Exam 2 Flashcards
Chapters: 10, 14, 32, 34, 35, 39, 42
What are some effective coping strategies for dealing with stress?
- Must focus on the principles of balance, relaxation, and nutrition
- An imbalance of activity and rest contributes to further physiologic and physical signs of stress
- Time management: prioritizing tasks, setting goals, increasing concentration skills, decreasing distractions, avoiding procrastination, setting boundaries, and maintaining self discipline
- Anger management: **may need the assistance from a professional for effective application** BUT expressing feelings in a calm and non-confrontational manner, exercising, identifying potential solutions, taking a time out, forgiving, diffusing the situation with humor, “owning” the negative feelings, and doing deep breathing exercises
- Nutrition management: eating a balanced diet (fruit, vegetables, legumes, fish, poultry, & whole grains), multivitamins, and herbal supplements
- Support Groups: **Social worker can help with this** they find legitimate support groups that are national recognized. This can help people feel like they are not alone
- CAM therapy: therapeutic touch, Reiki, biofeedback, massage therapy, relaxation, guided imagery; these are mind-body therapies and may require additional education to facilitate
Factors involved in coping with stress?
- Number, duration, and intensity of stressors
- Past experiences
- Current support system
- Available resources (financially)
What is Health Literacy?
AND
How should education be written for a patient?
the ability to obtain, process, and understand basic information and services needed to make appropriate health decisions and follow instructions for treatment
- Mutually agreeable outcomes
- Prioritize the learning objectives with clients needs
- Methods that emphasize the learning style
- Age appropriate
- Speak and write in the second person, not the third (your leg, NOT the leg)
- Avoid using all caps, minimize white space, and small type in print materials
- Provide electronic education resources
- Use reliable internet sources
- Organize learning activities to move from simple to more complex tasks (known to unknown concepts)
- Speak and write in active voice (“take the medication” and not “the medication should be taken”)
- Incorporate active participation
- Schedule teaching sessions at optimal times for learning
Physical signs of fluid excess?
AKA: Hypervolemia
- Vitals: Tachycardia, bounding pulse, hypertension, tachypnea, increased central venous pressure
- Neuromusculoskeletal: Confusion, muscle weakness
- GI: Weight gain, ascites (fluid in the gut)
- Respiratory: Dyspnea, orthopnea, crackles
- Other Findings: Edema, distended neck veins
Causes of Hypervolemia
FLUID RETENTION
- Heart failure, cirrhosis, and an increase in glucocorticosteroids can cause chronic stimulus to the kidney to conserve sodium and water
- Kidney failure can cause altered kidney function with reduced excretion of sodium and water
- Hypertonic fluid and burns can cause interstitial to plasma fluid shifts.
- Sodium bicarbonate antacids, hypertonic enema solutions can cause excessive sodium intake from IV fluids, diet, or medications
- Head injuries
- Barbiturates
- Anesthetics
- Water replacement without electrolyte replacement
- Syndrome of inappropriate ADH production
Physical Signs of Dehydydration?
AKA: Hypovolemia
Vitals: Hypothermia, tachycardia, thready pulse, hypotension, decreased central venous pressure, tachypnea, hypoxia
Neuromusculoskeletal: Dizziness, syncope, confusion, weakness, fatigue
GI: Thirst, dry mucous membranes, dry furrowed tongue, nause, vomiting, acute weight loss Renal: Oliguria (decreased production of urine)
Other: Diminished capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins, absence of tears, decreased skin turgor
Causes of dehydration?
