Exam 3 NURS 3346 Flashcards
(143 cards)
1
Q
Acute Pain
A
o Acute <3 months Protective Focused at site of injury Self-limited Few psychological implications Relieved with treatment of underlying disease Recovery expected Activation of sympathetic nervous system (SNS)
2
Q
Chronic Pain
A
o Chronic >3 months No biological benefit It is the disease Pain without injury Unrelenting Psychological implications Treatment focused on symptom management Fair to poor chance of recovery Adaptation of the SNS
3
Q
Referred
A
feel pain not at the site of origin
4
Q
Radiating
A
start at site of origin and move out
5
Q
Superficial
A
pain resulting from stimulation of skin
6
Q
Deep visceral pain
A
pain resulting from stimulation of internal organs
7
Q
Numerical Pain Scale
A
0-10 scale
8
Q
Wong-Baker Faces Scale
A
Helpful with kids, people with other languages. People need to be cognitively aware of what 0-10 means
9
Q
Richmond Agitation and Sedation Scale
A
+4 Combative to -5 Sedation
10
Q
Behavioral Indications
A
Vocalization
Facial expressions
Body movement
Social interaction
11
Q
Barriers to effective pain management
A
o Misconcenptions about pain
o Lack of knowledge
o Cultural beliefs about pain and pain interventions
o Controversy among healthcare providers
12
Q
Complications of ineffective pain management
A
Undertreatment of pain can cause increased anxiety with acute pain and depression with chronic pain
13
Q
• Identify non-pharmacologic pain relieving techniques
A
o Distraction o Prayer o Relaxation o Music o Massage o Heat/cold o Movement o Rest o Immobilization o Transcutaneous Electro-neural Stimulation (TENS)
14
Q
Identify appropriate pain intervention using the WHO ladder
A
Step 1: nonopioid analgesics, NSAIDS
Step 2: weak opioids
Step 3: strong opioids, methadone, oral administration, transdermal patch
Step 4: Nerve block, epidurals, PCA pump, neurolytic block therapy, spinal stimulators
15
Q
Acetaminophen: action, use of, serious side effects related to overdose
A
Action: only inhibits COX in the CNS only: no anti-inflammatory or anti-coagulant effects
Use of: antipyretic (reduced fever), analgesic (controls pain)
Side Effect
toxic doses-liver toxicity
hypertension with daily use
liver and renal disease
contraindicated with alcohol
DO NOT EXCEED MAX DAILY DOSE OF 4 GRAMS PER DAY
Abdominal pain, nausea, vomiting and diarrhea are early signs of overdose.
Acetylcysteine will treat overdose of acetaminophen. Most effective when given within 8-10 hours
Identify priority nursing actions
- check BP
- Assess for jaundice
- Assess skin rash
16
Q
o NSAIDs: general action, use of, adverse effects (aspirin, ibuprofen)
Aspirin COX-1 and 2 Inhibitor
A
Action Inhibit prostaglandins- lower inflammation and platelet aggregation inhibition Adverse Effects o Gastric upset, heartburn, nausea, ulceration o Bleeding o Kidney dysfunction o Salicylism o Reye’s syndrome Drug interactions: o Anticoagulants o Glucocorticoids o Alcohol Use and Expected Effects o Treatment of mild to moderate pain o Inflammation suppression o Fever reduction (antipyretic)
Identify priority nursing actions
- Monitor for salicylism (tinnitus, vertigo, decreased hearing activity)
- Prevent gastric upset by administering the medication with food or antacids
- Monitor bleeding with long-term NSAID use
17
Q
ID Medications within the classification opioids
A
codeine, hydrocodone, morphine, dilaudid
18
Q
Explain the general action of opioids
A
- Binds to the opioid receptor in the brain
- Anagesia
- Sedation
- Euphoria
- Resp. Depression
- Decrease GI Motility
19
Q
ID Nursing implications for administering analgesics
A
- Stay away from placing on hair, tattoo, scars
- Check RR and monster level of consciousness
20
Q
ID serious side effects of opioids
A
- Respiratory depression
- Sedation
- Immune system suppression
21
Q
ID Interventions to prevent side effects of opioids
A
- Sedation: monitor level of consciousness and take safety precautions
- Respiratory depression: monitor RR prior to administering and following administering
- Orthostatic hypotension: tell client to sit or lie down if lightheadedness or dizziness occur. Have clients avoid sudden changes in position. Provide assistance with ambulation
- Urinary retention: monitor intake and output assess for distension. Administer bethanechol, and catheterize
- Nausea/ vomiting: administer antiemetics, advise clients to lie still and move slowly, and eliminate odors
- Constipation: use a preventative approach (monitor bowel movements, fluids, fiber intake, exercise stool softeners, stimulant laxatives, enemas)
22
Q
ID priority actions if side effects occur as a result of opioids
A
Moniter breathing
Naloxone
HOB up
23
Q
Action of Naloxone
A
Reverse action of opioids by competing for same receptor sites
24
Q
Explain use of PCA
A
• Patient is able to not wait for pain med. o Decreases anxiety • Must be congintievly aware • May forget to push the button • People have died from PCA by proxy
25
Discuss the role of adjuvant analgesic drugs such as gabapentin in pain management
Originally meant to treat other conditions but in combination with opioids help treat pain
26
ATC v. PRN analgesic administration
Around the clock is scheduled doses at all times. Used when pain is anticipated so that client doesn't need to be in unnecessary pain. Ex. Surgery, burns.
