exams 1-4 Flashcards
personality traits
behaviors and patterns of perceiving or relating to others; and of thinking about self and others in environment
personality traits may be
adaptive or maladaptive
maladaptive traits are
inflexible;significant functional impairment and subjective distress
persistent maladaptive traits =
personality disorder
personality disorders are
long standing, believed to rise from very beginnings of personality developent
what to look for in personality disorders
connections to Erickson’s developmental task completion, trust issues, autonomy issues are very common themes
enduring personality disorders
a “cure” is unlikely
personality disorders are
not responsive to short-term psychotherapy or drug therapy
which axis are personality disorders identified
axis 2
increased stress in patients with personality disorders
causes exacerbation of symptoms
Cluster A
(secretive, suspicious)Cognitive = unable to trust, indecisive, poverty of thoughtAffective = Quick anger, social anxiety, blunted affectBehavioral = eccentric, craves solitude, argumentative, odd speechSociocultural = impaired or nonexistent relationships, occupational difficulties
Cluster B
(flamboyant, dramatic, attention-seeking)Cognitive = considers self special, unique, egocentric, no long range plans, often identity disturbancesaffective = intense, labile, no sense of guilt, anxious, depressedbehavioral= dramatic, craves excitement, wants immediate gratification, self mutilationsociocultural = manipulates and exploits others, stormy relationships, no amount of attention is enough
Custer C
(fearful, indecisive)Cognitive = moralistic, low self esteem, low self confidenceAffective = anxious, fearful, depressedBehavioral = Tense, rigid routines, submissive, inflexible, passive-aggressiveSociocultural = Dependent on others, avoids overt conflict, seeks constant unconditional love
Cluster A disorders
( Eccentric, isolative with major lack of trust)Paranoid personality disorderschizoid personality disorderschizotypal personality disorder
paranoid personality disorder
increased risk in malessubstance abuse commonincreased risk if family history suspiciousdifficulty adjusting to changesensitive, argumentativefeels irreversible injury by others - often without evidence unwilling to forgive even minor eventsanxiety, difficulty relaxingshort temperdifficulty problem solvinglack of tender feelings toward othersjealous of significant other - often without evidence
schizoid personality disorder
lack of desire to socialize ; likes solitudelacks strong emotionsdetached, self absorbedlacks trustmay have brief psychotic episodes when stresseddifficulty expressing anger passive reaction to crisis
schizotypal personality disorder
often seek help for anxiety or depression30-50% also have major depressionincorrectly interprets external events - believes all events refer to selfsuperstitious, preoccupied with paranormal phenomenabelieves in magical control of othersconstricted or inappropriate affectanxious in social situationsgenerally seeks therapy for depression, anxiety, dissociative D/O
Communication strategies for Cluster A
reinforce reality limit discussion to concrete familiar topicsclear, simple messages to avoid misinterpretation of words/phrasesresist using logic to counteract clients inappropriate statements- client may engage in power struggle to defend selfdon’t use humoracknowledge pain, fearoffer gentle reassurance when perceptions are frighteningdon’t touch the client - may be misinterpreted
Cluster A pharmacological therapy
usually treated for axis 1 problemantidepressants, anxiolytics, low dose antipsychotics
Cluster B Disorders
(dramatic, self centered)antisocial personality disorderborderline personality disorderHistrionic personality disorderNarcissistic personality disorder
antisocial personality disorder
Usually diagnosed by age 18 H/O conduct D/O High % in prison or h/o legal trouble High % with substance abuseincreased incidence in malesIrresponsible –Fail to honor financial obligations including child careLack guiltDifficulty learning from mistakesInitial charm becomes coldness, manipulation, blaming othersLacks empathyIrritable affect
borderline personality disorder
75% female H/O physical, sexual abuse, neglect, hostile conflicts Often early parental loss/separationIntense, stormy relationshipsDichotomous thinking – all good or all badImpulsive – often engages in reckless behavior - e.g. binging, spending money, reckless driving, unsafe sexual activitySelf-mutilatesDifficulty identifying selfNegative/angry affectFeels empty, boredDifficulty being alone, feelings of abandonment
dichotomous thinking
all good or all bad
characteristics of borderline personality disorder
Usually above average intelligenceOften initially very charming, ingratiatingTend to be very demanding - demand others meet their needsNo sense of boundaries - others’ assertion of boundaries feels like rejection or punishmentNot all traits may be present Don’t focus on analysis of condition but on behavior and your response to itBPD overlaps with many other disorders especially PTSDPeople with BPD suffer a lot of emotional pain and they don’t know what to do to feel betterMost of behaviors come from unconscious motivations - little insight into “why” they feel and act as they doThe best thing we can do for ourselves and people with BPD is set boundaries
boundaries for borderline personality disorder
Communicate honestly, fairly and consistentlyDon’t argue or bargainFollow through - message must be consistent in words and actionsRemain calm - refrain from responding emotionally to provocation or manipulation Avoid power struggles by enforcing rules and limits consistently and refusing to respond to manipulative behavior (remember manipulation could be quite charming or ingratiating)Give positive feedback when appropriate - help person identify strengthsStay focused on topic of discussion - don’t get side-tracked to other issues, what other people did, etc.Be compassionately objective - clear - consistentRespect your own boundaries and model that behavior - we teach others what our boundaries are by how we let others treat us
Histrionic personality disorder
More common in womenRapid fluctuation in emotionsAttention-seeking, self-centeredSexually seductive, flamboyantVery attentive to own appearanceDramatic style of speechVague logic-lacks conviction in arguments, often switches sidesShallow emotional expressionCraves immediate satisfactionMany c/o physical illnessSuicide gestures
narcissistic personality Disorder
50-70% are malesGrandiose view of selfLack of empathyNeeds to admiredPreoccupied with fantasies of success, brilliance, beauty, ideal love
communication strategies for Cluster B
Don’t argue, rationalize or bargainStay calm!Communicate expectations clearlyAvoid power strugglesHelp client focus on thoughts/feelings behind self-destructive actionsBe consistent!Confront inappropriate behavior – try to assess if behavior stems from fear or attention-seekingBe compassionately objectiveGive positive feedback when appropriateHelp client stay focused on topic of discussionHelp client assume responsibility for feelings
Cognitive therapies for Cluster B
DBT, CBTWork with client to see consequences of inappropriate behaviorsBuild trusting relationshipHelp client develop strategies for self-destructive behaviorsHelp client develop skills for social adaptation
pharmacological therapy for cluster B
Aimed at Axis 1 diagnosisAnti-depressants, axiolytics
Cluster C disorders
(Fearful, anxious)avoidant personality disorderdependent personality disorderobsessive compulsive personality disorder
avoidant personality disorder
Fearful of criticism, disapproval, rejectionAvoids social interactionsWithholds thoughts, feelingsNegative sense of self, low self-esteem
dependent personality disorder
Submissive, clingingUnable to make decisions by themselvesCannot express negative emotionsDifficulty following through on tasks
obsessive-compulsive personality disorder
Preoccupied with perfection, organization, structure, controlProcrastinatesAbandons projects due to dissatisfactionExcessive devotion to workDifficulty relaxingRule-consciousSelf-criticism, unable to forgive own errorsReluctant to delegateUnable to discard anythingInsist others conform to own methods, ideas
Communication strategies for Cluster C
Help client explore misinterpretation of others’ actions/remarksas criticismDiscuss and model assertive communication & behaviorsHelp client learn to express feelingsHelp client learn to have fun/develop leisure activities
cognitive therapy for cluster C
Learn new ways to cope with anxiety,anger,other emotionsHelp client recognize/eliminate unrealistic expectations of self/othersFormulate ways to increase client’s social interactionsPlan activities to enhance client’s self-esteem, decision-making
pharmacological therapy for cluster C
Aimed at Axis 1 dxAnti-depressants, axiolytics
interventions for cluster C
Promote safetyAssess for suicidal ideationContract for safetyAssess for escalation of anger -> rage; impulsive violent actionContract for no violent actsTeach alternate means to manage angerGroup therapy to practice problem-solving/explore alternativesAssess for self-mutilationContract to talk c staff if urge to self-mutilatePut pt. on close observation until pt identifies need for self-harm has passed Identify other means of emotional release – i.e. wrap in sheet movement therapy If wounds occur treat in non-judgmental way – with little discussionEncourage journalingPhysical restraint if necessary
what are interventions aimed at
aimed at modifying life-long disruptive/dysfunctional behaviors/thoughts
major thing to remember about antisocial personality disorder
there is no sense of guilt. Nothing is their fault
what to remember about borderline personality disorder
neglect, a lot of sexual abuse , emotional separation of a parent, or physical separation
borderline personality disorder (important)
attempt suicide with no clear expectation of death , death is not the goal
anti social is very
id oriented. They only think about themselves
important for narcissitic disorder
help client assume responsibility for feelings
Delegation
A process that transfers to a competent individual the authority to perform a selected task in a specific situation.
