Final Exam Flashcards
What are some contributing factors to developing diverticular bowel disease?
- advanced age
- constipation
- diet: low in fiber, high fat, red meats
What protein should someone with a diverticular bowel disease eat instead of red meats?
- lean protein
What are some interventions (diet) that a pt can use if they have a diverticular bowel disease?
- meatless Monday
- they shouldn’t have meat more than 7 times a week
What is diverticulosis?
- pouch like herniation in the colon wall
What are the clinical manifestations of diverticulosis?
ES: CIBH, AB, B, F
- usually asymptomatic
- early signs are changes in bowel habits, abdominal bleeding, bloating, and flatulence
What are the clinical manifestations of diverticulitis?
LLQP, PAM, F
- LLQ pain
- palpable abdominal mass
- N/V
- fever
What are some treatment options for a pt w/ diverticulitis?
Initial + after
- initial treatment: NPO, NG to low suction, IV fluids
- post: clear liquids adv. to low fiber diet, pain meds and antibiotics
What are some complications to monitor for w/ diverticular diseases?
BIC
- bleeding
- infection
- constipation
What are some examples of mechanical obstructions?
A, H, C, S , I
- adhesion
- hernia
- Cancer
- Stricture
- intussusception
What are some examples of non mechanical obstructions?
disorders
- neuromuscular disorders like paralytic ileum
- vascular disorders like mesenteric artery occlusion
What are the CM of small intestine obstructions?
RO, SP, VVC, AB
onset? pain?
- rapid onset,
- sporadic pain
- vomiting very common
- acidic bile
What are some CM of large intestinal obstruction?
GO, PCP, IV, AD
- gradual onset
- persistent cramping pain
- infrequent vomiting
- abdominal distention
What are some nursing interventions for pt’s w/ an intestinal obstruction?
Diet, LS, IVF + ER, EA, PS
- NPO
- NG to low suction
- IV fluids and electrolyte replacement
- early ambulation
- possible surgery
What are the risk factors for colorectal cancer?
- first degree relative
- personal/ family Hx of CRC, IBS, DM
- obseity
- smoking
- alcohol
- red meats
What are the early signs of colorectal cancer?
- asymptomatic
- nonspecific such as weight loss and fatigue
What are the late signs of colorectal cancer?
PAM, AT, A , HM
- palpable abdominal mass
- abdominal tenderness
- hepatomegaly
- ascites
What can polyps develop. Into after 5 yrs?
Cancer
How is colorectal cancer diagnosed?
- double contrast barium enema
- CEA level ( carcinoembryonic antigen)
What is cholelithiasis?
Stones in the gallbladder
What is Cholecystitis?
Inflammation of the gallbladder wall associated with/ cholelithiasis
What are the risk factors gallbladder disease?
W, OC, ET, O, SL, FHX
- women
- oral contraceptive
- 40 yrs on estrogen therapy
- obseity
- sedentary lifestyle
- fam hx
What are the clinical manifestations of cholelithiasis?
FP, RUQP, SP, J, CCS, I, BT, PWM
Asymptomatic
- late signs:
- flank pain
- RUQ pain
- shoulder pain
- jaundice
- clay colored stool
- itching
- bleeding tendency ( vitamin k)
- pain more intense w/ movement
What are some abnormal finding in draining tubes?
- no drainage
What are the S+S of FVE?
- bounding pulse
- weight gain
- edema
- crackles in the lungs ( primary sign)
- increased BP
What are the S+S of a FVD?
- dry mucous membranes
- poor skin turgor
- increased HR + RR
- decreased cap refill
- orthostatic hypotension
- hyperthermia
What are the severe clinical manifestations of Na+ imbalance?
Seizure, coma, and vomiting
What does potassium (K+) play a big role in?
Muscles including the heart
What are clinical manifestations for hypo and hyperkalemia?
- muscle weakness
- twitching
- cardiac dysrhythmias
- decreased LOC
- decreased reflexes
- parathesias
- N/ V
How is hyperkalemia reversed?
- kayexalate ( causes pt to excrete K+ in the form of stool)
- loop thiazide ( diuretic)
- dialysis
- insulin
- albuterol
- calcium
What labs/ assessments need to monitored in pt’s with a potassium imbalance?
ECG
pulses
IV ( K+ is a vein irritant, check pts IV for redness, swelling, pain, etc.)
decreased UO
What is the primary level of prevention for cancer prevention?
smoking cessation
decreased or elimination of alcohol use
sunscreen 15- 30 SPF or higher
promote healthy behaviors
What are the warning signs of cancer?
