues
Myopia/Eye trauma/Long term steroids
76
Q

Open Angle Glaucoma

A

Optic nerve damage

Possible ocular pain, headache

Halos

Usually bilateral

Can be treated with medications

90% of people with glaucoma have this type

77
Q

Angle Closure Glaucoma

A

Rapidly progressive visual impairment

Ocular emergency

Pain with nausea/vomiting and bradycardia

Halos

Pupil vertically oval, fixed, semi-dilated

Conjunctival hyperemia and congestion

78
Q

Treatment for Open Angle Glaucoma

A

Beta blockers

Miotics

Diamox

79
Q

Treatment for Angle Closure Glaucoma

A

ATROPINE AND MYDRIATICS ARE CONTRAINDICATED

Osmotic diuretics

Iridectomy

80
Q

Patient Education for Glaucoma

A

Do not drive for 1-2 hours after eye drops

Press lacrimal duct for 1 minute after meds

Keep extra drops at home

Avoid any valsalva maneuvers

Medical supervision on eye medications long term

81
Q

Cataracts

A

Noninfectious opacity that blocks light from reaching the retina

Cause is either congenital or acquired (smoking, tanning, trauma, aging, steroid use, heavy drinking)

82
Q

Signs and Symptoms of Cataracts

A

Painless

Blurring-loss of sight

Different eyes develop at different rates

Diplopia

Decrease in night vision

83
Q

Treatment for Cataracts

A

Surgery is safer with decreased IOP

INTRAOCULAR LENS IMPLANT (IOLI)

Mydriatics, cycloplegics, local anesthetics, diamox, antibiotic drops

84
Q

IOLI Post-Op

A

Sleep on unaffected side for 3-4 weeks

Avoid anything that will increase intraocular pressure

Protect the eye by limiting reading/television, wearing glasses, avoiding direct sunlight, no showers/shampoos for 1-14 days

Expect slight redness, mild watering, irritation, slight prosis

Notify with pain, redness, drainage, sudden vision changes

85
Q

Keratitis

A

Inflammation of the cornea caused by irritants, allergies, viral/bacterial infections, herpes simplex

Risk is swimming with contacts in

86
Q

Signs and Symptoms of Keratitis

A

Blepharospasm, visual disturbances/vision loss, eye pain, itching, bloodshot eyes, photophobia, tearing, edema

87
Q

Treatment of Keratitis

A

Keratoplasty (corneal transplant)

Irrigation

Topical antibiotics, avoid steroids

88
Q

Corneal Injuries

A

Results from injuries to corneal layers of the eye

Pain with movement of the eye, excessive tearing, pruritus, erythema of the conjunctiva

89
Q

Splash Corneal Injuries

A

Flush with normal saline/water

Antibiotic drops or ointment

90
Q

Ruptured Globe Corneal Injuries

A

Parenteral antibiotics

Tetanus/analgesics

91
Q

Penetrating Wounds Corneal Injuries

A

Do not remove object if present

92
Q

Enucleation

A

Removal of the eyeball

Caused by injury, disease, tumor

Pressure dressing post-op

Heals within 2-4 weeks, then shell prosthesis

Lose depth perception with only one eye

93
Q

Photocoagulation

A

Laser is directed into a small spot on the retina

94
Q

Vitrectomy

A

Intraocular procedure, incision into the eye allows removal of foreign body, sources of opacity

95
Q

Retinal Detachment

A

Separation of the retina from the choroid

Complete detachment leads to blindness

Flashes of light, floating spots, gaps in vision, loss of a specific field of vision, no pain

96
Q

Retinal Detachment Treatment

A

Scleral Buckle (compresses sclera to indent scleral wall from outside of the eye)

Vitrectomy

Pneumatic retinoplexy (gas bubble injected to help push retina back into place; prone position to keep in place)

97
Q

Macular Degeneration

A

Central Vision Loss

Most common cause of central vision loss in people older than 55

Caused by genetics, longterm exposure to UV light, smoking, light colored eyes, nutrition

Usually no treatment, encourage dietary supplements

98
Q

Signs and Symptoms of Macular Degeneration

A

Gradual and variable bilateral loss of vision

Distorted vision, straight lines appearing as curvy lines

Problems with color perception

99
Q

Dry Eye Disorders

A

Variety of disorders that have the characteristic of decreased tear secretion

Caused by keratoconjunctivitis sclera, Sjogren syndrome

Treated with artificial tears, cyclosporin, plug in the lacrimal duct

100
Q

Diagnosis of Dry Eye Disorders

A

Schirmer’s test: using filter paper and placing in the lower eyelid of the eye, evaluate after 5 minutes to see how much fluid is on it

101
Q

Signs and Symptoms of Dry Eye Disorders

A

Redness, stringy mucus production, eye fatigue, blurry vision, sandy or gritty sensation

