Nursing 301 - Exam 4
B
Following a generalized tonic-clonic seizure, the nurse can expect the client to: A. Be unable to move the extremities B. Be drowsy and prone to sleep C. Remember events before the seizure D. Have a decrease in blood pressure
A
The RN determines that a student nurse shows a good understanding of nasogastric tube standards of care when the student is observed: A. Securing the tube to the client's nose with tape B. Removing the NG in preparation to ambulate the client C. Irrigating the NG tubing with 90mL of sterile water D. Adjusting the intermittent suction to 120 mmHg
A
The amount of air inhaled with each breath is called: A. tidal volume B. residual volume C. vital capacity D. dead-space volume
B
The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse? A. "Do not worry. Epilepsy can be treated with medications." B. "The seizure may or may not mean your child has epilepsy" C. "Since this was the first seizure, it may not happen again" D. "Long term treatment will prevent future seizures"
PSV
aka pressure support ventilation often used with SIMV allows patient to take spontaneous breaths with little help from the ventilator to increase strength of respiratory muscles not used in AC mode! (pt cannot spontaneously breathe if in AC mode)
SIMV
aka synchronized intermittent mandatory ventilation a mode of ventilation where machine breaths are given at a preset rate and volume also allows for the patient to breathe at own rate and tidal volume minimum breaths per minute that matches the patient's effort and strength used for patients during slow weaning similar to AC - used when patients cannot spontaneously breathe at all
CIWA
alcohol withdrawal can cause anxiety, so if a patient who comes in withdrawal, which precautions should the nurse assess?
cognition
alert and oriented x4 oriented to person, place, time, situation nurse asks questions and observes patient: - do you have a significant other? who lives with you? - race/ethnicity? - general appearance - tremors? mobility concerns? ticks? speech patterns? - what brought you to the hospital? who is with you? - who is the president? what day of the week is it? what year is it?
delirium
an acute change in mental status characterized by disturbances of consciousness and cognition or perception with a fluctuating course four characteristics: 1. disturbance of consciousness with reduced ability to focus and/or sustain and shift attention 2. change in cognition or development of perceptual disturbance that has not been accounted for by a preexisting dementia 3. develops over a short period and fluctuates throughout the day 4. evidence to suggest that it is caused by physical condition such as a medical condition, substance, or medication brief duration - lasts 1 week to 1 month
depression
an alteration in mood that is expressed by feelings of sadness, despair, and pessimism loss of interest in usual activities; changes in appetite, sleep patterns, and cognition are common
vocal cords
an endotracheal tube goes through this structure in the throat, which is why an intubated patient is unable to speak
stressor
an external pressure that is brought to bear on the individual
mood
an individual's sustained emotional tone, which significantly influences behavior, personality, and perception; an inner feeling may have a major influence on a person's perception of the world
sedation vacation
an intervention performed twice a day to begin weaning of ventilation support - a minimum amount of sedation, which is restarted at 25% of previous dose also prevents ventilator-associated pneumonia
screenings for acute confusion and impaired mood regulation
anxiety - GAD-7 depression - PHQ-9 postpartum depression - Edinburg Postnatal Depression Scale 1 (EPDS) suicidal risk - SAFE-T, Columbia Suicide Risk Assessment alcohol use - CAGE alcohol withdrawal - CIWA delirium - Confusion Assessment Method (CAM)
dimpled, compressed
how does a nurse know that a JP drain is functioning?
every 8 hours
how frequently should cervical collar care be done?
30 minutes
how long should the NG tube be clamped after medications are given?
30 mL
how many mL of air should be injected into an NG tube before removal? (decreases aspiration risk, have patient hold their breathe)
96 hours
how often are PCA and epidural tubings changed?
48 hours
how often do PCA and epidural fluid bags need to be changed?
every 12 hours (twice a day)
how often should a nurse brush the teeth of a patient with an endotracheal tube?
every 6 hours
how often should a nurse suction a patient with an endotracheal tube?
every 8 hours
how often should output be marked from an NG tube?
24 hours
how often should the NG canister and tubing be replaced?
24 hours, 72 hours
how often should the NG tape be changed? how about a securement device?
24 hours
how often should the catheter tip syringe, water bottle, and small graduate be changed?