accountability
Being answerable for the actions or omissions of self or others in the context of delegation
assistive personnel are accountable for
Decision to accept delegationPerformance
Nurse’s are accountable for
Decision to delegateDelegated taskClient outcomes
assistive personnel is accountability is to
Self Delegating nurseEmployer
Nurse’s accountability is to
SelfClientsEmployerLicensing boardProfession
Delegation process
evaluationmonitoring delegation assessment
5 rights of assessment delegation
RIGHT taskRIGHT circumstanceRIGHT personRIGHT direction/communicationRIGHT supervision
assessment red flags
Complex nursing activityUnidentified client needsRequisite knowledge and skills missingInsufficient opportunity to trainInsufficient opportunity to monitor/supervise
steps for delegation
Communication of task to be delegatedMutual agreementTransfer of authority
process of how to delegate
WHO will doWHAT byWHEN andHOW, WHERE, andWHY it will be done
directions for delegation
Priority of activityExpected timelinesGuidelines for consulting mid-activityReportable conditionsGuidelines for reporting task completionRole as delegator and supervisor
red flags of delegation
Refusal to accept delegationIncomplete directionsFailure to confirm expectationsFailure to communicate
supervision
Provision of guidance or direction, evaluation and follow-up by the licensed nurse for a process and the outcomes of a delegated task
degree of supervision required depends on
Client needsStability of the clientCompetency of the assistantNature of the taskAvailable supervision
red flags for monitoring
Change in other client’s condition with impact on workloadFailure of assistant to report unexpected events or client outcomesWork completed incorrectlyWork not completedInadequate communication from assistantInadequate direction from delegatorInadequate or lack of monitoring from delegator
desired delegation outcomes
Protection of client safetyAchievement of desired client outcomesReduction of health care costsAccess to appropriate levels of health careDecreased nursing liability
inappropriate delegation may result from
Inadequate resourcesConflict of employee policies and lawInappropriate employer directionLack of knowledge about delegationFailure to accept accountability for nursing care provided
corrective action for delegation
Educate and trainRestate expectationsReturn skill demonstrationIdentify specific checkpointsIncrease frequency of check-insEvaluate directions
evaluation red flags
Failure to evaluate delegation effectivenessFailure to evaluate the delegator/assistant relationshipFailure to learn from work experience
keys to delegating affectively
Communicate continuouslyValue all team member contributionsDevelop trust between co-workersLearn from experience
what does a leader do
influence other people to obtain a goal
role of a nurse
meeting patients needs in an effective and timely manner
one of the biggest parts of communication is
listening
types of leaders
authoritarian/autocraticdemocratic/ benevolentlaissez-faire
authoritarian/autocratic
they will do whatever it takes to obtain the goal. the goal is the only thing that is important. My way or the highway type leader.(very efficient, get things done, but long term, their team falls apart)very stiffling relationshipwork by intimidation
what are some certain situations where a leader needs to take on an authoritarian role.
in an emergency
democratic/ benevolent
this does not mean that youre not a leader and you don’t direct people, or you aren’t in charge but you have good communication skills and value what other people have to say. Take a team approach. Really involved in your team. You make sure your team is involved in the decisions that are made.
democratic/ benevolent
not as efficient as authoritarian but still as effective and you have a team that sticks around
laissez-faire
a hands-off approach that allows followers to set rules and make decisions.try to give the least possible guidance tosubordinates, and try toachievecontrolthrough less obviousmeans. They believe that people excel when they are left alone to respond to theirresponsibilitiesandobligationsin their own ways.
if someone accepts a delegation
they are then accountable for completing it. they are accountable for accepting it and completing it.
what can’t a nurse delegate to unlicensed individuals
assessmentplanningteachingand evaluation
indirect delegation
a list of a CNA’s responsibilites (job profile). Things they are responsible for.You need to be aware of what they are and what they are comfortable doing.
RN skills that you can’t give up
assessmentplanningteachingcounselingevaluation
RN/ LPN IV meds
giving IV meds (some LPN’s have taking courses to give certain IV meds)IV push meds (RN only)Hanging blood (RN only)
LPN skills
vitalsmeds (not iv’s)some IV medsnot iv pushphysical carecontribute to data of assessment (but RN is responsible)
CNA skills
personal carehelp with feeding (on stable individual)
right task
are they abledo they have the experiencedoes it require alot of judgementdoes it require a lot of nursing knowledge
right circumstance
are these tasks free from independant nursing judgement
right direction/communication
clearly state what you want done
ectopic rhythm
irregular heart rhythm due to a premature heartbeat. Ectopic rhythm is also known as premature atrial contraction, premature ventricular contraction, and extrasystole.
Coronary artery
only place in the body perfused during Diastole
organs that take a lot of oxygen and will get damaged quick
brainkidneysandheart
left coronary artery
branches out into two significant branchesanterior descending branch (contracting of left ventricle, supplies all bundle branches)circumflex branch
when the anterior descending branch is blocked
anterior wall MImost serious MIresults in death
right coronary artery
supplies right side of heartsupplies the SA node and AV nodeMI on this side messes up the conduction of the heart. could result in a pacemaker .
SA node is
is the pacemaker of the heartthe cells in here generate an electrical impuleThis impulse spreadsThis causes the atria to contract / depolarization
SA node
has an intrisic ratethe rate that it fires at in normal situations (60-100 bpm)
depolarization
another term for contraction
AV node
gatekeeper. Receives impulses from SA.lets the impulses through to the ventricles. usually lets it through unless its over 180. Too many beats can cause a block.
AV nodes intrinsic rate
40-60 bpmthis is what it creates on its own. (if your SA node gives out) Normally SA node intrinsic ratewins out
junctional rhythm
unstable rhythm
impulse travels
impulse goes through the bundle of his, to pukinje fibers, to ventricles
idioventricular rhythm
20-40 bpm
ventricles intrinsic rate
less than 40 bpm
sympathetic
norepinephrine increases heart rate and bp
parasympathetic
slows heart rate and BP via acetocholine
vagal nerve
controlled by parasympathetic nervous system causing your heart rate to slow way way down. ventricle can’t fill with enough blood to contract
interupted rhythms
when you interupt the rhythm the SA node will pick back up again
12 lead ecg
4 limb leads6 B- leads (on chest)gives you 12 different views. need twelve views to see whats wrong
ischemia causes
st depression
atropine
speeds up heart . stimulates sympathetic heart
potassium
needs to be right at 3.5 -5.5low potassium irratates the heart causing ectopic rhythmshigh potassium depresses the heart causing blocks or a cardiac arrest.
calcium
too little ventricular arrythmiastoo much can cause an MI
magnesium
needed for calcium to be used by the heart
infection can result in
increases heart rate.
PR interval
impulse to get from the SA node through the AV node, just before depolarization.
qrs complex
depolarization
ST segment
time between ventricular depolarization and ventricular repolarization
T wave
ventricular repolarization
repolarization
getting back to stage 0 again
sodium
sodium make the cells more positive to make the heart contractthen the sodium must get into the blood and push potassium back into the cell .
during repolarization you have
refractory periodrelative or vulnerable refractory period
one minute is how many boxes
300 boxes
one box =
0.04 seconds
5 boxes
.20 secs
what are we interested in with a cardiac strip
ventricular response
pr interval has to be
.12-.20 seconds3-5 little boxes
qrs complex
.04-.10 secs1-2 1/2 boxes
.12 secs and above on a qrs
most likely a bundle branch block
st segment
should be flatdepressed is ischemiaelevated is cardiac injury
st segment is
end of ventricular depolarization and begining of repolarization .
T wave is
repolarization
tented T wave
hyperkalemia
flat plateau T wave
hypokalemia
qt interval
time betweeen the onset ventricular depolarization and the end of ventricular repolarizationaverage is .34 to .43 is average
qt interval should be
less than half the distance between 2 consecutive heart beats.
causes of bradycardia
digbeta blockerscalcium channel blockersheart diseaseMIhypothyroidismhypothermiaincreased intercranial pressure
bradycardia symptoms
dizzyconfusionSOBanginaBP lowdon’t feel good
what do you do for bradycardia
give atropine (first)
what if you can’t fix the bradycardia
they end up with a pacemaker . you can’t continue to give atropine continuously
sinus tachycardia
below 150 bpm
atrial tach
above 150 bpm
sinus tach symptoms/causes
dizzypounding sensationdiaphoreticSOBcaused by stimulantscoffeenicotinechocolate
sinus tach is treated with
beta blockerscalcium channel blocker
sinus arrhythmia
slightly irregular rhythmeverything else looks normalusually changes upon breathing. there might be slight differences between the qrs complexes
sinus arrhythmia
childrenelderlyathletesthey don’t treat it because you are still getting good cardiac output
sinus arrest orblock
sinus node falls asleep for a minute
premature atrial contraction
shorter distance between the qrs’s randomly. Still has a P wave, looks normal. But randomly beats are closermost premature beats are follow by a pause.non compensatory beat
Non- compensatory
take 3 beatsmove it over and see if the beat is coming in on time . if it does not come in on time it’s NON compensatoryif it comes in on time, its compensatory
causes of PAC’s
overtiredstresssmokingcaffeinedrugs (perscribed)hyperthyroidismalcohol
when is there a problem with PAC’s
if there is more than 6 or more a minutetrigenimy’sif they are happening on the T wavedon’t normally treat unless there is a potential for harm
most begnign of the premature beats
PAC’s
which do you treat first PAC’s or PVC’s
PVC’s are more dangerous
atrial tachycardia
over 151 bpm to 250 bpm
difference between Atrial Tach and SuperVentricular Tach
you can see a P wave in an atrial tach
what do you give for atrial tachycardia
calcium channel blocker (IV)adenosine (IV) only drug given fast
Synchronizedcardioversion
machine synchronizes with patients rhythm so theshock is NOTdelivered on T wave
atrial flutter
no P waves, flutter waves250-350 bpmyou can’t hear it with apical pulse because it does not effect ventricular ratesawtooth pattern
treatment for atrial flutter
meds (calcium channel blockers, beta blockers, potassium blockers,…)cardioversion first. Then drugs
atrial Fibrillation
350-500 bpm (atrial rate)No P waves., wavy baseline.second biggest cause of strokesif ventricular rate is60-100 -controlled A. Fib101-150 rapid ventricular responseover 150 - uncontrolled A. Fib
A Fib
cardioversionanticoagulant for ones you can’t fix (living with)they throw clots. (strokes)
psychosis
A state in which a person’s mental capacity to recognize reality; communicate; and relate to others is impaired Person moves in and out of reality Reality for the person is the world as that person perceives it- not necessarily as it exists
most common psychosis diagnosis
schizophrenia
two types of psychosis
functional and organicCurrent research emphasizes both biological and psychosocial factors
functional psychosis
results from interpersonal conflict, stress->psychogenic origin
organic psychosis
results from physiological damage/dysfunction
psychotic behavior
Person attempts to adapt, attempts to explain experiences and/or attempts to structure a “crazy” worldEx. Schizophrenic person may cut himself for reassurance that he is “real” because he bleeds and feels pain
cognitive factors of psychopathology
what a person knows/believes about self, others, principles, places, objects, actions, etc.