PRN: as needed is given when the pt reports pain
27
• Explain the role of kidney function in preventing medication toxicity
Main route of excretion. Filters out drugs.
28
Drug Tolerence
The drug doesn't work as well anymore
29
Physical Dependance
A state of adaption due to the body needing the drug and not having it anymore
30
Addiction
primary, chronic, neurobiological disease. Impaired control over drug use, compulsive use.
31
What is ventilation?
movement of oxygenated air in and out of the lungs
32
What is perfusion
delivery of O2 to the tissues
33
What is diffusion(oxygenation)
exchange of O2 and CO2 in the capillaries(gas exchange)
34
Identify modifiable risk factors influencing oxygenation
o Smoking
o Environmental factors: pollution, elevation, cold/hot—cold air can cause bronchospasm, irritants, pollen
Asthma: irritants initiate the inflammatory response
o Exercise
o Substance use
35
Explain client teaching to decrease risks associated with impaired oxygenation
```
o Obesity
o Smoking
o Substance abuse
o Stress
o Environmental factors
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36
Key Assessment Techniques for the Resp. System
```
o Rate, Rhythem, depth
o Comfortable at rest?
o O2Sat
o Sign of increased work to breath
o Auscultate lung sound
o Cough: productive/nonproductive: sputum/no sputum
o Sputum: color, consistency, odor
```
37
Identify cues associated with altered oxygenation
Early: Restlessness/anxiety, Increased resp. rate,
Increase work of breathing,
SOB with activity/DOE, Disorientation/confusion, Increased HR/extra beats
```
Late:
o SOB at rest
o Use of ancillary muscles
o Combativeness
o Bradycardia
o Hypotension
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38
"Crackles"
Sound the rice crispies. Means that there is fluid in the lungs
Pneumonia, Aspiration, excess fluid
Interventions: tripod positioning, deep breaking, chest tubes
39
"Rhonchi"
Snore/ course sound. Secretions in the large bronchus.
COPD
Intentional coughing, coughing, hydrating
40
"Wheezing"
Whisling, high pitched almost musical sound.
Asthma, COPD, Airway obstruction
The higher the pitch the worse it is. If you here nothing then airway is completely obstructed
Positioning: HOB >45. Pursed lip breathing
41
Plearal friction Rub
when we have something causing irritation in or around our pleural space. You can hear it with inhalation. Rubbing together of inflamed pleural spaces.
42
Diminished lung sounds
Atelectasis: when alveoli are not filling with air. Can be chronic problem or can happen to patients with pain and decreased mobility. Due to not taking deep breaths and not filling alveoli with air. You’ll hear diminished sounds. Can’t hear air moving in and out as loud.
