Nursing 150 - Final Exam
The nurse is caring for a patient who is scheduled for a left total hip replacement. Which assessment finding should be immediately reported to the surgeon? a. Ingrown toenail on left great toe that is red and tender to touch b. Patient complains of left hip pain that is 8/10 when walking c. Patient states he stopped taking warfarin (Coumadin) 7 days ago d. Patient's medical record indicates an allergy to Penicillin
a. Ingrown toenail on left great toe that is red and tender to touch
Which medications can cause bradycardia? a. Metoprolol (Lopressor) b. Dilitiazem (Cardizem) c. Amlodipine (Norvasc) d. hydrochlorothiazide (HCTZ)
a. Metoprolol (Lopressor) b. Dilitiazem (Cardizem) c. Amlodipine (Norvasc)
When teaching a patient about methotrexate (Trexall), what should the nurse include? a. You will need to have regular tests to monitor your blood cell counts. b. Be sure to use contraception during and for three months after treatment. c. Notify your physician if your symptoms do not improve within one to two weeks. d. If you begin to feel more tired and weak, notify your physician.
a. You will need to have regular tests to monitor your blood cell counts. b. Be sure to use contraception during and for three months after treatment. d. If you begin to feel more tired and weak, notify your physician.
While in the holding area, a patient reveals to the nurse that his father had a high fever after surgery. What action by the nurse is a priority? a) Place a medical alert sticker on the front of the patient's chart. b) Alert the anesthesia care provider of the family member's reaction to surgery. c) Give 650 mg of acetaminophen (Tylenol) per rectum as a preventive measure. d) Reassure the patient that his temperature will be closely monitored after surgery.
b) Alert the anesthesia care provider of the family member's reaction to surgery.
When administering alendronate (Fosamax) to a patient with osteoporosis, what action should the nurse take? a) Ask about any leg cramps or hot flashes. b) Assist the patient to sit up at the bedside. c) Be sure that the patient has recently eaten. d) Administer the ordered calcium carbonate with the alendronate.
b) Assist the patient to sit up at the bedside.
The health care provider prescribes an infusion of heparin and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). What is the most appropriate action for the nurse to take? a) Decrease the infusion when the PTT value is 65 seconds. b) Avoid giving IM medications to prevent localized bleeding. c) Have vitamin K available in case reversal of heparin is needed. d) Increase the infusion rate until the INR is 2-3.
b) Avoid giving IM medications to prevent localized bleeding.
which drug can cause severe hypotension with its first dose? a) Metoprolol (Lopressor). b) Doxazosin (Cardura). c) Clonidine (Catapress). d) Hydralazine (Apresoline).
b) Doxazosin (Cardura).
The nurse is caring for a patient who has been diagnosed with a stroke on the left side of the brain. The nurse should assess for what problems? select all that apply. a. Left hemiparesis b. Expressive aphasia c. Impaired comprehension of language and math d. Poor impulse control e. Impaired judgment
b) Expressive aphasia. c) Impaired comprehension of language and math. *** Signs of left-brain damage include right hemiplegia, aphasias, impaired comprehension related to language and math. Left hemiparesis, poor impulse control and impaired judgment are signs of right-brain damage.
Which data identified during the perioperative assessment alert the nurse that special protection techniques should be implemented during surgery? a) Stated allergy to cats and dogs. b) History of spinal and hip arthritis. c) Verbalization of anxiety by the patient. d) Having a sip of water 6 hours previously.
b) History of spinal and hip arthritis.
How do you explain to your fellow students the difference between Delegating and Assigning? a. I can only make assignments to Nursing Assistants. b. If I am delegating tasks I am still accountable for the action. c. LPN's can delegate tasks to RN's only d. The primary goal of delegation is to care for as many patients as possible.
b) If I am delegating tasks I am still accountable for the action. *** Delegation: "Transferring to a competent individual the authority to perform a selected activity in a selected situation. The delegator retains accountability for the delegation." Assignment: "Designating responsibility for implementation of a specific activity or set of activities to a person licensed and competent to perform such activities."
The nurse is teaching a patient with intermittent claudication about drug therapy for this condition. Which statements are accurate? select all that apply. a. Anticoagulants such as warfarin (Coumadin) are usually recommended. b. It is critical that this patient take an antiplatelet agent daily. c. Cilostazol (Pletal) can help to relieve symptoms of intermittent claudication. d. Nitroglycerin is used to treat acute episodes of intermittent claudication.
b) It is critical that this patient take an antiplatelet agent daily. c) Cilostazol (Pletal) can help to relieve symptoms of intermittent claudication. **** Intermittent claudication is a symptom of peripheral arterial disease. Antiplatelet agents are critical for reducing the risks of CVD events and death in PAD patients. Cilostazol inhibits platelet aggregationo and increases vasodilation, thus relieving symptoms of intermittent claudication. Anticoagulants are not recommended. Nitroglycerin is used for angina, not intermittent claudication.
What statement is correct regarding Diabetic Ketoacidosis (DKA)? a. DKA occurs mainly in Type 2 diabetics. b. Ketones are present in the urine in DKA. c. Electrolytes are usually normal in DKA. d. Severe hypoglycemia is a hallmark sign in DKA.
b) Ketones are present in the urine in DKA. *** DKA is caused by profound deficiency of insulin and is characterized by hyperglycemia, ketosis, acidosis and dehydration. Since Type II diabetics are still able to produce their own insulin that typically do not suffer from DKA.
A patient's forearm cast has been split due to severe arm pain, numbness and tingling. When these symptoms return one hour later, which nursing action is top priority? a) Administer an intravenous pain medication. b) Notify the physician immediately. c) cut the cast padding and spread the cast further. d) Elevate the arm on pillows above heart level.
b) Notify the physician immediately.
A patient has the following orders: Lantus qHs, Novolog TIDAC, and Novolog per High Dose Correction Scale TIDAC, HS, and 0200. The patient is made NPO for a procedure. Which insulin(s) do you hold? a) Lantus dose at bedtime (BG > 70). b) Novolog TIDAC doses. c) Novolog Correction Scale doses. d) Both B and C. e) Both A, B, and C.
b) Novolog TIDAC doses. *** the only insulin you hold for NPO patients is the one pertaining to meals.
When is a patient most susceptible to hypoglycemic symptoms after theadministration of insulin? a. Onset b. Peak c. Duration d. Duration and Peak
b) Peak *** The peak time for insulin is when the effect of insulin on the body is the highest. Therefore the potential for hypoglycemia is the highest at that time.
What is the primary goal of treatment for a patient with a venous thromboembolism (VTE)? a. Preventing development of a blood clot b. Preventing migration of the thrombus c. Encouraging frequent ambulation d. Monitoring anticoagulant therapy
b) Preventing migration of the thrombus
A patient with venous thromboembolism (VTE) is prescribed heparin. What are the goals of this therapy? (Select all that apply). a. Dissolving the blood clot. b. Preventing the clot from getting larger. c. Preventing new clots from forming. d. Preventing embolization of the clot.
b) Preventing the clot from getting larger. c) Preventing new clots from forming. d) Preventing embolization of the clot.
A patient is dizzy & has a HR of 42. Which drug would most likely cause these symptoms? a) Isosorbide (Imdur). b) Propanolol (inderal). c) Lisinopril (Prinivil). d) Furosemide (Lasix).
b) Propanolol (inderal)
The patient has a blood pressure of 150/92. What stage of hypertension does he have? a) prehypertension. b) Stage 1. c) Stage 2. d) Normal BP.
b) Stage 1 -> normal = 120/80 -> prehypertension = 121-139 -> stage 1 = 140-150 -> stage 2 = 160 & over
How should the nurse instruct the patient to take repaglinide (Prandin)? a. Take the medication one hour prior to a meal. b. Take it from 30 minutes to just before the meal. c. Take the medication regularly, even if a meal is skipped. d. Take the medication after eating a meal.
b) Take it from 30 minutes to just before the meal. *** Rationale = Repaglinide is a meglitinide, which increases insulin production from the pancreas. It should be taken during the 30 minute period prior to a meal, and should not be taken if a meal is skipped.
What are the most appropriate measures to prevent venous thromboembolism in hospitalized patients? select all that apply. a. Ambulating in the hallway twice daily b. Wearing graduated compression stockings consistently c. Wearing intermittent pneumatic compression devices (SCDs) while in bed d. Anticoagulant therapy
b) Wearing graduated compression stockings consistently. c) Wearing intermittent pneumatic compression devices (SCDs) while in bed. d) Anticoagulant therapy. **** For VTE prevention, patients should ambulate four to six times per day. Graduated compression stockings, when fitted correctly and worn consistently, decrease VTE risk. SCDs help prevent VTE when worn correctly and continuously except during ambulation. Anticoagulants are used routinely for VTE prevention and treatment.
A patient comes to the ED with a headache, blurred vision, & a BP of 224/110. What is the priority? a) treat headache with opioid medication. b) administer antihypertensive drugs to lower blood pressure. c) notify ophthalmologist to evaluate blurred vision. d) institute seizure precautions.
b) administer antihypertensive drugs to lower blood pressure.
The nurse is working on a surgical floor and is preparing to receive a postoperative patient from the PACU. What should be the nurse's initial action upon the patient's arrival? a) assess the patient's pain. b) assess the patient's vital signs. c) check the rate of the IV infusion. d) check the MD's post-op orders.
b) assess the patient's vital signs.
A post-op pt. develops sudden shortness of breath and chest pain. What should the nurse do first? a) auscultate breath sounds. b) assess vitals. c) administer morphine. d) call MD.
b) assess vitals.
My patient is on a heparin drip and is going to the OR this morning. What should I do? a) stop the drip & inform OR staff when transporting to the OR. b) call MD to clarify order. c) continue drip as ordered. d) draw PT before transporting patient to the OR.
b) call MD to clarify order.
Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy? a) air embolus. b) cerebral hemorrhage. c) expansion of the clot. d) resolution of the clot.
b) cerebral hemorrhage.
A patient complains of shortness of breath & chest pain. What is your first action? a) administer oxygen per hospital guidelines. b) check vital signs. c) auscultate lung sounds. d) obtain EKG.
b) check vital signs.
A patient had thoracic surgery one week ago and is complaining of abdominal pain & distention. Which medications would most likely address these complaints? Select one or more. a) morphine b) colace (docusate) c) Senna (sennosides) d) miralax (polyethylene glycol)
b) colace (docusate) c) Senna (sennosides) d) miralax (polyethylene glycol)
during treatment of the pt. with an acute attack of gout, the nurse would expect to administer.... a) aspirin b) colchicine c) allopurinol (zyloprim) d) probenecid (benemid)
b) colchicine
A nurse enters a room and finds the pt. lying on the floor. Which action should the nurse perform first? a) call for help to get the pt. back in bed. b) establish whether the pt. is responsive. c) assist the pt. back to bed. d) ask the pt. what happened.
b) establish whether the pt. is responsive.
My patient refuses to use the incentive spirometer. How can I get her to comply? a) offer prizes if she uses it every 4 hours. b) explain that the incentive prevents pneumonia. c) explain that the incentive prevents blood clots. d) explain that the incentive prevents a PE (pulmonary embolism).
b) explain that the incentive prevents pneumonia.
select all the signs/symptoms that occur with a right sided stroke: a) right side hemiplegia. b) impulsive. c) impaired time concepts. d) spatial-perceptual deficits.
b) impulsive. c) impaired time concepts. d) spatial-perceptual deficits.
Unless contraindicated by the surgical procedure, which position is preferred for the unconscious patient immediately postoperative? a) supine. b) lateral. c) semi-fowler's. d) high-fowler's.
b) lateral.
what would make the nurse suspect that a patient has osteoarthritis? a) pain in both hands. b) pain in the left hip with walking. c) pain is accompanied by fatigue & weight loss. d) pain in lower back & curvature of the spine.
b) pain in the left hip with walking.
which statement is true about hypertension? a) primary hypertension is rarely diagnosed. b) primary hypertension has no identified cause. c) secondary hypertension is prevalent in younger patients. d) secondary hypertension can be caused by stress.
b) primary hypertension has no identified cause.
A patient had abdominal surgery. The estimated blood loss was 400 ml. The patient received 300 ml of 0.9% saline during surgery. Postoperatively, the patient is hypotensive. What should the nurse anticipate for this patient? a) blood administration. b) restoring circulating volume. c) an ECG to check circulatory status. d) return to surgery to check for internal bleeding.
b) restoring circulating volume.
What is the most appropriate nursing diagnosis for a patient with carpal tunnel syndrome? a) activity intolerance. b) self-care deficit. c) impaired mobility. d) knowledge deficit.
b) self-care deficit.
which of the following behaviors will have the greatest impact on increasing a patient's risk of cancer? a) a vegetarian diet. b) smoking. c) lack of exercise. d) sun exposure.
b) smoking (it is a complete carcinogen, as it initiates changes in the cell to cause cancer, but it also promotes the growth of cancer).
Monitored anesthesia care (MAC) is going to be used for a closed, manual reduction of a dislocated shoulder. What action does the nurse anticipate? a) securing an airtight fit for the inhalation mask. b) starting a 20 gauge IV in the patient's unaffected arm. c) obtaining a non-occlusive dressing to place over the administration site. d) teaching the patient about epidural anesthesia.
b) starting a 20 gauge IV in the patient's unaffected arm.
What should the nurse teach a patient about NSAIDs? a) take 30 mins prior to eating. b) take with food. c) take one hour prior to eating. d) can be taken with or without food.
b) take with food.
The nurse is preparing to administer digoxin to a pt. with heart failure. Lab results are reviewed with the following findings: sodium 139, potassium 2.6, chloride 103, & glucose 106. What would the nurse do next? a) withhold the daily dose until the following day. b) withhold the dose & report the potassium level. c) give the digoxin with a salty snack, such as crackers. d) give the digoxin with extra fluids to dilute the sodium level.
b) withhold the dose & report the potassium level.
What are the benefits of NTG when used by patients with coronary artery disease? a. NTG increases preload which improves blood pressure b. NTG dilates coronary arteries c. NTG decreases afterload d. NTG reduces heart rate
b. NTG dilates coronary arteries c. NTG decreases afterload
The nurse is teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which statement by the patient indicates understanding of the teaching? a. If I overeat at a meal, I need to watch for symptoms of hypoglycemia. b. This medication works by reducing the amount of sugar my liver produces. c. I need to be sure to eat regularly when taking this medication. d. This medication is an injection that cannot be combined with insulin.
c) I need to be sure to eat regularly when taking this medication. *** Rationale = Glipizide is a sylfonylurea, which works by increasing insulin production from the pancreas. A major side effect is hypoglycemia, so the patient should be sure to eat regularly and watch for symptoms of hypoglycemia. It is an oral drug, not an injection.
Clients with type 1 diabetes may require which of the following changes to their daily routine during periods of infection? a. No changes b. Less insulin c. More insulin d. Oral antidiabetic agents
c) More insulin
The nurse plans discharge teaching for a patient with chronic heart failure who has prescriptions for digoxin (Lanoxin) and hydrochlorothiazide. What is an appropriate instruction for the nurse to include? a. Limit dietary sources of potassium b. Take the hydrochlorothiazide before bedtime. c. Notify the health care provider if nausea develops. d. Take the digoxin if the pulse if below 60 beats/minute.
c) Notify the health care provider if nausea develops.
A patient has a blood glucose of 400. Which of the following medications could be the cause of the hyperglycemia? a. Glucotrol (Glyburide) b. Amoxicillin (Moxatag) c. Prednisone (Sterapred) d. Lasix (furosemide)
c) Prednisone (Sterapred). *** Prednisone is a steroid and can increase blood sugar in diabetic patients.
A patient is transferred from the postanesthesia care unit (PACU) to the clinical unit. Which action by the nurse on the clinical unit should be performed first? a) Assess the patient's pain. b) Orient the patient to the unit. c) Take the patient's vital signs. d) Start encouraging fluids.
c) Take the patient's vital signs.
Which action by a patient indicates that the home health nurse's teaching about glargine and regular insulin has been successful? a. The patient administers the glargine 30 minutes before each meal. b. The patient's family prefills the syringes with the mix of insulins weekly. c. The patient discards the open vials of glargine and regular insulin after 4 weeks. d. The patient draws up the regular insulin and then the glargine in the same syringe.
c) The patient discards the open vials of glargine and regular insulin after 4 weeks. *** Rationale = Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Short-acting regular insulin is administered before meals, and glargine is given once daily.
Which laboratory result is important to communicate to the health care provider for a patient who is taking methotrexate to treat rheumatoid arthritis (RA)? a) Rheumatoid factor is positive. b) Fasting blood glucose is 90 mg/dl. c) The white blood cell (WBC) count is 1500/uL. d) The erythrocyte sedimentation rate is elevated.
c) The white blood cell (WBC) count is 1500/uL.
The nurse is teaching a patient who is being discharged home with a prescription for cyclobenzaprine hydrochloride (Flexeril). What should the nurse include in the teaching? a) Be sure to take a dose before you drive to your physical therapy appointment. b) Blurred vision is a rare adverse effect of this medication, but it can be permanent. c) This medication may cause drowsiness or dizziness. d) If you miss a dose, take two doses at the next scheduled time.
c) This medication may cause drowsiness or dizziness.
A patient taking the medication Precose (Acarbose) asks when is the best time to take this medication. What is the best response? a. 1 hour prior to eating. b. 1 hour after eating. c. With the first bite of food. d. At bedtime.
c) With the first bite of food. *** Precose is used to control blood sugars after eating and must be taken with the first bite of food. It blocks the absorption of carbohydrates that the patient eats.
A pt. with Type 1 Diabetes has a fingerstick glucose level of 258 mg/dl at bedtime. An order for a sliding scale insulin exists. What should the nurse do? a) call the physician. b) encourage the intake of fluids. c) administer the insulin as ordered. d) give the client 1/2 cup of orange juice.
c) administer the insulin as ordered.
What is the most effective intervention to prevent VTE? a) compression stockings. b) frequent range of motion exercises. c) ambulation. d) SCDs.
c) ambulation.
A CNA 1 will be caring for a post-op day 1 pt. who had a colostomy placed. Which of the following tasks should be performed by the RN, and not be delegated to the CNA? a) taking vital signs. b) assisting the pt. to the side of the bed. c) assessing the ostomy site. d) collecting a urine specimen for culture & sensitivity (C&S).
c) assessing the ostomy site.
A nurse is providing discharge info to a pt. with peripheral vascular disease. Which of the following info should be included in the instructions? a) walk barefoot whenever possible. b) use a heating pad to keep feet warm. c) avoid crossing the legs. d) use antibacterial ointment to treat skin lesions at risk of infection.
c) avoid crossing the legs.
what is a side effect of the beta blockers? a) tachycardia. b) increased appetite. c) depression. d) hypertension.
c) depression. *** using beta blockers can mask the symptoms of hypoglycemia!
Which signs & symptoms could be caused by the neuromuscular blocking agent that your patient received in the operating room? a) dry mouth postoperatively. b) drowsiness. c) difficulty taking a deep breath. d) double vision.
c) difficulty taking a deep breath.
What should the nurse teach a patient who is starting treatment with Allopurinol (Zyloprim)? a) symptoms should subside after 2-3 days. b) fluids should be restricted when taking this drug. c) follow-up lab work will be needed to assess effectiveness. d) dietary changes will not be needed.
c) follow-up lab work will be needed to assess effectiveness.
Your patient has a BP of 124/78. Metoprolol (Lopressor) is due to be given. What is your next action? a) wait 1 hour & re-check BP before giving the antihypertensive med. b) notify MD to decrease or discontinue the antihypertensive med. c) give the antihypertensive as ordered. d) hold the antihypertensive med until the next dose is due.
c) give the antihypertensive as ordered.
how does hypertension contribute to heart disease? a) hypertension does not affect cardiac output. b) lowering blood pressure increases afterload. c) hypertension can cause heart disease. d) heart disease can improve with hypertension.
c) hypertension can cause heart disease.
select all the signs & symptoms that occur with a stroke on the right side of the brain: a) right side hemiplegia. b) aphasia. c) impulsive. d) aware of limitations.
c) impulsive
which type of stroke would a pt. with atrial fibrillation most likely have? a) ischemic thrombosis b) hemorrhagic c) ischemic embolism d) ischemic stenosis
c) ischemic embolism *** atrial fibrillation is when some blood is sedentary in the heart & is not being pumped effectively, so the blood starts to clot.
My patient is being discharged after abdominal surgery. What discharge instructions should I give her? a) stay in bed as much as possible. b) restrict fluids to 800 ml per day. c) monitor wound and report drainage or redness. d) have patient avoid fruit & high fiber foods.
c) monitor wound and report drainage or redness.
which symptoms would indicate increased intracranial pressure? a) pinpoint pupils b) narrowing pulse pressure c) nausea & vomiting d) increased heart rate
c) nausea & vomiting
What symptom indicates compartment syndrome? a) pain requiring opioids for relief. b) pain that is relieved with elevation of extremity. c) pain with passive extension of digits. d) pain that is relieved by application of ice.
c) pain with passive extension of digits.
what are some lifestyle modifications you could teach your patient with hypertension? a) increase protein intake. b) exercise at least 1 hour a day. c) stop smoking. d) restrict fluids.
c) stop smoking.
What accurately describes the promotion stage of cancer development? a) characterized by increased growth of tumor & metastasis. b) irreversible alteration in the cell's DNA. c) withdrawal of promoting factors will reduce risk of cancer development. d) air pollution is an example of a promoting factor.
c) withdrawal of promoting factors will reduce risk of cancer development.