Cognitive disruptions of psychopathology
Thinking DistortionsCommunicating DistortionsDelusionsHallucinations
Thinking distortions of psychopathology
Selective Abstraction Overgeneralization Magnification Superstitious thinking Dichotomous thinking
selective abstraction
“I’m still too fat – look how big my hands and feet are.”
overgeneralization
“You don’t see fat people on TV. So you have to be thin to be successful at anything in life.”
magnification
“If I gain 2 pounds, I know everyone will notice it.”
superstitious thinking
“If I wear all black I’ll lose weight”
dichotomous thinking
“If I’m not thin I’m fat” (black and white thinking)
communications distortions
loose associationsflight of ideasword salad
loose associations
“Don’t you think my stomach is getting bigger? Fall is when lots of food is harvested like corn and pumpkins.”
flight of ideas
“The weather looks like it’s changing. These pants make me look thin Lunch was really bad. I don’t think I should be taking all those pills.”(speech is rapid and there is a continuous flow of words)
word salad
“animals, cars, bedtime, dark, prayers closets…”
Delusions
Fixed, firm beliefs contrary to reality
examples of delusions
grandiositypersecutioncontrolreligioussin/guiltsomaticideas of referencethought broadcastingthought withdrawal thought insertion
grandiosity
I’ve been a member of the President’s Cabinet since the Reagan years. No president can do without my advice.”
persecution
See those people in the hall? They’re not really visitors, they’re from the CIA. They’re here to spy on me.”
control
“I have a wire in my head. My family had it implanted so they can control me. They control everything I say. I can’t do anything on my own.”
religious
“I can’t stop to talk with you I have to keep reading this Bible out loud so God will hear me and make sure nobody can hurt me.”
sin/guilt
“I am being punished now because when I was growing up I was a bad kid. That’s why I when I get a job and start doing good I have to quit to make up for my bad behavior. I shouldn’t be happy, not after as bad as I was”
somatic
“My esophagus is being torn apart because there’s a rat in my stomach and sometimes he comes up to my throat. He eats away at my esophagus. Look in my throat you can probably see him.”
ideas of reference
That doctor and nurse at the desk are talking about me. You say they aren’t but I know they are. You people talk about me all the time.”
thought broadcasting
“I’m afraid to think anything because I know you can read my mind and know exactly what I’m thinking.”
thought withdrawal
“I can’t tell you what I’m thinking. Somebody just stole my thoughts.”
thought insertion
“You think what I’m telling you is what I’m thinking but it isn’t. My father keeps putting all these thoughts in my head. There’s no room for my thoughts. These aren’t mine.”
Hallucinations
Perceptual experiences occurring in the absence of any appropriate sensory stimuliDo not confuse with illusions which result frommisinterpretation of sensory experience-magiciansMost frequent types of hallucination = visual andauditory- but can arise from any of five sensesOften hallucinations have religious contentAssessed at different levels of intensity
hallucinations levels of intensity
comfortingcondemningcontrolling conquering
comforting hallucinations characteristics
Pt has intense emotions like anxiety, loneliness, guilt, fear-tries to focus on comforting thoughts to anxiety; knows thoughts & sensory experiences are controllable if anxiety is managed
comforting hallucinations behaviors
Grinning, laughter that seems inappropriate; moving lips without making sound; rapid eye movement; slowed verbal responses as if preoccupied
condemning hallucinations characteristics
Sensory experience repulsive & frightening; pt begins to feel loss of control; may attempt to distance self from perceived source; may feel embarrassed by experience and withdraw from others
condemning hallucinations behaviors
autonomic nervous system signs of anxiety; attention span narrows; preoccupation with sensory experience; loss of ability to differentiate hallucination from reality
comforting hallucinations
Moderate level of anxietyHallucination generally pleasant in nature
condemning hallucinations
Severe level of anxietyHallucination generally repulsive
controlling hallucinations
Severe level of anxietyHallucination becomes omnipotent
hallucinations can be
auditoryvisual(are most frequent)but they can be tactile
controlling hallucination characteristics
Pt gives up trying to combat experience & gives in to it; content of hallucination may become appealing; pt may experience sadness/loneliness if hallucination ends
controlling hallucination behaviors
Directions given by hallucinations will be followed rather than objected to; difficulty relating to others; attention down to only a few minutes at best, may be only seconds; unable to follow directions; sx of intense fight or flight response
conquering
Panic level of anxietyHallucination becomes elaborate & interwoven with delusions
conquering hallucination characteristics
Sensory experiences may become threatening if pt doesn’t follow commands; without therapeutic intervention hallucinations may last for hours or days
hallucinations, what to ask patient
are you hearing/seeing something.i can’t hear it, what do you hear what are you hearing, what do you seedescribe what are you are seeing/hearingare they soft, or loud
conquering hallucination behaviors
Terror-stricken behavior such as panic; strong potential for suicide/homicide; physical activity reflects content of hallucination i.e. violence, agitation, withdrawal, catatonia; unable to respond to most directions; unable to respond to more than one person
schizophrenia
18-22 is normally when a schizophrenics first psychotic break happensthey start hearing voices in their teens maybe even earlier
affect
How a person feels - Mood Assessment data/conclusions about patient’s affect come, in part, from cognitive and behavioral assessment
descriptors of affects
AppropriateInappropriateStableLabileElevatedDepressedOverreactiveBluntedFlat
appropriate affect characteristics
Mood in agreement with immediate situation
inappropriate affect characteristics
Mood not related to immediate situation
stable affect characteristics
Mood resistant to sudden change when there is no provocation in milieu
Labile affect characteristics
Mood shifts suddenly in a way that cannot be understood in the context of the situation
Elevated affect characteristics
Mood is euphoric not necessarily related to immediate situation
depressed affect characteristics
Mood is despondent no necessarily related to immediate situation
overreactive affect characteristics
Mood is appropriate to the situation but out of proportion
blunted affect characteristics
Mood is dulled response to the immediate situation
flat affect characteristics
No visible clues to the person’s mood
Behavior
How a person acts, what a person doesFreud: all behavior has meaningBehavioral assessment may give valuable information about cognitive clarity and/or affectExamples of Behavioral Assessment Factors Insomnia/hypersomnia – marked sleep disturbances Inappropriate social contacts – behaviors may range from hyperactivity, excessive talking, (laughing, joking) -> complete withdrawal from voluntary contactsMarked impairment in personal hygiene – noticeable changeImpaired role functioning – noticeable difference in performance of role (s) i.e. spouse, employee
Congruency/Consonance
Cognitive, affective and behavioral aspects all operating together = congruency/consonanceBeliefs, feelings and behavior toward a given ”thing” are all positive/negativeIf one aspect is out of “sync” the person will attempt to change that aspect to achieve congruencyEx.: A paranoid person believes (delusionally) that all store clerks want to destroy him. He feels afraid and may act out against a store clerk (behavior) to make all aspects congruent.
an accurate assessment drives the rest of the steps of the nursing process. The nursein charge understands that the management function that drives effective management is
planning
which action is an example of a nurse working independently
assigning another nurse to administer medications(delegating tasks is an independant task)
which is most basic for a nurse new to a management position
strong interpersonal comunication skills
a unit manager mentors a new unit manager as part of orientation to the position. which type of power is being used by the unit manager mentor
expert (expert power is the respect one receives based on one’s ability, skills, knowlege and expierience)
a nurse identifies that a post op patient is hemorrhaging. The nurse direct another nurse to call the surgical resident and sends the nurses aid to grab equipment from utility room and then proceeds to try to stop the bleeding.Which style of leadership did the nurse use in this situation
autocratic
which intervention should an RN perform rather than delegate to an unliscensed nursing assistant
assess the skin on a newly admitted patient
A nurse arrives on the unit for the last 5 minutes of a 20 minute change of shift report for a second time within a week. How should the charge nurse handle this situation
discuss the lateness with the nurse in private, immediately after the report
which specimen collection should a registered nurse delegate to LPN rather than a unlicensed nursing assistant.
wound drainage for culture and sensitivity
a nurse manager considers that there are “Five rights of delegation” - right task, right person, right communication, right time, and right…..