"back pedal"
if a nurse inserts an NG tube and it comes out the mouth, what should he or she do? (hint...try to reinsert it while the patient swallows)
assess the patient and their airway
if a nurse walks into a room to assess the patient and found that he or she self-extubated, what would the priority intervention be? (hint...may not have to reintubate or may have to apply oxygen, bag them, and wait for team to reintubate)
discontinue suction and clamp the tube
if a patient wants to ambulate with an NG tube in place, what should the nurse do with the NG tube?
clamp it
if a patient with an NG tube wants to get out of bed, what action should the nurse take?
call provider
if a patient's epidural is leaking, what should the nurse do? (hint...remember that nurses cannot remove them)
15 ml/hr
if the patient is going to begin PCA or epidural therapy and there is no continuous infusion, what is the standard rate of IV fluids?
5-10 mL
in between each medication through a NG tube, how many mL of water should the nurse flush through the tube?
delirium interventions
interventions for _______: - repeat reminders - sleep promotion - hearing aids, glasses - clock - reorient often and when necessary - orient to bathroom/room/surroundings - personal belongings within reach - care board - avoid restraints - early mobilization, activity - monitor
interventions to prevent ventilator-associated pneumonia
interventions to prevent ______ ______ _______: - oral care q2h - suction q6h - brush teeth q12h (twice a day) - HOB elevated to at least 30 degrees - sedation vacation - nurse hand hygiene - OG or NG tube to LIS to remove secretions - promote activity (move extremities) - extubate ASAP
intermittent
is a PCA intermittent or continuous medication administration?
continuous
is an epidural intermittent or continuous medication administration?
sedation
may be used to help the patient tolerate intubation
anxiety medications
medications for ______: - give Ativan first - usually a one time dose - give benzodiazepines (Klonopin, Ativan) - highly addictive - give seroquil to the elderly - second: safety
cognition
mental operations that relate to logic, awareness, intellect, memory, language, and reasoning powers; thought patterns and process
analitic depression
refers to children who became depressed after being separated from their mothers for an extended period of time during the first year of life characterized by: - excessive crying - anorexia - withdrawal - psychomotor retardation - stupor - generalized impairment in normal growth process
risk of acute confusion
risk factors for ______ _______: - age > 60 - alteration in cognitive functioning - alteration in sleep/wake cycle - dehydration/electrolyte imbalances - hx of stroke - impaired metabolic function (decreased hemoglobin, - elevated BUN/creatinine) - impaired mobility - malnutrition - pain - pharmaceutical agent - sensory deprivation - substance abuse (constant, withdrawal) - urinary retention - infection
violence
risk factors for ______: 1. past hx 2. client dx 3. current behavior 4. substance abuse - single largest risk factor 5. visible signs (throwing objects, punching, clenched fists)
anxiety risk factors
risk factors for ________: - difficulty managing conflict - distorted or faulty thinking - genetics - trauma (sexual abuse, childhood abuse, car accidents, combat) - situational (medical conditions, hospital visits) - emotions - biochemical changes (elevations in lactate) - norepinephrine - females are at greater risk than males
postpartum depression risk factors
risk factors for __________ __________: - previous episodes of partpartum depression, depression, or anxiety - social factors: lack of coping skills, lack of support, and financial burdens
GAD-7
screening for anxiety
flat affect
someone who lacks emotional expression, which is often seen in severely depressed patients
PCA
stands for patient-controlled analgesia enables patients to self-administer medication provides a way to reduce anxiety and to satisfy the patient's pain needs family members should never deliver medication through this device d/t the following safety features: 1. prescribed dose 2. minimum time interval between doses (lockout) 3. maximum dose allowed over a given period of time
anxiety
subjective emotional process and/or response to that stressor a feeling of discomfort, apprehension, or dread related to anticipation of danger, the source of which is often nonspecific or unknown increased norepinephrine levels, decreased GABA levels includes specific phobias, SAD, PTSD, GAD, panic disorder, and OCD
Aspen collar
the preferred cervical collar
cognition
underlying problems affecting ______: - physical problems like UTIs - metabolic problems like decreased hemoglobin, electrolyte imbalance, elevated BUN and creatinine, thyroid issues - side effects of medications - increased cortisol levels (stress hormone)
postpartum depression screening
use the Edinburgh postpartum depression screening can also use the PHQ-9 ask mom how things are - give her time to allow for honesty!!