CAUTION
- Change in bladder and bowel habits
- A sore that doesn’t heal
- Unusual bleeding / discharge
- Thickening or lump in the breast or elsewhere
- Indigestion or difficulty swallowing
- Obvious change in wart or mole
- Nagging cough or hoarseness/ change in voice
How are cancers classified
TNM
- Turmeric size and invasiveness
- Node - prescience or absence spread to regional lymph node
- Metastasis
What other rapid dividing cells does chemotherapy kill off?
- GI
- bone marrow
- skin, hair, and nails
What are the main safety concerns with patients being treated by chemo?
infection and their bodily secretions are still toxic 48 hours after treatment
What should the nurse educate the chemo patient on 48 hours after treatment?
- use separate toilets and double flush
- replace toothbrush
- abstain from sex
- all body secretions are poisonous 48 hr after treatment
What is protocol for a central line extravasation?
- stop the infusion
- pull drug from the line
- contact HCP
What are some safety concerns for pt’s receiving external radiation therapy?
- gently clean with water and mild soap (no scents)
- avoid powders, lotions, or creams unless Rx
- avoid sun exposure
What is external radiation therapy?
Radiation to a specific body part marked by radiology
What are some safety concerns for pt’s receiving internal radiation?
- they are radioactive after treatment
- limited visitors
- nurses wear lead aprons and cluster care
What is internal radiation therapy ?
Sealed radiative implants into the tumor or nearby the tumor
Which therapy doesnt leave the pt radioactive after treatment?
External radiation therapy
What are the adverse effects of chemo and radiation therapy?
- bone marrow suppression
- anorexia
- N/V
- alopecia
- leukopenia
- reproductive problems
What are some nursing interventions that can be put into place to prevent bone marrow suppression from effecting the WBCs?
EIS, AI, APT
- enhance immune system through diet, rest, and handwashing
- avoid infection by implementing neutropenic precautions
- asses the pt’s temp daily
What should the patient report immediately to the HCP?
BTS, UexB, UB
black tarry stool
unexplained bruising
uncontrolled bleeding
What is the diagnostic criteria for DM?
- Hgb A1C greater than 6.5%
- fasting glucose greater than 126 mg/dL
What is the main goal of DM treatment?
maintain normal BG and prevent acute/ chronic complications
What are some interventions used to maintain normal BS?
- monitor blood glucose levels
- adequate Nutrtion
- physical activity
- recognize CM of hypo/hyperglycemia
- correct use of medication
What are the CM of DKA?
- fruit breath
- kussmaul respirations
- dehydration
- serum glucose: >250mg/dL
- ketones present
What is the CM is a priority in a hypoglycemic pt?
- diaphoresis (sweating)
What are the CM of hypoglycemia?
S, D, P, CCS, A, P , N
- shakiness
- diaphoresis
- palpitations
- cold clammy skin
- anxiety
- pallor
- nervousness
What is the rule of 15?
Hypoglycemic protocol
- 15g of fast acting carbs, recheck BS every 15 min
What are the CM of primary HTN?
fatigue
dizziness
palpitations
angina
dyspnea
What is peripheral artery disease (PAD)?
- thickening of arterial walls r/t atherosclerosis
- reduces blood flow to lower extremities causing ischemia
What are the CM of PAD?
IC, P, D/AP, EP/DR
- intermittent claudication ( cramping, pain from lack of blood flow)
- paresthesia
- diminished or absent pulses
- elevation pallor and dependent rubor
What does the skin on the leg of PAD look like?
T, S, T, H
- thin
- shiny
- taut
- hairless
How is PAD managed?
- antihypertensive, anti diabetic
- anti platelets
- lifestyle mods
What is an aortic aneurysm?
Out-pouching or dilation of arterial wall
What is a true aortic aneurysm?
at least 1 layer intact due to congenital or acquired problems
What is a false aneurysm?
involves all layers due to injury or trauma
What should the nurse look for post aortic aneurysm repair?
- circulation to the lower extremities and blood pressure
what are the CM of chronic venous insufficiency (CVI)?
- edema
- leather skin
- Brownish discoloration
- Venous leg ulcer
What are the diffrent managements used for CVI treatment?
- compression therapy
- frequently elevate legs
- wet to dry dressings
What are the risk factors for FVD?