- Hyperventilation
- Prolonged fever
- Diabetic ketoacidosis
- Enteral feeding without sufficient water intake
- Diarrhea, vomities, NG suctioning
- Diaphoresis
- Diuretic therapy, diabetes insipidus, kidney disease, adrenal insufficiency, osmotic diuresis
- Burns
- Loss from a wound
- Hemorrhage
- Anorexia, nausea, impaired swallowing, confusion, NPO
Importance of ambulation related to postoperative surgery?
think ABC – Airway, Breathing, Circulation
Big Picture:
-
Neurological: Altered sensory perception
- Ineffective coping
-
Cardiovascular-Orthostatic hypotension
- Less fluid volume in circulatory system
- Diminished autonomic response
- Decreased cardiac output leading to poor cardiac effectiveness, which results in increased cardiac workload
- Increased O2 requirement
- Increased risk of thrombus development
-
Respiratory-decreased oxygenation and carbon dioxide exchange
- Stasis of secretions and decreased and weakened respiratory muscles (can result in collapsed lung & hypostatic pneumonia)
-
Integumentary-increased pressure on skin
- Decreased circulation to skin causing pressure ulcers
-
Metabolic-altered endocrine system
- Loss of appetite
- Loss of weight
- Alterations in calcium, fluid, and electrolytes
- Reabsorption of calcium from bones
- Decreased urinary elimination of calcium resulting in hypercalcemia
-
Elimination
- Change in calcium metabolism with hypercalcemia resulting in renal calculi
- Poor perineal care, decreased fluid intake, catheter can cause UTIs
- Decreased peristalsis
- Constipation, then fecal impaction, then diarrhea
-
Musculoskeletal
- Decreased muscle endurance, strength, and mass
- Impaired balance
- Atrophy of muscles
- Osteoporosis
- Altered joint mobility
Explain evisceration and how it happens.
The displacement of organs outside the body. Risk factors; The presence of an evisceration is a surgical emergency. Usually trauma related.
Explain dehiscence and how it happens.
Def: the partial or total rupturing of a sutured wound; usually involves an abdominal wound in which the layers below the skin also separate.
Risk factors: (1) A patient who is at risk for poor wound healing (e.g., poor nutritional status, infection) is at risk for dehiscence. (2) Obese patients have a higher risk of wound dehiscence because of the constant strain placed on their wounds and the poor healing qualities of fat tissue
What are the ABG normal values?
pH: 7.35 (acidic) – 7.45 (basic)
PaCO2: 45 (acidic) –35 (basic)
- high PaCO2 = hypoventilation
- low PaCO2 = hyperventilation
PaO2: 80-95 mm Hg
Bicarbonate (HCO3-): 22 (acidic) -26 (basic)
- low HCO3- = metabolic acidosis
- high HCO3- = metabolic alkalosis
O2 Saturation: 95-99%
ABG Interpretation?
Uncompensated:
Abnormal pH & CO2 OR HCO3 NOT BOTH
Partially Compensated:
All 3 are abnormal
Fully Compensated:
Normal pH & Abnormal HCO3 AND CO2
What are the rights of delegation?
Right Task –The right task is one that you delegate for a specific patient such as tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have potential minimal risk.
Right Circumstances – Consider the appropriate patient setting, available resources, and other relevant factors. In an acute care setting patients’ conditions often change quickly. Use good clinical decision making to determine what to delegate.
Right Person – The right person is delegating the right tasks to the right person to be performed on the right person.
Right Direction/Communication – You give a clear, concise description of the task, including its objective, limits, and expectations. Communication needs to be ongoing between the registered nurse and NAP during a shift of care.
Right Supervision/Evaluation – Provide appropriate monitoring, evaluation, intervention as needed, and feedback. NAP need to feel comfortable asking questions and seeking assistance.
Describe the process of informed consent, from both ethical and legal points of view. Include implications for nursing.
- Explanation of the patient diagnosis and proposed treatment or procedure
- The name and qualifications of the person who will perform the procedure or treatment
- Available alternatives to the recommended treatment
- Possible complications of the treatment or procedure
- Patient’s right to refuse treatment without having care discontinued
- Nursing implications: The doctor must explain the above information. The nurse’s role is to make sure the patient understands it. We sign consent as a witness to that.
What are Kubler-Ross stages of grief?