Ativan
usually a one-time dose of a benzodiazepine to ease anxiety and promote calmness *always give the lower dose first - can always give more
anger
usually a secondary emotion to unresolved grief, depression, fear, anxiety, and post-traumatic stress manifested by... - continuous state of tension (posturing) - clenched fists - low-pitched verbalizations - yelling, shouting - intense eye contact - passive-aggressive behaviors - sarcasm - lack of control - very short responses - swearing
PHQ-2, PHQ-9
what are the two screenings that assess for situational depression? (make sure to question answers if you notice behaviors or statements that do not match answers from these questionnaires)
hit carina or patient coughs
what are the two ways to determine how far to insert the suction catheter? (patient with endotracheal tube)
stimulate mind consistency
what are two important interventions that can keep the cognition "in check?"
EtCO2
what assessment value should the nurse always monitor when a patient has an epidural or a PCA? (hint...good indictor of sedation state)
over sedation
what does an EtCO2 reading greater than 45 indicate?
flumazenil (Romazicon)
what is lorazepam's (Ativan) reversal agent? (hint...the reversal agent for all benzodiazepines)
abdominal xray
what is the "gold standard" that is used to verify NG tube placement?
tachycardia
what is the biggest side effect that may be seen after a nebulizer treatment?
infection
what is the main cause of shifts in ABGs?
highly addictive
what is the one concern with using benzodiazepines for the treatment of anxiety?
sleep appetite concentration
what three things does an increased cortisol level affect?
every 4 hours
when a patient has an epidural or PCA, how often should a nurse assess pain?
every 2 hours
when a patient has an epidural or PCA, how often should the nurse assess and document a respiratory rate and sedation score?
anxiety assessment
when a patient is anxious, assess... - HR/BP - discomfort (GI symptoms) - reason for feeling this way - sleep, appetite, concentration - behavior during the interview/assessment - cognitive behavior changes (ADLs, work, relationships) - how long has this been going on?
within 6 hours
when an extrication collar is placed, within how many hours should it be changed to an Aspen or Miami J collar?
20-40 mmHg
when attaching an NG tube to intermittent suction, what is the appropriate suction pressure?
depth measurement
when confirming the placement of the NG tube during an assessment, what should the nurse look at?
head of bed
when performing cervical collar care, where should the person who is stabilizing the head stand while cleaning the skin under the collar?
high-Fowler's
which position should the patient be placed in for insertion, medication administration, and removal of an NG tube? (hint...greater than 45 degrees)
AC
which vent mode is most appropriate for a patient who has no spontaneous breathing?
exercise respiratory muscles
why is it important to give a patient who is being weaned from a ventilator periods of less ventilator support alternated with periods of more ventilator support before extubating the patient?
complications of self-extubation
1. vocal cord damage 2. larynx damage 3. aspiration prevention interventions... restraints, sedation, weaning from vent ASAP
interventions for acute confusion or impaired mood regulation
1. assessment is SO important - documental mental health assessments and any screenings completed 2. referral or consult 3. pharmaceuticals 4. fix underlying problems if applicable (stress, UTI) 5. therapy - relaxation therapy (deep breathing, mindfulness, mediation) 6. cognitive behavioral therapy
B, C, D
A client who recently had laparoscopic surgery to treat a ruptured appendix has developed subsequent peritonitis. The client currently has two JP drains placed in the abdomen. Which finding(s) would the nurse report immediately to the surgeon? SATA A. Serosanguineous drainage B. Fever C. Cloudy drainage D. Painful abdominal distension E. Pain level 3 on a scale of 1 to 10
D, E
A client with a cervical vertebrae injury is admitted to the hospital with a cervical collar in place. Which of the following actions is the nurse responsible for when caring for this client? SATA A. Allowing the client to adjust the collar for comfort B. Providing pin site care per the hospital policy C. Ensuring that the weights are not resting on the floor D. Changing the extrication collar to an Aspen Vista collar E. Washing the skin under the collar
A
A client with a morphine sulfate PCA is drowsy, has a respiratory rate of 12, oxygen saturation of 89% on 2 liters of oxygen via nasal cannula and EtCO2 of 43. Which of the following interventions should the nurse complete first? A. Raise the head of the bed and try to arouse the client B. Change the oxygen delivery device to a non-rebreather C. Provide albuterol nebulizer treatment D. Administer Narcan (naloxone) per the protocol
A
