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2539 > Test 3 > Flashcards

Test 3 Flashcards

1
Q

nursing interventions for fluid volume excess

A

Monitor I&O, daly weight, edema, crackles and serum electrolyte levels, LOC

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2
Q

nursing interventions imbalanced nutrition- less than required

A

monitor I&O, daily weight, BUN, anorexia, nausea, committing, dietary restrictions, oral mucosa, serum electrolytes, serum protein and albumin levels

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3
Q

nursing interventions risk for ineffective renal

A

monitor I&O, daily weight, BUN and creatinine, serum electrolytes, uremia

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4
Q

nursing interventions risk for decreased cardiac output

A

monitor HR and ECG changes, peripheral pulses, serum electrolyte levels, Arterial blood gas analysis, BP, LOC

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5
Q

activity intolerance nursing interventions

A

monitor for fatigue, serum electrolytes, H& H, BUN, creatinine

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6
Q

normal BUN and creatinine

A

BUN 8-20
CR 0.6-1.2
if these are going down- pt is improving

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7
Q

hyperkalemia EKG

A

Tall, peaked T wave, prolonged QRS

bradycardia, conduction blocks, v fib, muscle weakness

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8
Q

hypokalemia EKG

A

prominent U wave, ST depression

PVCs, Vtach, muscle weakness

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9
Q

priority intervention hypok

A

respirations- muscle weakness increases the WOB

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10
Q

suspect HF- diagnostics?

A

Echo, cardiac cath, x ray

echo is gold standard for DX

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11
Q

hyperphosphatemia

A

AKI can reduce excretion of phosphorous causing too much- give aluminum hydroxide to reduce phosphate.

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12
Q

should transfer to a burn center

A

partial thickness >10%, burn on face, hands, feet, genital/perineum or major joints, third degree, electrical, chemical or inhalation, complicated by comorbidity or special needs, children in hospital ill equipped for burn

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13
Q

Baxters formula

A 
to estimate fluid replacement post burn
4 X kg X %burned.
1/2 within 8 hrs of burn
1/2 over next 16 hours
Goal is min of 0.5 mL/kg/hr UO
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14
Q

NMS like S&M

A

Get hot, stiff, and sweaty, BP, HR, RR all increase and you start to drool

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15
Q

in heart failure BNP is?

A

greater than 100

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16
Q

Administering potassium chloride

A

IV or PO. Never IVP, highly vesicant. monitor IV site hourly for phlebitis or infiltration. infiltration=necrosis. never give faster than 10mEq/hr, always dilute and mix well.

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17
Q

Priority assessment for left sided HF

A

Respiratory! Fluid is backing up into the lungs and are fatigued

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18
Q

Heart Failure treatment all kinds

A

treat underlying cause, circulatory assist decides, daily weights, sodium and fluid restriction, monitor I&O, monitor electrolytes, drug therapy (diuretics, ACE Inhib, vasodilators, Beta blockers, positive inatropes, morphine, possibly antidysrythmias and or anticoagulants)

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19
Q

ADHF treatment

A

High fowler’s position, oxygen by NC or mask, biped, continuous ECG, pulse ox, and hemodynamic monitoring, conserve energy, maybe intubation mechanical ventilation and or cardio version, ultrafiltration (UF-removes sodium and water from circulation)

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20
Q

Hypokalemia- ekg, priority assessment

A

prominent U wave, ST depression
PVCs, VTach risk
priority assess respiratory- muscle weakness

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21
Q

Hyperkalemia ekg

A

Tall peaked T wave, prolonged QRS
conduction blocks, fib
bradycardia, numb/tingling around mouth

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22
Q

diagnostics for AKI

A

BUN, creatinine, UO, urine osmolality, urine sodium, and specific gravity. serum electrolytes, renal ultrasounds, renal scan, CT scan

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23
Q

Prerenal AKI

A

lack of adequate perfusion to kidneys could be from hypotension, dehydration, bradycardia, hypovolemic shock. the kidney is okay and just need to give fluids. if is prolonged, can lead to damage- intrarenal AKI

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24
Q

intrarenal AKI (intrinsic?)