- Denial (cant believe it happened)
- Anger
- Bargaining (if I only had one, what if we try other treatment, what if we go to Sweden)
- Depression (Depressed about situation)
- Acceptance
Important to remember: People do not go through this in order: they could go through anger, bargaining, and back to denial. They can go in and out in whatever form works for patient and give patient the space to go through them. We want it to be a linear process, but it’s not.
What are smart patient goals?
S: specific
M: measureable
A: attainable
R: realistic
T: timely
Examples:
Goal and Outcome #1: Patient will perform ROM exercises each hour during the shift.
Goal and Outcome #2: Patient will ambulate from bed to door twice by the end of shift.
Signs, Symptoms, & Causes of hypokalemia
Hyponatremia (not enough sodium)
Underlying causes:
- Hypovolemic, Hyponatremia Diuretics
- GI fluid loss (vomitng, diarrhea)
- Profuse diaphoresis
- Hypervolemic, Hyponatremia Water Intoxication
- Prolonged use of hypotonic IV solutions
- SIADH (Syndrome of Inappropriate Antidiuretic hormone secretion: A condition in which high levels of a hormone cause the body to retain water.)
Clinical Manifestations:
- Lethargy, confusion, weakness, muslce cramping, seizures, anorexia, nausea, vomiting, osmolarity <280
Interventions:
- Monitor vital signs
- Monitor I&Os
- Monitor lab results (e.g. serum sodium & osmolality)
- Encourage foods high in sodium
- Restrict water intake
- Administer hypertonic IV solutions as ordered
Signs, Symptoms, & Causes of Hypernatremia
Hypernatremia (too much sodium)
Underlying Causes:
(Excess sodium due to)
- Excessive sodium intake
- Hypertonic IV solutions
- Hypertonic enteral feedings without adequate water
(Excessive loss of water due to)
- Diarrhea
- Inadequate intake of water
- Insensible loss due to fever
Clinical Manifestations:
- Thirst, dry sticky mucous membranes, weakness, elevated temperture
- Severe hypernatremia causing confusion and irritability, decreased levels of consciousness, hallucinations, and convulsion
- Serum osmolarity >300
Interventions:
- Monitor vital signs
- Monitor level of consciousness
- Monitor I&Os
- Monitor lab results (e.g. serum sodium & osmolarity)
- Limit salt intake and foods high in sodium
- Increase water intake
- Administer hypotonic IV solutions as ordered
What are the signs, symptoms, and causes of Hypokalemia?
Hypokalemia (loss of potassium)
Underlying Causes:
(Loss of potassium due to)
- Vomiting, gastic suction, diarrhea
- Laxative abuse, frequent enemas
- Use of potassium-wasting diuretics
- Inadequate intake seen in anorexia, alcoholism, debilitated parents
- Hyperaldosteronism
Clinical Manifestations:
- Weak, irregular pulse
- Fatigue, lethargy
- Anorexia, nausea, vomiting
- Muscle weakness & cramping
- Decreased peristalsis (hypoactive bowel sounds)
- Paraesthesia
- Cardiac dysrhythmias
- Increased risk of digitalis toxicity
Interventions:
- Monitor vital signs especially heart rate and rhythm
- Monitor cardiac rhythm w/ ECG
- Monitor lab results (e.g. potassium levels)
- Assess signs of digitalis toxicity
- Encourage foods high in potassium
- Administer potassium supplements as ordered: IV potassium is diluted properly and administered slowly usually by infusion NEVER ADMINISTER POTASSIUM AS AN IV BOLUS OR IV PUSH
What are the signs, symptoms, and causes of hyperkalemia?
Hyperkalemia
Underlying causes:
- Renal failure
- Massive trauma, crushing, injuries, burns
- Hemolysis
- IV potassium
- Potassium-sparing diuretics
- Acidosis-especially diabetic ketoacidosis
Clinical Manifestations:
- Anxiety
- Irritability
- Confusion
- Dysrhythmias (bradycardia, heart block)
- Muscle weakness, flaccid paralysis
- Paresthesia
- Abdominal Cramping
Interventions:
- Monitor vital signs (especially heart rate and rhythm)
- Monitor cardiac rhythm with ECG
- Monitor lab results (e.g.potassium levels)
- Limit potassium-rich foods
- Administer cation-exchange resins (Kayexalate) as ordered
- Administer glucose and insulin as ordered (potassium moves back into cell)
What are the sings, symptoms, and causes of hypocalcemia?