A nurse delegates to a nursing student to perform oral care per standard on an assigned patient in the ICU who is on a ventilator. How often should the student plan to perform oral hygiene? A. Every two hours B. Every four hours C. Once during the shift D. Should not perform because the patient has an endotracheal tube in the mouth
C
A nurse is analyzing the ABGs for a patient on a ventilator. Which values indicate the patient is in respiratory acidosis? A. pH 7.40, PCO2 35, HCO3 22, O2 77% B. pH 7.45, PCO2 45, HCO3 20, O2 65% C. pH 7.28, PCO2 50, HCO3 18, O2 100% D. pH 7.50, PCO2 26, HCO3 38, O2 80%
A
A nurse is caring for a client who has a JP drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes? A. To prevent fluid from accumulating in the wound B. To limit the amount of bleeding from the surgical site C. To provide a means for medication administration D. To eliminate the need for wound irrigations
B
A nurse is caring for a client who has a postoperative ileum and an NG tube that has drained 2500 mL in the past 6 hours. Which of the following electrolyte imbalances should the nurse monitor the client for? A. Elevated sodium level B. Decreased potassium level C. Elevated magnesium level D. Decreased calcium level
D
A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching? A. "Perform a finger sweep to clear the client's mouth when the seizure begins" B. "Apply soft wrist restraints when the client reports sensing an aura" C. "Place the client on their back when the seizure begins" D. "Do not allow the client to swim while unattended"
A, C, E
A nursing student is reviewing the standards of care for a client who experiences a seizure. Which of the following should the nursing student include in the plan of care? SATA A. If the client is sitting in a chair, ease the patient to the floor B. Restrain the client with soft wrist restraints to prevent pulling IVs out C. Protect the head with pillows to prevent injury D. Insert a bite block in the client's mouth to prevent tongue biting E. If the client is in bed, raise the padded side rails F. Offer sips of cold water during the post ictal phase of the seizure
A, E, F, G
A patient with a brain tumor is admitted and has a risk for seizures. In the patient's plan of care, which of the following actions should be taken in initiating seizure precautions? SATA A. Prepare oxygen and suction at bedside B. Place bed in highest position C. Remove all pillows from the patient's head D. Have restraints on stand-by E. Apply padded bed rails F. Remove restrictive objects or clothing from patient's body G. Obtain IV access
B, D, E
A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient? SATA A. Modifying the traction weights as needed B. Assessing the patient's skin integrity C. Releasing the traction for 30 minutes each morning D. Administering pain medication E. Providing passive range of motion
B
A patient with second-degree burns has been receiving morphine through patient-controlled analgesia (PCA) for a week. The patient wakes up frequently during the night reporting severe pain. The most appropriate action by the nurse is to: A. Administer a dose of morphine every 1-2 hours from the PCA machine while the patient is sleeping B. Consult with the healthcare provider about using a different treatment protocol to control the patient's pain C. Encourage the patient to use the bolus dose of morphine to be given when the patient awakens with pain D. Teach the patient to push the button every 10 minutes for an hour before going to sleep, even if the pain is minimal
CAM assessment
Confusion Assessment Method completed q8-12h
A, C, D, E, G
How does the nurse decide when the patient is ready to be extubated from the ventilator? SATA A. sedation is low enough B. sedation is needed C. stable vital signs D. stable ABGs E. absence of diaphoresis F. respiration rate of 6 G. tolerating breathing
C
The nurse assess a client who has fentanyl infusing at 50mcg per hour in an epidural and notices that the epidural dressing and bed sheets are wet. Which of the following actions should the nurse take first? A. Remove the dressing and advance the catheter B. Administer 50mcg of IV fentanyl C. Call the physician to remove the catheter D. Decrease the rate of the epidural on the pump
B
The nurse assesses a postoperative patient who is receiving morphine through patient-controlled analgesia (PCA). Which information is most important to report to the healthcare provider? A. The patient complains of nausea after eating B. The patient's respiratory rate is 6 breaths/minute C. The patient has not had a bowel movement for 3 days D. The patient reports having a "mild" headache
C
The nurse is caring for a client in a halo traction device. Which of the following demonstrates proper management of the device? A. Have the client remove the halo traction device for one hour daily B. Use the halo device to reposition the client's head C. Attach the device wrench to the client's head of bed D. Cleanse the halo traction pins with soapy water
C
The nurse is caring for a client who is paralyzed and requires mechanical ventilation. The client is unresponsive and has no spontaneous ventilatory effort at the present time. What type of ventilation should the nurse expect the physician to order? A. SIMV B. BiPAP C. AC D. PSV
