Final Flashcards
Alzheimer’s risk factors
Family history of AD or Down Syndrome
Advanced age
Chemical Imbalances
Genetic predisposition, apolipoprotein E
Environmental agents or virus (herpes virus, metal, or toxic waste)
Previous head injury
Assigned female at birth
Ethnicity/race (AA or Hispanic)
PTSD
assessment tools for Alzheimers
mini mental state exam (MMSE)
clock drawing test
Mental cognitive assessment test (MOCA)
Brief interview for mental status
Set test using fruits, animals, colors, and towns (FACT)
Nursing care of Alzheimer’s patient
Bowel and bladder schedules
promote self care
avoid overstimulation
support group for family
reorient patient
allow rest periods
update white board
provide frequent walks to avoid wandering
secure or remove dangerous objects
Delirium risk factors
Advanced age
* Hearing or visually impaired
* Dehydrated
* Malnutrition
* Metabolic disorders
* ETOH/Drug abuse
* Pre-existing dementia
* Sleep deprived
* Receiving benzodiazepine medications
3 hallmark signs of delirium
1.Inattentiveness
2.Confusion/Disorganized
thoughts
3.Alteration in LOC
Signs of hypoactive delirium
withdrawn/drowsy
more common
harder to detect
higher risk of mortality
signs/ characteristics of hyperactive delirium
agitated
hallucinations
restless
aggressive
prevention of delirium
Glasses
* Hearing aids
* Day/night orientation
* Method of communicating if barrier
* Board in room with place & date
* Clock in view
* Noise control
* Promote sleep
* Cluster care activities
what are the screening tools of delirium
Richmond Agitation Sedation Scale (RASS)
Confusion Assessment Method(CAM)
Confusion Assessment Method for ICU (CAM-ICU)
Delirium Index (DI)
TX of delirium
identify reversible causes
avoid benzos
psychiatric consult if needed
Nursing interventions for delirium
don’t overstimulate
reorient frequently
speak in a calm voice
calming music
update board
clock in room
monitor o2
Do not overstimulate
* Anticipate and prevent or manage complications
* Urinary incontinence
* Immobility and falls
* Pressure ulcers
* Sleep disturbance
* Feeding disorders
risk factors of Parkinson’s
male
genetic
exposure to toxins
chronic use of antipsychotics (chlorpromazine)
4 cardinal symptoms of Parkinson’s (TRAP)
Tremors
Muscle rigidity
akinesia
postural instability
what is the goal of anticholinergic medication in the treatment of Parkinson’s?
reduce tremors, drooling and rigidity
what should you monitor for when a Parkinson’s patient is taking a dopamine agonist?
orthostatic hypotension, dyskinesia, hallucinations
what is deep brain stimulation and what should the nurse monitor for postoperatively?
targeted area received mild electrical stimulation to reduce tremors and rigidity
monitor for- infection, strokelike findings, brain hemorrhage
nursing actions for a Parkinson’s patient
administer meds
nutrition- at risk for aspiration, elevate HOB (45-90)
suction equipment at bedside, stool softener and fluid intake, communication strategies
implement safety precautions- falls sleep depravation, high risk tasks
ph normal range
7.35-7.45
PaCO2 normal range
35-45
HCO3 normal range
22-26
SaO2 normal range
95-100%
What is the acid base imbalance?
pH 7.37
PaCO2 47
HCO3 25
Compensated respiratory acidosis
What is the acid base imbalance?
pH 7.26
PaCO2 35
HCO3 16
Uncompensated metabolic acidosis
What is the acid base imbalance?
pH 7.30
PaCO2 58
HCO3 30
partially compensated respiratory acidosis
What is the acid base imbalance?