A

poor perfusion, toxins, uncontrolled HTN or DM has damaged the kidneys. amitriptyline is nephrotoxic, NSAIDS, antibiotics… most common cause acute tubular necrosis. monitor LOC, respiratory (crackles?), weight and give aluminum hydroxide fro bind with phosphorus

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25
Q

post renal aki

A

urine is blocked and can’t leave kidneys, enlarged prostate, kidney stones, tumor, edematous stomach

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26
Q

clinical manifestations of aki

A

weakness and fatigue from disturbed Na K exchange, diminished deep tendon reflexes, bradycardia (muscle weakness)

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27
Q

treatment aki

A

insulin, calcium gluconate to reduce risk of v-fib while potassium high, kayexelate if pt can handle it

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28
Q

hypokalemia sxs

A

weakness and fatigue, muscle cramps, palpitations, arrhythmias, deliriums, magnesium, and potassium will be low together, dysrhythmias,

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29
Q

causes of high creatinine

A

could be from medications- cimetidine, trimethoprim
and not kidney damage
increases with more than 5% of nephrons damaged

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30
Q

IV fluids and Na and K

A

IV fluids will force Na and K to switch places

sodium is extracellular and K is intracellular

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31
Q

hypotonic fluids

A

causes cells to pull water in and swell

hypo its going to blow

32
Q

hypertonic fluids

A

cause the vessels to pull water out of the cell and the cell shrinks

33
Q

Frank-Starling Law

A

to a point, the more the myocardial fibers are stretched, the greater their force of contraction. (Lewis 689)

34
Q

Right side heart failure sxs

A

increased veinous pressure (‘CVP >12), JVD, enlarged organs (hepatomegaly), edema, weight gain, ascites, fatigue, polyuria at night/nocturia and most reliable way to assess fluid loss is weight!
NOT cyanotic, tachycardia or crackles

35
Q

Oliguric phase AKI

A

injury leads to decreased UO (100-400/day) leading to FVE, hyperkalemia, phosphatemia, and ammonia because can’t excrete them. too much ammonia= metabolic acidosis- give continuous RRT, will have kussmaul respirs (and increased rate) to blow off CO2, EKG changes from the hyperk, cardiogenic shock is another cause of metabolic acidosis.

36
Q

priority assessment with electrical burn

A

EKG!

37
Q

tx for alcoholics

A

thiamine, lorazepam (DTs), benzos- valium, librium (milk, long term) no NSAIDS or alcohol

38
Q

encephalopathy assessment

A

TEMP (infection?), BP (increased ICP?), MENTAL STATUS/ LOC, MEDICATIONS, toxins, hx of brain tumor, head injury, liver d/s, alcoholism, poor nutrition, metabolic d/o?

39
Q

Increased ICP sxs

A

bradycardia, nucal rigidity, widening pulse pressure, increased systolic pressure causes- suctioning, intubation, defecation, cough sneeze

40
Q

Clozapine

A

2nd gen antipsychotic that can cause agranulocytosis (WBC 2000-3000, ANC <1000) increased risk for seizures, need weekly WBC for 6 pos, has sedative and anticholinergic SE, increase morbidity for elderly

41
Q

risperdone

A

can prolong Q-T interval, c/i for those at risk for dysrhythmia

42
Q

2nd gen antipsychotics

A

Significant reduction in EPS, but causes significant weight gain
metabolic syndrome- weight gain, dyslipidemia, altered glucose metabolism, increased risk for DM, HTN, atherosclerotic heart d/s

43
Q

positive sxs schizophrenia

A

alterations in thought (delusions, concrete thinking), alterations in speech (associative looseness, clang association, word salad, neologisms, echolalia, paranoia) alterations in perceptions (depersonalization, derealization, hallucination, illusions) alterations in behavior (stereotyped behaviors, echopraxia- mimicking, catatonia, motor retardation or agitation, waxy flexibility, negativism, impaired impulse control, gesturing/ posturing, boundary impairment

44
Q

negative sxs of schizo

A

affect- float, blunted, inappropriate or bizarre

affective blunting, anergia, anhedonia, abolition, poverty of content of speech, poverty of speech, thought blocking

45
Q

paplau phases

A

preorientation (preparing to meet), orientation (meet), working, termination- has started once have set a last meeting date

46
Q

Antisocial characteristics

A

cluster B- can seem normal- sociopath, seductive, aggressive, exploitive, manipulative
many things may have caused

47
Q

antisocial nursing guidelines

A

be wary of manipulation, set clear limits that all staff follow, document manipulation and aggression, be aware will instill guilt if not getting what they want, well organized treatment program for substance abuse before therapy of personality d/o
psychotherapy, meds for anxiety rage and depression, ritalin for ADHD, anticonvulsants for impulsivity

48
Q

cluster A

A

odd/erratic- shizoid, schizotypal and paranoid, more men

49
Q

cluster B

A

dramatic, emotional, erratic

antisocial, borderline, histrionic, narcissistic

50
Q

cluster C

A

fearful, anxious

avoidant, OCD and Dependent

51
Q

avoidant PD characteristics

A

cluster C, excessively anxious in social situations but desire interaction, hypersensitive to negative evals
men and women, biologic