D, B, C, E, A
The nurse is caring for a patient with a Jackson-Pratt drain. Place in order, from first to last, the actions the nurse will perform. Use all options A. Replace the cap on the bulb B. Empty the bulb's contents into the small graduate C. Wipe the outlet of the bulb with an alcohol swab D. Remove the cap from the bulb E. Fully compress the bulb
B
The nurse is educating a client and the family about different types of stabilizing devices. Which statement by the patient indicates that the client understands the benefit of using a halo fixation device instead of Gardner-Wells tongs? A. "I will have less pain if I use the halo device" B. "The halo device will allow me to get out of bed" C. "I am less likely to get an infection with the halo device" D. "The halo device does not have to stay in place as long"
B
The nurse is ordered to administer Lorazepam to a patient experiencing status epilepticus. As a precautionary measure, the nurse will also have what reversal agent on standby? A. naloxone (Narcan) B. flumazenil (Romazicon) C. calcium chloride D. digoxin immune fab (Digibind)
C
The nurse is preparing to administer medication through a nasogastric tube that is connected to low intermittent suction. To administer the medication, the nurse should take which action? A. Position the client supine to assist in medication absorption B. Aspirate the nasogastric tube after medication administration to maintain patency C. Clamp the nasogastric tube for 30 minutes following administration of the medication D. Decrease the suction setting to 10-20 mmHg for 30 minutes after medication administration
A, C
The nurse is preparing to instill medication into a client's nasogastric tube. Which actions should the nurse take before instilling the medications? SATA A. Assess the depth of the nasogastric tube B. Aspirate the stomach contents C. Turn off the suction to the nasogastric tube D. Remove the tube and place it in the other nostril E. Test the stomach contents for a pH of less than 3.5
C
When caring for a patient who is receiving epidural morphine, which information obtained by the nurse indicates that the patient may be experiencing a side effect of the medication? A. The patient describes a bitter taste in their mouth B. The patient becomes restless and agitated C. The patient has not voided for over 10 hours D. The patient reports having frequent watery stools
E
Which ABGs would represent a patient who is ready to wean from the ventilator? A. pH 7.40, PCO2 35, HCO3 22, O2 70% B. pH 7.45, PCO2 45, HCO3 20, O2 65% C. pH 7.28, PCO2 50, HCO3 18, O2 100% D. pH 7.50, PCO2 26, HCO3 38, O2 80% E. pH 7.38, PCO2 40, HCO3 24, O2 96%
C
Your patient has entered the post ictal stage for seizures. The patient's seizure presented with an aura followed by body stiffening and then recurrent jerking. The patient had incontinence and bleeding in the mouth from injury to the tongue. What is an expected finding in this stage based on the type of seizure this patient experienced? A. Crying and anxiety B. Immediate return to baseline behavior C. Sleepy, headache, and soreness D. Unconsciousness
outcomes
______ for acute confusion and impaired mood regulation: - patient will be alert and oriented to person, place, and time in 24 hours - patient will list 2 effective coping strategies by the end of the shift - patient will have a decreased heart rate, blood pressure, and respiration rate - patient will report decreased levels of stress
seizure interventions
_______ interventions: safety - side rail padding left lateral recumbent position with HOB flat pillows under the head loosen any tight or restricting clothing apply oxygen - 100% nonrebreather mask administer lorazepam have suction ready at the bedside
suicide risk factors
_______ risk factors: - previous attempts - access to firearms and ammunition - hx of medical conditions - specific plan or intent - giving away valuables, personal items - major life events, losses - protective factors (family, pets, morals, beliefs, etc.)
delirium signs and symptoms
_______ signs and symptoms... - disoriented - rapid onset - restless, agitated - inability to focus - disruption of awareness - change in cognition (fluctuations) - altered speech, rambling, disorganized thinking - asking where they are, why they are here - disruptive sleep - inattention - altered LOC
violence interventions
_________ interventions: - have a plan - body language, show of support - safety - PRN medications - physical restraints - de-escalation techniques - remove unnecessary equipment that could be used as weapons - PRN chemical restraints - therapeutic communication - debrief after incident - behavioral consult - unique treatment plan (UTP) - maintain appropriate distance from patient other interventions... 1. remain clam 2. isolate the patient 3. watch patient body language 4. keep it simple 5. use reflective questioning 6. use silence 7. follow through - consistency!