43
Rational ambulation
loosens secretions so they are easier to get rid of
44
Rational positioning
Position HOB >45. Tripod positioning. More straight airway and supports trunk muscles which increases surface area of the lungs
45
Incentive spirometer
Encourages voluntary deep breathing by providing visual feedback. Prevents atelectasis. Suck like a straw
46
Explain how deep breathing and intentional coughing help with airway clearance
o Deep Breathing: fill up alveoli and increase surface area for gas exchange in alveoli
o Intentional Coughing: loosen secretions and cough them up
Acapella/Flutter valve: cough into valve and membrane in pickle vibrates
47
Explain how to perform incentive spirometry
o Incentive Spirometry: pt. take deep breath ball move up and ball move up and let out naturally
48
Discuss the purpose of chest physiotherapy and postural drainage
o Chest Physiotherapy: gently pound on back to loosen secretions. Vest that does it or nurse/RT can
o Postural Drainage: Change position every hour so don’t ever have secretions sitting long enough so stick. Abt 1-2 hrs
49
Discuss care of the client with a chest tube (purpose, assessment points, positioning of chest tube drain and client, and what to do when drainage suddenly increases)
Purpose: chest tubes can remove air and fluid in the pleural space. For people who have liver failure, cancer in the abdomen, ovarian cancer, post op from surgery. Chest tube reestablishes negative pressure in the lungs so the lungs can re -expand
Assessment points: evaluate RR, breath sounds, SpO2 levels, and insertion site for subQ emphysema
Positioning of chest tube, drain, and client: the drain always needs to be below the level of the chest to drain the fluid. The tube needs to an have unencumbered flow and needs to be secured to the chest wall. The fluid needs to leave the chest and get into the drainage. The drain needs to be below.
When drainage is suddenly increased: alert MD?
50
Explain why clamping of chest tubes is generally prohibited
Could result in a tension pneaumothorax
51
Hypoventilation
o Hypoventilation: decrease movement of O2 in and out
| Ventilation not enough to supply body or eliminate CO2. Mental status change, dyrythmias, cardiac arrest
52
Hyperventilation
o Hyperventilation: increases movement of O2 in and out
| More CO2 being removed then produced. Creates acidbase imbalance. Anxiety, infection, increased body temp
53
Hypoxia
o Hypoxia: inadequate tissue perfusion(cellular level)
54
Differentiate between early and late signs of hypoxia
o Restlessness/anxiety
o Increased resp. rate
o Increase work of breathing
o SOB with activity/DOE
o Disorientation/confusion
o Increased HR/extra beats
o SOB at rest
o Use of ancillary muscles
o Combativeness
o Bradycardia
o Hypotension
o Cyanosis: mucous membranes. Also context.
Progressing problem: later sign and indicates serious problem
Acute problem: cyanosis may come early and is a serious sign
Chronic problem: cyanosis might be always present and is not a good indicator of current status
55
Identify and prioritize interventions for respiratory distress
o Calm environment: dim lights, turn volume down on beeping, close the door. Decrease stimulation of SNS and decreases oxygen demand
o Positioning: HOB >45. Tripod positioning- allows to increase surface area.
o Coughing techniques
-Acapella/flutter valve (The purpose of these is to loosen secretions and also to cough them up.)
o Deep breathing
-Incentive spirometer
o oxygen administration
o Hydration: thins the mucus
o Pursed lip breathing: breath in through your nose, purse your lips and breathe out. The purpose is to get rid of CO2.
o Ambulation: helps increase deep breathing. Any type of mobility will help loosen secretions
o Postural drainage: positioning the client to expand the chest. Keep secretios moving
o Chest physiotherapy: cup hands and gently cupping along their back to loosen secretions
o Suction: pull out secretion because they are so tight
o Respiratory muscle training: helps increase surface area
o Breathing exercises
56
Explain appropriate positioning of a client in respiratory distress
Tripod or >45
57
Identify complications associated with hyperventilation, hypoventilation, and hypoxemia.
Hypoventilation: occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide. Can lead to respiratory acidosis and respiratory arrest.
Hyperventilation: a state of ventilation in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism. Can result in respiratory alkalosis.
58
Describe orthopnea
o SOB when laying flat
59
Differentiate between nasopharyngeal and nasotracheal suctioning
o Nasopharyngeal: pt able to cough but unable to clear own secretions all the way out
o Nasotracheal: unable to cough, no artificial airway present
60
Discuss the appropriate technique for sterile airway suctioning
- The trachea is considered sterile and you do not want to introduce any other type of organisms to that area.