What instruction should the nurse include when teaching a patient about pramlintide (Symlin)? a. Stop taking insulin while taking this medication. b. This drug should be injected subcutaneously in the upper arm. c. This drug is injected once daily at bedtime. d. Be alert for signs of hypoglycemia while taking this medication.
d) Be alert for signs of hypoglycemia while taking this medication. *** Rationale = Pramlintide is an amylin analog that glows gastric emptying, reduces glucagon secretion, and increases satiety. Is is used concurrently with insulin in patients with type 2 or type 2 diabetes who do not have good glucose control on ideal insulin therapy. It is only used concurrently with insulin. It is injected subcutaneously in the thigh or abdomen prior to meals. It cannot be injected into the arm because absorption from this site is too variable. The concurrent use of this drug and insulin increases the risk of severe hypoglycemia during the 3 hours after injection.
An outpatient who has chronic heart failure returns to the clinic after 2 weeks of therapy with metoprolol (Toprol XL). Which assessment finding is most important for the nurse to report to the health care provider? a. dry cough b. Heart rate of 62 beats/minute c. Complaints of increased fatigue d. Blood pressure of 88/42 mm Hg
d) Blood pressure of 88/42 mm Hg
Which drug has a dry cough as a side effect? a) Diltiazem (Cardizem). b) Spironolactone (Aldactone). c) Prazosin (Minipress). d) Captopril (Capoten).
d) Captopril (Capoten)
When caring for a patient who has received a general anesthetic, the circulating nurse notes a red raised rash on the patient's arms. Which action should the nurse take immediately? a) Apply lotion to the affected areas. b) Cover the arms with sterile drapes. c) Recheck the patient's arms in 30 minutes. d) Notify the anesthesia care practitioner (ACP) immediately.
d) Notify the anesthesia care practitioner (ACP) immediately.
It is 6:00 AM. The anesthesiologist prescribes preoperative medications for a patient who is scheduled for surgery at 7:30 AM: cefazolin (Ancef) IV to be infused 30 minutes before surgery; midazolam (Versed) before surgery and scopolamine patch (Transderm Scop) behind the ear. Which medication should the nurse administer first? a) Cefazolin (Ancef) b) Fentanyl (Sulimaze) c) Midazolam (Versed) d) Scopolamine (Transderm Scop)
d) Scopolamine (Transderm Scop)
Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)? a. The patient's blood glucose level is 174 mg/dL. b. The patient is scheduled for a chest x-ray in an hour. c. The patient has gained 2 lb (0.9 kg) in the past 24 hours. d. The patient's blood urea nitrogen (BUN) level is 52 mg/dL.
d) The patient's blood urea nitrogen (BUN) level is 52 mg/dL. *** Rationale = The BUN indicates possible renal failure, and metformin should not be used in patients with renal failure. The other findings are not contraindications to the use of metformin.
A nurse from a med-surg unit is asked to work on the orthopedic unit. The med-surg nurse has no orthopedic nursing experience. Which client should be assigned to the med-surg nurse? a) a pt. with a cast for a fractured femur & who has numbness & discoloration of the toes. b) a pt. with balanced skeletal traction & who needs assistance with morning care. c) a pt. who had an above-the-knee amputation yesterday & has a 101.4 degree fever. d) a pt. who had a total hip replacement 2 days ago & needs blood glucose monitoring.
d) a pt. who had a total hip replacement 2 days ago & needs blood glucose monitoring.
A patient has been prescribed ibuprofen (Motrin). Which effect should the nurse instruct the patient to immediately report? a) blurred vision b) nasal stiffness c) urinary retention d) black or tarry stools
d) black or tarry stools
what is the priority during the pre-operative phase? a) completing hibiclens shower. b) teaching family about post-operative care. c) starting IV fluids as ordered. d) completing a thorough assessment.
d) completing a thorough assessment.
My patient is a DNR and starts having chest pain. What should I do first? a) call a Code Blue. b) call the family. c) give Percocet as ordered. d) elevate head of bed, assess vitals & pain, & call MD.
d) elevate head of bed, assess vitals & pain, & call MD.
what is an appropriate treatment for venous stasis ulcers? a) place affected extremity in dependent position. b) inspect wound weekly. c) leave wound open to air as much as possible. d) encourage pt. to wear compression stockings.
d) encourage pt. to wear compression stockings. *** Compression stockings gently squeeze your legs to move blood up your legs. This helps prevent leg swelling and, to a lesser extent, blood clots.
My patient is going to receive TIVA. How do I explain this to him? a) it is anesthesia with only narcotics. b) it is an anesthesia that will last the longest. c) don't worry your doctor knows what they are doing. d) it is anesthesia with only IV medications.
d) it is anesthesia with only IV medications.
What should you teach your patient about sublingual NTG? a) carry the NTG on your person at all times. b) take only when chest pain is rated at a 7 or more. c) continue normal activity after taking NTG. d) keep NTG in its original bottle.
d) keep NTG in its original bottle.
A patient is having elective cosmetic surgery performed on her face. The surgeon will keep her at the surgery center for 24 hours after surgery. What is the nurse's postoperative priority for this patient? a) manage patient pain. b) control the bleeding. c) maintain fluid balance. d) manage oxygenation status.
d) manage oxygenation status.
What would indicate a fat embolism in a patient who fractured their femur 24 hours ago? a) swelling of the leg. b) GI bleeding. c) pain in the calf of the leg. d) restlessness.
d) restlessness.
A 78 year old patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery? a) sterility b) paralysis c) urine output d) skin integrity
d) skin integrity
A 78 year old is having surgery. What risk areas will the nurse need to be aware of for this patient during surgery? a) sterility. b) urine output. c) paralysis. d) skin integrity.
d) skin integrity.
What type of traction is used for a patient with a hip fracture? a) skeletal. b) halo. c) Bryant's. d) skin.
d) skin.
Heart Failure: nursing diagnoses & goals
nursing diagnoses - impaired gas exchange. - decreased cardiac output. - excess fluid volume. - activity intolerance. nursing goals - decrease symptoms. - decrease in edema. - increase in exercise tolerance. - adherence to treatment regimen. - no complications.
Sprain concept map!!!
pt. teaching, nursing care/interventions, & what to expect related to sprains!
tasks should be delegated when....
the pt.'s condition is stable & predictable.
insulin therapy: self-management patient education
we must teach insulin pt.s..... - keep the vial in use at room temperature; unopened vials should be kept in the fridge until the pt. starts using it. - protect vial from extremes of heat & cold. - roll vial; don't shake to mix. - check vial expiration date; once a vial is opened, it is good for 28 days (4 weeks). - use an appropriate syringe. - time insulin use with meals & exercise. - wear ID. - carry insulin supplies with you while traveling. - teach the effects of too much or too little insulin.
Coronary Angiography: what the image looks like
* refer to picture *
types of insulin:
*** refer to picture ***
types of fractures:
*** refer to picture!
the delegate is accountable for:
- accountable for completely completing tasks allocated to him/her within the allotted time period & for the consequences of their work. - responsible for performing tasks consistent with their legal scope of practice; they share liability for any harm or injury they cause pt.s in the performance of their duties.
why would a patient want a TIVA?
- it is a more rapid recovery.
rheumatoid arthritis: nursing diagnosis
- pain. - self-care deficit. - fatigue r/t disease. - ineffective therapeutic regimen management. - body image disturbance. - altered family processes (typically affects younger women).
UAP (unlicensed assistive personnel) & nurse aid must be able to:
- prioritize tasks that are delegated. - report abnormal values to the nurse. - identify risk to pt. safety. - quickly report problems to the nurse. - adapt to change.
Discharge teaching:
- wound care. - medications. - activity level. - diet. - symptoms to be reported. - follow up care. - documentation.
how can you prevent a stroke?
---> everything you can do in order to manage your cardiovascular health is how you prevent a stroke from happening.
Late Effects of Radiation and Chemotherapy:
-> Increased risk for leukemias & other secondary malignancies; ex: Multiple myeloma and Non-Hodgkin's lymphoma. -> smoking may significantly increase the risk of secondary malignancies. -> secondary malignancies are usually resistant to therapy.
PCA delivery mode:
-> depends on MD's orders. -> all methods are set up with NS infusing as the carrier fluid! 1) Continuous: - ex. pt. will get 1mg of morphine every 10 minutes regardless of pushing the button. 2) Bolus: - most common type. - ex. the pt. will receive medication whoever they push the button, as long as it's within the time limits; they won't get med. if they don't push the button. 3) Both: - combined continuous & bolus. - ex. 2mg of morphine will infuse every hour continuously, and also on top of that, the pt. is able to push the button every 15 mins for another 1mg of morphine.
Intra-Operative Pharmacology:
1) Anesthesia: step 1 -> General Anesthesia... - loss of sensation, loss of consciousness, loss of reflex (no cornea/gag reflex). - starts with an IV induction agent, & the purpose is to induce rapid & pleasant sleep; these are typically short acting & allow for the patient to be intubated & facilitates inhalation agents to be used. - Induction Agents examples... 1) Barbiturates: Pentothal (Sodium Thiopental) & Brevital (Methohexital Sodium). 2) Hypnotics: Propofol (most common) & Amidate. 2) Inhalation Agents: step 2 -> administered with anesthesia equipment that essentially mixes & vaporizes the inhalation agents. - some of them can be volatile (substance is easily evaporated at normal temperatures; concern for OR fires). - these agents can be irritating to the bronchiole system. -> they are absorbed/excreted by the alveoli. -> they act as bronchodilators, vasodilators (drops BP), myocardial depressants, & muscle relaxants. 3) Neuromuscular Blocking Agents: step 3 -> these drugs relax & paralyze all skeletal muscles in the body; stops the nerve transmissions for the neuromuscular system, & blocks impulses from the skeletal muscle system including the diaphragm. -> we use these because even while a patient is sleeping under anesthesia, they could still have a twitch or muscle spasm, which would not be good during a major surgery. - has no affect on the CNS!!!!, so we must always give this drug paired with a sedative! - this drug will paralyze the patient, but will not sedate them. 4) TIVA - Total Intravenous Anesthesia -> there is no gas involved; no inhalation agents used. -> this is used because it significantly reduces a pt.'s recovery time. - the process starts with an induction loading dose & then it's switched to just maintenance of the dose. - typically Propofol is used (or another agent) for the IV infusion. 5) Local Anesthesia: -> loss of sensation without loss of consciousness. - the medicine is injected into the area that we want to be numbed. - examples: Lidocaine, Novocaine, Marcaine (longest acting; 12 hours; some doctors may inject this at the incision site when they're closing so the site doesn't hurt when the patient wakes up after surgery). - all of these drugs may be given with epinephrine (epi is a vasoconstrictor so it helps reduce the amount of bleeding). *** EMLA cream is a topical numbing agent; has to be left on for a little while, at least half an hour before it's effective. 6) Regional Anesthesia: -> Nerve Blocks.... - a local anesthetic is injected into & around a nerve group that supplies sensation to an area of the body; however it's important that the agent is not accidentally injected into a blood vessel because that could cause cardiovascular complications. 7) Spinal & Epidural Anesthesia: -> loss of sensation to a region following nerve block without loss of consciousness. -> Spinal Anesthesia = injection of a local anesthetic agent into a CSF (cerebral spinal fluid) via the subarachnoid space; pt. cannot feel or move, and as it wears off, the pt. won't be able to feel anything belly button down, and then hips down, and then thigh down, and so forth; pt. may have a head ache afterwards. -> Epidural Anesthesia = injection of a local anesthetic agent into the extradural space. 8) IV Moderate Sedation (Conscious Sedation): -> an IV sedative is given with or without local anesthetic. - pt. does not totally loose all of their protective reflexes; they still have gag reflex, can still maintain their airway, etc. - this minimally depresses pt.'s consciousness. - pt. can still respond to verbal stimulation & maintains airway & respirations. - as a nurse, if you have been checked off on this skill, you are allowed to administer this to a pt. - pt. vitals must still be monitored every 5 mins during the actual procedure, & afterwards as well per MD orders.
Once your patient is out of PACU and onto the med-surg floor, we need to try to prevent & assess for....
1) Atelectasis & Pneumonia: -> risks: failure to deep breath, history of smoking, abdominal or thoracic surgery, obesity, immobilization, retained secretions. - atelectasis can progress to pneumonia! 2) Respiratory Depression: -> the greatest predictor of respiratory depression is advancing sedation (pt. is alert & wake one minute, & then falling asleep a few minutes later). - the risk for this is greatest within first 4 hours after leaving PACU. -> pt.s most at risk for this include: 65 yrs & older, history of sleep apnea, cardiac/lung disease, obesity, smoker, receiving other CNS depressant meds. 3) Changes in Cardiac Output: ----> HR x Stroke Volume = Cardiac Output -> Cardiac Output = how much blood the heart is pumping out. -> signs of a good CO = good mental status, urine output, HR, temp, skin color, capillary refill, Hypotension & Hypovolemia: - blood loss/dehydration are common causes for changes in CO. - assess dressings & drains for any bleeding. 4) Hypertension: - BP is 20-30% above their baseline, typically from 'Sympathetic Stimulation'. -> sympathetic stimulation = the person is asleep under anesthesia during surgery & doesn't feel any pain, but the body still registers all of the stimulation that it went through during the surgery; the sympathetic nervous system is stimulated. -> causes for this hypertension could also include: pain, bladder distention, respiratory insufficiency, hypothermia, pre-existing conditions, malignant hypertension. - we want to assess & address the cause for this hypertension! 5) Fluid & Electrolyte Imbalances: -> fluid overload = body retains fluid after surgery due to stress response; over hydrated; pt. may look puffy & have edema sometimes if the fluid moves from the blood vessels (supposed to be there) & into the tissues (not supposed to be there), so even though they have so much fluid in them, their BP & urine output is still low. -> fluid deficit = loss of fluids; fluid deficit if IV fluid replacement is inadequate. -> Hypokalemia = low potassium; caused by fluid loss, vomiting/diarrhea, loop diuretics, NG tube to suction, NPO status for a long period of time; can exacerbate digoxin toxicity; can precipitate cardiac dysrhythmias (late symptom); in general, potassium affects cardiac contractility & nerve transmission; normal potassium level is 3.5-5, but they may give potassium supplements if pt. is 3.6 & also if pt. has cardiac issues. Treatment/Prevention: powder/capsule/pill supplements, IV potassium for NPO surgical pt; IV potassium complications include pain at IV site or phlebitis (inflammation of a vein), exceeding administration rate/concentration can be fatal & can burn, typically 10 meq per 100 cc bag ran over an hour is standard, NEVER IV push potassium (will stop the heart), if there is pain at IV site, MD can order lidocaine to be added to the infusion. 6) Venous Thromboembolism (VTE): -> the #1 thing that pt.s can die from in the hospital that is preventable. - clots may form in the leg veins as a result of inactivity, body position, & pressure, which leads to venous stasis & decreased perfusion. - common to develop in calf or thigh, but may travel up to lungs & cause a pulmonary embolism. Prevention: early ambulation for everyone (most important thing); assessment of risk factors for each pt. (may be prescribed Lovenox = low molecular weight heparin (LMWH) or just regular Heparin, & may use SCDs = sequential compression devices). 7) Pulmonary Embolism: - symptoms: sudden & unexplained shortness of breath, sharp chest pain that's worse with deep breathing, hemoptysis (coughing up blood), anxiety, feeling of dread, fainting, elevated HR & resp rate. - treatment: oxygen, IV heparin, administer analgesics, therapeutic APTT. 8) Altered Urinary Output: -> post-op void should be 200 ml within 6-8 hours of surgery. - urinary retention may be caused by medications used in anesthesia, narcotics, pt. lying flat in the bed. - check for bladder distention by palpating and/or bladder scan. 9) GI Complications: - gas pain, nausea/vomiting, abdominal distention, hiccups. - pt. will be NPO initially until gag reflex returns & there's no more nausea/vomiting; next step is clear liquids, then progress to a normal diet. - auscultate all 4 quadrants to assess for bowel sounds. - interventions to promote peristalsis & prevent paralytic ileus. * if pt. has nausea/vomiting, no bowel sounds, & distended belly, they probably have a paralytic ileus; so they will get NG tube to drain extra liquid out. 10) Alterations in Comfort: -> Pain: most severe in first 48 hours; IV narcotics are the most common treatment; may also consider NSAIDS; pain is what the patient says it is. -> Nausea & Vomiting: anesthesia is the most common cause; delayed gastric emptying & slowed peristalsis; antiemetic treatment. 11) Prevention of Syncope: - fainting. - caused by decreased cardiac output, fluid deficits, & postural hypotension. - treatment: monitor I&O & hematocrit levels. - when getting pt. out of bed, proceed slowly & cautiously. 12) Wound Assessment: - only change dressing with MD order. - notify MD of drainage or bleeding. - document status of dressing every shift. - drains prevent accumulation of fluid. -> perform focused assessment based upon the nature of the surgery; note neurovascular status; note dressing assessment; note any drains/tubes. 13) Fever (post-op complication): - mild elevation is normal (up to 100.4 in first 24 hours). - moderate elevation (greater than 100.4 in first 48 hours) is most commonly associated with respiratory congestion, atelectasis, or dehydration if the surgery was routine with no associated infection; going to tell the pt. to cough & deep breathe frequently.
Drug therapies for HF pt.s:
1) Diuretics -> they decrease volume overload, which then decreases preload. - corrects sodium & water retention. --> examples: 1) Thiazides = common for pt.s in mild-mdreate hf; they are cheap & effective; oral form. 2) Loops = Lasix; works quickly, can be given via IV; if pushed too fast via IV it can cause ototoxicity (hearing loss). **we need to be watchful for hypokalemia (low potassium) when giving these 2 drugs; if potassium gets too low, that can cause arrhythmias. 2) Ace Inhibitors -> current favored drug class for HF pt.s. -> they work by blocking the renin-angiotensin-aldosterone system (RAAS). -> they cause: decreased aldosterone, decreased SNS activity, vasodilation, sodium & water excretion, & inhibits ventricular hypertrophy/remodeling. -> side effects: low BP, a dry hacking cough, hyperkalemia, angio edema (allergic reaction involving swelling of the face/airways), renal insufficiency (when taking in high doses), & CANNOT be taken in combination with NSAIDs. 3) for patients who cannot tolerate Ace Inhibitors ->ARBs (angiotensin 2 receptor blockers). -> ARB/neprilysin inhibitor (valsartan/sacubitril or Entresto). - these 2 drugs work just like Ace inhibitors do! 4) Aldosterone Antagonists -> they block aldosterone & are potassium sparing diuretics. - Spironolactone (Aldactone) & Eplerenone (Inspra). 5) Beta Blockers -> directly block SNS, so it blocks epinephrine & norepinephrine. -> 3 beta blocks that have been shown to reduce mortality & improve ejection fraction..... 1) Metoprolol Succinate (Toprol XL) 2) Bisoprolol (Zebeta) 3) Carvedilol (Coreg) -> they reduce the contractility of the heart, so you want to start at a low dose & increase as tolerated. -> side effects: - fatigue. - depression. - if pt. has asthma/lung disease, they need to be careful because the non-selective beta blockers cause bronchiole restriction. 6) Vasodilators 1) Nitrates: -> decreases both preload & afterload. - directly dilates vessels. - dilates coronary arteries. - keep in mind that tolerance can develop. 7) Positive Inotropic Drugs 1) Digoxin: -> increases contractility. - decreases HR. - increases stroke volume (more blood is pumped out with each contraction). - reduces symptoms. - increases exercise tolerance. - no decrease in mortality. ---> there is a very narrow window between therapeutic range & toxicity, so we must monitor pt. closely. ----> one of the most common causes of digoxin toxicity is hypokalemia (so if pt. is taking digoxin with a thiazide or loop diuretic, they are at high risk for toxicity). ----> signs of Dig toxicity: - nausea/vomiting. - visual changes (yellow haze). - arrhythmias (especially bradyarrhythmias). - if pt. is taking Digoxin, you want to take their apical pulse for a full minute & if the apical pulse is below 60, you withhold the med & notify MD.
angina treatment:
1) determine the risk: --> is the pt. in a low risk or high risk category? Low Risk: - pt.s who usually have stable angina & show no EKG changes. - is usually treated with conservative treatment, such as drug therapy (meds that increase oxygen supply or decrease oxygen demand), continuous monitoring, & further testing (stress test). High Risk: - pt.s with unstable angina that is accelerating with more frequent episodes. - pt. may have vital sign changes, new heart murmurs, heart rhythm changes, they become hypotensive. - if pt. is over 75 or having arrhythmias. - if pt. has elevated cardiac enzymes. - we treat with re-vascularization (intervention or surgery to restore blood flow). - if the pt. comes to a hospital that does not have the means to re-vascularize, they may be treated with drug therapy such as a thrombolytic agent (powerful anticoagulant that dissolves blood clots). - can also do bypass surgery if it is warranted. - high risk calls for much more invasive treatments. 2) Nitrates: --> nitroglycerin; this has been the mainstay for angina drug treatment for years. - can be used to treat an acute episode of angina. - can also be used long term to prevent angina flare-ups. - nitroglycerin can be given via sublingual, IV, chewable, tablets, capsules, ointments, patches, or sprays. - it is a vasodilator, so if your pt. has taken Viagra (Sildenafil) or Tadalafil (Cialis), you need to be extremely careful giving nitroglycerin because it can cause a profound drop in blood pressure. - people on long term nitrates need to discontinue the use of NSAIDs because it can cause cardiac events. - store nitroglycerin in a light resistant bottle because it deteriorates when exposed to light. - pt. must get a new supply every 6-9 months; if the nitroglycerin is still good, it will cause a tingling sensation on the tongue. - store it in a dark, cool, dry place. - if applying nitrate patches or ointment, the nurse should apply it with gloves because it could cause a drop in BP or severe headaches if it gets on the skin. - if pt. is getting a nitrate patch, they will get it in the morning & have it removed before bed time, because using nitrates long term can cause your body to develop a tolerance (nitrate won't work as effectively) so having a nitrate free period while sleeping helps prevent this tolerance. how to give nitroglycerin ----> if pt. is having angina, make sure pt. is sitting or lying down since it is a vasodilator (will decrease BP), take pt.'s BP (will not give nitroglycerin if BP is below 90), give 1 sublingual of nitroglycerin (if it works, it will work in 3-5 mins, lasts 20-45 mins), ask pt. how they are feeling, if pain is not resolved take BP again & if it's okay, give another sublingual & wait 5 mins; may repeat one more time if pain is still not resolved. ---> RECAP : may give a total of 3 sublingual doses, 5 mins apart; if pain still not resolved, call 911. 3) in addition to nitrates, we can also use.... -> Anti-platelets = aspirin is first line of therapy for angina treatment because most of the time an MI is caused by platelets sticking to the areas of atherosclerosis & causing a blockage; does not reduce cardiac workload though; examples are clopidogrel (Plavix), prasugrel (Effient), ticagrelor (Brilinta). -> Beta Blockers = examples are metoprolol (lopressor), atenolol (tenormin), inderal; blocks the beta 1 receptors in the heart, which blocks the effects of the sympathetic nervous system so HR goes down & BP goes down, which decreases cardiac workload; some beta blockers also block the beta 2 receptors in the lungs causing bronchiole constriction (not good if pt. has asthma or any other breathing problems). "Selective" beta blockers only effect the beta 1 in the heart, "Non-Selective" beta blockers effect both the beta 1 in heart & beta 2 in lungs. -> Ace-Inhibitors = they work by inhibiting the effects of the renin angiotensin system, resulting in diuresis & vasodilation, which reduces cardiac workload. -> Calcium Channel Blockers = they slow the heart rate & reduce contractility & reduce BP, which all reduces cardiac workload. -> Statins = recommended for all angina pt.s unless there is a specific contraindication. ***all of these work by reducing the oxygen demand! 4) Percutaneous Coronary Intervention: -> these are the procedures that are done in the cardiac Cath lab: 1) Angioplasty (balloon dilation) = they insert a wire with a blood into the coronary artery & inflate the balloon to widen the artery. 2) Stent = about the size of a pen spring; it is inserted into the artery & helps to hold the artery open; becomes permanent because the epithelial cells grow into it and lock it into place, however if their is overgrowth of the epithelial cells sometimes the stent can actually become an occlusion itself. 5) Thrombolytics: - meds that will actually dissolve blood clots. 6) Coronary Artery Bypass Graft (CABG): - surgery is performed to create an actual bypass around the area of blockage. - usually done if there are multiple blockages or the blockages are in a tricky spot to treat. *** treating angina is all about balancing the supply & demand for oxygen! *** something to keep in mind, if nitroglycerin doesn't relieve angina pain, sometimes we can give morphine because it helps with the pain & is also a vasodilator!
