Test 3 Flashcards
nursing interventions for fluid volume excess
Monitor I&O, daly weight, edema, crackles and serum electrolyte levels, LOC
nursing interventions imbalanced nutrition- less than required
monitor I&O, daily weight, BUN, anorexia, nausea, committing, dietary restrictions, oral mucosa, serum electrolytes, serum protein and albumin levels
nursing interventions risk for ineffective renal
monitor I&O, daily weight, BUN and creatinine, serum electrolytes, uremia
nursing interventions risk for decreased cardiac output
monitor HR and ECG changes, peripheral pulses, serum electrolyte levels, Arterial blood gas analysis, BP, LOC
activity intolerance nursing interventions
monitor for fatigue, serum electrolytes, H& H, BUN, creatinine
normal BUN and creatinine
BUN 8-20
CR 0.6-1.2
if these are going down- pt is improving
hyperkalemia EKG
Tall, peaked T wave, prolonged QRS
bradycardia, conduction blocks, v fib, muscle weakness
hypokalemia EKG
prominent U wave, ST depression
PVCs, Vtach, muscle weakness
priority intervention hypok
respirations- muscle weakness increases the WOB
suspect HF- diagnostics?
Echo, cardiac cath, x ray
echo is gold standard for DX
hyperphosphatemia
AKI can reduce excretion of phosphorous causing too much- give aluminum hydroxide to reduce phosphate.
should transfer to a burn center
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
Baxters formula
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
NMS like S&M
Get hot, stiff, and sweaty, BP, HR, RR all increase and you start to drool
in heart failure BNP is?
greater than 100
Administering potassium chloride
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.
Priority assessment for left sided HF
Respiratory! Fluid is backing up into the lungs and are fatigued
Heart Failure treatment all kinds
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)
ADHF treatment
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)
Hypokalemia- ekg, priority assessment
prominent U wave, ST depression
PVCs, VTach risk
priority assess respiratory- muscle weakness
Hyperkalemia ekg
Tall peaked T wave, prolonged QRS
conduction blocks, fib
bradycardia, numb/tingling around mouth
diagnostics for AKI
BUN, creatinine, UO, urine osmolality, urine sodium, and specific gravity. serum electrolytes, renal ultrasounds, renal scan, CT scan
Prerenal AKI
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
intrarenal AKI (intrinsic?)
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
post renal aki
urine is blocked and can’t leave kidneys, enlarged prostate, kidney stones, tumor, edematous stomach
clinical manifestations of aki
weakness and fatigue from disturbed Na K exchange, diminished deep tendon reflexes, bradycardia (muscle weakness)
treatment aki
insulin, calcium gluconate to reduce risk of v-fib while potassium high, kayexelate if pt can handle it
hypokalemia sxs
weakness and fatigue, muscle cramps, palpitations, arrhythmias, deliriums, magnesium, and potassium will be low together, dysrhythmias,
causes of high creatinine
could be from medications- cimetidine, trimethoprim
and not kidney damage
increases with more than 5% of nephrons damaged
IV fluids and Na and K
IV fluids will force Na and K to switch places
sodium is extracellular and K is intracellular
hypotonic fluids
causes cells to pull water in and swell
hypo its going to blow
hypertonic fluids
cause the vessels to pull water out of the cell and the cell shrinks
Frank-Starling Law
to a point, the more the myocardial fibers are stretched, the greater their force of contraction. (Lewis 689)
Right side heart failure sxs
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
Oliguric phase AKI
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.
priority assessment with electrical burn
EKG!
tx for alcoholics
thiamine, lorazepam (DTs), benzos- valium, librium (milk, long term) no NSAIDS or alcohol
encephalopathy assessment
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?
Increased ICP sxs
bradycardia, nucal rigidity, widening pulse pressure, increased systolic pressure causes- suctioning, intubation, defecation, cough sneeze
Clozapine
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
risperdone
can prolong Q-T interval, c/i for those at risk for dysrhythmia
2nd gen antipsychotics
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
positive sxs schizophrenia
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
negative sxs of schizo
affect- float, blunted, inappropriate or bizarre
affective blunting, anergia, anhedonia, abolition, poverty of content of speech, poverty of speech, thought blocking
paplau phases
preorientation (preparing to meet), orientation (meet), working, termination- has started once have set a last meeting date
Antisocial characteristics
cluster B- can seem normal- sociopath, seductive, aggressive, exploitive, manipulative
many things may have caused
antisocial nursing guidelines
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
cluster A
odd/erratic- shizoid, schizotypal and paranoid, more men
cluster B
dramatic, emotional, erratic
antisocial, borderline, histrionic, narcissistic
cluster C
fearful, anxious
avoidant, OCD and Dependent
avoidant PD characteristics
cluster C, excessively anxious in social situations but desire interaction, hypersensitive to negative evals
men and women, biologic
avoidant interventions and therapy
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)
borderline characteristics
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
borderline guidelines and therapies
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
Dialectical behavior therapy
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.
dependent guidelines
ID and help address current stress, try to satisfy pt needs with limits, be aware of strong countertransference, teach and role model assertiveness
dependent therapy/tx
insight oriented psychotherapy, CBT- cognitive behavior therapy, behavior therapy, family and group therapy, anti anxiety agents and antidepressants for symptoms
histrionic guidelines
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
histrionic therapies
group therapy, psychotherapy, anti anxiety and antidepressant as needed
narcissistic personality d/o guidelines
remain neutral, avoid engaging in power struggles or becoming defensive, convey unassuming self confidence
narcissistic therapies
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
OCD guidelines
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
OCD therapies
supportive or insightful psychotherapy, clomipramine and SSRIs for obsessional thinking and depression, prozac is FDA approved, self help groups
Paranoid guidelines
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
schizoid guidelines
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
paranoid therapies
anti anxiety antipsychotic, psychotherapy and then CBT,
schizoid characteristics
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
schizotypal characteristics
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.
manifests ideas of reference
schizotypal and borderline
Delusions where one interprets innocuous events as highly personally significant .
med for self mutilation
naltrexone- borderline- and for suicidal
Schizoid meds
wellbutrin and a 2nd gen antipsychotic like risperidone or olanzapine
which personality D/O gets an SNRI
Avoidant. cymbalta or venlafaxine
also get an SSRI (citalopram)
which gets prozac?
OCD- prozac is an SSRI
what is often prescribed to borderline
Depakote/valporic acid anticonvulsant for mood stabilization
which d/o high risk for substance abuse?
antisocial- don’t give benzos