suicide interventions
__________ interventions: - ask about a plan - assess to firearms? items for self harm? - do they have hope? - contract for safety - do not leave them alone - help from friends and family - daily appointments or inpatient treatment - trust and rapport are necessary - medication for depression
fear
a cognitive process that involves the intellectual appraisal of threatening stimulus
postpartum depression
a depressive disorder often seen in new moms; mom looks disheveled tends to be worse during the evening 50-85% blues, 10-20% moderate depression; severe psychosis 1% allow mom to voice frustrations mild - depressed mood, varies from day to day - anxiety, impaired concentration - begin 48 hours after delivery (euphoria begins to subside) - peaks 3-5 days and last 2 weeks - fairly "normal" for most women to experience the "blues" moderate - more bad days than good, worse in the evening - fatigue, decreased libido - loss of appetite - sleep disturbances - irritability - lasts weeks to months - can impact ability to care for child
MDD
a depressive disorder that causes impaired social and occupational functioning for at least 2 weeks strong genetic contribution!! melancholic features - symptoms are exaggerated and interest in activities is virtually lost more likely to turn to substances (alcohol is a depressant, drugs bring a euphoric effect), which causes an increase risk for self-harm or suicide characterized by... - loss of interest - feelings of worthlessness/excessive guilt - decreased energy, fatigue - changes in sleep - changes in appetite - isolation - not reaching out, feeling like a burden - suicide/recurrent thoughts of death - psychomotor agitation, retardation - hard time concentrating or making decisions - usually paired with some anxiety
persistant depressive disorder (dysthymia)
a depressive disorder that has somewhat milder symptoms than those ascribed with MDD describe mood as sad or "down in the dumps" - chronically not happy; no joy in life depressed mood for most days for at least 2 years characterized by... - poor appetite, overeating - insomnia/hypersomnia - has not went w/o symptoms for more than 2 months at a time - causes significant distress or impairment in social and occupational areas of life
situational depression
a depressive disorder that lasts less than 6 months in duration triggered by a stressful life event screening tools include a PHQ-2 and PHQ-9 *use PHQ-2 first; if yes to the first two questions, proceed to PHQ-9
racemic epinephrine
a medication that may be administered through a nebulizer opens airways and relaxes bronchial smooth muscle
impaired mood regulation
a mental state characterized by shifts in mood or affect comprised of manifestations varying from mild to severe characterized by: - changes in verbal behavior - dysphoria - excessive self-awareness, self-blame, guilt - hopelessness - impaired concentration - influenced self-esteem - irritability - psychomotor agitation, retardation - sad affect - withdrawal - lack of appetite
post-traumatic stress disorder (PTSD)
a multisymptomatic response that is triggered by an extremely traumatic event characterized by... - reexperiencing the traumatic event - sustained high level of anxiety or arousal - general numbing of responsiveness - intrusive recollections - nightmares depression symptoms are often common d/t trauma and guilt must be present for 1 month and impair social and occupational functioning
phobia
a persistent, intensely felt, and irrational fear of a specific object, activity, or situation that results in a compelling desire to avoid the feared stimulus responses are typically intense anxiety or panic attacks
social anxiety disorder (SAD)
a social phobia - excessive fear of situations in which a person might do something embarrassing or be evaluated negatively by others essentially scared of being out in public may have a coexisting dx of depression baby steps when working toward treating this disorder
crisis
a sudden event in one's life that disrupts homeostasis, during which usual coping mechanisms cannot resolve the problem depends on... 1. perception of the even 2. availability of situational supports 3. availability of adequate coping mechanisms
panic
a sudden overwhelming feeling of terror or impending doom usually accompanied by behavioral, cognitive, and physiological signs/symptoms considered to be out of the range of normalcy
Miami J collar
a type of cervical collar that is not used as often due to its high risk for skin breakdown
cognitive behavioral therapy
a type of therapy that focuses on changing "automatic thoughts" that spontaneously occur and contribute to the distorted affect
acute confusion
abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time
15 hours
after an intrathecal injection, how many hours must the patient NOT receive an opioid?