How does the parasympathetic nervous system affect the heart?
1) it decreases the heart rate. *** it also causes vasodilation (decreases BP)!!
the 5 rights of delegation:
1. Right task 2. Right circumstance 3. Right person 4. Right communication 5. Right supervision
Ordered: Cardizem to run at 10 mg/hour. IV bag is mixed 100 mg in 100 ml. At what rate will you set the IV pump?
10 ml/hr
Match the medication to the effect on potassium levels:
Hydrochlorothiazide (Microzide) = hypokalemia Furosemide (Lasix) = hypokalemia Spironolactone (Aldactone) = hyperkalemia Lisinopril (Zestril) = hyperkalemia
The nurse is teaching a patient about modifying their risk factors for CAD. Which action would provide the greatest risk reduction? a. Manage psychological stress and adhere to treatment regimen for depression. b. Use dietary supplements with ephedrine to attain ideal body weight. c. Manage diabetes to achieve Hb A1C less than 8%. d. Maintain BP less than 120/80.
Maintain BP less than 120/80.
Which of the statements below is true concerning cell growth? a. All normal cells grow in number continuously b. Differentiation of cells is abnormal c. Normal cells have contact inhibition d. Only cells of the reproductive organs contain stem cells
Normal cells have contact inhibition.
What side effects could occur with thiazide diuretics? Select one or more: a. Dizziness b. Myalgia c. Hyperkalemia d. Hypokalemia e. Hyperglycemia f. Orthostatic hypotension
Orthostatic hypotension. Myalgia. Hyperglycemia. Dizziness. Hypokalemia.
250 ml NS with 25,000 units heparin is infusing at 1800 units/H. what is the rate (ml/H) for this drip?
Remember: units supplied = units/H desired mL supplied mL/H desired 25,000 = 1800 units/hour 250 X ml/hour 25,000X = 450,000 X = 18 ml/hour
what causes a blood clot to form?
Virchow's Triad = 3 things have to occur in order for a blood clot to develop..... 1) venous stasis (pt. is immobile for long time periods). 2) endothelial damage (trauma, IVs, broken bones, diabetes, sepsis, etc). 3) hypercoagulability (pt.'s coagulation system is on overdrive; occurs during sepsis, dehydration, pregnancy, etc).
Which lab value should be monitored when a patient is taking lovastatin (Mevacor)? a. Liver enzymes b. Troponin c. Serum K+ d. CBC
a. Liver enzymes
The insulin that has the most rapid onset of action would be: a. Lente b. Lispro c. Ultralente d. Humulin N
b) Lispro
which patient problem is a risk factor for deep vein thrombosis (DVT)? a) malnutrition. b) femur fracture. c) hypertension. d) rheumatoid arthritis.
b) femur fracture.
what is the highest priority nursing diagnosis for a patient with a hemorrhagic stroke? a) impaired physical mobility. b) impaired swallowing. c) disturbed thought processes. d) interrupted family processes.
b) impaired swallowing
The pt. has a potassium level of 5.7. Which med is most likely the cause? a) Furosemide (Lasix). b) Terazosin (Hytrin). c) Spironolactone (Aldactone). d) Amlodipine (Norvasc).
c) Spironolactone (Aldactone) *** lasix would drop pt.'s potassium!
What instructions should be given to a patient taking clonidine (catapres)? a. Advise patient not to take at bedtime b. Avoid grapefruit when taking this drug c. Do not stop taking unless instructed by physician d. Do not take this medication with ASA
c. Do not stop taking unless instructed by physician
Which sign or symptom would indicate that clopidogrel (Plavix) should not be given to your patient? a. Patient's blood pressure is 180/112 b. Patient's heart rate is 52 c. Patient reports dark tarry stools d. Patient complains of blurred vision
c. Patient reports dark tarry stools
chemotherapy effectiveness:
chemo would be most effective for..... - tumors with a rapid rate of proliferation. - smaller tumors. - younger tumors. - lung tumor (instead of brain tumor, bc chemo drugs would have to cross the blood-brain barrier). - cells that are more differentiated. - a patient with a positive attitude.
Novolog may be used as which components of the BBC (basal, bolus, corrective) model? a) Basal b) Meal Time c) Corrective d) Both B & C
d) Both B & C *** Novolog is a rapid-acting insulin.
My PACU patient is making loud snoring noises & their O2 sat is dropping. What should I do first? a) call the MD. b) administer oxygen by mask. c) give narcan. d) perform head tilt chin lift.
d) perform head tilt chin lift.
The nurse is teaching a patient with heart failure about lisinopril (Zestril). What statement by the patient indicates understanding of the teaching? a. "I will watch for swelling of my face and throat." b. "This drug can cause my blood pressure and potassium levels to go up." c. "I will take aspirin instead of ibuprofen for mild pain." d. "I will stop taking my water pill since this drug has the same effect."
"I will watch for swelling of my face and throat."
Your patient had a lumpectomy earlier today. She tells you that she is very worried about what will happen to her family if she has cancer. What is the best way for you to respond? a. "I will call the Chaplain for you to discuss your feelings with." b. "Tell me more about your concerns." c. "Don't worry, I am sure that you will be fine." d. "I will bring you some brochures about the cancer resources in your area."
"Tell me more about your concerns."
what pre-operative lab tests are routinely ordered?
- CBC (complete bood count) - BMP (basic metabolic panel) - urinalysis - possibly a pregnancy test - blood gas test (to see what their oxygenation is like) - chest x-ray or EKG - pulmonary function test *** EKG, chest x-ray, & incentive spirometer (checking tidal volume) are diagnostic tests!
what are the priorities during the intra-operative phase?
- OR safety measures: "time out" & fire safety. - the importances of aseptic technique. - the roles of the different team members involved in the OR.
the determinants of health:
- genes & biology = 10% - physical environment = 10% - clinical care = 10% - health behaviors = 30% - social & economic factors = 40%
chemo pt.s: pain control
--> we are not worried about addiction, but controlling pain. --> numerous drug options for pain control. --> long-acting opioids used for around-the-clock control. --> examples: - Morphine (MS Contin, Oramorph SR) q12h - Oxycodone (OxyContin) q12h - Hydromorphone (Palladone) q24h - Fentanyl (transdermal) (Duragesic) q48-72 h
Ordered: Glucagon 0.75 mg IM. Supplied: Glucagon 0.5 mg/0.2ml. How many ml will you administer? (round to the hundredths place and include only numbers and decimals in your answer)
0.3 *** Rationale = 0.75 mg /0.5 mg = x/0.2 ml 0.5x = 0.15 x = 0.15/ 0.5 x = 0.3 ml
The patient is receiving Dilaudid PCA with no continuous rate and a demand dose of 0.4mg. The lockout is 15 minutes. How much Dilaudid is the maximum that this patient can receive in 1 hour? (Include only numbers in your response)
0.4 mg x (60 minutes/15 minutes)= 0.4 x 4= 1.6 mg Answer is 1.6
case study example: 1) Pt. arrives in the ED with slurred speech & weakness of her left arm & leg. What is the first question you will ask them? 2) Pt. states her symptoms were present upon waking up this morning. Is the pt. a candidate for thrombolytic therapy?
1 When did this start happening? 2) No, unless you can narrow that time window down; but if you can't, she won't be a candidate.
Match the patient description with the most probable diagnosis:
1) A patient with edema and tenderness of the right lower leg. → Venous thromboembolism 2) A patient with numbness of the toes and shiny, taut skin with no hair on the lower legs. → Peripheral arterial disease 3) A patient with large, bulging blood vessels visible on the lower legs. → Varicose veins 4) A patient with leathery, brown skin and edema of the lower legs. → Chronic venous insufficiency 5) A 35 year old patient with pain in the lower extremities with walking. → Buerger's disease 6) A patient who states her fingers turn blue frequently. → Raynaud's phenomenon
Put the treatments for osteoarthritis in order, beginning with typical initial therapy.
1) Acetaminophen 2) NSAIDs 3) Intraarticular corticosteroids 4) Joint replacement surgery
classifications of heart failure:
1) Left-Sided -> when the left ventricle is not working correctly (left ventricle is what pumps blood to the rest of the body). -> more common than right-sided hf; left-sided hf will eventually lead to right-sided hf. -> it could be a systolic or diastolic problem... Systolic problem = inability of the heart to pump/squeeze effectively. Diastolic problem = inability of the ventricles to relax during diastole; ventricle cannot relax & fill with blood because the ventricle is so stiff. -> you can have both a Mixed Systolic & Diastolic failure! - seen in pt.s with dilated cardiomyopathy. - poor systolic function / weak muscle = poor ejection fraction. - dilated left ventricular walls that are unable to relax = poor filling capacity. 2) Right-Sided -> when the right ventricle is not pumping correctly. -> can be caused by........ - could be a problem with the right ventricle itself. - can be caused by left-sided hf (left-sided hf causes increased pressure to the pulmonary vasculature, & the right ventricle pumps blood to the pulmonary vasculature; so right ventricle has to try to work against increased pressure, & overtime it cannot keep up with the workload). - could be caused by right ventricular MI. - could be caused by pulmonary issues where there is increased pressure in the lungs & that causes direct right-sided hf.
types of medications that are used for PCA:
1) Morphine Sulfate: -> 1 mg/ml in 30 cc NS = 30mg 2) Fentanyl: -> 10 mcg/ml in 30 cc NS = 300 mcg 3) Dilaudid: -> 0.2 mg/ml in 30 cc NS = 6 mg ***always have Narcan available!
How does the sympathetic nervous system affect the heart?
1) increases the heart rate. 2) speeds rate of conduction of impulses. 3) increases force of contraction of ventricles. *** it also causes vasoconstriction (increases BP)!!
after a patient has a stroke, we need to....
1) manage hypertension = hypertension is a risk factor for stroke, but it is also the body's defense mechanism after a stroke, because the blood is trying to be pumped through the brain adequately & efficiently; so after a stroke, a pt.'s BP may be high for that reason, & that is okay. 2) avoid hyperthermia = an elevated temperature increases cerebral metabolism, & we do not want the brain to be working harder. 3) avoid hyperglycemia = having high blood sugars will make cerebral ischemia worse.
Nonpharmacologic therapies for HF pt.s:
1) oxygen therapy: -> o2 saturation in the blood is decreased because of the impaired gas exchange happening in the lungs. 2) controlling precipitating & complicating factors: -> preventing pt.s from getting the flu/pneumonia, so having pt.s getting their vaccines. 3) rest: -> ability to exercise depends on the severity of the hf. -> cardiac rehab programs. 4) CardioMems system: -> device that is implanted into pt.'s pulmonary artery, & the device sends data to the Dr. so that we can prevent exacerbation of hf or the worsening of hf.
arterial disorders: complications
1) skin atrophies 2) ischemic ulcers - usually in the lower leg & ankle areas. - very hard to heal, because there isn't good blood flow. - leaves skin dark & discolored from ulcer.
case study example question: The nurse administers regular insulin 5 units & Humulin N 15 units at 7:30am. 1) When should the nurse assess the pt. for hypoglycemia? 2) What could the pt. do to prevent hypoglycemia?
1) the regular will start to peak in 2 hours, so we need to start monitoring at 9:30am; the NPH starts to peak in 4 hours, so we would monitor the pt. again at 11:30am. 2) the pt. should eat!!
what are the nursing roles for cancer pt.s?
1) to decrease risks (if pt. is predisposed to melanoma, encourage pt. to wear sunscreen; encourage pt. to get lung screenings if lung cancer runs in family; etc). 2) help with compliance (help pt.s to stay dedicated to their cancer treatments/taking medications/etc). 3) to provide support (a pt. hearing their diagnosis for the first time will be devastated, & will be so anxious & scared & will have lots of questions). 4) to teach (pt.s will have so many questions about their treatments/diagnosis).
The nurse who is beginning a shift on a cardiac telemetry unit is assigned four patients. Prioritize the order, from most urgent to least urgent, in which the nurse should assess the patients.
1. A 68 year old patient who had a coronary stent placed yesterday and has developed new-onset atrial fibrillation with rapid ventricular response. 2. A 42 year old patient who had a mitral valve replacement two days ago. BP 120/78, HR 112, RR 28, and Temperature 101.2. 3. A 54 year old patient admitted with angina receiving intravenous heparin and has a partial thromboplastin time (PTT) due back in 30 minutes. 4. A 62 year old patient admitted with unstable angina who is scheduled for stent placement this morning.
various reasons surgery may be performed:
1. diagnosis (maybe trying to figure out if a patient has a tumor). 2. cure (removing a tumor or clearing an obstruction). 3. palliation (relieving symptoms; the whole tumor can't be removed, but part of it can be removed & will provide some pain relief). 4. prevention (pt. has a suspicious mole so it's removed in order to prevent it from becoming cancerous). 5. cosmetic improvement (nose jobs, boob jobs, etc). 6. exploration (we don't know what we'll find during surgery, but we are trying to find the cause of a problem).
Ordered: Trulicity 1.4 mg SC. Supplied: Trulicity 2mg/2ml. How many ml will you administer? (round to the tenth place and include only numbers and decimals in your answer)
1.4 *** Rationale = 1.4 mg/ 2 mg = x/ 2 ml 2x = 2.8 x = 2.8/2 x = 1.4 ml
Ordered: Labetalol 70 mg IV push. Supplied: Labetalol 5 mg/ 1 ml, 20 ml vial. How many ml will you administer?
14 ml
Ordered: Tissue Plasminogen Activator 50 mg IVPB over 40 minutes. Supplied: Tissue Plasminogen Activator 20 mg/ml, 10 ml vial. How many ml will you need to add to IV bag to administer dose? (round to the tenth place and include only numbers and decimals in your answer)
2.5
Ordered: Nafcillin sodium 1 Gm to infuse over 20 minutes. Supplied: Nafcillin sodium 1 Gm/100 ml NS. At what rate will you set the infusion pump? (round to a whole number)
300 ml/hr ***the math explained.... --> 100 ml/20 min = x ml/hr / 60 mins --> 20x = 6000 --> x = 300 OR --> 60 mins / 20 mins = 3 --> 3 x 100ml = 300 ml
The MD has ordered a Lasix drip to run at 8 mg/hour. The pharmacy supplies an IV bag that is mixed Lasix 125 mg/100 ml. At what rate (ml/hour) will you set the IV pump? (Round to the nearest tenth and include only numbers and a decimal in your answer).
6.4
A patient with a recent diagnosis of heart failure has been prescribed furosemide (Lasix) in an effort to physiologically do what for the patient? A) Reduce preload. B) Decrease afterload. C) Increase contractility. D) Promote vasodilation.
A) Reduce preload.
What is the most common cause of hypertensive crisis? A. Cocaine or crack use B. Uncontrolled diabetes C. Abruptly stopping medications D. End-stage renal failure
Abruptly stopping medications.
managing arrhythmias:
Atrial Arrhythmias (Afib) -> Pharmacologic: - anticoagulants. - antiarrhythmics. -> Electricity: - cardioversion (times/synchronous defibrillation). - CRT (Pacemaker). -> Interventional: - ablation (they zap/kill the cells that are causing the arrhythmia). Ventricular Arrhythmias (VT/VF) -> if pt.'s ejection fraction is < 35%, they are at high risk for sudden cardiac death; Implantable Cardioverter Defibrillator (ICD) is recommended. -> if pt.'s left & right ventricles are not synchronized, CRT is recommended.
The nurse would be alerted to the occurrence of malignant hyperthermia when the patient demonstrates what manifestation? A. Hypocapnia B. Muscle rigidity C. Decreased body temperature D. Confusion upon arousal from anesthesia
B. Muscle rigidity
The nurse is caring for a patient 3 days post MI. The patient states "I'm so tired, much more than yesterday." Assessment findings include dyspnea with exertion, heart rate 116, RR 28, and BP 172/94. Generalized edema is present. Which action by the nurse is most appropriate? a. Administer one sublingual nitroglycerin b. Compare the admission and current weight c. Advise the patient to reduce the amount of activity for today d. Administer oxygen via mask
Compare the admission and current weight.
What are the normal effects of aging on the cardiovascular system? select all that apply. a. Slowed response to stress b. Decreased heart rate c. Systolic murmer d. Decreased blood pressure e. Distant heart sounds f. Increased heart rate g. More rapid response to stress h. Increased blood pressure
Decreased heart rate. Increased blood pressure. Distant heart sounds. Systolic murmer. Slowed response to stress.
What are the beneficial effects of diuretics for patients with heart failure? a. Increases preload, thus improving ventricular function b. Increases myocardial contractility c. Decrease afterload, thus reducing cardiac workload d. Decreases preload, thus improving ventricular function
Decreases preload, thus improving ventricular function.
Casts: ambulation
Degree of weight bearing ambulation: - non-weight bearing (NWB). - partial weight-bearing (toe-touch, or touch down WB; can put foot on the floor to help with balance but can't really out weight on it). - full weight-bearing (FWB). Assistive devices: - cane: use it on strong side. - crutches: it is important to have two fingers' space between top of crutch & Axilla to prevent brachial nerve injury; teach pt. to put weight on their hands instead of armpit. - walker: teach pt. to take small steps.
teaching pt. signs/symptoms of HF exacerbations:
Fatigue Activity limitations. Chest congestion/cough. Edema. Shortness of breath. *** teach pt. that if they experience any of these symptoms, they need to call MD because their hf may be worsening.
Factor Xa inhibitors:
Indications... - used for VTE prophylaxis & treatment. * coagulation monitoring is not needed with these!!! 1) Fondaparinux (Arixtra) = given SQ 2) Rivaroxaban (Xarelto) = given oral 3) Apixaban (Eliquix) = given oral
Your neighbor shows you a mole about the size of a quarter on her neck. It is almost black in color with an irregular border. What advise would you give her? a. Advise her that she will probably need chemotherapy. b. She should schedule an appointment with her physician as soon as possible. c. She should have it removed if it starts to grow. d. Advise her to apply sunscreen to the area when she goes outside.
She should schedule an appointment with her physician as soon as possible.
Medications: 1. Hydrochlorothiazide (HCTZ; a thiazide diuretic; blood pressure med) 2. Fish Oil 3. Motrin 4. Alcohol (ETOH) 5. Coumadin 6. Metformin 7. Plavix 8. Insulin 9. Ginseng 10. Prednisone
Side effects that could occur during surgery if pt. is taking that specific medication: 1. increased blood pressure. 2. increased risk of bleeding. 3. increased risk of bleeding. 4. withdrawal symptoms during post-op period; increased risk of bleeding (alcohol affects liver which it where clotting factors are made). 5. increased risk of bleeding. 6. hypo or hyperglycemia. 7. increased risk of bleeding. 8. hypo or hyperglycemia. 9. increased blood pressure. 10. decreased wound healing.
the process of cancer development:
Stage 1: Initiation - a mutation in a cell's genetic structure (DNA) occurs. -> only 5% of cancers are inherited within the pt.'s cell. -> the other 95% of cancers are acquired damage to our cells that happens during our lifetime. - if we have an abnormal cell & the immune system does not repair/kill it, that abnormal cell could grow into abnormal daughter cells, which continue to grow & grow into a tumor. Stage 2: Promotion - this is the phase where we may be doing certain things that are actually encouraging the growth of the cancer. - in this phase, we can REVERSE the proliferation of the altered cells so that the cancer does not develop & become a problem for us!!! - up to 1/3 of all cancers can be prevented if we fix the factors that contribute to cancer development. ---> Promoting Agents: 1) dietary fat (a high fat diet increases risk for breast cancer & gallbladder cancer; a low fiber diet increases risk for colon cancer; low protein diet helps cancers grow; foods in the cabbage family decrease the chance of cancer). 2) obesity. 3) alcohol consumption (too much alcohol increases chances for oral, esophageal, & liver cancer; alcohol & smoking increases chances for neck, esophageal, & bladder cancer). 4) cigarette smoking (a complete carcinogen; capable of initiating abnormal changes within the cell AS WELL AS promote the growth of the cancer). *** there is a long latent period regarding these promoting agents; you may be partaking in these habits for years & years & be fine - but it may take a long time for the cancer to develop from these habits; you have to have up to a million cancer cells before a tumor is detected. Stage 3: Progression - the final stage of cancer development. - during this stage, there is increased growth of the tumor, & invasiveness/metastasis. -> invasiveness = the cancer grows into other tissues at its specific site. -> metastasis = the cancer can move to & grow in another site; certain cancers have an affinity of where it likes to metastasize to (colon cancer -> the liver). - the most common areas that cancers metastasize to are the brain, bone, lung, & liver. -> tumors can go through angiogenesis (tumor develops its own blood supply).