supervision
what should the manager do first to overcome resistance to change
ensure that the planned change is within the current beliefs and values of the group
what activities does a nurse manager engage in who values the importance of positive role modeling
following the policies of the agency (positive role modeling, follow the rules and your employees will too)
when condisering leadership styles an “autocratic” leader is to “authoritarian” as a “democratic” leader is to
consultative
what nursing care delivery model is based on case management
primary nursing
which statement is most significant in relation to the concept of change theory in the health-care environment
weigh the risks and benefits
several nurses complain to the nurse manager that one of the patient care aides constantly takes extensive lunch breaks. What should the nurse manager do
talk with the patient care aide to explore the reasons for the behavior and review expectations
what should the nurse do to ensure efficiency when managing a daily assignment
organize care around legally required activities
a supervisor communicates expectations about a task to be completed and then delegates the task. Which management function is being implemented by the supervisor
directing
a student nurse in the clinical area is given an appropriate patient assignment by the instructor. What should the student nurse do
assume accountability for the tasks that are assigned by the instructor
which statement is most significant in relation to the concept of change theory in the health care environment
change generates anxiety by moving away from the comfortable
a patient is to be discharged from the hospital. which discharge task can be delegated to a nursing assistant
obtaining the patient’s temperature, pulse, and respiratory rate
what is the major focus of nursing management
accomplishing an objective
A staff nurse must solve a complex problem. Which is the nurse’s most effective resource
unit’s nurse manager
when delegating a specific procedure to a patient care aide, the aide refuses to perform the procedure. What should the nurse do first
explore why the patient care aide refused to perform the procedure
what is the first thing the nurse hould do when planning to apply for a new position within an agency
review the job description
The most important reason why a nurse aide must fully understand how to implement a delegated procedure is because the nurse aide must be able to
complete the procedure safely
The nursing team leader delegates a wound irrigation to a licensed practical nurse. It has been a long time since the LPN performed this procedure. To ensure patient safety the nursing team leader should
Have the LPN demonstrate how to perform the procedure
a nurse manager is informed that a large number of patients will be admitted in response to a terrorist attack. Which type of leadership style is most appropriate in this situation
authoritarian
a nurse manager is experiencing staff resistance when implementing change. What is the most important action by the nurse manager to overcome resistance to change
identify the reason for the resistance
what is the major focus of leadership
inspiring people
The primary difference between effective leaders and managers is that managers have
Responsibility
which situation is most reflective of the saying “a stitch in time saves nine?”
collecting equipment for a procedure before entering the room
A RN delegates a procedure to an LPN. what is the primary purpose of delegation
improve productivity
a nurse manager plans to provide feedback to a subordinate who needs a change in behavior. What is the best intervention by the nurse manager
identify the unacceptable behavior
what is the main reason the nurse manager achieves a consensus when making a decision within a group
facilitate cooperative effort toward goal achievement
The nurse manager evaluates the performance of a subordinate. Which mangement function is being implemented by the nurse manager
controlling
which is most related to systems theory
cyclical process
The nurse and a nursing assistant (unlicensed assistive personnel) are working together on a surgical unit. which nursing activity should the nurse assign to the nursing assistant
emptying a urine collection bag that is attached to continuous bladder irrigation
which tasks should be delegated to a RN (select all that apply)obtaining vitalsproviding dishcarge teachingevaluating a patients repsonse to morphineadministering a cleansing enema to a patienttransporting a patient to the OR for surgery
providing discharge teachingevaluating a patients response to morphine
Lewin’s planned change theory progresses through phases. Order these statements by the nurse manager as change moves through the process1. “let’s implement a pilot project next week”2. “this is a new venture that should be exciting”3. “I know it may be difficult but you are doing a great job”
2.”this is a new venture that should be exciting”1.”let’s implement a pilot project next week”3.”I know it may be difficult but you are doing a great job”
which predisposing factor would be implicated in the etiology of paranoid personality disorder
the individual may have been subjected to parental antagonism and harassment
The nurse is assessing a client diagnosed with the borderline personality disorder. According to Mahler’s theory of object relations, which describes the client’s unmet develppmental need
the need for awareness of separateness of self
Using interpersonal theory which statement is true regarding development of paranoid personality disorder
clients diagnosed with paranoid personality disorder frequently have been family scapegoats and subjected to parental antagonism and harassment
when confronted a client diagnosed with narcissistic personality disorder states “contrary to what everyone believes, I do not think that the whole world owes me a living”. This client is using what defense mechanism
denial
a client diagnosed with borderline personality disorder coyly requests diazepam. When the physician refuses, the client becomes angry and demands to see another physician. What defense mechanism is the client using
splitting
A diabetic client admitted to a medical floor for medication stabilization has a history of antisocial personality disorder. Which documented behaviors would support that Axis II diagnosis
“Began cursing when confronted with drug-seeking behaviors.”
Irresponsible guiltless behavior is to a client diagnosed with Cluster B personality disorder as avoidant dependent behavior is to a client diagnosed with a
cluster C personality disorder
A client tells the nurse, when I was a waiter I use to spit in the dinners of annoying customers. This statement would be associated with which personality trait
passive-aggressive personality trait
a client diagnosed with a personality disorder insists that a gradmother through reincarnation has come back to life as a pet kitten. The thought process described as reflectie of which personality disorder
schizotypal personality disorder
a client diagnosed with a personality disorder states you are the very best nurse on the unit and not at all like that mean nurse who never lets us stay up later than 9 pm. This statement would be associated with which personality disorder
borderline personality disorder
a male client diagnosed with a personality disorder boasts to the nurse that he has to fight off female attention and is the highest paid in his company. These statements are reflective of which personality disorder.
narcissistic personality disorder
A nurse encourages an angry client to attend group therapy. Knowing that the client has been diagnosed with a cluster B personality disorder, which client response might the nurse expect.
sarcastically states that group is only for crazy people with problems
a client has been diagnosed with a cluster A personality disorder. Which client statement would reflext cluster A characteristics
my dinner has been poisoned
personlaity disorders are grouped in clusters according to their behavioral characteristics. In which cluster are the disorders correctly matched with their behavioral characteristics
Cluster C; avoidant, dependent, obsessive-complusive disorders, anxious or fearful characteristic behaviors
which behavior would the nurse expect to observe if a client is diagnosed with paranoid personality disorder
the client sits alone at lunch and states, everyone wants to hurt me
according to the DSM-IV-TR, which diagnostic criterion describes a characteristic of schizotypal personality disorder
exhibits behavior or appearance that is odd, eccentric or peculiar
according to the DSM-IV-TR which of the following diagnostic criteria describes the characteristics of borderline personality disorder? (select all that apply) Arrogant, haughty behaviors or attitudes frantic efforts to avoid real or imagined abandonment recurrent suicidal and self-mutilating behaviors unrealistic preoccupatioin with fears of being left to take care of self. chronic feelings of emptiness
frantic efforts to avoid real or imagined abandonment recurrent suicidal and self-mutilating behaviors chronic feelings of emptiness
According to the DSM-IV-TR which of the following diagnostic criteria describes the characteristics of avoidant personality disorder ( select all that apply) fearing shame and/or ridicule, does not form intimate relationships has difficulty making everyday decisions without reassurance from others is unwilling to be involved with people unless certain of being liked shows perfectionism that interferes with task completion views self as socially inept, unappealing and inferior
fearing shame and/or ridicule, does not form intimate relationships is unwilling to be involved with people unless certain of being liked views self as socially inept, unappealing and inferior
when assessing a client diagnosed with histrionic personality disorder, the nurse might identify which characteristic behavior
attention-seeking flamboyance
when assessing a client exhibiting passive-aggressive personality traits, which characteristic behavior might the nurse identify
The client seeks subtle retribution when feeling others have wronged him or her
although there are differences among the three personality disorder clusters, there also are some traits common to all individuals diagnosed with personality disorders.. which of the following are common traits. (select all that apply) failure to accept the consequences of their own behavior self-injurious behaviors reluctance in taking personal risks cope by altering environment instead of self lack of insight
failure to accept the consequences of their own behavior cope by altering environment instead of self lack of insight
a client diagnosed with antisocial personality disorder states “my kids are so busy at home and school, they don’t miss me or even know im gone” which nursing diagnosis applies to this client
ineffective denial
a client diagnosed with borderline personality disorder superficially cut both wrists is disruptive ingroup, and is splittingstaff. Which nursing diagnosis would take priority
risk for self-mutilation R/T need for attention
a client diagnosed with schizoid personality disorder chooses solitary activities, lacks close friends and appears indifferent to criticism. Which nursing diagnosis would be appropriate for this clients problem
social isolation R/T discomfort with human interaction AEB avoiding others
a client exhibiting passive aggressive personality traits continuously complains to the marriage counselor about a nagging husband who criticizes her indecisiveness. which nursing diagnosis reflects this client’s problems
impaired social interaction R/T inability to express feelings openly.
a nurse is discharging a client diagnosed with narcissistic personality disorder. which employment opportunity is most likely to be recommended by the treatment team
prison warden
which client situation requires the nurse to prioritize the implementation of limit setting
a client verbally provoking another patient who is paranoid
a client newly admitted to an in-patient psychiatric unit is diagnosed with schizotypal personality disorder. The client states “I envision my future death by fire.” Which is the most appropriate nursing response
I can see your thoughts are bothersome. how can I help
A suicidal client is diagnosed with borderline personality disorder. Which short-term outcome is most benficial for the client
the client with express feelings without inflicting self-injury by discharge.