- hemorrhage
- inadequate fluid intake
- vomiting
- abnormal loss of bodily fluids
What the potential complications of FVD?
- impaired cardiac output
- hypovolemic shock
What are the risk factors for FVE?
- renal or cardiac disorders
- fluid retention
- too much sodium
What are the potential complications of FVE?
- pulmonary edema
what should you teach a pt w/ FVE?
- elevate legs
- fluid restriction
- diuretics and watch potassium levels
What are the risk factors for developing pneumonia?
- Age: 65 years and older
- residents of long term facilities
- abdominal/ chest surgery
- alt level of consciousness
- smokers
what are the clinical manifestations of pneumonia?
C, F, CHI, H, PCP, F/CC
- cough
- fever
- chills
- headache
- chest pain ( pleuritic)
- fine or coarse crackles
what are the clinical manifestations of pneumonia that are specific to older adults?
C, H
- confusion
- hypothermia
what are normal readings on an ABG?
pH, PaO2, PaCO2, HCO3
pH ( 7.35- 7.45)
PaO2 ( 80- 100mmHg)
PaCO2 ( 35- 45mmHg)
HCO3- 22-26 mEq/L
what can be done to prevent pnumonia?
F/PV, EA, IS, FP
- flu and pnumococcal vaccines
- early ambulation
- Incentive spirometer
- feed precautions
What intervention is important in a pt w/ pneumonia?
nutrition
- rest before meals
- use bronchodilator before meals
- avoid excuse 1 hour before and after meals
- limit fluid w/ meals because they will get full before they eat
- moderate carb, high caloric
- eat 5 to 6 small meals a day
What are the none obvious signs of lung cancer?
- change in voice
- hoarseness
What are the clinical manifestations of lung cancer?
PC, D, BTS, PNR, A, F
- persistent cough
- dyspnea
- blood tinge sputum
- pneumonia that’s not responding to treatment
- anorexia
- fatigue
what is COPD?
chronic obstructive pulmonary disease
when air can’t leave the lungs because it’s trapped in the lungs ( persistant expiratory airflow limitation causing an abnormal gas exchange)
what are the CM of COPD?
cc, d, ef, uoam, bc, pet, dc, db, w
- chronic cough
- dyspnea
- easily fatigued
- use of accsessory muscles
- barrel chest
- prolonged expiratory time
- digital clubbing
- decreased breath sounds
- wheezing
what are the complications of late stages COPD?
PHTN, CP
- pulmonary HTN
- cor pulmonale
what is respiratory acidosis?
pH down
low pH, increased CO2, normal HCO3
what are the manifestations of respiratory acidosis?
H, L , W, C, HK, DBP, DR
- headache
- lethargy
- weakness
- confusion
- hyperkalemia
- hypotension
- dysrthymia
what is metabolic acidosis
breathing off sugar
low pH, CO2 N, HCO3 low
what are the manifestations of metabolic acidosis?
H, L, W, C, HK, DBP, DMR
headache
lethargy
weakness
confusion
hyperkalemia
hypotension
decreased muscle reflexes
what is respiratory alkalosis?
chicken little scene
high pH, CO2 low, HCO3 normal
what causes respiratory alkalosis?
anxiety attack
when the pt is hyperventilation breathing off too much CO2
what are the manifestations of respiratory alkalosis?
LH, HC, HK, HV, T, N/T
- lightheadedness
- hypocalcemia
- hypokalemia
- hyperventilation
- tachycardia
- numbness and tingling
what is metabolic alkalosis
expolsive
high pH, CO2 normal, HCO3 high
What interventions can be used for a pt experiencing metabolic alkalosis?
1 stop the loss
# 2 replace what has been lossed
what are the signs of hypoxia?
- restlessnes
- frantic
- cyanosis
What interventions can be preformed for a pt exp. Hypoxia?
sit them up and check pulse aux
What is the most important education for any pt w/ COPD?
avoid respiratory infection
What is an intervention for a pt at risk for cholelithiasis?
loose weight and hydrate
What is an intervention for a pt at risk for cholelithiasis?
loose weight and hydrate
What is a nursing intervention for the side effect of chemotherapy ( tumor lysis syndrome)?
flushing w/ IV fluids
( buildup of chemo in the system)
what are the CM of parkinson’s disease?