102
Q

Conjunctivitis

A

Inflammation of the conjunctiva

Caused by hands touching the eyes, allergies, environmental factors

103
Q

Signs and Symptoms of Conjunctivitis

A

Redness, swelling, mucopurulent drainage and crusty discharge, itching, burning

104
Q

Treatment of Conjunctivitis

A

Chemical splash

Warm compress

105
Q

Diabetic Retinopathy

A

Disorder of the retina, microaneurisms in the eye that lead to hemorrhages and scarring and decreased vision

106
Q

Signs and Symptoms of Diabetic Retinopathy

A

Visual problems, progressive loss of vision, floaters

107
Q

Treatment of Diabetic Retinopathy

A

Photocoagulation

Vitrectomy

108
Q

Eye Changes with Aging

A

Visual acuity declines, loss of night vision, pupils decrease in size

109
Q

Arcus Senilis

A

Hazy gray ring around the cornea

110
Q

Hordeolum (Stye)

A

Acute infection of the eyelid

111
Q

Chalazion

A

Inflammatory cyst

112
Q

Blepharitis

A

Inflammation of the eyelid margin

113
Q

Electronystagmography

A

Electrical activity of the extraocular muscles

114
Q

Ear Health

A

With a URI, blow nose with both nostrils open

Do not swim in stagnant waters

Do not use outdated ear drops

115
Q

Ear Changes with Aging

A

Tympanic membrane becomes atrophies and sclerotic

Cochlea cells degenerate

Cerumen becomes harder and drier

50% of elderly have a hearing impairment

Presbycusis

116
Q

Ototoxic Medications

A

Aminoglycosides

Aspirin

Loop diuretics

Platinum-based antineoplastic medications

Quinine

117
Q

Nursing Interventions for Hearing Impairment

A

Face the patient

Speak clearly in a normal tone

Repeat with different words

Move closer, write things down

Encourage hearing aids

Use gestures, do not appear annoyed

118
Q

Otalgia

A

Feeling of fullness and pain in the ear, with or without hearing loss

119
Q

How to Help a Cerumen Impaction

A

If TM is intact:

Warmed glycerin, mineral oil, or 1/2 strength hydrogen peroxide before irrigation

Irrigate with warm water on low pressure

Direct visual mechanical removal

120
Q

Otitis Externa

A

Swimmer’s ear caused by water in the ear canal, trauma of the skin, systemic problem

121
Q

Signs and Symptoms of Otitis Externa

A

Pain with movement of auricle or chewing

Erythema, scaling, pruritus, edema, watery discharge, and crusting of the external ear

122
Q

Treatment for Otitis Externa

A

Oral analgesics, corticosteroids

Antibiotic or antifungal ear drops, oral antibiotics

123
Q

Otitis Media

A

Inflammation or infection of the middle ear caused by microbes/bacteria in the eustachian tube or a cholesteatoma (tumor of the inner eardrum)

Acute, Serous, or Chronic

124
Q

Signs and Symptoms of Otitis Media

A

Tympanic membrane is red and bulgy

Edema decreases hearing

Fullness in the ear, hearing loss

Severe, deep, throbbing pain

Tinnitus, sensitivity to noise

Fever

125
Q

Treatment of Otitis Media

A

Antibiotics, analgesics, nasal decongestants

Local heat

Aspiration of fluid from behind the eardrum

Myringotomy

126
Q

Myringotomy

A

Surgical incision of the tympanic membrane

Drainage to decrease pressure

Tubes may be inserted for 6 months to several years

Take antibiotics until they are gone

127
Q

Otosclerosis

A

Ossification of stapes against the oval window

Soft low tones

Gradual, progressive conductive hearing loss

Tinnitus, dizziness to vertigo

128
Q

Treatment of Otosclerosis

A

Stepedectomy: removal of the stapes and replacement with a prosthesis

Air conduction hearing aid

129
Q

Nursing Interventions for Post-Op Stapedectomy

A

Reinforce dressing, call if dressing dislodges

Bedrest for 48 hours, HOB elevated to 30 degrees

No bending or lifting, blowing nose, sneezing

No shampoo for a week

130
Q

Meniere’s Disease

A

Disorder of inner ear fluid balance

Chronic disease of the inner ear

Episodic vertigo, tinnitus, fluctuating sensorineural hearing loss

131
Q

Treatment of Meniere’s Disease

A

Decrease fluid pressure, low-salt diet

Antihistamines, tranquilizers, antiemetics, diuretics

Surgery to relieve pressure (endolymphatic shunt, vestibular nerve section)

132
Q

Nursing Interventions for Meniere’s Disease

A

Avoid sudden movements

Take measures to prevent falls

Stop driving

Sit down

Keep medications available

Low salt diets, diuretics

Don’t smoke, avoid aspirin

133
Q

Labyrinthitis

A

Inflammation of the labyrinth canals of the inner ear

Most common cause of vertigo

Viral or bacterial

Severe and sudden vertigo, ataxic gait

Hearing loss, tinnitus

134
Q

Treatment of Labyrinthitis

A

Antibiotics

Dramamine or meclizine for vertigo

IV fluids if nausea and vomiting are present

Adult Health Nursing II (22 decks)

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