Tumor/Lymph Node/Metastasis (TNM) classification system:
T0 = no sign of primary tumor. T-is = carcinoma in situ. T1-4 = increase in tumor size/involvement. Tx = cannot measure (tumor too severe). N0 = no disease in lymph nodes. N1-4 = lymph node involvement. Nx = unable to assess lymph nodes (disease too severe). M0 = no evidence of metastasis. M1-4 = increase in metastasis. Mx = cannot be determined (metastasis too severe).
Which of the following are appropriate nursing considerations related to the administration of potassium-sparing diuretics? select one or more. a. Teach patient to avoid potassium-rich foods. b. Use with caution in patients on ACE inhibitors. c. Contraindicated in patients with renal failure. d. Encourage the consumption of potassium-rich foods. e. Effective in patients with renal insufficiency.
Teach patient to avoid potassium-rich foods. Contraindicated in patients with renal failure. Use with caution in patients on ACE inhibitors.
True or False: A patient recovering from surgical repair of a hip fracture should not be allowed to sit on the toilet.
True
Which statement by the pt. with peripheral arterial disease indicates understanding of their treatment plan? a) "it is important I quit smoking." b) "a walking program would be beneficial in treatment of my PAD." c) "to prevent my feet from getting too cold, I will use a heating pad." d) "I can continue getting a pedicure at the salon weekly."
a) "it is important I quit smoking." b) "a walking program would be beneficial in treatment of my PAD." *** if the pt. does not have good sensation, they should not use a heating pad because they can burn themselves. *** pt. should not get a pedicure because they are at increased risk for infection, since their extremity blood flow is so limited.
A patient with diabetes is on a basal/bolus/corrective insulin regimen. What is the appropriate action for the nurse to take when the patient is NPO for a procedure? a. Administer the corrective and basal doses. b. Hold all insulin doses until the patient returns from the procedure. c. Administer only the corrective doses. d. Administer the corrective and bolus doses.
a) Administer the corrective and basal doses.
A patient with chronic peripheral arterial disease is prescribed cilostazol (Pletal). What are the expected actions of this medication? (Select all that apply) a. Antiplatelet b. Vasodilation c. Pain relief d. Increased blood viscosity
a) Antiplatelet b) Vasodilation c) Pain relief
What is a cause of secondary hypertension? select all that apply. a) aortic stenosis. b) Crohn's disease. c) brain tumors. d) angina.
a) aortic stenosis c) brain tumors
The surgical unit nurse has just received a patient with a history of smoking from the postanesthesia care unit. Which action is most important at this time? a. Auscultate for adventitious breath sounds. b. Check the patient's allergies to inhalation agents. c. Remind the patient about harmful effects of smoking d. Ask the health care provider about prescribing a nicotine patch.
a. Auscultate for adventitious breath sounds (Priority for this patient as her respiratory status may be compromised due to the history of smoking).
Which medication can be substituted if a patient is allergic to Aspirin? a. Clopidogrel (Plavix) b. Enoxaparin (Lovenox) c. Enalapril (Vasotec) d. Nifedipine (Procardia)
a. Clopidogrel (Plavix)
The nurse is assessing a patient who has been prescribed atorvastatin (Lipitor). What are the expected therapeutic effects of this medication? a. Decreased LDL b. Decreased HDL c. Muscle weakness d. Decreased episodes of angina
a. Decreased LDL
Your patient has a K+ of 2.9. Which medication is mostly likely the cause of this result? a. Furosemide (Lasix) b. Spironolactone (Aldactone) c. Atenolol (Tenormin) d. Enalapril (Vasotec)
a. Furosemide (Lasix)
What characteristics are typical of Rheumatoid arthritis? select all that apply. a. Peak incidence is between ages 30 and 50 b. Joint pain is the primary symptom c. Joint symptoms usually occur bilaterally d. Is an autoimmune, inflammatory disease
a. Peak incidence is between ages 30 and 50 c. Joint symptoms usually occur bilaterally d. Is an autoimmune, inflammatory disease
The nurse is teaching the patient who has a lower leg plaster of Paris cast. Which self-care instructions should the nurse include? select all that apply. a. Regularly move joints above and below the cast b. Use hair dryer on cool setting to relieve itching under the cast c. Sprinkle powder in the cast to decrease moisture from sweating d. Ice may be applied if placed in a plastic bag so that the cast does not get wet
a. Regularly move joints above and below the cast. b. Use hair dryer on cool setting to relieve itching under the cast. d. Ice may be applied if placed in a plastic bag so that the cast does not get wet.
what signs & symptoms would indicate the pt. may be experiencing peripheral arterial disease? a) "If I stand or sit too long, my legs start to feel heavy & achy." b) "it hurts to elevate my legs." c) "I often have to dangle my leg out of the bed to ease the pain." d) "when I'm walking, my legs start to cramp & I can't walk any further."
b) "it hurts to elevate my legs." c) "I often have to dangle my leg out of the bed to ease the pain." d) "when I'm walking, my legs start to cramp & I can't walk any further." *** pain when sitting or standing too long is about the venous return problem, when the blood is having a hard time flowing back up.
The nurse is reviewing the laboratory test results for a 68-yr-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. On postoperative day 2, the international normalized ratio (INR) result is 2.7. Which action by the nurse is most appropriate? a) Hold the daily dose of warfarin. b) Administer the daily dose of warfarin. c) Teach the patient signs and symptoms of bleeding. d) Call the physician to request an increased dose of warfarin.
b) Administer the daily dose of warfarin.
A nurse calls a physician with the concern that a pt. has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed? a) the pt. is somnolent with decreased response to the family. b) the pt. suddenly complains of chest pain & shortness of breath. c) the pt. has developed a wet cough & the nurse hears crackles on auscultation of the lungs. d) the pt. has a fever, chills, & loss of appetite.
b) the pt. suddenly complains of chest pain & shortness of breath.
A patient has recently been prescribed Clonidine (Catapress). What teaching should you provide? a) they should stop the drug if they have drowsiness. b) they should not stop taking the drug abruptly. c) they should avoid leafy green vegetables. d) they should take the first dose at bedtime.
b) they should not stop taking the drug abruptly.
Which laboratory findings are indicative of a myocardial infarction? select all that apply. a. Elevated serum creatinine b. Elevated CK-MB c. Elevated Troponin d. Elevated platelet count e. Elevated BUN
b. Elevated CK-MB c. Elevated Troponin
With peripheral arterial insufficiency, leg pain during rest can be reduced by: a. Elevating the limb b. Lowering the limb so it is dependent c. Massaging the limb d. Applying a cold compress
b. Lowering the limb so it is dependent *** arterial is when there is a problem with the blood getting to the extremities, so lowering the leg allows gravity to help get the blood out to the extremities.
Which medication should not be used for a patient with a history of depression? a. Spironolactone (Aldactone) b. Metoprolol (Lopressor) c. Doxazosin (Cardura) d. Amlodipine (Norvasc)
b. Metoprolol (Lopressor)
A 38-year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? a. The patient's lack of knowledge about postoperative pain control measures b. The patient's statement that her last menstrual period was 8 weeks previously c. The patient's history of a postoperative infection following a prior cholecystectomy d. The patient's concern that she will be unable to care for her children postoperatively
b. The patient's statement that her last menstrual period was 8 weeks previously
A laminectomy and spinal fusion are performed on a patient with a herniated lumbar intervertebral disc. During the postoperative period, which finding is of most concern to the nurse? a. Paralytic ileus. b. Urinary incontinence. c. Greater pain at the graft site than at the lumbar incision site. d. Leg and arm movement and sensation unchanged from preoperative status.
b. Urinary incontinence.
the effects on the body from left-sided heart failure:
backward effects: fluid overload in the lungs -> left ventricle is not ejecting blood out to the body; so the blood starts to back up from the left ventricle into the left atrium, & then into the pulmonary blood vessels; so there is now excess blood & excess pressure in the pulmonary vessels, that then backs into the pulmonary capillaries; with all the excess pressure, the serous fluid actually oozes out of the pulmonary capillaries & surrounds the alveoli; if the alveoli are surrounded by fluid, this causes impaired gas exchange & creates pulmonary problems. forward effects: decreased cardiac output -> the left ventricle is not getting blood out to the rest of the body like it is supposed to, which causes a decreased cardiac output; so all the tissues in the body will have decreased perfusion.
A patient is started on alendronate (Fosamax) once weekly for the treatment of osteoporosis. The nurse determines that the pt. understands the instruction about the drug when the pt. says.... a) "I should taker the drug with a meal to prevent stomach irritation." b) "this drug will cause new bone growth to increase my bone density." c) "I need to sit or stand upright for at least 30 mins after taking the drug." d) "I will be able to stop taking my calcium supplements while taking this new drug."
c) "I need to sit or stand upright for at least 30 mins after taking the drug."
A patient with Type 1 diabetes is NPO for a procedure. The patient's blood sugar is currently 176. The current insulin orders are shown below. What would be the most appropriate action for the nurse to take? Lantus 18 units sub q at 9 am. Humalog Insulin 5 units at mealtimes. Humalog Insulin per high dose sliding scale. **** refer to picture **** a. Hold all insulins until after procedure is completed. b. Administer Lantus insulin only. c. Administer Lantus and Sliding scale dose of Humalog. d. Administer half of all insulins ordered since patient is NPO.
c) Administer Lantus and Sliding scale dose of Humalog. *** When a patient is NPO the corrective and the basal insulins should still be given. The only insulin that should be held is the meal time dose of insulin since the patient is not going to have a meal.
The patient developed gout while hospitalized for a heart attack. Because the patient takes aspirin for its antiplatelet effect, what should the nurse recommend in preventing future attacks of gout? a) Limited fluid intake. b) Administration of colchicine (Colcrys). c) Administration of allopurinol (Zyloprim). d) dministration of nonsteroidal antiinflammatory drugs (NSAIDS).
c) Administration of allopurinol (Zyloprim).
A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't have a fever." Which action should the nurse take? a. Document that the aspirin was refused by the patient. b. Tell the patient that the aspirin is used to prevent a fever. c. Explain that the aspirin is ordered to decrease stroke risk. d. Call the health care provider to clarify the medication order.
c) Explain that the aspirin is ordered to decrease stroke risk.
A patient has an order for aspirin 325 mg daily. What is the purpose of this medication? a) need more info about patient to determine. b) prophylactic pain management. c) platelet inhibitor. d) prevent GI bleeding.
c) platelet inhibitor.
Which of the following tasks should Amy, the LPN, not be permitted to do during her shift according to her scope of practice? a) delegate checking vital signs to a UAP. d) reinforce incentive spirometry teaching taught by the RN on the previous shift. c) precept a new graduate RN who recently started on the unit. d) adjusting the rate of IV fluids.
c) precept a new graduate RN who recently started on the unit.
What position is best for a patient who is recovering from a left BKA? a) left leg elevated on pillow while in bed. b) reverse Trendelenburg. c) prone for at least 30 minutes four times a day. d) any position that provides pain relief.
c) prone for at least 30 minutes four times a day.
hypertension can cause which complication? a) liver cirrhosis. b) cataracts. c) renal failure. d) memory loss.
c) renal failure
The nurse asks another nurse who didn't hear shift change report to double check a pt.'s BP, as it's been erratic all day. The nurse measures the BP in the left arm, which has an arteriovenous shunt. Which "right" of delegation did the nurse violate? a) right task b) right person c) right communication d) right circumstance e) right supervision
c) right communication
A pt. who has hemianopia is at risk for injury. How can you educate the pt. to prevent injury? a) wearing anti-embolism stockings daily. b) consume soft foods & tuck in chin while swallowing. c) scanning the room from side to side frequently when walking. d) muscle training.
c) scanning the room from side to side frequently when walking. *** hemianopia affects a person's field of vision.
Which topic is most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy? a. Care for the surgical incision b. Medications used during surgery c. Deep breathing and coughing techniques d. Oral antibiotic therapy after discharge home
c. Deep breathing and coughing techniques
The nurse is teaching a patient with angina about the proper use of nitroglycerin (NTG). What information should the nurse include? select one or more. a. You may take a nitroglycerin every five minutes for a total of five doses. b. If the symptoms do not resolve completely with nitroglycerin, call 911. c. If symptoms of angina occur, sit down and place one NTG tablet under your tongue. d. If the nitroglycerin tablet causes a tingling sensation, it is outdated.
c. If symptoms of angina occur, sit down and place one NTG tablet under your tongue. b. If the symptoms do not resolve completely with nitroglycerin, call 911.
What instructions should the nurse provide to the patient that is prescribed NTG? a. Continue normal activity after taking NTG b. Call 911 if chest pain is not relieved after 1 NTG tablet c. Keep the tablets in their original bottle d. Remove NTG patches at bedtime
c. Keep the tablets in their original bottle d. Remove NTG patches at bedtime
A patient has been hospitalized with a femur fracture. What intervention is most important in preventing a fat embolism? a. Early ambulation and/or frequent range of motion exercises b. Administration of prophylactic anticoagulants c. Maintaining immobilization of the fractured extremity d. Encourage coughing and deep breathing and give supplemental oxygen as ordered
c. Maintaining immobilization of the fractured extremity
The nurse assesses that the oxygen saturation is 89% in an unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago. Which action should the nurse take first? a) Suction the patient's mouth. b. Increase the oxygen flow rate. c. Perform the jaw-thrust maneuver. d. Elevate the patient's head on two pillows.
c. Perform the jaw-thrust maneuver.
nutrition therapy: patient education
carbs -> 1 serving size is 15 grams. - typically recommended that pt. consumes 45-60 grams per meal. - pt.'s insulin bolus dose is based off of the number of carbs being consumed for that meal. - teach about exchange lists! meal planning - timing (med administration in relation to meals). - pt.s should measure portions. - fat-free foods should be cautioned (often have more sugar). - consume high fiber (fiber slows down the digestion process, which causes blood glucose to rise more slowly). - avoid concentrated sugars (basically anything that tastes sweet; candy, cookies, ready, cake, etc). 1 gram of carbs portion size examples: - 1/2 cup of cooked beans, peas, corn, mashed/boiled potatoes. - 3/4 cup cereal. - 1 slice of bread, 1/4 of a bagel, 1/3 cup cooked rice or pasta. - fruits: small banana, apple, or orange. - milk: 1 cup skim, whole, or 2% milk. a diabetic pt.'s meal plate should include.... -> half the plate should be non-starchy veggies (broccoli, cabbage, salad). -> 1/4 of the plate can be starch/bread. -> 1/4 of the plate can be meat/other protein. ***** this is based on a 9 inch plate!!!
A post-surgical patient refuses to get up and walk. What rationale should the nurse explain to the patient for early ambulation? a) "early walking keeps your legs limber and stronger." b) "early ambulation will help you be ready to go home." c) "early ambulation will help you get rid of your syncope & pain." d) "early walking is the best way to prevent postoperative complications."
d) "early walking is the best way to prevent postoperative complications."
A patient who has begun to awaken after 30 minutes in the postanesthesia care unit (PACU) is restless and shouting at the nurse. Blood pressure and heart rate are elevated , and recent laboratory results are all normal. Which action by the nurse is most appropriate? a) Increase the IV fluid rate. b) Assess for bladder distention. c) Notify the anesthesia care provider (ACP). d) Assess oxygen saturation.
d) Assess oxygen saturation.
The LPN delegates the task of taking vital signs of all the pt.s on the med-surg unit to a UAP. Specific written and verbal instructions are given to not take a post-mastectomy pt.'s BP on the left arm. Later as the RN is making rounds, the nurse finds the BP cuff on that pt.'s left arm. Which of these statements is most accurate? a) the RN has no accountability for this situation. b) the RN did not delegate appropriately. c) the UAP is covered by the RN's license. d) the UAP is responsible for following instructions.
d) the UAP is responsible for following instructions.
The nurse interviews a patient scheduled to undergo general anesthesia for a hernia repair. Which medication history is most important to communicate to the surgeon and anesthesiologist before surgery? Select one or more. a) the patient takes Tylenol as needed for headaches. b) the patient takes baby aspirin daily but stopped taking aspirin 10 days ago. c) the patient is prescribed NTG as needed for chest pain. d) the patient has just started taking Coumadin one week ago.
d) the patient has just started taking Coumadin one week ago.
A patient is starting on Digoxin & Lasix. What instructions should you provide them? a) they should restrict potassium rich foods in their diet. b) they should weigh themselves monthly. c) they should increase their fluids to 10 glasses a day. d) they should notify their doctor about visual changes.
d) they should notify their doctor about visual changes.
A patient reports that he experiences nausea and vomiting before he arrives at the clinic for his chemotherapy administration. What would be the best response by the nurse? a. Instruct the patient to eat a high fiber diet. b. Encourage the patient to only have a yogurt for breakfast when receiving chemotherapy. c. Advise the patient to see a psychologist for their symptoms. d. Ask the physician to order an antiemetic for the patient to take an hour before the appointment.
d. Ask the physician to order an antiemetic for the patient to take an hour before the appointment.
The nurse is preparing a patient for discharge after a right below the knee amputation. What teaching should the nurse include? select all that apply. a. Elevate the residual limb on a pillow above heart level when resting b. If irritation develops under the prosthesis, pad the area with cotton gauze c. Change and launder the residual limb sock weekly d. Lie in the prone position with hip fully extended for 30 minutes three times a day
d. Lie in the prone position with hip fully extended for 30 minutes three times a day
A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia. While in the post-anesthesia care unit (PACU), what assessment finding is most important for the nurse to report? a. Lethargy b. Complaint of nausea c. Disorientation to time d. Weak chest movement
d. Weak chest movement
what is the difference between delegation & assignment?
delegation = "transferring to a competent individual the authority to perform an activity. The delegator still retains accountability for the delegation." assignment = "designating responsibility for implementation of a specific activity or set of activities to a person licensed and competent to perform such activities."
diabetes: nursing implementations
health promotion: - identify, monitor, & teach pt.s at risk. - obesity = primary risk factor. - routine screening for all overweight adults, & those older than 45. - diabetes risk test.
how do we diagnose coronary artery disease?
lab tests: 1) Cardiac Enzymes (enzymes that are released from damaged or dead heart muscle cells; if these enzymes are elevated, that is evidence that pt. has had a heart attack). -> 2 kinds of enzymes..... 1) Troponin (specific to cardiac muscle cells, so if it's elevated, it's evidence that pt. is having or has had an MI). 2) CK with isoenzyme of MB (your total CK can be elevated by both cardiac & skeletal muscle cell damage, so if total CK is elevated, they will check for the specific type of CK with isoenzyme of MB, which is only released by heart muscle cells). -> so if pt. has both of these specific enzymes, it is evidence that the pt. has had an actual MI because these enzymes are released by heart muscle cells as they die. -> these enzyme levels are only valuable in the acute phase, as they rise rapidly & are back to normal levels within a number of hours. 2) Lipid Levels 1) cholesterol. 2) LDL. 3) HDL. 4) Triglycerides. Chest x-ray: - we can't see the arteries in an x-ray, but we can tell if the heart is enlarged or if the lungs have fluid in them (which is a sign of heart failure). EKG: - on the 12th lead EKG, we can see if there are signs of myocardial ischemia, if the pt. is having a current MI, or if the pt. has had an MI in the past (all the signs are different for each scenario). - we can find evidence of CAD through an EKG (we look for signs of ischemia!!). -> stress test (pt. wears an EKG & then begins to exercise until their heart rate reaches a certain point & we monitor for signs of ischemia; sometimes pt. may be getting adequate blood flow to the heart during periods of rest, but not during periods of stress).......if pt. cannot exercise, we can give them meds to elevate their HR to mimimic the stress test effects! Nuclear Imaging: - a radioactive material is injected into the heart muscle, and if a certain part of the heart muscle has been damaged, it will take up that material differently than the normal heart muscle parts. - ischemic areas will light up on the imaging screen. - you can see ischemia or if the pt. has had an MI, but you cannot see the actual coronary arteries. Echocardiogram: - an ultrasound that will show us the structure & function; we can see chambers/ventricles of the heart, & we can see if they are functioning properly. - we can measure the pt.'s ejection fraction (amount of blood ejected from the ventricle with each beat). - you can also do a stress echocardiogram!!! - we cannot see coronary arteries though. Coronary Angiography: - also know as cardiac catheterization. - basically an IV is threaded through an artery all the way into the heart, & we inject dye into there, which allows us to see areas of blockage/occlusion within the coronary arteries. - this is done using fluoroscopy the entire time. nursing considerations............... --> you would need to ask the pt. if they are allergic to x-ray dye or if they are allergic to shellfish (dye is iodine based). --> inform pt. they will not be put to sleep for the procedure but they will be medicated with pain meds, & that the dye can make them feel as if they are having a hot flash. --> if pt. is allergic to shellfish, they can still have the procedure, but the Dr. may medicate them with steroids/Benadryl & use a lesser amount of dye or a different kind of dye. -----> after the procedure, we want to monitor pt. vital signs because we are concerned about bleeding potential, & monitor the site (palpate the site because if we feel a hard knot that keeps growing, it is a hematoma so we need to call Dr. right away. We also want to do a neurovascular assessment & check the purses distal to that site to ensure proper circulation. We want to follow any position restrictions (femoral site, cannot bend knee or raise head of bed). We need to keep pt. hydrated, because the dye is excreted through the kidneys & if the pt. doesn't excrete out all that dye, it can cause acute renal failure.