- Because you do not want to cause infection in the lungs which can lead to pneumonia
61
o Explain reasons why continuous suctioning is harmful
you can pull up mucous membranes- You will suck inside of the bronchial tree, causing inflammation, causing damage
- Do not take out too much oxygen which causes decreased HR, o2 sat. will drop
- Dry mouth
- Infection and inflammation
- hypoxemia
62
Describe care for a client receiving oxygen via a nasal cannula
Check orders
Compare orders with what client is actually receiving
Assess for skin breakdown (around ear, auricle, across the cheekbone,
Client comfort
Use of humidification
Document respiratory assessment
Wean as tolerated, if allowed by MD order
o Oxygen saturation less than or equal to 92%
63
Simple O2 Mask
Useful for short periods such as pt transport. Contraindicated in pt who retain CO2. May induce feeling claustrophobia. Interrupted with eating and drinking. Increased risk of aspiration6-12 L/min. FiO2: 35-45%
64
Venturi Mask
Provide specific amount of oxygen with humidity added. Low constant O2. Mask and therapy may irritate skin
65
Non-rebreather mask
Hot and confining. May irritate skin and R. seal is necessary. Interpheres with eating and drinking. Bag may twist or kink. Use for short periods, delivers increases O2, easily humidifies. Does not dry mucous membranes. 10-15L/min. FiO2: 60-90%
66
Explain how pt would eat when receiving O2 by mask
Depends on how much O2 and what kind of mask. Would be on nasal canal high flow while eating or would not be eating and getting nourishment through NG tube.
67
Explain the effects of dehydration on the respiratory system
o Dries out mucous membranes and makes removal of pulmonary secretions difficult
68
Discuss use of continuous positive airway pressure, Identify indications for this treatment
CPAP: delivers a constant pressure which forces air into the lungs when you inhale with a set pressure. The pressure helps the lungs expand. A pressure is also set at exhalation which helps keep the airways open. Helps increase oxygen levels in the lungs and decreases how hard a person has to work to breathe.
BIPAP
They help blow off CO2 and increase air/O2 getting to the bases of the lungs; they require an MD order and need respiratory therapy to set up in the hospital
Req. MD Order
69
Identify key assessment techniques for the cardiac system.
```
o Blood pressure:
o Heart sounds: Auscultate with
o Palpate pulse points
o Auscultate over abdominal aorta and carotids
o Temperature of skin
o Edema
o Color
o Capillary refill
```
70
Identify correct cardiac landmarks for auscultating: closure of mitral and tricuspic valves, closure of aortic and pulmonic valves
o Mitral: 5 intercostal space close to the boob
o Tricuspid: 4 intercostal space, close to the L external border
o Aortic- 2nd intercostal space. R. external border(1st spot we listen to)
o Pulmonic- 2nd intercostal space- L. ext border
71
Describe the relationship between preload, afterload, contractility, and cardiac output
o Preload: amt blood into ventricle before contraction. Effected by blood volume
o Afterload: Resistance heart has to beat against
o Myocardial Contractility: actualy squeeze of muscle. Affected by damage
o HR: affected by drugs, age, volume, etc.
o Stroke volume: amt that leaves heart every time heart squeezes. Never 100%
o All work together to circulate blood efficiently and correctly
72
Explain how afterload is affected by peripheral vascular resistance
o Afterload is the amt of resistance the heart has to beat against. If there is a lot of resistance, then the heart has to work harder.
73
Identify complications occurring as a result of altered cardiac conduction, altered cardiac output, impaired valvular function, myocardial ischemia, and impaired tissue perfusion.
o Altered cardiac conduction: calcification of the conduction pathways, thicker and stiffer heart valves caused by lipid accumulation and fibrosis and a decrease in the number of pacemaker cells in SA node.
o Altered cardiac output: primary coronary artery disease, cardiomyopathy, valvular disorders, and pulmonary disease.
o Impaired valvular function: heart murmurs, stenosis (hardening) or impaired closure of the valves. Left or right sided failure can occur.
o Myocardial ischemia: angina and myocardial infarction.
o Impaired tissue perfusion: myocardial infarction
74
Identify what angina is and explain what causes it
o Angina: Lack of oxygen delivered to the heart muscle to the point where the cells are dying. Causes heaviness across chest, SOB, left arm pain, nausea, Transient imbalance between myocardial oxygen supply and demand.
A condition of severe pain in the chest. Insufficient oxygen to the heart muscle. Caused by narrowing of coronary arteries.
75
• Describe the significance of the following findings
| o Bruit
o Bruit: turbulent blood flow over an artery
76
• Describe the significance of the following findings
| o Murmur
turbulent blood flow over a valve
77
Explain the cause of a myocardial infarction (MI):
blockage in coronary artery leading to lack O2 being delivered to heart. Impaired tissue perfusion.