a client diagnosed with an avoidant personalit disorder has the nursing diagnosis of social isolation R/T severe malformation of the spine. AEB “I can’t be around people looking like this. Which short term outcome is appropriate for this clients problem
the client will be able to participate in one therapy group by end of shift
a client diagnosed with an obsessive compulsive personality disorder has a nursing diagnosis of anxiety R/T interference with hand washing AEB “ill go crazy if you don’t let me do that. Which short term outcome is appropriate for this client
within 72 hours of admission, the client will notify staff when signs and symptoms of anxiety escalate
A client diagnosed with antisocial personality disorder demands at midnight to speak to the ethics committee about the involuntary commitment process. which nursing statement is appropriate
I realize youre upset; however this is not the appropriate time to explore your concerns
a client diagnosed with antisocial personalty disorder is observed smoking in a nonsmoking area. which initial nursing intervention is appropriate
confront the client about the behavior
after being treated in the ED for self inflicted lacerations to wrists and arms, a client with a diagnosis of borderline personality disorder is admitted to the psychiatric unit. Which nursing intervention takes priority
observe client frequently
a 15 year old client living in a residential facility has a nursing diagnosis of ineffective coping R/T abuse AEB defiant responses to adult rules. Which of the following interventions would address this nursing diagnosis appropriately? (Select all that apply) set limits on manipulative behavior refuse to engage in controversial and argumentative encounters obtain an order for tranquilizing medication encourage the discussion of angry feelings remove all dangerous objects from the clients environment
- set limits on manipulative behavior
- refuse to engage in controversial and argumentative encounters
- encourage the discussion of angry feelings
A client diagnosed with a borderline personality disorder is given a nursing diagnosis of disturbed personal identity R/T unmet dependency needs AEB the inability to be alone. Which nursing intervention would be appropriate
help the client identify values and beliefs
a client diagnosed with a dependent personality disorder has a nursing diagnosis of social isolation R/T parental abandonment AEB fear of involvement with individuals not in the immediate family. Which nursing interventions would be appropriate.
role-model positive relationships
a client diagnosed with paranoid personality disorder needs information regarding medications. Which nursing intervention would best assist this client in understanding prescribed medications
provide one on one teaching in the clients room
a nursing student is studying the historical aspects of personality disorder. which entry on the examination indicates that learning has occurred
hippocrates in the 4th century B.C., identified four fundamental personality styles
a nursing student is learning about narcissistic personality disorder. Which student statement indicates that learning has occured
these clients express a grandiose sense of self-importance
a nursing instructor is teaching about personality disorder characteristics. which student statement indicates that learning has occurred
personality disorders cannot be cured or controlled successfully with medication
a client is diagnosed with intermittent explosive disorder. The clinic nurse should anticipate potentially teaching about which of the following medications? (select all that apply) Sertraline paliperidone buspirone phenelzine valproate sodium
paliperidone (invega)valproate sodium
nail biting, scratching, and hair pulling for extended periods of time in a private setting are symptoms associated with the diagnosis of
trichotillomania
a client diagnosed with dependent personality disorder has a nursing diagnosis of altered sleep pattern R/T impending divorce. The client is prescribed oxazepam prn. Which is an appropriate outcome for this nursing diagnosis.
the client sleeps 4-6 hours a night by day 3
a client diagnosed with paranoid personality disorder is prescribed risperidone. The client is noted to have restlessness and weakness in lower extremities and is drooling. Which nursing intervention would be most important.
give the ordered prn dose of trihexyphenidyl
a client diagnosed with obsessive-compulsive personality disorder is admitted to a psychiatric unit in a highly agitated state. The physician prescribes a benzodiazepine. Which medication should the nurse expect to administer
clonazepam
what must a doctor do before putting a patient onquinadine
they need to digitilize the person first because the dig takes care of the heart rate.
quinidine
exacabates CHFcauses thrombocyteapeniaextends refractory period
Norpace side effects
dry mouthexacabates CHFurinary retentionthrombocytopenia
Lidocaine for the heart
has to be preservative free (No epinephrine)makes it harder for a patient to go into a v fibtreats pvc’sprevents patient from going into v tachanestasizes the heart0.5-1 mg/kg depending on your person
lidocaine IV can cause
causes seizurespush over 1-2 minutes (preferably 2 minutes)can cause confusion (especially in elderly)can get a psychosiscardiovascular hypotensionbradycardiapossible blocks and arrestsother arrthymiasdouble vision
important about lidocaine
make sure you pick the right lidocainemake sure you put it in its own line. Do not mix with other drugs in IV line
class 1 C drugs.
This class of drugs are used when other things don’t work. Used for PAF, Life threatening ventricular arrhythmias. 150 to 300 mg po q. 8hrs.Monitor for increase in arrhythmias, CNS effects ( dizziness, anxiety, ataxia, confusion, and seizures.Used for life threatening ventricular arrhythmias. Can cause new or worse arrhythmias. CHF because of negative inotropic effect. Use for AF, PSVT.100mg po BID. Maximum dose of 400 mg.Monitor for increase & severity of arrhythmia. Monitor for CHF, tremors,dizziness and visual disturbances.
class 1 c drugs
Agents: . Flecainide (Tambacor) . Propafenone hydrochloride ( Rythmol )Action: . Most potent Class I agents. Slows conduction through atria , purkingee system and ventricals. Decreases repolarization rate. Decreases contractility. . Causes decrease in PVCS and VT
class 2 Beta blockers
Action: . Only group of antiarrhythmics shown to prolong life . Beta 1 receptors in heart attach to calcium channels. Blockage decreases Ca++ influx. Depresses phase 4 of depolarization. Decreases automaticity, heart rate, and BP. Decreases AV conduction.Agents: . Propranolol ( Inderal )—non selective . Metoprolol ( Lopressor )—selective . Atenolol ( Tenormin ) . Sotalol ( Betapace )Adverse effects: . CV: Bradycardia, hypotension, edema, CHF, Pulmonary Edema , . Resp: Bronchospasm . CNS: Fatigue, weakness, dizziness, mental changes, insomnia, confusion . GI: Constipation, diarrhea, nausea, vomiting . GU: Impotenceendocrine: blood sugar variations
negative inotropic effect causes
heart failure
dromotropic effect causes
(1) Refers to a change in the speed of conduction through the AV junction(2) A positive dromotropic effect results in an increase in AV conduction velocity(3) A negative dromotropic effect results in a decrease in AV conduction velocity
inotropic effect
(1) Refers to a change in myocardial contractility(2) A positive inotropic effect results in an increase in myocardial contractility(3) A negative inotropic effect results in a decrease in myocardial contratility
chronotropic effect
(1) Refers to a change in heart rate(2) A positive chronotropic effect refers to an increase in heart rate(3) A negative chronotropic effect refers to a decrease in heart rate
interactions with Beta Blockers
. Caution with other antiarrhythmics. Can cause additive effects. . NSAIDS may decrease antihypertensive effect. . Cimetidine can increase the effect of inderal. . In diabetics can mask signs of hypoglycemia.
nursing considerations for Beta Blockers
. Monitor vital signs frequently during period of adjustment. Notify MD if pulse falls below 50 to 60 beats / minute and / or SBP falls below 90 to 100. . If meds given IV must be on a monitor during administration and for several hours later. Monitor hepatic, renal and CBC function. . Monitor I&O, daily weight, and check for CHF. . Give with meals or immediately after eatting. Extended release tablets should be swallowed whole. Do not crush.
potassium channel blockers
Action: Block potassium channels, prolong repolarization and refractory periods. They effect fast tissue and commonly are used to manage difficult to treat arrhythmias.Agent: Amiodarone ( Cordarone) Ibutilide fumarate ( Corvert )
potassium channel blockers
ex. AMIODARONEUse: . Treatment of life threatening recurrent V-Fib and hemdynamically unstable V-Tach and SPVT, AF, PAF.Dose: PO—800 to1600 mg/ day for 1 to 3 wk and reduce to 600 to 800 mg/ day for 5 wks: usual maintenance dose, 400 mg/ day. IV: Give through central line if possible.
contraindications of potassium channel blockers
. Severe sinus bradycardia since drug slows heart rate by interfering with SA nodal firing. AV nodal blockage since drug slows conduction through AV node. May cause complete heart block resistant to atropine.
precautions for potassium channel blockers
CHF may be worsened. Hypokalemia may block amiodarone action.Side Effects / Adverse reactions: . CNS—ataxia, tremors . CV—–SA & AV blockage, bradycardia, myocardial depression, IV-hypotension . EYE—small corneal deposits that can impair vision may develop with long term use. When drug is discontinued deposits may slowly disappear. . GI——anorexia, nausea, constipation, abdominal pain . PULMONARY—pulmonary fibrosis, pneumonitis . SKIN—light sensitivity caused by crystals deposited in the skin producing a bluish color
nursing considerations for potassium channel blockers
. Assess EKG , BP and pulse . Assess lung sounds. Rales, decreased lung sounds or friction rub may indicate pulmonary toxicity. Check weight, I&O and signs of CHF . Check skin for bluish coloration. Check gait and check for tremors . Eye exam should be done before and at regular intervals during therapy. Avoid sunbathing, tanning salons because of photosensitivity. Limit outdoor activity between 10 am and 2 pm. . Increase dietary intake of fruit, fiber , fluids and exercise to combat constipation. . Missed dose: Omit. Do not double up on missed dose. Notify MD if two or more doses are missed.