Stroke: Clinical Manifestations
neuromotor function ---> the muscles go through a period of flaccidity, followed by spasticity.... - affects mobility & the ability to squeeze hand muscles. - respiration is affected because of the diaphragm/intercostal muscles. - affects swallowing & speech because of the facial muscles. - affects the gag reflex. - overall, self-care abilities are affected. communication ---> most common with left-sided stroke patients. -> Global Aphasia = total loss of comprehension & use of language. -> Dysphasia (or "aphasia") = partial disruption of comprehension or use of language; Receptive Dysphasia = loss of understanding of speech & Expressive Dysphasia = loss of ability to express speech. -> Dysarthria = disturbance in muscular control of speech. affect ---> emotions may become exaggerated or unpredictable. - pt. may suffer depression related to changes in body image & loss of function. intellectual function - stroke can affect memory & judgement. spatial-perceptual alterations ---> most common with right-sided stroke pt.s. - erroneous perception of self & illness (ex: "my arm & leg are dragging but it's fine, I'm probably tired"). - erroneous perception of self in space (ex: pt. thinks chair may be behind them, but the chair is 2 feet to the right of them). - agnosia (pt. loses the ability to recognize objects; ex: pt. may think their cup is a bowl; sometimes pt. may not even recognize their loved one). - apraxia (pt. cannot perform a series of steps; ex: you ask the pt. to put lotion on their hands, but they have a hard time figuring out the steps to open the bottle, then squeeze the lotion out, then to spread the lotion around in their hands).
Dislocation & Subluxation concept map!!!
pt. teaching, nursing care/interventions, & what to expect related to dislocation/subluxation!
"The Look" if your pt. is having a heart attack:
you walk into your pt.'s room & the pt. is having...... Persistent chest pain -- "my chest won't stop hurting." Upset stomach -- "I think I need to throw up." Light-headed -- "I feel like I'm going to pass out." Shortness of breath -- "I can't catch my breath." Excessive sweating -- "I'm sweating a lot." --> if pt. is having these symptoms, call rapid response team or code blue!!!
corrective dosing:
*** refer to picture for example! ---> formerly called "sliding scale". --> this is when you take a pt.'s blood sugar level & if the blood glucose is elevated, you administer a certain amount of units, usually of short-acting insulin. -> we give the corrective doses on top of the pt.'s regular insulin regimen. -> if correction insulin is used extensively, then the scheduled insulin should be initiated or increased; because corrective doses should NOT be the pt.'s regimen, they should only be used to control break-through glucose spikes. -> corrective dosing is given regardless of whether the pt. is eating or is NPO.
cancer: treatment goals
***varies among patients! Cure = after treatment, the patient will be free of disease & have a normal life span; typically pt. is declared cured after the 5 year mark of being cancer free. Chronic = chronic cancers are not cured, but are controlled by therapies for many years (ex. Multiple Myeloma & chronic Lymphocyte Leukemia). Palliative = relief of symptoms & maintaining quality of life. *** treatment goals can change depending on how the pt. is responding to treatment, & how the tumor is responding to the treatment; if a cancer comes back, sometimes it is more resistant to chemotherapy.
self-monitoring of blood glucose (SMBG):
- Enables decisions regarding diet, exercise, and medication. - Accurate record of glucose fluctuations. - Helps identify hyperglycemia and hypoglycemia. - Helps maintain glycemic goals. - A must for insulin users. - Frequency of testing varies (type 1 may have to test 4-8 times a day; type 2 may only have to test 1 time a day). pt. teaching - how to use/calibrate their meter. when to test - before meals (especially for bolus dose). - 2 hours after meals. - when hypoglycemia is suspected. - during illness. - before, during, & after exercise.
What other measures in the OR can prevent infection?
- OR zones. - different types of air flow.
if diets & supplements do not help lower cholesterol levels, we can use medications to help.......
- Statins (HMG-CoA Reductase Inhibitors) = lower LDL levels. - Nicotinic Acid = increases HDL levels. - Fibric Acid Derivatives = decrease triglycerides & increase HDL levels. - Bile Acid Sequestrants = increase the conversion of cholesterol to bile acids. - PCSK9 Inhibitors = inactivates the PCSK9 protein, which increases the liver's ability to remove LDL from the blood.
diabetes complications: Hyperosmolar Hyperglycemic Syndrome (HHS)
- a medical emergency with a high mortality rate. 2) Hyperosmolar Hyperglycemic Syndrome (HHS) --> an acute complication. --> occurs in type 2 patients; typically the elderly. --> the pancreas produces some insulin, but not enough; so there is hyperglycemia, so a precipitating event (illness/infection/a newly diagnosed type 2 pt. with a history of inadequate fluid intake/etc) leads to polyuria, & increased mental depression/confusion. ---> occurs when a person's blood glucose levels are too high for a long period, leading to severe dehydration (extreme thirst) and confusion. symptoms: - there is some insulin circulating, so that fat stores do not have to be used for metabolism. - ketosis is minimal or absent & the pt. is NOT acidotic. - fewer symptoms early on, so the glucose levels may get really really high without being noticed. - the high BG levels can cause increased serum osmolality, which causes neurological symptoms (hemiparesis/aphasia). - severe dehydration. lab values: - BG > 600. - pH > 7.3 - serum osmolality > 320 - no ketones present. - not acidotic. treatment: - IV access to restore fluids (NaCl) is primary, then we administer IV insulin. - monitor serum potassium, as it will follow glucose back into the cells, so we need to watch for hypokalemia.
the nurse is accountable for:
- accountable for the nursing care provided by personnel to whom that care is delegated. - accountable for the consequences related to one's own action in delegation. - responsible for the actions or non-actions taken by the delegate.
PCA rules:
- always put a sign in the pt.'s room alerting that they are on a PCA. - always give pt. rules & info. - pt. is the only person who can press the button. - do not press if dizzy or sleepy. - do not eat if you are sleepy. - no not take any other home meds. - do not take any other narcotics!!!
In order for a patient to be transported from the PACU (post-anesthesia care unit) back to their room, the pt. must....
- be awake. - have stable vitals. - have no excessive bleeding or drainage. - have no respiratory depression. - have O2 saturations at the designated level. - be cleared by anesthesiology. - meet agency guidelines for transport.
amputations: nursing diagnosis
- body image disturbance r/t amputation. - impaired skin integrity r/t immobility & improperly fitted prosthesis. - pain r/t phantom limb sensation. - impaired physical mobility r/t amputation of lower limb.
how does chemotherapy affect normal tissues?
- chemo has the greatest effect on cells that are rapidly dividing (cells in bone marrow, so chemo really really affects RBCs, WBCs, platelets; & cells in GI tract, which is why nausea/vomiting is a big side effect with chemo; & cells in your hair, which is why chemo pt.s lose their hair). - chemo cannot distinguish between normal cells & cancer cells. --> side effects are the result of the destruction of normal cells.... Acute: nausea/vomiting, pain, anticipatory nausea/vomiting, allergic reactions, & cardiac arrhythmias. Delayed: days or up to a week after receiving chemo; continued nausea/vomiting, mucositis, losing hair, skin rashes, RBC/WBC may drop, diarrhea, constipation, neurotoxicity (chemo brain). Chronic: chronic damage to heart, liver, or kidneys related to chemo treatment; may last years or for the rest of pt.'s life. *** Nadir = refer's to pt.'s blood count; the Nadir point is when the blood count reaches its lowest level; takes 7-28 days depending on the agent.
signs & symptoms of right-sided heart failure:
- distended jugular veins. - anorexia & complaints of GI distress (swollen abdomen from fluid build up). - enlarged liver & spleen (there are lots of blood vessels in these areas, so if there is increased pressure in the veins, serous fluid will ooze out of the veins & the fluid will accumulate in the abdomen, fingers, hands, feet, legs; entire venous system is swollen). - swelling in hands & fingers. - increased peripheral venous pressure. - dependent edema (swelling in whatever body part is the lowest during a patient's position; ex = pt. is walking so their feet are swollen since the feet are lowest at that moment). - ascites. - fatigue (pt. is tired because of the decreased cardiac output).
what are the diagnostic studies for HF?
- electrocardiogram. - chest x-ray. - echocardiogram. - nuclear studies. - cardiac Cath. - arterial blood gases. - ejection fraction (a NORMAL ejection fraction is ABOVE 50%). - BNP (hormone produced in response to ventricular dilation; the higher the BNP the more severe the HF). *** the lower the ejection fraction, the more severe the HF.
examples of pre-operative teaching for post-operative interventions:
- encouraging deep breathing & coughing (most important; prevents post-op pneumonia). - encouraging turning & repositioning. - encouraging early ambulation. - configuring methods of pain control. - as a nurse, be as specific as possible when discussing with your patient!
transportation to OR:
- escort the pt. being transported. - make sure pt. is wearing only their gown & that they have their ID band on. - the chart & checklist goes with the patient. - provide the pt.'s family with instructions (waiting room & pt.'s belongings are secured). - prepare the room for the pt.'s return, unless otherwise noted.
caring for a pt. who has had lower back surgery:
- flat bed rest with logrolling (side to side) if MD orders. - if you see clear, straw colored drainage on pt. dressing, there may be a CSF (cerebral spinal fluid) leak which can cause severe headaches; report to MD immediately. - perform frequent neurovascular checks of lower extremities (5 Ps). - assess bowel & bladder function (the nerves that feed into these functions stem from the lower back, so we need to know what these functions' baseline is to know if the surgery caused any complications to those nerves). - for spinal fusions, assess the donor site (if the bone graph came from the pt.) because there's often more pain at that site instead of their back.
how does aging affect the cardiovascular system?
- heart rate decreases. - reduced cardiovascular response to stress. - slowed recovery from activity (if older person is exercising, it may take longer for their HR to rise, & then longer for their HR to return to normal once they finish exercising). - heart sounds may be distant, or their may be murmurs. - BP increases, but systolic BP increases more and faster than the diastolic. - widened pulse pressure (the difference between the systolic & diastolic becomes greater). - orthostatic or postprandial hypotension.
nurse management of casts:
- heat from plaster cast can increase edema. - don't handle wet cast with fingertips. - finger space between cast & skin. - elevation of extremity. - ice for 24-48 hours. - monitor areas of drainage. - assess for odor & edema. - neurovascular checks. - prevent constipation & renal calculi. - pt. teaching. first priority = second priority =
Total Joint Replacements: nursing diagnosis
- impaired physical mobility r/t pain & surgical procedure. - pain r/t surgical procedure. - self-care deficit r/t physical restrictions. - risk for infection r/t surgical procedure. - ineffective management r/t lack of knowledge of follow-up care.
why do we need delegation?
- increased acuity of pt.s. - longer life expectancies. - increased economic constraints/decreased budgets. - increased use of Unlicensed Assistive Personnel (UAPs) & Practical Nurses (PN). - increased RN responsibilities in the management of nursing unit/organization. - accelerated pace & changing health care environment.
diabetes: nursing problems
- ineffective self-health management. - risk for unstable BG levels. - risk for infection. - risk for peripheral neurovascular dysfunction.
how can a nurse explain what malignant hyperthermia is to a family member?
- it can be inherited. - it has to do with the calcium in our muscles. - it makes your temperature go really high. - it can be really serious/fatal.
Traction: nursing care
- keep weights hanging freely. - assess for skin integrity. - assess for infection at pin sites: pin care. - maintain correct body alignment. - prevent complications of immobility (constipation, foot drop). - skin breakdown. - muscle relaxants for muscle spasms. - neurovascular checks. top priority = second priorities =
how can our patient's diet help lower their cholesterol levels?
- low fat. - low cholesterol. - low added sugar. - low salt. - moderate alcohol (1 drink/day for women, 2 drinks/day for men). - supplements such as omega 3s & yeast rice capsules. - eating more plants & less fried foods. - the Mediterranean diet.
CVA risk factors:
- men have a greater risk than women do, however women tend to die from strokes more often than men do. - stroke risk doubles once you reach age 55. - African Americans are at a high higher risk. - having hypertension (if we control hypertension, we can cut the stroke risk in half). - diabetes pt.s are at a 5 times higher rate of having a stroke, because of how diabetes affects the vessels. - high cholesterol causes atherosclerotic changes, which contributes to stroke risk.
primary hypertension:
- most common form. - can be related to obesity, lack of exercise, high fat diet, etc; but there is no identified cause. --> secondary hypertension is caused by a specific disease; for example, pt. has hypertension because they have cirrhosis of the liver.
Your post-op patient is prescribed Percocet (oxycodone/acetaminophen) on discharge. What side effects should the nurse teach the patient?
- nausea & vomiting. - constipation. - excessive drowsiness.
PCA side effects:
- nausea. - itching. - drowsiness. - urinary retention. - constipation. - hallucinations. - slow rate of breathing. - over sedation!!!
risk factors for type 2 diabetes:
- obesity (main risk factor). - family history. - being over 40 years old. - ethnicity; Native Americans have the greatest risk; African Americans/Asians have a greater risk than Caucasians. - pregnant women who develop gestational diabetes (infants often born > 9 lbs) have a greater risk for developing type 2 diabetes later on in life. - pt.s with Metabolic Syndrome (elevated glucose, abdominal obesity, hypertension, dyslipidemia) have a greater risk of developing type 2 diabetes.
case study example: - L.M. tells you "I knew I would get cancer one day since my mother had it." What can you tell her about the genetic link in the initiation phase of cancer development?
- only about 5% of cancers have a genetic component, so cancer is not necessarily an inherited disease. - cells are constantly changing and being influenced by our environment, so our cells are not the same as when we were born with them. - if we have one abnormal cell in our body, our body could repair the cell or our immune system could kill it & we would be fine; it becomes a problem when those abnormal cells multiply.
chemotherapy: methods of administration
- oral. - IM. - IV (most common). - intracavitary. - intrathecal. - intraarterial.
low back pain: nursing diagnosis
- pain r/t muscle spasms, muscle strain, & herniated disk. - impaired physical mobility r/t limited ROM, movement restrictions, & muscle spasms. - ineffective individual coping r/t effects of chronic pain.
Pre-operative patient teaching:
- pt. has a right to know what to expect. - pt. teaching increases pt. satisfaction. - pt. teaching reduces post-op fear, anxiety, & stress. - pt. teaching reduces post-operative complications! (biggest reason for pre-operative teaching). - we must reinforce pt. teaching in the post-op phase.
how can paralytic agents affect patients after surgery?
- pt. may be weak all over. - difficulty breathing or taking deep breaths.
Who can use a PCA?
- pt. must be mentally, emotionally, & physically able to assess his/her own pain needs. - children 7 years of age or older who have normal cognitive development. - use cautiously with pt.s with a history of drug/alcohol abuse, respiratory distress, & the elderly.
signs & symptoms of left-sided heart failure:
- restless & confusion (first signs of decreased gas exchange, & alveoli are surrounded by fluid). - orthopnea (when fluid is in the lungs & pt. lies flat, pt. beings to suffocate; pt. needs 2-3 pillows to sleep). - tachycardia (stress from increased work of breathing). - exertional dyspnea (pt. is short of breath upon activity). - cyanosis (blueish color around the mouth, hands, & feet). - paroxysmal nocturnal dyspnea (PND) (caused by fluid shifts when pt. lies flat; pt. has sudden & acute shortness of breath). - elevated pulmonary capillary wedge pressure (the BP in the pulmonary blood vessels is increased because of the fluid in them). - cough (typically a dry cough, because the fluid is not in the airways, but it is surrounding the alveoli). - crackles & wheezes (due to fluid in the lungs; important to document where in the lungs you hear it). - blood tinged sputum (very late sign of left-sided hf).
peripheral artery disease: goal of care
- save the extremity; maintain or improve circulation. - protect the extremity from injury. - inspect the extremity frequently. - reduce risk factors. - teach pt. about good foot & skin care.
risk factors for DVT (deep vein thrombosis):
- surgery - immobility - smoking - trauma with fracture - obesity - diabetes - hyper-coagulable states (pregnancy, etc).
You are caring for a women who has been given a prescription for Fosamax. What instructions will you give her?
- take it when she first gets up in the morning with a full glass of water. - don't eat, drink, or lie down for 30 mins after taking the drug.
A patient is being discharged after being fitted with a prosthesis. What should we teach the pt. about?
- teach pt. to do ROM exercises on their residual limb. - pt. should lay on stomach (prone position) for 30 mins a day several times a day in order to prevent flexion contracture. - ensure pt. will continue rehab with physical therapist & that the pt. can use the prosthesis safely. - teach pt. how to properly use any compression bandages if they need to continue shaping their residual limb. - teach pt. how to inspect the residual limb daily, & when to notify the MD of any physical changes. - pt. must wash the residual limb nightly & expose limb to air for at least 20 mins after washing. - pt. must clean bandage/stocking daily, & prevent skin breakdown.
patient education to avoid hypoglycemia:
- test BG if feeling the level may be low. - follow a regular eating pattern. - snacks may be needed between meals & before bedtime. - eat additional food when engaging in exercise. - closely monitor BG levels. - wear an ID bracelet that indicated diabetes. - "I'm sweaty, cold, & clammy; give me some candy (lifesavers!!!)"
who is responsible for obtaining patient consent?
- the MD (physician).
what are the highest priorities in the pre-operative phase?
- the assessment. - pt. teaching. - identifying risks. - coming up with a plan of care.
case study example: L.M. begins to cry & tells you she spends a lot of time in the sun and never used sunscreen, even though she promised her mother she would. What do you about the role of sun in the development of skin cancer?
- the sun (UV radiation) is a carcinogen, so people who have a great amount of sun exposure are at a much higher risk of having skin cancer. - L.M. should take preventative measures like wearing sunscreen, wearing long sleeves outside,
case study example: - L.M. is an 18 year old friend of yours. She comes to you with a "spot" on her back. She is very worried because her mother died of cancer. Because you are a nursing student, L.M. asks you to explain what cancer is and how it occurs. What do you tell her?
- there are over 200 kinds of cancers, so just because her mother died of a specific type of cancer doesn't mean that she's at higher risk for another kind of cancer. - cancer is unregulated & abnormal cell growth. - if she is concerned, she should have it checked out by a doctor.
tips for providing feedback:
- timing. - focus on the behavior/performance of the task. - clarity. - "I" statements. - restatement of the feedback from the delegate. - private. - ask for feedback from the delegate.
what type of monitoring do you need to do for patients after they receive pre-operative medications?
- vital signs. - oxygen saturation. - level of consciousness. - making sure they are safe in bed with the side rails up (fall risk).
how can I assess my patient's cardiac output without a fancy hemodynamic monitoring system?
- we can use different types of catheters that can measure all the pressures of the heart. - if we don't have catheters, we can judge their cardiac output based on their skin color (pale or pink), skin temp (cool or warm), capillary refill time, & their BP/HR.
caring for a neutropenic patient with suspected infection....
- what is the most common cause of infection? -> their own flora. - what are additional sources of infection. -> a sick family member/healthcare worker. - what is the most important measure to prevent infection? -> hand hygiene. - what are the signs/symptoms of neutropenia? -> cough, sore throat, etc. _______________________________________________________________________ - the absolute neutrophil count is 1000-1500. - cultures are taken to identify the offending organism. - antibiotic therapy is started. - pt. placed in protective isolation. - administer Neupogen (filgrastim), because it reduces the time for neutrophil recovery & duration of fever; avoid use for 24 hours before/after chemotherapy.
what is cancer?
----> it is unregulated, abnormal growth of cells. - all cancers start within the DNA of the cell itself; something changes within the DNA & then the way the cell grows is completely abnormal. - can occur in all age groups, but 77% of all cancers are diagnosed in pt.s older than 55. - African American men have a 16% higher chance of dying from cancer. - more men are diagnosed with cancer than women. - 1.5 million people are diagnosed with cancer every year, nationally. - cancer is either the 2nd or 3rd most common cause of death. - lung cancer is the most prevalent kind of cancer that kills pt.s; the 2nd most prevalent kind of cancer that kills pt.s is breast cancer (for women) & prostate cancer (for men). - 5 year survival rate of cancer is about 69%. Prevention: - annual mammograms (women). - colonoscopy (starting at age 50). - annual prostate exams (men). - annual dermatologist visits (if predisposed to melanoma).
health promotion for HF patients:
----> we need to increase the emphasis on prevention/slowing progression of heart failure. --> identify & treat risk factors: - manage hypertension. - manage cholesterol. - get flu/pneumonia vaccines. - early valve replacements. - coronary re-vascularization. - anti-arrhythmic drugs or pacing.
diabetes: stress & counter-regulatory hormones
---> anytime there is stress or counter-regulatory hormones that are secreted, that causes an elevation in blood glucose levels. ---> counter-regulatory hormones: - glucagon. - epinephrine. - growth hormone. - cortisol. - somatostatin. -> stressful factors include psychological stress, & physiological stress such as surgery, or infection/illness.
cancer diagnosis: Biopsy
---> biopsy involves histologic examination of a piece of tissue by a pathologist. --> the tissue is obtained by: - needle or aspiration. - incisional procedure (removing a piece of the tissue from the tumor). - excisional procedure (removing the whole tumor to examine it). *** this all depends on where the tumor is, how large it is, & what is all involved.
insulin reaction: hypoglycemia
---> blood glucose < 70 is considered hypoglycemic!!! ---> when there is too much insulin in proportion to the amount of glucose. --> caused by: too much insulin, too much exercise, or not enough food. --> symptoms: - shakiness, nervousness, anxiety. - palpitations, diaphoresis. - mental status changes (the brain requires constant glucose). - hypoglycemic unawareness (autonomic neuropathy; autonomic nervous system is not working like it's supposed to, meaning there won't be any epinephrine secreted, so the pt. won't have any symptoms, & their blood sugar can get dangerously low without them even knowing). -> when your body senses that your blood sugar is low, the sympathetic nervous system takes over & secretes epinephrine, which causes the hypoglycemic symptoms.