52
Q

avoidant interventions and therapy

A

a friendly accepting, reassuring approach, don’t push into social situations
psychotherapy focused on trust, group therapy, assertiveness training, antidepressants (SSRI- citalopram and SNRI- venlafaxine)

53
Q

borderline characteristics

A

more women, usually with another mental illness, caused by biologic and a separation from mom issue, separation anxiety, clingy, impulsive, self mutilation, suicide, engages in splitting

54
Q

borderline guidelines and therapies

A

rotate nurses caring for, set realistic goals with clear action words, clear consistent boundaries, be aware of manipulative behaviors, avoid rejecting or rescuing, assess for suicidal or self mutilating behavior.
psychotherapy, DBT, CBT, Group therapy, antipsychotics for anger and brief psychosis, antidepressants (SSRI and MAOI), benzos for anxiety
anticonvulsant mood stabilizers, low dose antipsychotics, omega 3 supplement. naltrexone to reduce self mutilation behavior

55
Q

Dialectical behavior therapy

A

DBT combines cognitive and behavioral techniques with mindfulness, which emphasizes being aware of thoughts and actively shaping them.
The goals of DBT are to increase the patient’s ability to manage distress, improve interpersonal effectiveness skills, and enhance the therapist’s effectiveness in working with this population.

56
Q

dependent guidelines

A

ID and help address current stress, try to satisfy pt needs with limits, be aware of strong countertransference, teach and role model assertiveness

57
Q

dependent therapy/tx

A

insight oriented psychotherapy, CBT- cognitive behavior therapy, behavior therapy, family and group therapy, anti anxiety agents and antidepressants for symptoms

58
Q

histrionic guidelines

A

understand seductive behavior is response to stress, keep interactions professional, encourage and model use of concrete and descriptive rather than vague and impressionistic language, teach and role model assertiveness

59
Q

histrionic therapies

A

group therapy, psychotherapy, anti anxiety and antidepressant as needed

60
Q

narcissistic personality d/o guidelines

A

remain neutral, avoid engaging in power struggles or becoming defensive, convey unassuming self confidence

61
Q

narcissistic therapies

A

individual CBT, group may help empath and family therapy, psychotherapy only works after patient acknowledges narcissism, usually not medicated but Li may help with mood swings, antidepressants also used

62
Q

OCD guidelines

A

guard against power struggles with pt, need for control is very high, intellectualization, rationalization, reaction formations, isolation, and undoing are the most common defense mechanisms

63
Q

OCD therapies

A

supportive or insightful psychotherapy, clomipramine and SSRIs for obsessional thinking and depression, prozac is FDA approved, self help groups

64
Q

Paranoid guidelines

A

same nurses care for, avoid being too nice or friendly, give clear and straightforward explanations of tests and procedures before, use simple, clear language, avoid ambiguity, project neutral but kind affect, warn about any changes, S/Es, reasons for delay, written plan may help encourage cooperation

65
Q

schizoid guidelines

A

avoid too friendly or nice, do not try to increase socialization, perform through d assessment as needed to ID sxs or d/o the pt is reluctant to discuss, wellbutrin, 2nd gen antipsychotic

66
Q

paranoid therapies

A

anti anxiety antipsychotic, psychotherapy and then CBT,

67
Q

schizoid characteristics

A

may have been raised in a cold, neglectful environment, reclusive, avoidant, uncooperative, flat, dull affect, absence of warmth/feelings, feel like spectator of life rather than participant

68
Q

schizotypal characteristics

A

Cant relate to others, magical thinking, odd speech, aloof, cold, socially inept, isolated, anxious, manifests ideas of reference, shows cognitive and perceptual distortions- 1st on schizophrenia spectrum, may have brief psychotic s=xs, but can be made aware of them.

69
Q

manifests ideas of reference

A

schizotypal and borderline

Delusions where one interprets innocuous events as highly personally significant .

70
Q

med for self mutilation

A

naltrexone- borderline- and for suicidal

71
Q

Schizoid meds

A

wellbutrin and a 2nd gen antipsychotic like risperidone or olanzapine

72
Q

which personality D/O gets an SNRI

A

Avoidant. cymbalta or venlafaxine

also get an SSRI (citalopram)

73
Q

which gets prozac?

A

OCD- prozac is an SSRI

74
Q

what is often prescribed to borderline

A

Depakote/valporic acid anticonvulsant for mood stabilization

75
Q

which d/o high risk for substance abuse?

A

antisocial- don’t give benzos

2539 (2 decks)

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