78
ID signs and symptoms of a MI
```
Tightness across chest
SOB
Jaw ache, left arm pain, numbness
Diaphoresis
Nausea
Fear/feeling of doom
Dizziness
```
79
Explain how a MI puts a client at risk for heart failure
MI=heart muscle death. even if O2 restored those heart cells will never beat the same leading to impaired heart function
80
Signs and Symptoms of Heart Failure
Fatigue, activity intolerance, weight changes due to fluid excess, edema, breathlessness, dizziness, and confusion. Crackles, SOB, cough, and dyspnea, tachycardia, nocturia, skin changes, behavioral changes: restlessness, anxiety, fear
81
Discuss priority assessments for a client with heart failure (poor cardiac output)
HR, weight, blood pressure, assess level of fatigue
82
Sinus Bradycardia
HR too slow. Fine. HR Assess
83
Sinus Tachycardia
HR too fast. Fine. HR Assess
84
Atrial Fibrillation
No P wave. Ventricular wave is irregular. Depend on how fast heart is going.
85
Ventricular Tachycardia
SA node is fine. Heart is not coordinated. BP drop, dying, feel fine, feel dizzy. Need electrical shock to get out of rythem. BAD
86
Ventricular Fibrillation:
fast then flutter. No blood circulating. No resp. CPR time. BAD WORST
87
Nursing Interventions Dysrhythmias
```
ECG monitering
Monitering VS
O2 therapy
IV access
Administer meds
Prepare to initiate CPR
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88
Explain indications for cardio-pulmonary resuscitation
o V-fib
o No pulse
o No resp
89
Identify heart healthy foods
Leafy green vegetables, whole grains, berries, walnuts, almonds, avocados, beans, fatty fish and fish oil.
90
Explain why is a low-sodium diet essential with cardiovascular disease
Na causes water retention
91
Identify the physiologic processes that regulate fluid volume and fluid distribution
```
Osmosis h20 moves from high to low []
Active Transport
Filtration
Diffusion
ADH: causes kidneys to retain h20o Renin-Angiotensin-Aldosterone System: influence Na and H20 excretion
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92
Identify common fluid, electrolyte, and acid-base disorders
```
o Dehydration
o Hypovalemia
o ECF excess
o Resp. alkalosis/acidosis
Metabolic alkalosis/acidosis
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93
Accurately calculate intake and output
- Output includes urine, diarrhea, vomitus, gastric suction, drainage from postsurgical wounds or other tubes.
- Intake includes all liquids that a person eats, drinks, or receives through nasogastric or jejunostomy feeding tubes. IV fluids. Water swallowed while taking pills counts.
- Ice chips are half the volume (if 8oz cup, its 4 oz of liquid)
94
Identify risk factors for dehydration
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o Drainage
o Burns
o Hemorrhage
o GI losses
o Diabetes Insipidus
o Inadequate intake
o Cognitively impaired
o Physical limitations
o Fever
o Hyperglycemia
o Older adult
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95
Identify risk factors for fluid overload
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o Heart Failure
o Renal Failure
o Syndrome of Inappropriate ADH
o Long-term use of corticosteroids
o Parenteral replacement
o Liver Failure
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96
Explain how the stress response effects urine output
Stress causes ADH to increase, so less urine output. Cortisol can cause diuresis.