NSAIDs.....
---> can interfere with the interaction of Ace Inhibitors & Diuretics! --> they can contribute to sodium retention, which worsens HF!
Stroke: right side VS left side
---> if you have a stroke on the right side of your brain, it will affect the left side of your body. ---> if you have a stroke on the left side of your brain, it will affect the right side of your body. Right-Sided Stroke effects: - paralyzed left side. - left-sided neglect. - spatial-perceptual deficits. - tends to deny/minimize problems. - rapid performance, short attention span. - impulsive; safety problems. - impaired judgement. - impaired time concepts. Left-Sided Stroke effects: - paralyzed right side. - impaired speech/language aphasias/impaired ability to understand language. - impaired right/left discrimination. - slow performance; pt. is very cautious. - aware of deficits (depression/anxiety). - impaired comprehension to language/math.
Before surgery, where is the patient's IV access verified and/or initiated?
---> in the pre-op holding area.
what nursing actions should you do in order to alleviate fracture pain?
---> it all depends on the nursing assessment! - before we treat pain, we must assess. - always assess first, some types of pain may indicate an impending complication, such as an embolus or compartment syndrome. - get pt. to describe the pain & rate it.
automaticity:
---> it means the heart generates its own electrical impulses. - the impulses travel through the conduction system, which is like a series of rows going through the heart, carrying the impulses to all of the heart muscle cells, & this is what makes the heart muscle cells depolarize & contract.
what is a Stroke?
---> known as a Cerebrovascular Accident (CVA), or brain attack. - occurs as a neurological symptom when there is a disruption of blood flow to the brain. - it is the 5th leading cause of death in the US. - up to 25% of pt.s who suffer from a stroke require long term care for at least 3 months after their stroke. 2 main types of strokes: 1) Ischemic Stroke -> when there is a blockage in a blood vessel, that is causing a problem. - 2 types: Thrombotic & Embolic. 2) Hemorrhagic Stroke -> when there is bleeding somewhere in the brain that is causing a disruption in the blood flow.
Mrs. Banks is being discharged home, but must continue to take Lovenox injections for a blood clot that developed post-operatively. Amy teaches Mrs. Banks about Lovenox, watches her administer the Lovenox to herself, & evaluates that Mrs. Banks understands what has been taught to her. Are Amy's actions within the scope of practice for the LPN?
---> no
cancer: genetic influence
---> only 5% of cancers are genetically inherited. -> inherited genetic mutations (2 types)...... 1) BRCA1 & BRCA2 - if a pt. has these genes in their family, then they are at an increased risk for breast cancer & ovarian cancer. 2) HNPCC - if a pt. has these genes in their family, then they are at an increased risk for colon cancer; if a woman has this gene, they are at increased risk for ovarian cancer as well. -> cancer families (where cancer runs in the family): pre-menopausal breast cancer, lung cancer (higher in families who are smokers & who have members that have had the disease; ex: if you are a smoker, & your mom had lung cancer, then you are at higher risk for it), leukemia is higher in identical twins (both twins having it).
nutriton therapy: protein
---> protein should make up to 15-20% of the total calories for a diabetic pt. ---> high-protein diets are not recommended for diabetic pt.s.
Frank-Starling Law of the Heart:
---> represents the relationship between stroke volume & end diastolic volume. The law states that the stroke volume of the heart increases in response to an increase in the volume of blood in the ventricles, before contraction, when all other factors remain constant. ---> the farther the heart muscles stretch, the harder they contract!!!
Sensory Neuropathy: chronic diabetes complication
---> sensory neuropathy (loss of sensation) to the feet is a major risk factor for amputation in diabetic pt.s. - pt.s may injury themselves on their feet without even realizing it, & since there is already impaired circulation to the extremities, the injury may be difficult to heal. pt. teaching: - do wash feet daily; dry well between toes. - do inspect feet daily. - do file or cut nails straight across. - do change socks/stockings daily; make sure there's no holes/frays. - weather shoes with good, supportive soles (leather soles). - do use unscented lotion on dry skin. - do see podiatrist or physician regularly, & when lesions appear. - don't soak feet in hot water. - don't use a heating pad to warm feet. - don't sit with legs crossed. - don't wear tight socks, hose, or garters. - don't go barefoot. - don't use commercial corn removers or sharp objects to remove corns or calluses. - don't wear shoes that rub blisters.
stroke procedure: surgical intervention
---> surgical intervention is the treatment of choice for subarachnoid hemorrhage strokes; the surgery basically repairs the aneurysm that has developed. - they perform the repair by doing an aneurysm clipping/wrapping/coiling; the purpose is to keep the aneurysm from bursting. - this treatment does not get rid of the aneurysm, but it keeps it from getting bigger & from rupturing. post-op care: - critical time for re-bleeding is 24-48 hours after surgery, & then also critical again 7-10 days after surgery.
systemic vascular resistance (SVR):
---> the amount of resistance that your blood vessels are creating; the amount of resistance that the heart has to overcome in order to force blood through the vessels.
Treatment for Malignant Hyperthermia:
---> the antidote is Dantrium (Dantrolene). - this medicine drives the calcium back into the cells, & reduces muscle rigidity. - the medicine comes in large vials. -> we will also be using cooling measures to help cool the patient down: such as cooling blankets, chilled normal saline, & ice packs. -> these cooling measures will be used in conjunction with other supportive measures: such as meds to lower BP, etc.
pre-diabetes: the pathophysiology
---> the blood glucose is elevated, but not high enough to be diabetes. -> there's an impaired fasting glucose (IFG) = fasting glucose is 101-125 mg/dl. -> there's impaired glucose tolerance (ITG) = 2 hr post load glucose = 141-199. - it's estimated that 86 million people in the US have pre-diabetes; without a lifestyle change, the majority will go on to develop type 2 diabetes within 10 years. pt. should be tested for pre-diabetes if.... - age is 45 & up, & if BMI is > 25. - younger pt.s with > 25 BMI & inactive lifestyle. - if pt. has any of the type 2 risk factors. --> screenings should be repeated every 3 years.
DVT: treatment
---> the primary goal of treatment is that we do not want that clot to break off & travel to the pt.'s lungs, causing a pulmonary embolism. medications: -> anticoagulants = the pt. will probably be on a heparin drip in the hospital; if they go home on Coumadin/etc, we need to adequately teach the pt. -> analgesics = to help manage their pain, depending on how bad it is. - pt. may be on bedrest for 3-6 days with extremity elevated (to decrease swelling). - use of support hose. - encourage smoking cessation. - surgical treatment = thrombectomy (when they surgically remove the clot, not done very often); or Greenfield filter (inserted into the inferior vena cava, & it catches the clots that are traveling back up to the rest of the body; usually not removed, but can be removed/replaced if it gets clogged up; refer to picture!!!).
stroke volume:
---> the volume of blood that is ejected with each beat. primarily affected by.... 1) Preload (volume) = the amount of blood in the ventricle at the end of diastole; the more blood in there, the more the ventricle is stretched out, & the greater the degree of stretch, the harder the force of the contraction is. 2) Contractility = the force of contraction. 3) Afterload (resistance) = the force or load against which the heart has to contract to eject the blood; the lower the afterload, the more blood the heart will be able to pump out; when there is vasoconstriction, the afterload is greater; when there is vasodilation, the afterload is lower; created by the blood vessels.
type 2 diabetes mellitus: the pathophysiology
---> there is insulin resistance; so "the insulin key if fine, but something is wrong with the lock, & so the glucose cannot enter the cell", which causes a build up a glucose in the bloodstream, which causes the pancreas to produce more insulin. -> eventually after trying to control the elevated blood glucose, the beta cells in the pancreas will tire out, & there will be a decreased insulin production. -> one of the liver's main functions is to release glucose accordingly pertaining to the body's needs, but in type 2 diabetes, there is inappropriate & unregulated hepatic glucose production. -> in type 2 diabetes, there is an altered production of hormones & cytokines by adipose tissue (adipokines, which play a role in glucose & fat metabolism, as well as causing chronic inflammation). - gradual onset of symptoms, if there are any symptoms at all (possible fatigue, or repeated infections due to the compromised immune system).
nutriton therapy: carbohydrates
---> these include: - fruits. - vegetables. - whole grains. - legumes. - low-fat milk. ---> diabetic patients need a minimum of 130 grams of carbs per day. ---> diabetic patients should have 25-30 grams of fiber per day. ---> 3 ways for a pt. to keep track of their carbs: - carb counting. - exchange lists of food groups that pt.s can choose from. - experienced based estimation (an experienced diabetic who is used to counting crabs can get a pretty good sense of how much they've had without actually counting them all up). --> pt.s can also use the glycemic index, which tells them how fast a certain food makes their blood sugar rise (ex. foods with a high glycemic index will raise their BG higher & faster than low glycemic index foods).
types of oral & adjunct injectable meds (other than insulin):
---> these meds CAN be used in combination with each other. ---> these meds work on 3 effects of type 2 diabetes: 1) insulin resistance. 2) decreased insulin production. 3) increased hepatic glucose production. 1) Biguanides -> ex: Metformin (Glucophage); the most widely used oral agent. -> reduces glucose production by the liver, & makes the tissues more sensitive to insulin, & therefore improves glucose transport into the cells. -> it may cause weight loss. -> also given to pre-diabetes pt.s to prevent them from developing type 2 diabetes. -> if pt. undergoes a procedure where contrast medium is used, WITHHOLD the Metformin for 48 hours afterwards, & check their renal function (check creatinine) to make sure it's functioning properly. -> if we give Metformin & pt. has procedure done with contrast medium, it can cause renal failure. -> we don't really have to worry about possible hypoglycemia with this drug. 2) Oral Hypoglycemic Agents (Sulfonylureas) -> ex: Glipizide (Glucotrol); Glyburide (Micronase, DiaBeta, Glynase); Glimepiride (Amaryl). -> these are the oldest hypoglycemic oral drugs. -> these meds work by increasing insulin production from the pancreas. -> the major side effect is hypoglycemia. -> if the pt. is allergic to sulfa drugs, they are also allergic to these drugs. -> these drugs tend to become less effective over time, so pt. may eventually have to switch to a new drug. -> may cause weight gain. 3) Meglitinides (Glinides) -> ex: Repaglinide (Prandin); Nateglinide (Starlix). -> these work by increasing insulin production from the pancreas. -> the body rapidly absorbs & rapidly eliminates these types of drugs, so there is a much lower risk for hypoglycemia as long as the pt. eats. -> they should be taken anywhere from 30 mins prior to or right before the pt. eats. -> pt. should not take this drug if they are skipping a meal. 4) Alpha-Glucosidase Inhibitors -> ex: Acarbose (Precose); Miglitol (Glyset). -> they work by slowing down the absorption of carbohydrates in the small intestine; (sucrose/cane sugar is mainly what the drug works on). -> "starch blockers". -> the pt. should take these meds with the first bite of their meal. -> if ps. was to become hypoglycemic, giving them orange juice would not help them because this drug is slowing down the absorption of carbs; so we would give the pt. oral dextrose or glucose. 5) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (Incretin Mimetics) -> ex: Gliptins; Sitagliptin (Januvia); Saxagliptin (Onglyza); Linagliptin (Tradjenta). -> *Incretin is a hormone that is released by the intestines continuously throughout the day, but in greater response to a meal; incretin increases the amount of insulin that's released from the pancreas, & decreases hepatic glucose production.* -> these drugs work by blocking the inactivation (prolonging the action) of incretin hormones; causing more incretin to be available in the body. -> these drugs block the enzyme that stops incretin. -> these drugs increase insulin release, decrease glucagon secretion, & decrease hepatic glucose production. -> they don't cause weight gain. 6) Glucagon-like Peptide Receptor Agonists (Incretin Mimetics) -> ex: GLP-1 -> they work by stimulating one of the incretin hormones, the Glucagon-like peptide-1 (GLP-1). -> they increase insulin synthesis & release, inhibit glucagon secretion from the liver, decrease gastric emptying, & increase satiety (makes you feel full so you don't eat as much). -> since these drugs decrease gastric emptying, that will affect the absorption of oral drugs; so pt. must separate their meds & take their oral meds at least an hour before taking this injection medication. -> these drugs slow down the body's ability to absorb other oral meds. -> this drug is a subcutaneous injection, but it is not insulin! -> this drug is only intended for type 2 patients, because the pancreas must be secreting insulin in order for this drug to work. -> this med has been associated with thyroid cancer & pancreatitis. 7) Amylin Analog -> ex: Pramlintide (Symlin). -> this drug is a subcutaneous injection that is administered into the high or abdomen before meals. -> this drug works by slowing gastric emptying, reducing postprandial glucagon secretion of the liver, & increasing satiety. -> it is used concurrently with insulin (meal time insulin), but must be injected separately! -> may cause hypoglycemia, so we must be cautious for the 3 hours after administering it.
Autonomic Neuropathy: chronic diabetes complication
---> this is when the autonomic nervous system is not functioning correctly. ---> can cause: hypoglycemic unawareness, gastroparesis ( delayed gastric emptying), postural hypotension, resting tachycardia, painful myocardial infarction, sexual dysfunction, & neurogenic bladder (sensation in the inner bladder wall decreases & causes urinary retention).
what is the goal of delegation?
---> to goal of delegation is to provide quality care to our assigned patients using the resources that are available in the most efficient manner possible.
T/F: A patient who had an embolic stroke is a candidate for TPA.
---> true *** TPA is a clot buster!
T/F: The meal-time Novolog dose and the Correction Scale Novolog dose should be added together and given in one injection.
---> true. *** since they are the exact same kind of insulins, they can be combined.
acute coronary syndrome (ACS):
---> used to describe conditions caused by myocardial ischemia, such as unstable angina & myocardial infarction.
Chronic Heart Failure (CHF):
---> we want to teach these pt.s how to manage this condition so that they can stay at home & continue their lives. symptoms: - fatigue (from decreased cardiac output, as well as orthopnea or PND which interferes with sleep). - neurologic behavior changes; restlessness & agitation from poor gas change; chronic forgetfulness or poor attention span from poor perfusion to the brain; depression (1 in 5 HF pt.s) & anxiety. - respiratory changes; (same as left-sided hf = crackles, wheezing, blood tinged sputum, difficult sleeping positions, etc). - cardiovascular changes; tachycardia, palpations, dizziness, syncope, chest pain/heaviness, distended jugular veins. - edema; dependent (peripheral), liver (hepatomegaly), abdominal (ascites), lungs (pulmonary edema, pleural effusion). - skin; dusky looking, legs are shiny/swollen/lack hair, chronic swelling causes pigment changes (brown). - gastrointestinal; abdominal distention, ascites, hepatosplenomegaly, RUQ pain, nausea/vomiting (from poor perfusion), anorexia (cardiac cachexia = severe muscle wasting from lack of nutrition), weight gain (may be all fluid). - elimination; nocturia (have to pee at night, because of the fluid shift when they lay down the kidneys get better perfusion) & decreased daytime urinary output (due to decreased kidney perfusion during day).
Transient Ischemic Attack (TIA):
---> when a pt. has some neurological deficits (change in speech, a facial droop, change in their vision, a change in their strength), but these neurological changes are not permanent --- they usually last an hour or less. - "angina for the brain". - often gives the pt. warning signs to know that there is a problem with the circulation in their brain. - most often treated with anti-platelet medication (aspirin or plavix).
stroke procedure: carotid endarterectomy
---> when they make an incision into the carotid artery, & they clean out that blood vessel, & then they sew it back up. - this is typically done if a pt. has a stroke & they do an ultrasound afterwards to see if the carotid artery has any blockage. post-op care: - frequent neuro assessments. - BP management. - monitor for bleeding.
stroke procedure: clot extraction
---> when they thread in a device through the femoral artery all the way to the patient's brain, & then they activate the device to remove the clot that is causing the problems. - this procedure can be done if the pt. is not a candidate for TPA because of the time restrictions; it can be done 6-8 hours after symptoms have started.
What is the most common diagnostic test used in relation to the musculoskeletal system?
---> x-ray (shows bone) *nursing considerations = avoid over exposure of the patient & yourself; ask about possible pregnancy; remove any jewelry.
peripheral artery disease: treatment
--> Angioplasty = a balloon is inserted & inflated in order to open up a narrow/obstructed artery. --> Atherectomy = they use a cutting technique with the angioplasty to break up or remove clots. --> Stents = pt.s often need these after other procedures in order to keep the vessel open. --> Aortic-Femoral Bypass Graft = they do a bypass from the aorta down to the femoral artery, in order to bypass any blockages. --> Endarterectomy = going in & surgically removing the plaque within a vessel. --> Amputation = the very last thing we could do in order to save the pt.'s life.
Which team members perform a surgical scrub?
--> It is only required for the surgeon and the scrub nurse.
example amputation question:
--> Mr. K is a 65 year old pt. who has multiple necrotic areas on his left foot & ankle. His medical history includes diabetes & peripheral vascular disease. He is scheduled for a BKA. -> What do we need to teach Mr. K prior to surgery? - prosthetic devices. - phantom pain. - general post-op nursing care. - mobility issues.
How does a patient's weight relate to their surgical risk?
--> Obese patients: require more anesthesia; adipose tissue is less vascular & is slower to heal. --> Malnourished patients: older adults are at risk for malnutrition & fluid volume deficits.
What is the difference between PPEs and surgical gowns?
--> PPE serves to protect the nurse from the infection/disease that the patient has, meanwhile surgical gowns serve to protect the patient from the nurse's germs.
case study example: H.J. is told by his doctor that he has T2, N1, M0 testicular cancer. What does this mean?
--> T2 = cancer has spread to tissues near the tumor, so there has been some local spread. N1 = there is at least one lymph node involved. M0 = there is no evidence of metastasis.
Rheumatoid Arthritis:
--> a chronic, systemic (affects entire body) disease characterized by recurrent inflammation of the joints, stiffness, pain, and swelling that results in crippling deformities. - this disease is an inflammatory process, while osteoarthritis is not. - occurs mostly in ages 30-50, while osteoarthritis is mainly in older adults. - women are 2-3 times more likely to develop this disease than men are. - the most widely accepted theory of this disease is that it is an autoimmune disease where there are autoantibodies against IgG; this disease may be genetic because it tends to occur in families. - this disease can cause cardiovascular inflammation problems (pleurisy, pericardial effusions, cardiomyopathy) later on in life. 4 stages of the progression of this disease.... 1) stage one: joint inflammation, synovial membrane swelling, & increased synovial fluid. 2) stage two: granulation tissue invades the joint capsule. 3) stage three: granulation tissue converts to fibrous tissue. 4) stage four: fibrous tissue calcifies, resulting in joint immobilization. clinical manifestations: --> early: - fatigue, anorexia, weight loss, generalized stiffness. - usually effects joints bilaterally (unlike osteoarthritis), especially the hands. - joint stiffness upon rising in the morning or after inactivity. --> moderate: - joints become tender, painful, red, swollen & warm. --> late: - atrophy of muscle, destruction of joint & joint structures. - joint deformity. --> rheumatoid nodules: - non-tender masses that are usually found along the surfaces of the forearms, maybe fingers, base of spine, & back of head that come and go; they will come back if you try to remove them. diagnostic studies.... - anemia. - sed rate (a marker of inflammation) may become elevated. - serum rheumatoid factor (not 100% diagnostic for this problem). - ANA (anti-nuclear antibody); if that's elevated it points toward rheumatoid arthritis. - synovial fluid analysis (shows inflammatory changes); may see white blood cells in the fluid. - x-rays may only show bone demineralization in early stages; may show joint narrowing & cartilage destruction/deformity later on. management.... - rest & energy conservation. - heat & cold therapy. - joint protection. - balanced nutrition. - total joint replacement. -> DMARDs (disease modifying anti-rheumatic drug) suppressed inflammation, suppresses the immune system (pt. at higher risk for infection), they have the potential to lessen the permanent effects (as opposed to NSAIDs which only relieve the pain); however, they can take up to 6 months to become therapeutic. -> combination therapy! (NSAID + corticosteroid + DMARD; the NSAID & corticosteroid (oral) are used as a bridge treatment until the DMARD becomes effective). -> Biologic Therapy (if DMARD/combination therapy doesn't work) suppress inflammation/immune system by inhibiting TNF (tumor necrosis factor) which drives the immune response; examples = Etanercept (Enbrel), Infliximab (Remicade), adalimumab (Humira), anakinra (Kineret). --> DMARDs include.... 1) Methotrexate (Rheumatrex): - usually first choice; given oral, side effects are bone marrow suppression (monitor CBC regularly), causes birth defects if pt. is pregnant. 2) Hydroxychloroquine (Plaquenil): - may be used in mild disease; also used for malaria; can cause retinal degeneration (regular eye exams are important). ** corticosteroids can cause fluid retention (so monitor is pt. has high blood pressure); they are intraarticular injections used in flare-ups; used short term until DMARD starts to work; they are anti-inflammatory; can cause swelling in the face; should not be stopped abruptly;
Fat Embolism Syndrome:
--> a complication of fractures of long bones or multiple fractures associated with pelvic injury. -> usually 24-48 hours after injury. what happens... - bone fragments release fat globules into the blood stream. - these fat globules then go to the lungs, & cause problems with oxygenation (inflammatory changes occur in lung tissue). manifestions... - respiratory distress. - chest pain, tachycardia. - cyanosis. - apprehension. - memory loss, restlessness, confusion, headache. - increased temperature. - petechiae (little red bumps/spots, especially around the neck, mucous membranes of mouth, conjunctive of eyes). nursing care/treatment: ---> prevention is key: - prevent by maintaining careful immobilization until the fractures are stabilized. - the more the bone fragments move around, the greater the chance they will release fat globules. ---> treatment (symptom management): - maintain fluids. - maintain oxygen. - correct pH imbalance. - replace any blood loss.