Hypocalcemia
Underlying causes:
- Hypoparathyriodism
- Pancreatitis
- Vitamin D Deficiency
- Inadequate intake of calcium-rich foods
- Hyperphosphatemia
- Chronic alcoholism
Clinical manifestations:
- Confusion, anxiety
- Numbness and tingling of extremities
- Muscle cramps that progress to tetany & convulsions
- Hyperactive reflexes
- Cardiac dysrhythmias
- Positive Chvostek & Troussea signs
Interventions:
- Monitor heart rate and rhythm
- Monitor cardiac rhythm with ECG
- Instiuite fall and seizure precautions
- Administer oral and/or IV calcium supplements as order
- Encourage calcium rich foods
What are the signs, symptoms, and causes of Hypercalcemia?
Hypercalcemia
Underlying causes:
- Prolonged bed rest
- Hyperparathyroidism
- Bone malignancy
- Piget disease
- Osteoporosis
Clinical Manifestations:
- Lethargy, stupor, coma
- Decreased muscle strength and tone
- Anorexia, nausea, and vomiting
- Constipation
- Pathologic fractures
- Dysrhythmias
- Renal calculi
Interventions:
- Monitor heart rate and rhythm
- Monitor cardiac rhythm with ECG
- Encourage increased fluid intake
- Increase patient acitivity including active ROM
What are the signs, symptoms, and causes of Hypomagnesemia
Hypomagnesemia
Underlying causes:
- Decreased intake
- TPN without magnesium
- Decreased absorption
- Nasogastric suction
- Prolonged diarrhea
- Laxative abuse
- Malabsorption syndrome
- Ulcerative colitis
- Crohn’s disease
- Increased renal excretion
- Diuresis
- Loop and thiazide diuretics
Clinical manifestations:
- Irritable nerves and muscles
- Hyperactive deep tendon reflexes
- Seizures
- Dysrhythmias (especially tachyarrhythmias)
- ECG changes
- Altered consciousness
- Mood swings
- Delusions, hallucinations
- Dysphagia, nausea, vomiting
Interventions:
- Assess vital signs (esp. heart rate and rhthym)
- Monitor cardiac rhythm with ECG
- Assess mental status, changes in LOC
- Monitor lab results (potassium and calcium)
- Assess swallowing before medication admin, food, or fluid
- Institute seizure precautions
- Administer oral or IV supplements as ordered
What are the signs, symptoms, and causes of Hypermagnesemia
Hypermagnesemia
Underlying causes:
- Excessive intake of magnesium containing antacids or cathartics
- TPN with too much magnesium
- Prolonged use of IV magnesium sulfate
- Renal failure
- Severe dehydration
- Adrenal insufficiency
- Leukemia
Clinical manifestations:
- Warm, flushed appearance
- Nausea, vomiting
- Drowsiness, lethargy
- Decreased muscle strength
- Generalized weakness
- Decreased deep tendon reflexes
- Hypotension
- Dysrhythmias (bradycardia & heart block)
- Slow, shallow respirations; respiratory arrest
Interventions:
- Assess vital signs (esp. heart rate and rhythm)
- Monitor cardiac rhythm with ECG
- Assess mental status, changes in LOC
- Assess neuromuscular strength and activitiy
- Encourage increased oral intake, increased IV fluids
- Administer loop diuretics as ordered
- Provide respiratory support (supplemental oxygen or mechanical ventilation) as needed
Signs and symtoms of hypo/hyper glycemia
Explain how we assess pain?
What is the nursing process and what do the steps mean?
Nursing diagnosis prioritization (think in the sense of goal achievement)
It is something nurses can fix without the doctor’s order, we think about our patient’s strengths and weaknesses
General how pain effects each system