pH 7.52
PaCO2 26
HCO3 22
uncompensated respiratory alkalosis
risk factors for PAD
Hypertension
Hyperlipidemia
DM
Smoking
Obesity (BMI over 30)
Sedentary Lifestyle
Genetics
Female sex
Advanced age (over 50)
Elevated C-reactive protein
Hyperhomocysteinemia
clinical findings for PAD
Burning, cramping, and pain in the legs during exercise (intermittent claudication)
Numbness or burning pain primarily in the feet when in bed
Pain relieved by placing legs at rest in a dependent position
Bruit over femoral and iliac arteries
>3 sec cap refill
Decreased or nonpalpable pulses
Loss of hair on legs
Dry, scaly, mottled skin
Thick toenails
Cold and cyanotic extremity
Pallor of extremity with elevation
Rubor of the extremity in dependent position
Muscle atrophy
Ulcers and possible gangrene of toes
Positioning for client with PAD
elevate legs but not above the heart
what is a medical emergency you need to worry about with PAD
Compartment syndrome
6 P’s of Compartment syndrome
pain, paresthesia, pulselessness, pallor, poikilothermia, paralysis
Expected findings for a client with a DVT
Client can be asymptomatic
Calf or groin pain, tenderness, and a sudden onset of edema in the extremity
Warmth, edema, and induration and hardness over the involved blood vessel
Changes in size (circumference) to affected leg
!! SOB and CP can indicate that the embolus has moved to the lungs (PE)!!
diagnostics test for DVT
D dimer
doppler flow
Venous duplex and USN
complication of PVD
Pulmonary embolism
what does Raynaud’s disease cause
vasospasm of the arteries
primary Raynaud’s disease
Exposure to cold temp
Stress
Blood vessel vasospasm
secondary Raynaud’s disease
Scleroderma
Lupus Erythematosus
Rheumatoid Arthritis
Arterial Disease
Carpal Tunnel Syndrome
Manifestations and assessment of a pulmonary embolism
Dyspnea, CP, apprehension, “feeling of impending doom”, hemoptysis
Assessment values- Tachypnea, crackles, friction rub, S3 or S4, diaphoresis, petechiae over chest and axillae, and decrease SaO2
what should you do if you notice a Pulmonary embolimsm
NOTIFY the provider, assist client to comfortable position, O2, ABG, admin anticoag
client education for raynauds
medications side effects
stop smoking
exercise
stress reduction
limit caffeine
avoid cold temperatures
risk factors for cellulitis
older clients
weak immune system
break in skin
IV drug use
DM
clinical manifestations of cellulitis
Tenderness, inflammation
Skin sore or rash that spreads quickly
Tight, glossy appearance of the skin
Abscess w/ pus formation
Fever, elev WBC’s
medication for cellulitis
IV antibiotics
analgesics
COPD primary symptoms
Chronic cough
Sputum production
Dyspnea
copd chest shape
barrel chest
how should you instruct the client to breath with COPD
Pursed lip breathing
Diagnostic procedures of copd
ABG
CHEST X RAY
Spirometry is used to measure lung volumes and air flow. The two tests used are:
Forced Vital Capacity (FVC) — maximum volume of air exhaled during a forced expiration
Forced Expiratory Volume in 1 second (FEV1) — Volume of air exhaled in the first second of a maximal expiration after a maximal inspiration
what acid base imbalance would you expect for a client with COPD
respiratory acidosis
complications of COPD
pneumonia
chronic atelectasis
pneumothorax
respiratory insufficiency/failure
manifestations of asthma
Dyspnea, chest tightness, anxiety or stress
Physical Assessment Findings:
Cough, productive or not
Generalized wheezing
Mucous production
Use of accessory muscles
Prolonged exhalation
Hypoxemia and central cyanosis
Tachypnea
what is used for quick relief of asthma symptoms
Short-acting Beta2-adrenergic agonists (SABAs)
Anticholinergics
Long-acting medications
Corticosteroids
Long-acting beta2-adrenergic agonists (LABAs)
diagnostic tool for asthma
pulmonary function test
manifestations of pneumonia
Fever
Shortness of breath
Tachypnea
Pleuritic chest pain (sharp)
Productive cough
Color: yellow, blood-tinged, purulent, and/or rust-colored
Crackles, wheezing
Hypoxia
Dull chest percussion over areas of consolidation
lab and diagnostic tests for Pneumonia
Sputum culture and sensitivity: Obtain specimen prior to starting abx- why?