covert
potassium channel blockerUsed for AF, Atrial Flutter. 1mg IV over 10 min. for patients > 60kg. 0.01mg/kg for patients
class 1 sodium channel blockers
. Decrease rate of conduction. Prolongs action potential duration. Reduces speed of impulse conduction. For atrial and ventricular dysrhythmiasCLASS IaAGENTS. Procainamide ( Pronestyl ). Disopyramide ( Norpace ). Quinidine ( Quinidex )
indications of sodium channel blockers
ex:PROCAINAMIDE (PRONESTYL )Indications: Ventricular arrhythmias . Stable ventricular tachycardia . Premature ventricular contractions . Ventricular fibrillation Supraventricular tachyarrhythmias . PSVT, PAT, Junctional tachs. , . Atrial flutter and fibrillation
actions of sodium channel blockers
. Slows conduction. Is a negative inotrope with a ischemic myocardium . Decreases myocardial excitability . Is often used as drug of choice if resistance to lidocaineContraindicated in patient with myasthenia gravis.Caution with patients with MI, CHF, Digoxin intoxication.
adverse effects of sodium channel blockers
Adverse effects: . Myocardial depression. Prolongs duration of QRS, QT interval, AV conduction. . Hypersensitivity. Confusion, seizures, dizziness. . Hypotension if given too fast IV. Blood dyscrasias like thrombocytopenia. . Gastric: anorexia, diarrhea, nausea, vomiting.Nursing: . PO: Give with meals or snack to lessen GI distress. . Monitor EKG, BP, and pulse continously throughout IV administration. . Keep patient supine during IV admininstration. Assess QRS and QT intervals. . When IV, discontinue if QT increases by 50% or PR more than .20 second or if BP drops 15mm Hg.
QUINIDINE (QUINIDEX)
action: . Slows conduction through cardiac tissue. Refractory period is lengthened especially in atria. Used for atrial flutter or fibrillation to maintain sinus rhythm. . Has anticholinergic effect by inhibiting vagal action on SA and AV nodes. Sinus node may accelerate causing a dangerous sinus tachycardia. If Quinidine is given to people with A. Flutter or A. Fibrillation, they should be digitalized first to slow the SA and AV nodes.Dosage: . Quinidine Sulfate—200 to 400 mg every 4 to 6 hours. . Sustained release ( Quindex Extentabs—300 to 600 mg every 8 to 12 hours. . Quinidine Gluconate—324mg every 6 to 8 hours. . Quinaglute 324mg every 6 to 8 hours IM or IVAdverse Effects: . Most common effect is diarrhea. May have nausea and vomiting. . Can cause thrombocytopenia. . Hypotension, tinnitus, vertigo, visual disturbances, confusion, psychosis. . Arrhythmias like SA and AV blocks, sinus arrest. . Asthma like symptoms. Systemic Lupus like symptoms.Interactions: . Will increase digoxin levels. Nifedipine will decrease Quinidine levels.Nursing: . Prior to giving drug need baseline QT interval since drug can prolong it. . Give with meals to decrease GI upset. Do not crush sustained release. . Monitor vital signs, EKG and intake and output. Monitor platelets. . Monitor for CHF.
DISOPYRAMIDE ( NORPACE )
Action: . Prolongs refractory period. Decreases myocardial contractility. Has anticholinergic effect so patients with A. Flutter and A. Fibrillation should be digitalized first. Adverse effects: . Neuro: Blurred vision, dizziness, headache, agitation, depression. . Cardio: Conduction disturbances, hypotension, chest pain, CHF, fatigue, edema, weight gain. . GI: Dry mouth, constipation, nausea, pain, bloating, anorexia, diarrhea. . Resp: SOB . Thrompocytopenia . Renal: Urinary retention, hesitancy,and frequency . Endocrine: Hypoglycemia . RashNursing: . Monitor vital signs, EKG, QRS and QT intervals, I and O, weight. . Monitor for CHF. Check platelets. . Sugarless gum for dry mouth . Take on empty stomach . Eat high fiber diet. Bulk laxatives to treat constipation. . Monitor potassium levels. Ineffectve in hypokalemia. Toxic with hyperkalemia.
class 1 b drugs
Agents: . Lidocaine (Xylocaine) . Tocainide ( Tonocard) . Mexiletine ( Mexitil)
LIDOCAINE ( XYLOCAINE )
Action: . Elevates ventricular fibrillation threshold . Treats symptomatic PVCS. Suppresses ventricular tachycardia.Dosage: . Adult: 1mg/kg to 1.5 mg/kg bolus IV followed by 0.5 mg to 0.75/kg in 10 minutes. About 50 to 100mg. Reduce bolus dose by 5% in patients with CHF. . Infusion rate is 1 to 4 mg/minute. Can give endotracheal if IV not available. . Onset of action is 30 to 60 seconds IV . Therapeutic level is 1.5 to 6 ug/mlAdverse effects: . CNS: Paresthesias, numbness, agitation, confusion, seizures. . CV: Hypotension, bradycardia, cardiac arrest, arrhythmias . GI: vomiting . Integ: PhlebitisNursing; . Monitor vital signs, EKG, QRS and QT levels (3) . Monitor serum levels. Signs of toxicity include confusion, excitation, blurred or double vision, nausea, vomiting, tinnitus, tremors, convulsions, difficulty breathing. . Use only 1% or 2% solutions without epinephrine or preservative. . Administer over 1 to 2 minutes . If given too fast, increase risk of seizures. . Use infusion pump. Do not mix with other drugs.
calcium channel blockers (class IV)
Action: These drugs work by inhibiting the slow channel pathways or the calcium Dependent channels. By doing this they depress phase 4 depolarization. Therefore these drugs: . Prolong AV node effective refractory period . decrease AV node conduction and reduce rapid ventricular conduction due to A. Flutter, AF. Used for SVT Agents: . Ditiazem ( Cardizem ) . Verapamil ( Calan )
DILTIAZEM ( CARDIZEM )
Use: . Temporary control of rapid ventricular response in a patient with A. FIB or A. Flutter. Supraventricular arrhythmias . Vasospastic angina. Essential Hypertension . Unlabled use—prevention of reinfarction in non Q wave MIContraindications: . Hypersensitivity, sick sinus syndrome, 2nd or 3rd Heart , severe hypotension ( less than 90/60 ). Patients undergoing cranial surgery, bleeding aneurysmsCaution: . CHF especially if on beta blocker. Conduction abnormalities. Renal or hepatic impairmentDose: . IV—bolus dose 0.25mg/kg over 2 minutes; second dose 0.35mg/kg over 2 minutes after 15 minutes prn; then 5-10 mg/hr or higher by continuous infusion . PO—usual dose 180 to 360 mg/day in divided doses or 60 to 120 mg sustained releaseAdverse / Side effects: . CNS—headache, fatique, dizziness, drowsiness, nervousness, insomnia, confusion, tremor, gait abnormality . CV—edema, arrhythmias, angina, 2nd and 3rd degree heart block, bradycardia, CHF, hypotension, palpitations, syncope, flushing . GI –nausea, constipation, anorexia, vomiting, diarrhea, impaired taste, increased weight. .Skin rashDrug Interactions: . Increases digoxin levels. Additive effects on AV conduction with beta blocker. . Cimetidine can increase cardizem levelsNursing: . Withhold drug if SBP is blocks. Position changes slowly. Avoid driving until reaction to drug is known. Keep follow up appointments. . PO—AC and HS. IV—may be given direct as bolus over 2 minutes. May be continuous IV infusion. Recommended rate-5 to 15 mg/hr. Can add to D5W, NS and combos.
VERAPAMIL ( CALAN )
Dose: . PO—start with 80mg 3 to 4 times daily; daily range 240 to 480 mg.. . IV—5 to 10 mg bolus over 2 minutes; repeat dose of 30 minutesInteractions: . Beta blockers increase risk of CHF, bradycardia,heart block . Increases digoxin levels. . Lithium and cyclospore may be increased to toxic levels.Nursing: . PO—with food to decrease GI ditress. Capsules can be opened & sprinkled on food. Do not dissolve or chew capsule. . Transient asymptomatic hypotension may accompany IV bolus. Have patient remain in recumberant position for at least 1 hour after dose. (7) . Same as with cardizem
ADENOSINE ( ADENOCARD )
Action: . Slows impulse formation in SA node. Slows conduction time through AV node. Depresses left ventricular function and restores NSR. . General cardiac depressantUses: . Paroxysmal supraventricular tachycardiaPrecautions: . Sick sinus syndrome may be worsened by drug and produce sinus arrestDosage: . IV—6 mg by rapid push with saline flush over 1 to 2 seconds. If not effective, 12 mg by rapid push may be given 2 minutes later; repeat once if necessarySide Effects: . Arrhythmias , flushing, heart block, chest pain, SOB, cough, dizziness , numbness, tingling in arms.Nursing: . Continuous EKG. Monitor BP and pulse, lung sounds, respiratory
ATROPINE SULFATE
Used for bradycardia and heart block. 0.5 to 1mg IV bolus may be repeated every 3 to 5 min up to 0.04mg/kg. Monitor heart rate and rhythm. Assess for chest pain, urinary retention.
inotropic
force of contractionpositive inotropic increases the forcenegative inotropic decreases the force
dromotropic
conduction patternnegative dromotropic slows conductionpositive dromotropic speeds up contractionconduction goes from arrythmia to heart block
Chronotropic
heart rate (can go both ways)positive chronotropic speeds up heart ratenegative chronotropic slows down heart rate
negative inotropic
if contraction not forceful enough blood backs up causing heart failure
when starting a drip
know baseline QT interval
if there is 50% or more distance between 2 complexes
may be a block
cardioversion
used for every rhythm that has a T wave
defribilization
only for v fib (only only only)before you shock someone yell all clear and make sure you are not touching the patient
sodium channel blockers
stabilize membranesdecreases irritationdecreases etopic beats from starting
beta 2
lungs
beta 1
heart
lopresser IV
5mg (3 bolus’) then PO
if adenosine doesnt work
cardiovert
anatomy and physiology of an MI
. Sudden blockage of one of the branches of the coronary arteries. When blood flow acutely decreases by 80% to 90% ischemia develops. b. If blood flow is not restored myocardial tissue necrosis can happen over a period of hours.
what rhythm are patients usually in with an M.I.