Osteoarthritis:
--> also known as: degenerative joint disease (DJD). --> a slow, progressive disorder of articulating joints; the degeneration of articular joint cartilage. * the purpose of cartilage is to cushion the joints! --> the most significant risk factor is age; 1/3 of all adults have some evidence of osteoarthritis, and then in 60-80% of adults once they reach the age of 60. --> a person with previous joint injury, infection, congenital deformities, or excessive/repetitive stress may be predisposed to osteoarthritis. what happens... - degenerative changes over time cause cartilage to become yellow, opaque with rough edges, & areas of softening. clinical manifestations... - pain with activity. - stiffness after periods of inactivity. - progressive loss of function. - crepitation (crunching sound when the joint moves). - gross deformity & subluxation in advanced stages. - Heberden's (occur on distal finger joints) & Bouchard's (occur on proximal finger joints) nodes; most common is women & may run in the family; nothing can be done about them; they are disfiguring & look like swollen red bumps. diagnostic studies.... - x-rays. - bone scan, CT, or MRI may be used. - synovial fluid analysis. - no specific serological studies are useful in diagnosis. goals of therapy... - pain control. - prevention of progression & disability. - restoration of function. - rest & joint protection (braces). - heat, cold & exercise (staying in motion helps). - weight loss if pt. is obese (weight is extra pressure on joints). - complementary & alternative therapies (acupuncture). collaborative care.... -> drug therapy: - acetaminophen. - NSAIDs (if taking long term, pt. needs to have renal function periodically checked; these drugs interact negatively with antihypertensive meds). - intraarticular (directly into a joint) corticosteroids. - I/A hyaluronic acid (a series of 3 injections that are 2 weeks apart; pt. cannot take this if they are allergic to chicken/eggs; acts as a lubricant for joints; lasts longer than corticosteroids). -> surgery: - debridement. - arthroplasty. - osteotomy. - total joint replacement.
insulin pen:
--> an easier way for pt.s to give themselves insulin without having to draw it up in a syringe. *** refer to picture ***
Traction: 2 types
--> an external fixation used for fractures if pt. cannot undergo a ORIF (open reduction internal fixation). -> this is a pulling force used to realign bone. -> 2 types: skin & skeletal. 1) Skin: - weights attached to skin with slings, straps, etc. - no more than 7-10 pounds. - short term (48-72 hours). 2) Skeletal: - pins & wires attached to bone, then attached to weights. - 5-45 pounds. - can be used for longer periods of time. - risk of infection in bone at the pin site. - immobility complications if skeletal traction used for long periods of time.
how are our bodies able to defend itself from cancer agents?
--> our bodies perceive the abnormal cancer cells as "non-self"!!! The Role of the Immune System: -> cancer cells produce on their cell surface "Tumor-associated antigen" (TAAs). -> our body uses "immunological surveillance", where lymphocytes detect these TAA antigens & attempt to destroy the cancer cells. -> Immune Response includes.... - T-Cells (stops tumor growth). - Natural Killer Cells (can go in & destroy the tumors). - Macrophages & B-Lymphocytes (help identify abnormal cells in order to destroy them).
Hip Fractures:
--> over a quarter of a million hip fractures every year, & 1 in 5 people will die from them within a year. --> 60% of people with hip fractures never regain their full ambulation baseline of before the fracture occurred. --> surgical repair is the preferred method of management, however if pt. is unable to go through surgery immediately, MD may use skin traction (Buck's traction) until surgery can be performed. --> once pt. has had surgery to repair the hip fracture, the pt. should avoid these 3 positions in order to prevent dislocating the hip..... 1) greater than 90 degree flexion (sitting on the toilet does this, so these pt.s will need elevated toilet seat; picking something off the floor will do this, so these pt.s need a reacher/grabber device; pt. will need a device to help put on their shoes & socks). 2) internal rotation (pt. should not turn their feet inward). 3) adduction (pt. should not bring their legs together, so will have foam wedge to separate legs). nursing management... - neurovascular checks.
What is a PCA pump?
--> patient controlled analgesic pump - an IV device that allows pt. to take an active role in their pain control. - the pt. has control over when to receive the med. - we use PCA for better pain control & improved pt. satisfaction. - the pt. can press the button, & a predetermined dose of narcotic analgesic is delivered.
Osteoporosis:
--> porous bone, low bone mass, structural deterioration of bone tissue. - women are more likely to develop this because in general women have less bone mass; skinnier white/asian women are at greatest risk; pregnancy & breastfeeding can deplete calcium preserves. - osteoporosis is the leading cause of fractures in postmenopausal women (estrogen helps protect bones, so when women lose their estrogen during menopause, that's when osteoporosis develops). ---> the most common fracture areas r/t osteoporosis is the hip, spinal vertebrae, & the wrist. clinical manifestations... - often called a "silent disease" because there really are no big symptoms. - may cause the collapse of vertebrae, leading to loss of height or causing kyphosis. diagnostic tests.... - it will not be detected in a standard x-ray. - it can be detected in bone density scans, where you'll either be diagnosed as normal bone density, osteopenic (some loss of bone density but not sufficient enough to be called osteoporosis), or osteoporotic. osteoporosis prevention.... --> adequate calcium intake (premenopausal women = 1,000 mg calcium/daily; postmenopausal women = 1,200-1,500 mg calcium/daily); the body can only absorb up to 600mg at one time, so it's important to divide the doses unless taking a sustained release calcium; take it either by diet or supplements. --> adequate vitamin D (helps the body to absorb calcium). --> weight bearing exercises (swimming/cycling is not weight bearing; walking is the best; avoid high impact exercises such as jogging, if pt. already has osteoporosis; must be consistent = 30 mins/day, 5 days a week). --> stop smoking. --> decrease alcohol consumption. drug therapy.... *osteoblasts build bone, osteoclasts break down bone; with osteoporosis, the osteoclasts are overactive.* - estrogen: inhibits osteoclasts, but not given as primary treatment because of the risks of hormone replacement therapy. - estrogen receptor modulators: Raloxifene (Evista) mimics the effects of estrogen with fewer side effects, however pt. a little at risk for blood clots so may have to take this with aspirin. - calcitonin (calcimar): usually given by nasal spray; a thyroid hormone that inhibits osteoclasts. - denosumab (prolia): antibody that binds to the protein that's involved with osteoclasts, inhibiting osteoclasts; SQ injection given usually every 6 months. - bisphosphonates: given most often; includes Zoledronic acid (Reclast), Ibandronate (Boniva), Risedronate (Actonel), Alendronate (Fosamax); Boniva, Actonel, Fosamax are all oral meds that can cause jaw osteonecrosis & significant GI effects such as esophageal erosion, so tech pt. to take drug first thing in morning with full glass of water & don't eat drink or lie down for 30 mins!; Reclast is an IV infusion given once a year; Fosamax may cause fever stress fractures if taken for 5 years or more. - Teriparatide (Forteo): stimulates new bone formation by osteoblasts; SQ injection given once daily; mainly used for women who are at a very high risk for fractures.
Gout:
--> recurrent attacks of acute arthritis associated with increased levels of serum uric acid. - uric acid is the end product of purine (produced when your body digests meats/beer) catabolism & is excreted by the kidneys. - there's periods of flare-ups, & then periods of remission. - occurs predominantly in middle aged men. - 75% of the time it occurs in the big toe. GOUT PREVENTION.... - giving allopurinol (zyloprim) helps to decrease uric acid levels, ultimately preventing gout flare-ups! - weight reduction, as needed. - avoid alcohol & foods high in purines (red & organ meats). - adequate urine output (prevent kidney stones from high levels of uric acid). treatment..... -> for acute attacks of gout: - Colchicine (Colcrys) is most common med given; is a powerful anti-inflammatory, but does not have analgesic properties, so the pt. will need to take an NSAID for pain relief along with this med. **** concept map!!!!!
low back pain:
--> second most common complaint; first is "headache". --> results from muscle strain, arthritis, disk issues. clinical manifestations.... - pain & stiffness. - posture & gait may be affected. - limited ROM. diagnostic tests... - maybe nothing (if it's a simple strain). - x-ray, CT scan, or MRI (if more severe). - myelogram (dye is injected into the spinal canal so MD is better able to see the disks). who is at risk for low back pain.... - pt.s with lack of muscle tone (abdominal muscles). - pt.s with excessive weight. - pt.s with poor posture. - pt.s with jobs that require repetitive heavy lifting or vibration. - pt.s who smoke. management of low back pain.... -> for mild to moderate pain: analgesics, NSAIDs, muscle relaxants, bracing or corsets, bed rest (lying down with knees bent, reduced pressure on lower back), hot & cold therapy. -> for severe pain: corticosteroids & anesthetic injections; surgery = diskectomy (removal/partial removal of a specific disk), laminectomy (removal of the lamina which is a portion of the vertebrae), or spinal fusion (putting strips of bone between the vertebrae to stabilize them so that they can't move around). patient teaching.... - the best position while lying in bed = knees bent; use a pillow under knees when lying on back. - prevention = using good body mechanics, core strengthening exercises. - avoid being in the same position for long periods of time.
what speeds up/slows down the heart?
--> sympathetic nervous system speeds it up! --> parasympathetic nervous system slows it down! *** the faster the heart is beating, the more it is working.
RN specific tasks:
--> tasks that RNs may NOT delegate include..... - initial nursing & follow-up assessment if nursing judgment is indicated. - decisions & judgements about pt. outcomes. - determination & approval of a pt. plan of care. - interventions that require professional nursing knowledge, decisions, or skills. - decisions & judgments necessary for the evaluation of pt. care.
What parts of the surgical gown are considered sterile?
--> the chest area down to their waist, & just a few inches above their elbows are all sterile areas. *** shoulder areas are not sterile !!!!!
coronary circulation: left & right coronary arteries
--> the coronary arteries are located immediately above the aortic valve, & their purpose is to supply the heart tissue with oxygenated blood & nutrients. --> left coronary artery divides into the left circumflex & the left anterior descending. --> what happens when these arteries become narrowed or blocked? -> either ischemia or infarction. - ischemia is reversible; it's when there is not enough oxygen supplying the tissues, so the tissues become hypoxic. - infarction is when there is permanent loss of blood flow, & the cells die from that lack of blood flow.
pulse pressure:
--> the difference between the systolic & the diastolic blood pressure.
Statins (HMG-CoA Reductase Inhibitors):
--> the main drug used to reduce cholesterol levels; they are the most potent LDL cholesterol reducers! --> it works by restricting lipoprotein production in the liver. --> pt. will typically receive them at night because the body produces the most cholesterol at night. examples: 1) Lovastatin (Mevacor) 2) Simvastatin (Zocor) side effects: - mild, transient GI disturbances. - rash. - headache. - myopathy (muscle pain). - increase in liver enzymes (so we must monitor these periodically). ** current guidelines --> if pt. has high risk for CAD, or if pt. is over 40 & has diabetes, or if pt. is over 40 & has a high risk for CAD, they will probably be taking a type of statin.
Phantom pain:
--> the pt. feels as though the amputated limb is still present, as it hurts them. --> the pain is a real sensation, & should be treated with a prescribed analgesic. --> the pain should gradually diminish over a few weeks.
types of pre-operative medications that are frequently given:
--> these meds are used to prepare patients for surgery. --> these meds can be given on the floor or in the pre-op area by a nurse or anesthesiologist. 1) Benzodiazepines: -> used for amnesia & anxiety reduction. -> commonly used for procedural sedation or adjunctive to anesthesia (the more relaxed the pt. is, the less anesthesia they require). -> CNS depressant; causes sedation, lowers BP/respiratory rate, can cause hiccups. ex. Versed (Midazolam): 1-2.5 mg IV (1+1) over 2 mins each. ex. Valium (Diazepam): 2-10 mg (5 mg/min). ex. Ativan (Lorazepam): 1-2 mg diluted with equal amount of normal saline & IV push over 1 min. 2) Anticholinergics: -> used to inhibit secretions; causes dry mouth & prevents aspiration by inhibiting excessive respiratory secretions. - side effects = dilates pupils, decreases GI motility, may cause urinary retention, & can increase intraocular pressure (so caution with glaucoma). ex. Atropine Sulfate, Robinul (glycopyrrolate), scopolamine (transform scop). 3) Antiemetics: -> used to prevent nausea/vomiting. ex. Reglan (Metoclopramide): 10 mg IV (given over 1-2 mins); can cause extrapyramidal effects. ex. Zofran (Ondansetron): 4 mg IV (given over 30 seconds to 2-5 mins); can cause dysrhythmias, hypotension, & fainting. ex. Phenergan (Promethazine): 12.5-25 mg IV (given over 5-10 mins); can cause burning at site, sedation, bradycardia, & confusion, may act as a CNS depressant & lower BP. 4) H2 Receptor Antagonist: -> used to decrease acid in the stomach (NPO patients can have increased stress which causes increased stomach acid). -> helps prevent aspiration, or any kind of stomach ulcers/reflux. ex. Pepcid (Famotidine): 20mg IV in 5-10ml over 2 mins. ex. Zantac (Ranitidine): 50mg in 20ml NS (normal saline) over 5 mins. ex. Tagamet (Cimetidine): 300mg in 20ml NS over 5 mins. 5) Narcotics: -> used to decrease pain during pre-op procedures. - they may reduce the amount of anesthesia that's needed for the pt.'s surgery. - they are adjunctive to sedation or induction. ex. Fentanyl Sulfate. ex. Demerol (Meperidine). ex. Morphine Sulfate. ex. Dilaudid (Hydromorphone).
Benign vs. Malignant Neoplasms (tumors):
--> tumors can be classified as benign or malignant. -> benign have cells that tend to not be as undifferentiated as the malignant kind, & they don't metastasize. -> the ability of malignant tumor cells to be able to invade & metastasize is the major difference between benign & malignant neoplasms.
Total Joint Replacements:
--> usually performed to relieve pain, improve ROM, & correct deformities. --> replacement arthroplasty is available for elbow, shoulder, fingers, hip, knee, ankle & foot. 2 primary types of implants: 1) Cemented is recommend for older adults; doesn't last as long as cementless. 2) Cementless is recommended for adults with a life expectancy of 25 years or more; prosthetic has little holes in it so new bone can grow through it, & becomes a more permanent part of the joint. 2 issues to consider for pt.s undergoing a total joint replacement: 1) bleeding (so pre-operatively, all anticoagulants, NSAIDs, & anti-platelet meds must be stopped at least a week before surgery). 2) infection (so pt. must be free of any infection & acute joint inflammation prior to surgery, due to the high risk of post-op infection). nursing care post-op.... --> for total hip replacements, pt.s must avoid internal rotation, adduction, & 90 degree flexion for at least 4-6 weeks to prevent dislocation..... - so pt. will need abduction pillows, raised toilet seats, no driving or tub baths, & avoid bending over & don't cross legs. --> for total knee replacements, pt.s may have a compression immobilizer..... - pt.s may be up & walking with a walker for rehab the very next day! - pt.s may have a CPM machine (continuous passive motion; a machine that will slowly bend the pt.'s knee & then straightens it back out again). --> for total elbow/shoulder replacements, the rehab may be harder & longer than for hips/knees. potential post-op complications.... - pt.s will generally need Coumadin (or Lovenox) therapy for 3 weeks because there's a high risk of DVT (deep vein thrombosis). - pt.s may have NSAIDs prescribed for inflammation, as well as narcotic analgesics for pain. - pt.s may have IV or PO antibiotics because of the high risk for post-op infection. - we need to teach pt. how to use walker & cane safely & if there are any positioning restrictions (ex: hip replacements). - we must perform thorough & frequent neurovascular assessments.
palliative/hospice care:
--> usually when pt.s are in the last 6 months of their life. --> a concept of comprehensive, multidisciplinary approach focusing on symptomatic relief, & psychological support when cure & remission are no longer possible. --> work with family & pt. to prepare for death. --> works with family after the pt.'s death.
other types of arterial disorders:
1) Buerger's Disease (Thromboangiitis Obliterans) - an arterial problem. - inflammatory, thrombotic disorder that affects the medium sized arteries & veins of the upper or lower extremities. - predominantly a younger male problem. - there is a direct correlation with cigarette smoking, so pt. MUST stop smoking. - often results in amputation if not managed. 2) Raynaud's Phenomenon - an arterial problem. - spasm of the smaller arteries, typically in the hands & fingers. - is more common in women. - treated with calcium channel blockers. - symptoms are usually brought on by stimuli such as stress, cold, or caffeine. - it is an intermittent process, so may only need to take medication in the winter. - hereditary. - causes pain in hands/fingers. -> causes 3 color changes in hands/fingers......... 1) white (constriction) 2) blue (lack of O2) 3) red (recirculation)
diabetes complications: Diabetic Ketoacidosis (DKA)
1) Diabetic Ketoacidosis (DKA) - an acute complication. - caused by a profound deficiency in insulin (or decreases/missed dose of insulin, illness/infection, undiagnosed type 1, trauma, insulin noncompliance). - more likely in type 1, but could happen in type 2 (during periods of severe illness/stress when the pancreas cannot meet the demand for insulin). -> because there is no insulin, the cells get no glucose, so the cells turn to fat stores for fuel; a byproduct of fat metabolism is ketones, which are acidic. -> so the pt. will have hyperglycemia, ketones, & acidosis as a result. - pt. will usually experience severe osmotic diuresis, causing dehydration. -> if left untreated, DKA can cause coma, electrolyte imbalance, acidosis, & even death. symptoms: - fatigue & weakness. - headache. - polyuria. - dry mucous membranes. - thirst. - poor skin turgor. - dehydration. - Kussmaul respirations (rapid, deep breathing). - hypotension. - serum/urine ketones. - abnormal serum Na, K+, Chloride. - fruity (acetone) breath. - dizziness. - vomiting. - abdominal pain. - CNS depression. lab findings: - elevated blood glucose (> 250) - pH < 7.3 - serum bicarbonate level will be low (less than or equal to 16). - ketones will be high. - elevated BUN, creatinine, & H&H. treatment: - a big problem with DKA is hydration, so the first thing we want to do is start IV access with fluid resuscitation (NaCl 0.45% or 0.9%); add 5% to 10% dextrose when blood glucose level approaches 250 mg/dl. - then we want to start IV continuous regular insulin drip (usually starts 0.1 U/kg/hr). - administer potassium replacements as needed. *** as we start to correct the acidosis, potassium will follow glucose back into the cells, so we need to watch for hypokalemia.
fractures: 2 types of complications
1) Direct Complications - problems with bone union (bones don't grow back together properly). - avascular necrosis (bone cells die due to lack of blood supply). - bone infection (osteomyelitis). 2) Indirect Complications -> blood vessel & nerve damage results in.... - compartment syndrome. - venous thrombosis. - fat embolism. - shock.
Dislocation & Subluxation:
1) Dislocation - the total displacement of the surfaces of a joint. - with a hip dislocation, the affected leg will be shorter than the normal leg. 2) Subluxation - a partial displacement of the surfaces of a joint. -> signs & symptoms that indicate a dislocation: pain, asymmetry. -> nursing interventions: pain management, keeping the extremity immobile until it can be reduced. -> medical intervention: reduction = putting the joint back into proper placement; closed reduction is just manipulating the joint back into proper position, open reduction is surgical replacement. *** the longer the joint remains unreduced, the greater the risk for avascular necrosis (death of bone cells due to lack of blood flow). ---> dislocation patients are at risk for circulatory compromise!
how do you diagnose an arterial occlusion?
1) Doppler Flow Studies/Doppler Ultrasounds 2) Spiral CT scan *** we need to figure out the location of the occlusion in order to be able to treat it!
how can we diagnose a DVT/VTE?
1) Doppler studies - most common. - an ultrasound that can tell if you have a clot. - this would be done bilaterally, so MD can compare both extremities. 2) Venogram - an x-ray with contrast dye can detect if there are clots. 3) Spiral CT scan - detects more so the presence of a pulmonary embolism. 4) Pulmonary Arteriogram - an x-ray with contrast dye. - used to detect the location & size of a pulmonary embolism. 5) Coagulation studies - if pt. is on Coumadin, we are checking their PT & INR. - if pt. is on Heparin, we are checking their PTT.
varicose veins: treatment
1) Endovenous Ablation - a laser is used to seal off the blood flow to the affected veins. 2) Sclerotherapy - an irritating substance is injected into the affected veins, causing the veins to collapse. 3) Vein stripping - they make an incision & remove the vein. 4) Support Hose - pt. can start out by using these before any procedures to see if they help. - after any procedure, pt. will still typically need to wear them.
the 7 warning signs of cancer:
1. Change in bowel or bladder habits. 2. A sore that does not heal. 3. Unusual bleeding or discharge. 4. Thickening or lump in breast or elsewhere. 5. Indigestion or difficulty swallowing. 6. Obvious change in wart or mole. 7. Nagging cough or hoarseness. *CAUTION*
How does the PCA process work?
1. it starts with an MD order (med, amount, delivery mode). 2. nurse will program the PCA machine (must have another nurse double verify everything; if MD changes order in anyway, another nurse must also double verify any changes). 3. patient & family education (going over all the rules; the pt. is the ONLY one allowed to push the button). 4. lockout (ex. if PCA is set to every 10 mins, when pt. presses button, they won't be able to get any more med. for another 10 mins; however, the machine will ding every time the button is pressed, so gives almost a placebo effect).