TRAP
T: tremors
R: ridgity
A: ankinesia and bradykinesia
P: postural instability
what is parkinson’s disease?
chronic, progressive, uncurable neuro disorder that is caused by destruction of dopamine receptors
what signs will be present physically in a pt with parkinson’s diease?
- shuffling gait
- difficulty walking
- weakness
- unstable posture
what is Amyotrophic lateral sclerosis (ALS)?
progressive brain and spinal muscular atrophy from destruction of motor neurons
what are the clinical manifestations of ALS?
- muscle cramps
- stiffness
- pain
- sleep disorder
- GERD
- slow dragging gait
- drooling
- difficulty chewing and speaking
- tongue contractions
what disability do you usually see stone face/ lack of emotion?
parkinson’s disease
What is compartment syndrome?
Pressure build up and stops blood flow which causes pain
What is acute pyelonephritis?
Inflammation of the renal parenchyma and collecting system
What are the risk factors for developing acute pyelonephritis?
- dysfunction of the lower UT
- long term care residents
- pregnancy induced changes
- untreated UTI
What are the clinical manifestations of acute pyelonephritis?
N/V, F/C, FP, D, U, F , LBT
- N/V
- fever
- chills
- flank pain/ lower back tenderness
- dysuria
- urgency/ frequency
What clinical manifestation is more common in older adults w/ UTIs?
Cognitive effects like confusion (more common than burning)
What are the symptoms of a UUTI?
Acute pyelonephritis
- fever
- malaise
- N/V
- flank tenderness
What are the symptoms of a LUTI?
B, U, F, SSU, H, SPP
- burning
- urgency
- frequency
- strong smelling urine
- hematuria
- suprapubic pain
What are the risk factors for developing UT calculi?
- men
- 50’s and up
- genetics
- summer heat
What kind of education would you provide to a patient experiencing urinary tract calculi?
- low Na diet
- low calcium
- increase hydration
- decrease the use of tums, calcium vitamins + supplements
What is osteoporosis?
chronic and progressive metabolic bone disease
What are some preventative measures than can be used for osteoprosis?
- regular weight bearing exercise
- adequate intake of fluoride, calcium, vitamin D
What should the nurses assessment focus on in a pt w/ osteoporosis?
- proper nutrtion w/ calcium and vitamin d supplements
- exercises
- fall prevention
- drug therapy
What is rheumatoid arthritis?
a chronic systemic autoimmune disease, inflammation of the connective tissue
What are some nursing considerations for pt’s w/ arthritis?
Non curative, focus on
- managing pain/ inflammation
- preventing disability
- maintaining and improving joint function
- drug therapy supplements no drug treatments
What are some post op interventions for a total knee replacement?
- no pillow under the knee
- ROM: flexion and extension
- weight bearing as tolerated
What is osteoarthritis?
Slowly progressive non inflammatory disorder that cause the gradual loss of cartilage
What are some goals for pts w/ amputations?
- adequate relief from underlying health problem
- pain management
- max rehab
- Cope w/ body image change
- lifestyle adjustments
What is gout?
Type of arthritis that is caused by hyperdrive is and deposition of urine acid crystals in r or more joints
What are some foods high in purine that pt’s w/ gout should avoid?
OM, RM, S, SF/ D
- organ meats ( liver, kidney)
- red meats ( beef, lamb, pork)
- seafood
- sugary foods and drinks
What does potassium not affect?
Blood volume (BP)
What are some S+S of irritative bladder obstruction?
- dysuria
- nocturia
- incontinence
- bladder pain
What are some S+S of bladder obstruction?
- hesitancy
- dribbling
- intermittency
- weal stream
What are cute complications of an unmanaged blood sugar?
- hypoglycemia
- HHS
- DKA
What are the chronic complications of unmanaged Diabetes mellitus?
- retinopathy
- kidney issues
- stroke
- cardiac issues
What is the priority assessment for a pt with PAD?
- peripheral pulses
- cap refill
- temp
- color
What is the difference between PAD and CVI?
PAD: prolonged cap refill, decrease or absent pulses, loss of hair, resting pain , elevation pallor, cool to the touch
CVI: normal cap refill, pulses are hard to palpate, edema, painful ulcers, warm
What are the S+S of hypoxia?
- restlessness
- frantic
- cyanosis
What does albuterol cause?
- the pt to be hyped up ( increase in BP + HR)
What are some interventions with MS?
- teach them how to straight cath themselves
What is the sign of a large bowel obstruction?
Abdominal distention