V. Fib
M.I. anatomy and physiology
Can result in sudden death or gradual scarring over necrotic area. d. Most MIs are secondary to thrombus formation. Other factors are coronary artery spasm, platelet aggregation, and emboli. e. Cardiac cells can withstand ischemia about 20 minutes before injury occurs.
during an M.I.
Within 4 to 6 hours the entire thickness of the heart will become necrotic.
Around the area of infarction there are two zones:
. Zone of Injury Zone of ischemia
necrotic tissue is
electrically inert
zone of ischemia
really electrically unstablethats why the first 72 hours after an M.I. is so important because that ischemic tissue is so unstable and arrthymic
acute coronary syndrome
•When ischemia prolonged and not immediately reversible, ACS develops.•Encompasses a spectrum of unstable angina, non-ST segment elevation Myocardial Infarction ( NSTEMI ) and ST segment elevation Myocardial In farction.•Reflects the relationship among these disorders.
pathology of an MI
•Ischemia causes a decrease in cardiac functioning.•Can produce a permanent loss of contractile function in the injured area.•Cardiogenic shock can develop from decreased cardiac output and decreased contractility and pumping capacity.•Actual extent of MI depends on collateral circulation, anaerobic metabolism and workload demands on the myocardium.
promestyl
iv bolusgive Over 5 minutesif too fast causes seizures, blocks, hypotension
anterior wall MI
absolute worst MI. Obstruction of left anterior descending artery. 25% of all MIs. Highest mortality. b. Most likely to cause left ventricular heart failure and ventricular dysrhythmias. c. People with anterior MI more likely to die in the first year after the MI than those with other MIs. d. EKG shows ST elevations, abnormal Q waves.
inferior wall MI
right sidedResults from occlusion of right coronary artery. Is 17% of all MIs. 10% mortality rate. b. About 1/3 have right ventricular MI and right ventricular failure. c. EKG can show ST and T wave changes and Q waves.(T wave inverts, thats NOT NORmal)
posterior and lateral wall MI’s
least complications•Result from obstruction of the circumflex artery.•Posterior MI is 2% all MIs. Is uncommon.•Lateral wall MIs have the least complications.
gender differences in acute coronary syndrome(Men)
Men are developing CAD at a younger age than women and their death rates are declining. b. Initial cardiac event is more often MI than angina. c. Have higher rate of left ventricular hypertrophy. d. Have greater collateral circulation.
gender differences in acute coronary syndrome(Women)
CAD causes more deaths in women than men. Usually older and sicker with first MI. b. Initial cardiac event more often angina. c. After menopause risk of MI quadruples. Prior to menopause have higher HDL levels than men. After, LDL levels increase.Fewer women than men present with classic symptoms of MI. Fatigue often 1st sign of ACS. C/o palpitations more than men. e. More likely to experience fatal cardiac event within 1st year after an MI. f. Delay longer before seeking medical help.•Have higher mortality rate and complications after CABG surgery. h. Those on oral contraceptives and who smoke at greater risk for MI.
gerontologic considerations with an MI
•May have decreased responses to neurotransmitters so often pain is atypical. May have jaw pain of faint.•Have had time to develop collateral circulation so may not have lethal complications.
cultural and ethnic consideration for MI’s
•White, middle-aged men have highest incidence of CAD.•African Americans have early age onset od CAD.•African American women have higher incidence and death rate r/t CAD than white women.•African Americans have more severe CAD than whites.•Native Americans under 35 yrs have twice heart disease mortality as other Americans r/t obesity and diabetes.•Hispanics have lower death rates from heart disease than non Hispanic whites.
Risk Factors for CAD
•Non Modifiable: Age Gender (men > women until 60 yr) Ethnicity (whites > African Americans) Genetic predisposition and family history of heart disease)•Modifiable Risk Factors: Elevated serum lipids Hypertension: 140/90 or greater Smoking Physical inactivity Obesity: waist circumference greater than 39.8 in men & 34.3 in women.•Contributing factors: Diabetes Mellitus Fasting blood sugar > 110 mg/di Psychologic states Homocysteine levels-if elevated can contribute to atherosclerosis
stages of MI healing
•Onset until 3rd day Acute tissue degeneration. Infarct area soft, mushy & necrotic. Dead tissue electrically inert. Peri-infarct area ischemic and electrically unstable. Critical time period-majority of deaths from dysrhythmias.
stages of MI healing
•4th to 7th day: Softening of infarct area. Danger of aneurysm formation.•8th to 10th day: Newly formed capillaries develop around infarct but it is 2 to 3 weeks before any significant circulation.
stages of MI healing
•11th day on: Collagen forms about 12th day. Rupture of ventricle possible from onset 14th day. Takes 3 to 4 weeks before scar is firm. Takes 2 to 3 months before scar is at maximum strength.
clinical manifestations of an MI
•Severe continuous chest pain not relieved by nitroglycerine or rest.•Shortness of breath, pallor, cold clammy diaphoresis, dizziness, nausea, vomiting, BP changes, dysrhythmias, cyanosis, restlessness, and intense anxiety.•Women may experience heaviness, squeezing type of chest pain. May have sharp, fleeting pain that returns. May have pain in jaw, neck, back & shoulder. Often have palpitations, may faint, nausea & vomiting
Deviations in the manifestations of an MI
•Patients with diabetes may have dull pain r/t neuropathies.•African Americans may have dyspnea as major symptom.•Elderly may have mild or absent pain. May have associative symptoms like SOB. Patients over 80 may display confusion or disorientation with decreased cardiac output.
diagnostic evaluation
•Electrocardiogram-serial readings to monitor evolution of MI.•Troponin Levels-establishes diagnosis of MI.•Cardiac Enzymes-CK (Creatine Kinase).•Isoenzymes: CK-MB-Heart•Myoglobulin•White blood cell count, sedimentation rate•Coronary Angiography- patient with NSTEMI may have this to evaluate extent of MI.•Stress Test & Echocardiograms-may need to do dobutamine (Dobutex) stress echocardiogram if patient unable to exercise.
with an MI the
st segment elevatesT wave inversion
with ischemia of the heart
st segment depressionT wave inversion
what meds do they hold for Heart tests
usually beta blockers
goals for med management of MI
•Minimize myocardial damage, relieve pain & provide rest•Prevent complications
emergency management of an MI
•Ensure patent airway. Oxygen at 2 to 4 L via nasal cannula.•Insert 2 IV catheters.•Obtain ECG. Place on monitor.•Assess for pain (PQRST)•Nitro. sl and aspirin if not already done by EMTs. Morphine for pain.•Baseline blood work (cardiac markers) & chest xray•Assess for antiplatelet, anticoagulant, and thrombolytic therapy.•Give beta blocker and antidysrhythmic drugs as needed.
ongoing monitoring of an MI
•Monitor vital signs, level of consciousness, cardiac rhythm, and O2 sat•Monitor response to medications. Remedicate or titrate medications as indicated.•Provide emotional support and reassurance to patient and family.•Explain all procedures/interventions to patient in simple terms.•Anticipate need for intubation if respiratory distress is evident.•Prepare for CPR, defibrillation, cardioversion and transcutaneous pacing as indicated.
thrombolytic therapy
•Used to dissolve the thrombi in coronary arteries and to restore blood flow.•Most effective if done within 4 to 6 hours after start of chest pain where there is evidence of hyperacute or acute ECG changes in 2 or more leads.•Works directly or indirectly to convert plasminogen to plasmin, an enzyme that acts to digest the fibrin matrix of clots.