97
Identify signs and symptoms of fluid volume excess and deficit
```
o Deficit
Weight loss
Thirst
Decreased urine output
Restlessness, confusion, seizures
Hypotension
Rapid, weak pulse
Decreased capillary refill
Decreased urine output
Concentrated urine
Weakness, dizziness
Dry mucous membranes
Decreased skin turgor
Elevated hematocrit
o Excess
Weight gain
Headache, confusion, lethargy, seizures, coma
Dependent edema
Increased blood pressure
Jugular vein distention (full neck veins)
Bounding pulse
Lung auscultation: crackles, dyspnea(SOB)
Lower hematocrit
```
98
o Describe how fluid and electrolyte and acid base imbalance is reflected in the following assessments:
Blood pressure
• Hypotension or orthostatic hypotension = ECV deficit
• Light-headedness on sitting upright or standing = ECV deficit
Pulse
• Rapid, thread = ECV deficit
• Bounding = ECV excess
Cardiac rhythm
• Irregular pulse and ECG changes = K+, Ca2+, Mg2+, and/or acid-base imbalance
Neck veins
• Flat or collapsing with inhalation when supine = ECV deficit
• Full or distended when upright or semi-upright = ECV excess
Mucous membranes
• Dry between cheek and gum, decreased or absent tearing = ECV deficit
Level of consciousness
• Restlessness and mild confusion = severe ECV deficit
• Decreased level of consciousness (lethargy, confusion, coma) = hypernatremia, hyponatremia, hypercalcemia, acid-base imbalance
Respiratory rate and rhythm
• Increase rate and depth = metabolic acidosis (compensatory mechanism); respiratory alkalosis (cause)
• Decreased rate and depth = metabolic alkalosis (compensatory mechanism); respiratory acidosis (cause)
Reflexes
• Decreased deep tendon reflexes = hypercalcemia, hypermagnesemia
• Hyperactive reflexes, muscle twitching and cramps, tetany = hypocalcemia, hypomagnesemia
Bowel sounds
• Decreased bowel sounds = hypokalemia
Skin turgor
• Pinched skin fails to return to normal position within 3 seconds = ECV deficit
Daily weight
• Loss of 2.2 lbs. or more in 24 hours = ECV deficit
• Gain of 2.2 lbs. or more in 24 hours = ECV excess
Urine output, color, and specific gravity
• Urine output: small volume of dark yellow urine = ECV deficit
99
Explain how diarrhea causes metabolic acidosis and impacts fluid status
- Loss of bicarbonate (normal anion gap)
- Metabolic acidosis occurs from an increase of metabolic acid or a decrease of base (bicarbonate). The kidneys are unable to excrete enough metabolic acids, which accumulate in the blood, or bicarbonate is removed from the body directly as with diarrhea.
100
Explain how vomiting effects pH and fluid status
- Loss of metabolic acid
- Metabolic alkalosis occurs from a direct increase of base (HCO3-) or a decrease of metabolic acid, which increase blood HCO3- by releasing it from its buffering function.
101
Explain how acid base imbalance contributes to Kussmaul respirations
Rapid or labored breathing
| Try to get rid of CO2
102
Differentiate between isotonic, hypertonic, and hypotonic fluids
o Isotonic: neutral solution. Stays in the intravascular space. Does not shift. Good for maintaining BP.
o Hypertonic: more than 280. Draws water from cells into the intravascular space.
o Hypotonic: less then 280. Water moves from intravascular space in cell and causes cells to swell. Treat cellular dehydration.
103
Norm. Na+
135-145 mEq/L
104
Norm. K+
3.5-5.0 mEq/L
105
Norm Ca2+
8.6-10.2 mEq/L
106
Norm Cl-
98-106 mEq/L
107
Norm. Tot. CO2
22-30 mEq/L
108
Norm. Mg2+
1.5-2.5 mEq/L
109
Foods high in Na+
processed food
110
Foods high in K+
tuna, dark leafy greens, stone fruit
111
Food high in Ca2+
dairy
112
Food high in Mg2+
nuts, beans, dark leafy greens
113
Hyponatremia
<135
| Altered mental statuso apprehension, headaches, decreased level of consciousness, coma, seizures
114
Hypernatremia
>145 Altered mental status
Excessive thirst
hypotension
115
Hypokalemia
<3.5 Cardiac dysrhythmias
Respiratory distress
GI
Muscle weakness
116
Hyperkalemia
>5 Ventricular Fibrilation
Cardiac arrest
Muscle weakness
GI
117
Hypomagnesemia
Cardiovascular (dysrhythmias)
Neuromuscular (hyperreflexia)
GI (decreased peristalsis)
118
Hypermagnesemia
Cardiovascular (bradycardia, heart block)
Neuromuscular (hyporeflexia)
Respiratory (decreased rate, shallow)
GI (increased peristalsis)
119
Hypocalcemia:
Cardiovascular (dysrhythmias)
Respiratory (Laryngeal spasms, stridor)
Neuromuscular (twitching, numbness/tingling, Chvostek’s sign, Trousseau’s sign)
GI (increased peristalsis)
120
Hypercalcemia
Cardiovascular (dysrhythmias)
Neuromuscular (weakness, lethargy)
Musculoskeletal (bone pain, fractures)
121
Explain how potassium, calcium, and magnesium imbalances influence the cardiac system
- Potassium: decrease of it causes cardiac arrhythmias, an increase causes cardiac arrest
- Calcium: cardiac arrhythmias (only when extremely low or high)
- Magnesium: palpitations, arrhythmias (only when extremely low or high), angina, high BP.