AC
aka assist control a mode of ventilation where all breaths are ventilation delivered and a preset tidal volume used when patient is in acute respiratory distress and neurocognitive conditions that do not allow for strong enough breaths provides the most respiratory support
PEEP
aka positive end expiratory pressure minimum preset pressure maintained in lungs at expiration - does not allow total exhalation, which prevents alveoli collapse may decrease CO and BP - be careful in hypotensive patients
30 mL
before and after administering medications through an NG tube, how many mL of water should the nurse flush through the tube?
behaviors related to impaired mood regulation
behaviors associated with ____ ______ ______: - alteration in sleep pattern - anxiety - appetite change - chronic illness - functional impairment - impaired social functioning - loneliness - pain - psychosis - recurrent thoughts of death or suicide - social isolation - substance misuse - weight change
endotracheal securement device
benefits: can move the tube easier, less breakdown and sores
BiPAP
bilevel positive airway pressure works by providing assistance during inspiration and preventing airway closure during expiration two pressures - one on inhalation, and one on exhalation
therapeutic communication
caregiver verbal and nonverbal techniques that focus on the care receiver's needs and advance the promotion of healing and change encourages exploration of feelings and fosters understanding of behavioral motivation nonjudgmental, discourages defensiveness, and promotes trust - presence, active listening - focus on current crisis - observe reactivity/impulsivity - work toward restoration of self-worth, morals, control - self-thinking, affirm self-efficacy and self-worth - be available - help with coping strategies
causes of delirium
causes of ________: - medications (Ativan) - head trauma, seizures, migraines - malnutrition - surgery, ICU admission - fluid/electrolyte imbalance, dehydration - COPD, hypoxemia - uncontrolled pain, burns - infection, multiple system illness - fever, hypothermia - sleep deprivation - sensory deprivation or overload - social isolation, emotional stress - physical restraints
causes of depression
causes of _________: - lots of genetic components - if one grows up surrounded by depression = predisposition; individual may see it as normal - may be environmental - poverty; parents or siblings with depression or other mental health disorders; homelife - new medical diagnosis - biochemical - imbalances and decreased levels of serotonin, norepinephrine, and dopamine - medications to treat these imbalances!! - may take up to 4-6 weeks for full therapeutic effect
CPAP
continuous positive airway pressure a treatment for apnea involving keeping a patient's airways open using air pressure delivered via a face mask one pressure on exhalation - does not allow for total exhalation
nebulizer
device that creates a mist used to delivers medication for giving respiratory treatment need about 6-10L of oxygen to convert liquid medication into a mist hook tubing to the oxygen port (in hospital) 10-15 minute medication treatment usually a mask for children albuterol and racemic epinephrine biggest adverse affect: tachycardia
every 4 hours
every how often should a nurse assess an epidural site?
every 4 hours
every how often should the nurse review the PCA or epidural program? (also clear the demand and delivered history)
body dysmorphic disorder
exaggerated belief that they body is deformed or defective in some way common complaints... - flaws of face or head - wrinkles or scars - shape of the nose - excessive facial hair - facial symmetry unrealistically exaggerated but concern is grossly excessive often have other comorbidities associated (OCD, MDD, anxiety, eating disorders)
anxiety presentation
patient presents as... - restless - SOB - fearful - increased HR - pacing - tense - feel like they are out of control
affect
patient's external, observable, immediate expression of emotion associated with an experience is it congruent with mood? incongruent? appropriate or inappropriate?
stress
perceptions, emotions, anxieties, interpersonal, social, or economic events that are considered threatening to one's physical health, personal safety, or wellbeing includes PTSD, acute stress disorder, and adjustment disorder
generalized anxiety disorder (GAD)
persistent, unrealistic, and excessive anxiety and worry, which has occurred for at least 6 months and cannot be attributed to specific organic factors characterized by... - muscle tension - restlessness - feeling keyed up or on edge - procrastination in behavior or decision making - constant reassurance from others - may become isolative, leading to depression (comorbidity) treatment: medications - closely monitored and taper
cervical tongs
placed in the patient's skull to pull the vertebrae apart two types: Crutchfield, Gardner-Wells a short-term solution to reduce swelling before surgery do not let the weights rest on the floor - must be continuous traction (no breaks) pin care as ordered to prevent infection
halo
placed in the patient's skull to stabilize alignment of the cervical spine more of a long-term solution as it can be in place for 6 months do not drive - patient cannot turn the head pin care as ordered to prevent infection (half-strength hydrogen peroxide or NS) do not grab onto the bars when turning a patient with this device *lift up plastic to do CPR if needed
epidural
placed into the subarachnoid space of the spine may be delivered by bolus injection but most common is a PCA much smaller of a dose d/t the closeness of the action site biggest concern: hypotension
cervical collars