Thrombolytic side effects/adverse reactions
•Hemorrhage and anemia•Hypotension, fever•Bronchospasm, anaphylaxis•Periorbital swelling, itching, urticaria, headache•Reperfusion dsyrhythmias
contraindications for thrombolytic therapy
•Absolute: Active internal bleeding History of cerebral aneurysm, brain tumor, previous cerebral hemorrhage Ischemic stroke within 3 months. Significant closed head or facial trauma within 3 months Aortic dissection•Relative Contraindications: Active peptic ulcer disease Current use of anticoagulants Pregnancy Ischemic stroke over 3 months ago, dementia, intracranial pathology Recent internal bleeding within 2 to 4 weeks. Serious systemic disease.Uncontrolled hypertension over 180/110 Prolonged CPR Patients who weigh less than 65 kg have to dose adjusted because of increased likelihood of bleeding.
nursing implications of thrombolytic therapy
•Prior to treatment: Assess vs, neuro, and cardiac rhythm. Patient needs two IV lines Draw required labs. Avoid non essential punctures. Don’t shake the drug. It will foam.•During treatment: Assess vs, neuro, cardiac rhythm q 15 min. Check for signs of bleeding Monitor lab values•After treatment: Assess vs, neuro, cardiac rhythm q 15 min. then q 2 hours for 24 hours Monitor for signs of bleeding for 72 hours.
signs of reperfusion (thrombolytic therapy)
•Abrupt cessation of chest pain•Resolution of ST elevation/depression•Rapid rise of CK-MB•Reperfusion dysrhythmias—generally self limiting
complications of thrombolytic therapy
•Reocclusion of the artery. May start heparin therapy to prevent this.•Bleeding
nitroglycerine drug therapy
•May be used short term to reduce the infarct size, decrease heart workload and increase blood supply.•Hypotension, reflex tachycardia are side effects so BP and heart rate are monitored closely and drug is carefully titrated,•Want to keep BP above 90 systolic and heart rate below 110.
morphine sulfate
•Given for chest pain unrelieved by nitroglycerine. Is a vasodilator so decreases cardiac workload by lowering myocardial oxygen consumption.•Reduces contractility, BP and heart rate•Reduces fear and anxiety•In rare cases can depress respirations.
good thing about TPA
specific. Goes right for the clot
Drug therapy
•Beta blockers•Angiotensin-Converting Enzyme Inhibitors•Angiotensin II Receptor Antagonists•Aspirin•Anticoagulants•Antidysrhythmic drugs•Stool Softners•Lipid lowering drugs
nursing care for drug therapy
•Continue to monitor vs, cardiac rhythm, response to drug therapy.•Space activities with rest•After 48 hrs encourage gradual increase in self care activities. Monitor response to activity ie. Vs, O2 sat, changes in cardiac rhythm, chest pain.•Decrease meal time fatigue Small, frequent meals, no very hot or cold foods. Sufficient time for meals•Begin rehab teaching early•Encourage and supervise increased activity level. Start with lying & sitting exercises Increase length of ambulation Encourage exercise for 20 minutes twice a day.•Teach patient to monitor pulse during exercises and to stop if pulse doesn’t increase or if it rises to 20 over resting pulse.•Reinforce plans for home activity program
sodium channel blockers
neg chronotropicneg dromotropic
procainamide (pronestyle)
1a(ventricular arrhythmias)stable ventricular tachypremature ventricular contractionsventricular fibrillation(Supraventricular Tachy)PSVTPATJunctional tachs*atrial flutter and fibrillation
action of procainamide (pronestyle)
slows conductionnegative inotropedecreases myocardial excitability
adverse effects of procainamide (pronestyle)
myocardial depressionprolongs duration of QRS, QT interval, AV conductionHypotension if given too fast IV
labs for procainamide (pronestyle)
platelets
administration of procainamide (pronestyle)
bolus 50-100 mg IV SLOW over 5 minutes
Quinidine Norpase
positive anticholinergicpositive chronotropic
digitilize
give 3 doses of dig for therapeutic blood levels
Quinidine Norpase action
slows conduction through cardiac tissueused for atrial flutter or fibrillation to maintain sinus rhythm
what should you do before administering Quinidine Norpase
digitilize first
adverse effects of Quinidine Norpase
diarrheathrombocytopeniawill increase digoxin levels
nursing considerations for Quinidine Norpase
baseline QT interval monitor platelets
Lidocaine/xylocaine
anesthetizes myocardiumnegative inotropicnegative dromotropic
Lidocaine/xylocaine administration
IV push 1-2 minutes0.5 - 1 mg/kg bolus IV (NO PIGGYBACK)MAKE SURE PLAIN/NO ADDITIVESuse infusion pump, do not mix with other drugs
Lidocaine/xylocaine
PVC’s -Ventricular tachycardia
Lidocaine/xylocaine therapeutic level
1.5 to 6 ug/ml
Lidocaine/xylocaine adverse effects
paresthesiasconfusioncrosses blood/ brain barrier
Class 1c drugs
most potent class I agentsPVCS VTnegative dromotropic
Flecanamide/Rythmol
POTENTused if all other meds failventricular arrythmias rhythmsa fiba fluttersever svt
side effects of flecanamide/rythmol
Chf because of negative inotropic effectCHF, arrythmias
Beta Blockers
neg. chronotropicneg. inotropicneg. dromotropic
beta blockers used for
MI’sHTNcan be used for arrythmiasprolong life
administration of Beta Blockers
IV or PO
Block Beta 1
Heart
Block Beta 2
Lungs (caution in asthma)
monitor in Beta Blockers
BPHR notify doctor if pulse falls below 50-60 bpmor SBP falls below 90-100
potassium channel blockers
Potenttreatment of V-FibV-TachSPVT,A FibPAF
Amiodarone
potassium channel blockerincrease dose then taper to maintenancecan cause arrythmias and severe bradycardia
amiodarone nursing considerations
QT intervalvitalsrhythmcan worsen CHF
amiodarone side effects
blue skincorneal deposits in eyes (vision)may cause complete heart block resistant to atropine
amiodarone administration
Give through central line if possible
Calcium channel blockers
negative inotropicnegative dromotropic
Diltiazem (cardizem)
calcium channel blockerused for A. FibA.FlutterSVT arrhythmiasdecreases BPspasmodic angina
administration of diltiazem (cardizem)
IV- 2 minutes MINIMUM
diltiazem (cardizem) side effects
HAgait abnormality
diltiazem (cardizem) nursing considerations
can cause sick sinus syndromecaution use in CHF withhold drug if SBP is less than 90 or diastolic is less than 60
Verapamil (Calan)
bolus over 2 minutes
verapamil (calan) interactions
beta blockers increase risk of CHF, bradycardia, heart block increases digoxin levelslithium and cyclospore may be increased to toxic levels
Adenosine (adenocard)
given for SVTgive fast 6mg (rapid push over 1-2 secs)
Inotropic
increase or decrease contractilitydigoxin: positive inotropic (stronger)most meds : negative inotropic (depress contractilitywatch for CHF because not pumping blood out
Dromotropic
conduction system (impulses)positive : increased conductionmost meds : interfere with conductiontreat tachy arrythmiasdrugs have potential for blocks
chronotropic
rate @ SA nodestimulate SA node
women
have weird angina
diagnostic evaluation procedure
ECGtroponincardiac enzymesisoenzymesmyoglobulinWBCSed rate
CK
creatinine kinasegoes up fast then decreasesbest for determining early MI
Isoenzymes
CKMB (MB means heart)
WBC
increases because of inflammatory response to attack on heart
sed rate
stays increased for awhile
ECG changes
Q - does not go back to normalST elecatedT wave inversion
emergency management of MI
O22 IV’sECGnitro/asprin/morphinebloodwork/x-rays (enlarged heart)assess antiplatelet/anticoagulation?thrombolyticsbeta blockers/ antidysrhythmics
thrombolytics
TPA4-6 hours after start of chest pain (asap pre-damage)TPA goes to where its neededside effects: hemorrhage/anemiahypotension/feverbronchospasm/anaphyaxisperiorbital swelling/itching/uticaria/headachedysrhythmiascan cause another clot when a large clot is broken up
Heart failure
right side -fluid backupleft side - pulmonary
systolic ventricular dysfunction
not enough blood ejectionfoward failuredecrease cardiac output -fluid backs up
diastolic ventricular dysfunction
left ventricule cant relax enough to accumulate blood to pump out
right vs. left side heart failure
arteries Leftveins rightrt. failure can be caused by left failurert ventricular MI
high output failure
cardiac ouput can be okincrease metabolic demands on hearthyperthyroidseptecemia
what diagnoses Heart Failure
BNPfrom fluid in ventricleschest xrayechocardiogram
diltiazem (cardizem)
calcium channel blocker
metoprolol (lopressor)
beta blcoker
atenolol (tenormin)
beta blocker
Nifedipine (procardia)
calcium channel blocker
timolol (betimol)
beta blocker
amlodipine (norvasc)
calcium channel blocker
the condition of having a reduced clood supply to myocardial cells is call
myocardial ischemia
by causing venodilation, nitrates reduce the amount of blood returning to the heart thus decreaseing
cardiac output
which of the following is true regarding the effect of atenolol (tenormin) on the heart
it selectively blocks beta receptors
the primary mechanism of calcium channel blockers
reducing cardiac workload
what agent has the ability to inhibit the transport of calcium ions into myocardial cells and relaxes both coronary and peripheral blood vessels
diltiazem (cardizem)
what are the goals for pharmacotherapy of acute MI
restore blood supply to the damaged myocardium as quickly as possibleprevent associated dysrhythmias with antidysrhythmicsreduce post- MI mortality with aspirin and ACE inhibitors
in treating MI the function of thrombolytic therapy is to
restore blood supply to the damaged myocardium
the primary risk during thrombolytic therapy is
excessive bleeding
following an acute MI , metoprolol (lopressor) is infused slowly until
a target heart rate of 60-90 beats perminute is reached
opiods such as morphine sulfate are sometimes administered to patients with MI to
reduce acute pain associated with MI
the nurse should administer aspirin as soon as possible following an suspected MI in order to
reduce post MI mortality
patients at high risk for stroke are often treated with
antihypertensives