122
Explain how calcium and magnesium imbalances influence the musculoskeletal system
- Calcium: causes muscle contraction; imbalance—muscle weakness or severe cramping
- Magnesium: imbalance—twitches, cramps, muscle tension/soreness.
123
Describe positive Chvostek’s and Trousseau’s signs
Chvosteks: cheek spasm above jaw
Trousseau’s: when taking BP hand has involuntary spasm
Indicate hypocalcemia
124
Explain how a low sodium level influences the central nervous system
H20 enters cells by osmosis causing cells to swell. Cerebral dysfunction. Then channels and neurons will not work properly
125
Explain how hypoventilation contributes to respiratory acidosis
o pH: <7.35, PaCO2>45mmHg
o Retention of CO2 by lungs
Lower BP with vasodilation
Dyspnea. Hyperkalemia
126
pH
acid-base balance of arterial blood- 7.35-7.45
127
PaO2
pressure of dissolved O2 in plasma- 80-100 mmHg
128
PaCO2
pressure of CO2 in arterial blood- 35-45mmHg
129
HCO3
Bicarbonate which is a metabolic buffer for pH balance 22-26mEq/L
130
SaO2: %
hemoglobin oxygen carrying capacity used- >95%
131
Acid-base balance: Interpret whether the pH is normal, acidotic or alkalotic
Normal: 7.35-7.45
Acidosis <7.35
Alkalosis >7.45
132
Metabolic v. Resp. Acidosis:
• Metabloic Acidosis lower HCO3, low pCO2, low pH
• Resp. Acidosis: high pCO2, high HCO3, low pH
Metabolic: Focus on HCO3
Resp: Focus on pCO2
133
Metabloc v. Resp Alkalosis
• Resp. Alkalosis: Low pCO2, low HCO3, high pH
• Metabloic: high HCO3, high pCO2, high pH
Metabolic: Focus on HCO3
Resp: Focus on pCO2
134
Discuss purpose and procedure for initiation and maintenance of intravenous therapy
Purpose: med/comfort, rehydrate/maintain hydration, quick access, blood administration, nutrition
135
Differentiate between peripheral and central line access
o Peripheral: most utilized med devices. Risk infection.
o Central Line Access: Over 64X greater infection then peripheral IV.
Direct line access to large vein close to heart
136
Differentiate between a continuous and intermittent bolus IV
Bolus IV: a relatively large volume of fluid or dose of a drug or test substance given intravenously and rapidly to hasten or magnify a response
- Continuous: uninterruptedly given until instructed otherwise by physician
- Intermittent: given over a set period of time at prescribed intervals and then stopped until the next dose is required
137
Differentiate between a continuous and intermittent bolus IV
Bolus IV: a relatively large volume of fluid or dose of a drug or test substance given intravenously and rapidly to hasten or magnify a response
- Continuous: uninterruptedly given until instructed otherwise by physician
- Intermittent: given over a set period of time at prescribed intervals and then stopped until the next dose is required
138
Determine priority assessments when caring for clients with IVs
```
o Occlusion, Phlebitis, Fluid overload
o Adverse drug reaction
o Vitals—infection
o Skin—inflammation
o Pain
o Electrolyte balance
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139
Explain methods to protect the skin and veins of the older adult during IV therapy
o Smallest catheter: not much fat. Match size catheter with size vein.
o Avoid back of hand. (Avoid posterior surface)
o Prevent tearing of skin(tourniquet)
o Avoid excessive tape
140
Identify IV maintenance tasks that can be delegated to assistive personnel
AP can notify you if patient indicates any burning, bleeding, swelling, etc at catheter site. If dressing is wet or loose, if any alarms are going off. If fluid container is almost empty.
Basically they can report stuff
141
Identify complications caused by inaccurate infusion rates
fluid volume overload
142
Identify priority interventions for complications during IV therapy
Infiltration: Move pump/stop, replace w/new, elevate arm
Phlebitis: Stop the IV, relocate. Replace with new. Elevate arm, warm compress.
Extravasation: stop the IV, take out and relocate, call the Dr.
143
Complications of IV therapy
Risks of peripheral parenteral therapy:
- Fluid overload
- Electrolyte imbalance
- DVT/ embolism
- Occlusion
- Nerve, tendon, ligament damage
- Adverse drug reactions
- Localized and systemic infections