placed on all trauma patients with unknown possible cervical spine issues 6 hours to switch to an Aspen collar or Miami J collar do not remove until it is known that "C spines are clear and can remove the collar" skin care must be performed at a minimum of every 8 hours
lorazepam (Ativan)
preferred medication to stop a seizure a controlled substance that is refrigerated remember to dilute equal parts of saline - draw med first and then saline
crisis situations
psychological disequilibrium in a person who confronts a hazardous circumstance that constitutes an important problem that he or she can netter escape nor solve with usual problem-solving resources 1. suicidal ideation 2. homicidal ideation 3. aggression/violence 4. consequences of substance abuse 5. anxiety 6. stress 7. postpartum depression
panic disorder
recurrent panic attacks where the onset is unpredictable manifested by... - intense apprehension, fear, and terror - loss of control - feelings of impending doom - intense physical discomfort symptoms come on suddenly characterized by... - palpitations - sweating - trembling, shaking - SOB, smothering sensations - chills - fear of losing control, going crazy, dying only lasts a few minutes - be present with the patient
obsessive compulsive disorder (OCD)
the presence of obsessions or compulsions, or both, the severity of which is significant enough to cause distress or impairment in social and occupational areas of functioning individual recognizes the behavior is excessive and unreasonable (repetitive) but is compelled to continue to act common compulsions include... - hand washing - ordering, checking - praying - counting, repeating words usually chronic - may be complicated by depression or substance abuse treatment: find a routine to get their actions to be more "socially accepted"; therapy, some medications may work if anxiety is also present
suicidal ideation
the second leading cause of death behind accidents for ages 15-24 y.o. highest incidence in people older than 50 y.o. males at higher risk 50-80% who commit suicide have had previous attempts warning signs: - 8 out of 10 people give clues (often ignored) - cries for help - most occur within 3 months after the beginning of improvement - suicide of close family members increases risk - suicide threats should be taken seriously *ask what keeps someone alive each day
mentally healthy person
the successful adaption to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms - cope with stressors (talking with someone instead of lashing out) - realizing their abilities (stronger than one thinks) - asking for help, filling one's own cup - process of emotions - share their happiness with oneself and others
impacts of delirium
this acute change in mental status may cause... - increase in morbidity and mortality rate - increase risk for falls - increase length and cost of hospital stay - increase older patient risk of function and cognitive decline - increase risk for long term care placement - patients may remember their experience - families experience this alongside loved ones
epidural tubing
this kind of tubing has a yellow stripe through it to differentiate from other tubings
pharmacology
this type of treatment includes SSRIs, SNRIs, heterocyclic, and MAOIs concerns: side effects, weight gain takes 4-6 weeks for the full therapeutic effect
anxiety treatment
treatment for ______: - cognitive behavioral therapy - applied relaxation - mindfulness or meditation - prayer - exercise - regular sleep patterns - medication - essential oils
depression treatments
treatments for _________ include: - medications - downside: 4-6 weeks for therapeutic effects - therapy - educate about depression, anxiety, coping, etc. - new outlook on how to see things! - cognitive behavioral therapy - changing the way in which one thinks - state feeling and reason why - "I" STATEMENTS - "I feel frustrated b/c ..." - journaling, gratitude journal - mindfulness - relaxation therapy - referral/consult - light therapy - group therapy
true
true or false: a nurse can determine that a nebulizer treatment is complete when the medication well is empty and when there is no more mist coming from the mask
true
true or false: a patient can have oxygen per nasal cannula while an NG tube is in place
true
true or false: assessment data and outcome criteria must relate to each other (hint...if a patient is struggling with sleep, the outcome must be related to improving sleep patterns)
false
true or false: family members, nurses, and doctors can press the button on the PCA
false
true or false: if a patient has a CPAP mask on that only covers their nose, the patient can drink water and swallow pills with the mask on
true
true or false: it is necessary that the nurse clamps an NG or OG tube (if applicable) before suctioning of a patient on a ventilator
true
true or false: look at the medication list right away when an older adult becomes unusually and abruptly confused
true
true or false: neurologically intact patients will always have an increased level of sedation before exhibiting signs and symptoms of respiratory depression
true
true or false: only give Ativan while the seizure is occurring
false
true or false: the best position for a patient to receive a nebulizer treatment is in the side-lying position
true
true or false: the nurse does not have to check capability between an epidural and IV fluid because they are going through separate tubing and to different parts of the body
true
true or false: the nurse must pre oxygenate the patient before suctioning
true
true or false: when inserting an oral airway, it should be inserted upside down and rotated once in the patient's mouth