CBC: elevated WBC count = infection
ABG: Hypoxemia (decreased PaO2 less than 80 mm Hg)
Blood Culture: r/o organisms in the blood/sepsis
BMP: identify dehydration (elevated BUN, hypernatremia)
Community Acquired Pneumonia (CAP)
Diagnosed in community or early in hospital admission (less than 48 hours)
Most common type
Often occurs as a complication of influenza
Healthcare Associated Pneumonia (HCAP)
Non-hospitalized patients that have extensive contact with healthcare personnel
Often caused by Multidrug resistant (MDR) pathogens
More likely to be resistant to antibiotics
Linked to higher mortality
Hospital Acquired Pneumonia (HAP)
Develops 48 hours or more after hospital admission
Patients can be exposed to pathogens from different sources
Medical equipment
Provider contact
Shared facilities
Caused by various pathogens
Ventilator Associated Pneumonia (VAP)
Sub-type of HAP
When the condition manifests greater than 48 hours after the client is intubated
position for pneumonia patient
90 degrees, to maximize ventilation
nursing interventions for pneumonia patient
HOB above 30 degrees
use as few sedatives as possible
avoid stimulating the gag reflex with suctioning
thickened fluids for swallowing problems
prediabetes HA1C
5.7-6.4
Diabetees HA1C
greater than 6.5
diabetes Fasting blood glucose
greater than 126
prediabetes fasting blood glucose
100-125
DKA lab tests
Blood glucose level greater than 250 mg/dL
* Ketonuria (ketones in the urine)
* Arterial pH of less than or equal to 7.30
* Serum bicarbonate level of less than or equal to
18 mEq/L
* Positive anion gap
tx of DKA
Regular insulin- IV
Administer sodium bicarbonate to fix acidosis
Give d50 when sugar reaches 250 to minimize cerebral edema
Rapid infusion of sodium chloride in first 1-3 hours
Check vitals every 15 min until stable then every 4 hours
Check for signs of dehydration
dka manifestations
hyperventilation
polydipsia
polyphagia
lethargy
stupor
acetone breath
blurred vision
nausea/vomiting
abdominal pain
polyuria
glucose in urine
patient will be in metabolic acidosis
causes of HHS
infection
older adults in response to stress and infection
HHS Manifestations
Blood glucose greater than 600mg/dL
* pH greater than 7.4
* Serum bicarbonate levels greater than 15 mEq/L
* Absence of ketones in urine
* Serum osmolality greater than 320 mOsm/kg
* Negative anion gap
* Profound dehydration
* Alteration in level of consciousness
HHS tx
Fluid replacement with isotonic normal saline
* Treatment for altered mental status
‒ Airway management
* Insulin administration, usually by intravenous
delivery
‒ REGULAR INSULIN
GERD Contributing factors
Excessive ingestion of foods that relax the LES:
* Chocolate, caffeine, fatty and fried foods, peppermint, spicy foods, tomatoes, citrus fruit, alcohol
* Prolonged or frequent abdominal distention (from overeating)
* Increase abdominal pressure
* Constrictive clothing, obesity, pregnancy, bending at the waist, ascites
* Medications that can relax the LES or cause increased gastric acid
* Hiatal hernia
* Gastritis due to Helicobacter pylori
* Lying flat
GERD Clinical Manifestations
Report of dyspepsia (indigestion) after eating an offending food or fluid
* Radiating pain (neck, jaw, or back)
* Report of feeling of having a heart attack
Pyrosis (burning sensation in the esophagus)
* Odynophagia (pain when swallowing)
* Pain that worsens with position
* Pain that occurs after eating and lasts 20 min- 2 hours
* Throat irritation (chronic cough, laryngitis)
* Increased flatus and eructation (burping)
* Pain is relieved by drinking water, sitting upright, or taking antacids
* Chest congestion and wheezing
* Dental caries
peptic ulcer risk factors
H. Pylori infection
* excessive secretion of stomach acid
* chronic use of NSAIDs/ Corticosteroids
* Excessive alcohol consumption
* Blood type O
* Rare: Zollinger-Ellison Syndrome
* Rare: Gastrin Secreting Tumor
PUD manifestations
dull aching pain
* burning in the mid-
epigastrium area or
back
* heartburn and
vomiting may occur
* Bleeding is possible
PUD diagnostic tests
Upper endoscopy
* H. pylori testing (95% of non-NSAID
PUD patients are positive)
* Biopsy- with endoscopy
* Fecal Antigen test
* Urea breath test
* Serological antibody
* Stool culture
* Bleeding ulcer
* Periodic CBCs
* Fecal Occult blood