The patient is receiving Morphine PCA with a continuous rate of 3 mg/hour and a demand dose of 1.5 mg. The lockout is 10 minutes. How much morphine is the maximum that this patient can receive in 1 hour? (Include only numbers in your response)
1.5 mg x (60 minutes/10 minutes) = 1.5 mg x 6 = 9 mg + 3 mg continuous rate = 12 mg Answer is 12
Your patient is prescribed Toradol 25 mg IV push. The pharmacy supplies Toradol 15 mg/ml in a 2 ml. vial. How many ml would you need to draw up to give the correct dose? (Round to the nearest tenth. Include only numbers and a decimal in your answer)
1.7
Ordered: Zofran 3.5 mg IV push now. Supplied: Zofran 2 mg/1 ml, 5 ml vial. How many ml will you administer? (round to the tenth place)
1.8 ml
Your patient is prescribed Solu-Medrol 75 mg IV push. The pharmacy supplies Solu-Medrol 40 mg/ml in a 2 ml vial. How many ml will you draw up to give the correct dose? (Round to the nearest tenth and include only numbers and a decimal in your answer).
1.9
Patient is receiving Fentanyl PCA with a continuous rate of 10 mcg/hour and a demand dose of 10 mcg. The lockout is 10 minutes. How much fentanyl is the maximum that this patient can receive in 1 hour?
10 mcg x (60 minutes/10 minutes)= 10 mcg x 6 = 60 mcg 60 mcg + 10 mcg= 70 mcg Answer = 70 mcg per hour maximum
BBC insulin dosing model:
BBC = Basal, Bolus, Corrective Dose insulin Model. Basal Insulin: - mimics the constant amount of insulin secreted by the pancreas to maintain a blood glucose of 80-100for homeostasis. - administered to eating, NPO, TPN, or tube feed patients. Bolus Insulin: - "Meal Time", "Prandial", or "Nutritional" insulin. - mimics the meal time insulin that I secreted by the pancreas when the blood glucose rises over 100. - administered to only eating or bolus tube fed patients. Corrective Insulin: - given in addition to "correct" low bolus levels. - often thought of as the new "sliding scale". - administered to eating, NPO, TPN, or tube fed patients.
Match the medication with the correct conditions:
Biologic Therapy, such as -> Rheumatoid Arthritis adalimumab (Humira) Methotrexate (Rheumatrex) -> Rheumatoid Arthritis Oral corticosteroids -> Rheumatoid Arthritis Intra-articular corticosteroids -> Osteoarthritis Colchicine (Colcrys) -> Gout Allopurinol -> Gout Hyaluronic acid (Synvisc) -> Osteoarthritis Zoledronic acid (Reclast) -> Osteoporosis Alendronate (Fosamax) -> Osteoporosis
diabetes: lab value goals!!!!
Blood Glucose: -> fasting & pre-prandial BG: < 130 mg/dl. -> peak post-prandial BG: < 180 mg/dl. HgA1C: < 7% BP: -> systolic: < 140 LDL: < 100 when to call the MD -> BG drops below 80 for no explainable reason. -> BG spikes above 200 for 3 days in a row. -> if pt. has a pattern of BG spiking at the same time every day.
Identify which of the items below are carcinogens? select one or more. a. Sun exposure b. Human Immunodeficiency virus (HIV) c. Cigarette smoking d. Obesity e. Charlotte drinking water f. Dietary fat g. Hepatitis B virus h. Estrogen replacement therapy i. Air pollution
Cigarette smoking. Hepatitis B virus. Sun exposure. Estrogen replacement therapy. Air pollution. Human Immunodeficiency virus (HIV).
compensated heart failure VS. decompensated heart failure:
Compensated HF -> when the compensatory mechanisms succeed in maintaining adequate cardiac output. Decompensated HF -> the compensatory mechanisms are no longer able to maintain the cardiac output.
A male patient with a long-standing history of heart failure has recently qualified for hospice care. What measure should the nurse now prioritize when providing care for this patient? A Taper the patient off his current medications. B Continue education for the patient and his family. C Pursue experimental therapies or surgical options. D Choose interventions to promote comfort and prevent suffering.
D Choose interventions to promote comfort and prevent suffering.
The nurse is caring for a patient on an antihypertensive medication. In preparing to administer the medication, the nurse checks the BP and obtains a reading of 120/74. What is the most appropriate action for the nurse to take? A. Withhold the medication and clarify the order with the physician. B. Give the medication. C. Hold the medication and recheck the BP in one hour. D. Give the medication and notify the physician.
Give the medication.
how to treat hypoglycemia (parentally):
IV access: push 20-50 ml IV of D50 (Dextrose 50%); notify the MD; check blood glucose after 5 mins. If there is no IV access: give 1 mg of Glucagon IM; notify the MD, check blood glucose after 15 mins (glucagon stimulates the liver to convert glycogen to glucose, which makes glucose more readily available). --> follow with D5 IV solution if the level of consciousness decreases. *** glucagon can make a pt. feel nauseous, so if they have altered level of consciousness & now feel nauseous, they are at risk for aspiration, so we want to elevate head of the bed!
how to care for a SICK diabetic patient:
If pt. has a cold/flu: - continue regular meal plan. - continue oral agents or insulin. - increase non-caloric fluids. If pt. is febrile: - adequate fluids (1/2-1 cup per hour). If pt. has vomiting/diarrhea: - small amount of liquid every 15-30 mins. Call MD if: - vomiting/diarrhea for 6 hours. - no intake for 24 hours. - moderate to large ketones in urine. - blood glucose is > 240 for 2 tests in a row. *** being sick makes the blood sugar increase, so these patients should NOT stop taking their insulin; type 2 patients may even require insulin.
HF pt.s - Nutritional Therapy:
Low Sodium Diet: - if hf pt. has a lot of sodium, water follows salt, so it will cause fluid retention & that isn't good for a hf pt!! - one of the most common reasons that hf pt.s are readmitted is their failure to adhere to a low sodium diet. -obtain a detailed diet history. - include what, when, where, how the patient eats. - include cultural values related to food. - use this info to help pt.s with diet choices. Fluid Restriction: - for pt.s who are in moderate-severe hf. - less than 2 Liters a day. - the best measure of your patient's fluid status is recording their daily weights. - the general rule is to notify MD if pt. gains 3 lbs over 2 days, or 3-5 lbs over a week.
diabetes: chronic complications
Macrovascular --> complications that arise from the larger blood vessels. -> includes cerebrovascular, cardiovascular, & peripheral vascular. Microvascular --> result from changes in the small arterioles or capillaries, as a result from hyperglycemia. -> these complications are specific to diabetes, & they include: retinopathy (changes to the retina; leading cause of adult blindness), nephropathy (damage to the kidneys; leading cause of end stage kidney disease in US), & dermopathy (darker skin lesions). - these complications usually appear 10-20 years after the diagnosis.
Aspirin:
NSAID & blood thinner --> inhibits platelet aggregation. --> also used for pain relief/fever. - if it's being used for pain, it will typically be on the MAR as PRN for pain or a scheduled dose every 6 hours. - it the pt. is only getting one aspirin a day, it is probably to inhibit platelet aggregation. - typical dose is 81 mg (baby aspirin) - 325 mg (adult) once per day. Adverse Effects... - nausea & vomiting. - GI bleeding. - bleeding. - thrombocytopenia (low blood platelet count). Contraindications... - allergies to aspirin or NSAIDs. - if pt. is pregnant or lactating. - history of bleeding or stomach ulcers.
Match the analgesics with the appropriate pain scale rating:
Pain rated as a "2" = Tylenol/Acetaminophen Pain rated as a "6" = Oxycodone Pain rated as a "10" = Dilaudid/Hydromorphone
Problems with insulin therapy:
Somogyi Effect --> pt.'s blood sugar is really high when they wake up in the morning. --> the pt.'s blood sugar drops when they are asleep so the body senses hypoglycemia & secretes counter-regulatory hormones, which causes a rebound affect & puts the body into hyperglycemia. --> pt. may report headaches upon awakening & nightmares/night sweats. --> diagnosed by: check blood glucose between 2-4 AM. --> treated by giving less insulin at bedtime, or eating a snack before bed. Dawn Phenomenon --> pt.'s blood sugar is really high when they wake up in the morning. --> this occurs because the pt. has really high levels of growth hormone & cortisol naturally in their body. --> more common in adolescence & young adults. --> treated by increasing the insulin dosage.
Match the cancer disease process with the correct classification according to the Tumor Node Metastasis Classification System:
T : Tumor T0 = no evidence of primary tumor. Tis = Carcinoma in situ. T1-T4 = Increase in tumor size/involvement. Tx = Cannot measure. N : Lymph Nodes N0 = No disease in lymph nodes. N1-N4 = Lymph node involvement. Nx = Unable to assess lymph nodes. M : Metastasis M0 = No evidence of metastasis. M1-M4 = Increase in metastasis. Mx = Cannot be determined.
how to treat hypoglycemia (orally):
The Rule of 15 --- 15 grams of carbs is 1 serving! ---> we want to give 15 grams of easily digested carbohydrates (simple carb); a donut or snickers would not be good to give because the fat in those complex carbs actually slows down digestion. ---> check the blood glucose 15 mins after administering; if no change, can repeat two more times. ---> once the blood glucose is stable, follow up with a complex carb & protein meal or snack (slice of bread, PB crackers, or sandwich). examples of 15 gram simple carb choices: 1) 1/2 cup of apple or orange juice. 2) 1/2 cup of a regular soft drink. 3) 1 tbsp of honey or syrup.
The nurse is evaluating a patient with class 3 heart failure. Which findings indicate that the patient is ready to be discharged home? select one or more. a. A home care nurse is scheduled to see the patient the day after discharge. b. The patient is taking furosemide (Lasix) 20 mg IV twice daily. c. A smoking cessation consult is scheduled for 2 days after discharge. d. There is a scale in the patient's home. e. The patient is ambulating with minimal discomfort.
There is a scale in the patient's home. The patient is ambulating with minimal discomfort. A home care nurse is scheduled to see the patient the day after discharge.
True or False: A dislocation should be reduced as quickly as possible.
True
The patient with expressive aphasia is having difficulty communicating with the nurse. Which action by the nurse would be most helpful? a. Ask the patient to use gestures or point to needed objects. b. Speak slowly and clearly when providing instruction or asking questions. c. Reduce frustration by nodding and agreeing when unable to understand the patient. d. Ensure that the patient is facing the nurse when attempting to speak.
a) Ask the patient to use gestures or point to needed objects.
Which class of drug is commonly prescribed to treat Raynaud's Phenomenon? a. Calcium channel blockers b. Beta blockers c. Central acting adrenergics d. Vasodilators
a) Calcium channel blockers
Which of the following tasks must be performed by an RN? select all that apply. a. Develop a plan of care for a patient with Heart Failure. b. Perform a fingerstick on a new diabetic. c. Evaluate the care provided by an LPN. d. Perform a dressing change that requires modification based on condition of wound.
a) Develop a plan of care for a patient with Heart Failure. c) Evaluate the care provided by an LPN. d) Perform a dressing change that requires modification based on condition of wound. *** These are specified tasks that RNs may not delegate because they are specific to the discipline of professional nursing...... • Initial nursing and follow-up assessment if nursing judgment is indicated. • Decisions and judgments about client outcomes. • Determination and approval of a client plan of care. • Interventions that require professional nursing knowledge, decisions, or skills. • Decisions and judgments necessary for the evaluation of client care.
A patient with chronic heart failure has a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider prior to administering which medication? a. Digoxin (Lanoxin) 0.25 mg/day b. Metoprolol (Lopressor) 12.5 mg/day c. Ibuprofen (Motrin) 400 mg every 6 hours d. Lantus insulin 24 units subcutaneously every evening
a) Digoxin (Lanoxin) 0.25 mg/day
The nurse is preparing to administer the thrombolytic t-PA to a patient with symptoms of stroke. What actions by the nurse are appropriate? (Select all that apply). a. Ensure that the symptoms of stroke began within the past 3-4.5 hours. b. Ensure the medication is started prior to sending the patient for a head CT scan. c. Assess blood pressure to be sure that the systolic pressure is less than 185. d. Ask if the patient has had any recent surgery, trauma or GI bleeding.
a) Ensure that the symptoms of stroke began within the past 3-4.5 hours. c) Assess blood pressure to be sure that the systolic pressure is less than 185. d) Ask if the patient has had any recent surgery, trauma or GI bleeding.
What are possible side effects of corticosteroids? (Select all that apply). a) Fluid retention b) Hypotension c) Increased blood sugar d) Increased risk of infection
a) Fluid retention c) Increased blood sugar d) Increased risk of infection
What instruction should the nurse include when teaching a patient about acarbose (Precose)? a. Hypoglycemia must be treated with oral dextrose instead of sucrose (cane sugar). b. This drug works by increasing insulin sensitivity of the tissues. c. Take the medication regularly, even if you skip a meal. d. This drug is an injection that cannot be combined with insulin.
a) Hypoglycemia must be treated with oral dextrose instead of sucrose (cane sugar). *** Rationale = Acarbose is an alpha-glucosidase inhibitor which works by slowing down absorption of carbohydrates in the small intestine. For this reason, hypoglycemia must be treated with oral dextrose, whose absorption is not inhibited by acarbose, instead of cane sugar. It should be taken with the first bite of a meal. It is an oral medication.
What are the actions of sitagliptin (Januvia)? (Select all that apply). a. Increases insulin release from the pancreas. b. Decreases glucagon secretion from the liver. c. Prolongs action of incretin hormones. d. Slows down absorption of carbohydrates in the GI tract.
a) Increases insulin release from the pancreas. b) Decreases glucagon secretion from the liver. c) Prolongs action of incretin hormones. *** Rationale = Sitagliptin is a DPP-4 inhibitor. These drugs prolong the action of incretin hormones, resulting in increased insulin release and decreased hepatic glucose production. They do not affect the absorption of carbs in the GI tract.
What should you teach your patient about HCTZ (thiazide diuretic)? a) take medication first thing in the morning. b) take medication before bedtime to prevent dizziness. c) advise pt. to eat more protein. d) advise pt. to report abdominal pain to MD.
a) take medication first thing in the morning.
The nurse is explaining to her patient why she is administering Fentanyl as a pre-operative medication. What would be the most accurate explanation? a) to reduce the anesthesia required during surgery. b) to decrease post-operative pain medication requirements. c) to decrease nausea after surgery. d) to increase oxygen requirements during surgery.
a) to reduce the anesthesia required during surgery.
orthopedic surgery: Amputations
* AKA = above the knee amputation. * BKA = below the knee amputation. the goals of amputation surgery.... - removing infected, damaged or ischemic tissue while preserving as much extremity function as possible. - amputations that are below the knee or below the elbow joint allow for better prosthetic devices, as well as improved function (better process with rehab). Indications... - circulatory impairment that cannot be fixed any other way. - traumatic & thermal injuries (burns). - malignant tumors. - uncontrolled infections. - congenital disorders. 2 major groups of pt.s that have to undergo amputations... 1) Surgical: - due to effects of peripheral vascular disease & diabetes. - both of those diseases impair circulation to the extremities, so if circulation cannot be fixed, we amputate. 2) Traumatic: - due to accidents or injuries. Nurse's role in amputation prevention... 1) ex: You are caring for a 74 year old diabetic pt. What could you do for this pt. that could potentially prevent a lower extremity amputation? --> controlling their blood sugar, & properly caring for their feet to help preserve circulation. 2) ex: You are caring for a 24 year old pt. who shares with you that he enjoys extreme sports. Is there any way to prevent a traumatic amputation? --> teaching regarding safety & using proper gear in order to prevent injuries. nurse's role in preventing post-amputation complications... -> short term: hemorrhage (look for signs of bleeding, look underneath the extremity, look at vital signs like increased HR & decreased BP). -> long term: contracture (a bent joint that cannot be straightened actively or passively; place pt. in prone position on stomach with hip & leg in extension for 30 mins 3-4 times a day; we must shape the residual limb to prepare it for prosthesis by using compression bandages or shrinker stockings).
the most common areas where arterial blockages occur:
* refer to picture * --> diabetic pt.s typically have them most often below their knees, or ankle areas.
Nutrition Therapy Goals:
*** MNT = medical nutrition therapy. --> The ADA (American Diabetes Association) has established a list of goals for healthy foods to help improve metabolic control, such as..... - maintain blood glucose levels to as near normal as safely possible. - normal lipid profiles & blood pressure. - prevent or slow complications of diabetes. - individual needs; personal/cultural preferences. - maintain pleasure of eating.
Heparin practice math questions:
*** always verify order, dosage calculation, vial & amount to be given with 2 RNs prior to administering the IV dose! Question 1: Order: IV heparin at 2400 units/hour Supplied: heparin 25,000 units/250 ml NS What is the flow rate (ml/hour)? ----> 25,000 units = 2,400 units/hour -------------- ------------------ 250 ml X ml/hour -------> 25,000X = 250 x 2,400 units -------------> X = 24 ml/hour Question 2: Upon assessment, you find the following: Heparin 25,000 units/500 ml NS at 27 ml/hour What dose (units/hour) is infusing? ----> 25,000 units = Xunits/hour --------------- ------------- 500 ml 27 ml/hour -------> 25,000 units x 27 ml = 500X -------------> X = 1350 units/hour Question 3: Order reads: Heparin 8,200 units IV push now. The vial from pharmacy is marked: Heparin 10,000 units/10 ml How many ml do you give? ----> 10,000 units x 8,200 units -------------- ------------- 10 ml X --------> X = 8.2 ml **ROUNDING RULES** -> if the answer is more than 1 ml, round to the nearest 10th (ex. 1.47 = 1.5) -> if the answer is less than 1 ml, round to the nearest 100th (ex. 0.466 = 0.47) -> remember that continuous IV drips are rounded to a whole number!!
what kind of diagnostic tests can we use to determine if pt. has had a stroke?
*** if we think a pt. has had a stroke, the goal is to get that pt. a CT within 25 mins of when they were brought into the hospital. ---> most common tool used is the NIHSS; it is a very thorough neurological evaluation that aims to determine if the pt. has had a stroke. CT: non contrast -> the primary diagnostic test used to determine what is going on. - used after a stroke. - differentiates between if it is a infarction (ischemic) stroke & or a hemorrhagic stroke. MRI -> a more specific test. - determines the extent of the brain injury. CTA/MRA: imaging angiography -> can see any perfusion or filling defects. -> can see any vascular lesions or blockages. Angiography -> a catheter is inserted into the blood vessels of the brain, & examines the intracranial arteries. - risky, because it could dislodge a clot or puncture vessels. Cardiac Assessments -> EKG = to determine the pt. is not having any arrhythmias. -> TEE = (trans esophageal echocardiogram) to determine if they are in atrial fib or if they have a lot of clots sitting in their heart. Lumbar Puncture - not super common. -> may be performed in order to look for red blood cells if a hemorrhagic stroke is suspected, but the CT was too inconclusive to tell. - normal pt.s do not have blood in the cerebral spinal fluid (it's very clear), but hemorrhagic stroke pt.s will have blood in their spinal fluid. - not done with increased ICP.
clinical manifestations & complications of a DVT:
*** it depends on where (superficial or deep) the clot is & how big it is!!! -> the area may be red, warm to touch, & painful. -> however, sometimes there are no symptoms at all. - if the clot is in the upper extremities, it is most often related to their IV line. complications: -> pulmonary embolus = we are worries about the clot breaking off & traveling to the lungs. -> chronic venous insufficiency = after having a DVT, that vein may remain swollen & painful, & doesn't get good venous return blood flow. -> ulceration with gangrene = if a vein doesn't get good venous return, it is at a higher risk for infection or an ulcer that doesn't fully heal.
how does insulin work?
*** refer to picture *** --> "insulin is the key that unlocks the door to the cells, & once the door is open, glucose can enter the cells." - if the insulin cannot unlock the door, no glucose gets into the cell. - if the cell doesn't get enough glucose for fuel, the cell will turn to the fat/protein for fuel. - ketones are byproducts of fat & protein metabolism, and they are acidic; so someone will enter into ketoacidosis if their cells don't get enough glucose.
Comparison of type 1 and type 2 diabetes:
*** refer to picture *** Type 1 -> insulin produced? No -> insulin therapy? Yes -> age of onset? < 40 years old -> body type? Slim -> onset of symptoms? Rapid Type 2 -> insulin produced? Yes -> insulin therapy? Not at first -> age of onset? Older adults -> body type? Obese -> onset of symptoms? Gradual
coronary artery disease (CAD):
---> "Atherosclerosis" ---> it is the build-up of fats & lipids in the inner lining of the coronary arteries, which are responsible for supplying blood to the heart muscle. - men are more likely to develop CAD than women; but the opportunity equalizes after age 65. race - CAD is the leading cause of death in women, killing 10 times as many women as breast cancer does each year; women are more likely to have silent ischemia & not have the typical symptoms of CAD, meaning they are often misdiagnosed. - this disease can start when your'e young (20-30), & can build up over time; we won't know it's there until the blockages are big enough to cause a problem. - it starts off as fatty streaks; lipid cells start lining & streaking the inner linings of the arteries......as the lesion grows, it becomes more complicated; collagen & other substances start to be deposited there......eventually it becomes so big that it closes off the artery & a clot forms, which causes a heart attack. - some patients can develop collateral circulation, which is the body's way of forming a natural bypass around the blocked artery...... however, sometimes the collateral is not sufficient to meet the needs of the heart, especially during stress/exercise; women & diabetics typically do not develop collaterals.
Risk Factors for developing CAD:
---> 2 main categories: modifiable & non-modifiable... -> Modifiable: things you can change that are major contributors to CAD, such as elevated serum lipid levels (cholesterol/triglycerides), hypertension (major risk factor), smoking (no matter how long you've been smoking, if you stop for a year, your cardiovascular risk decreases by half), sedentary life style (obesity/diabetes), psychological state (if you're always grumpy & negative, that may contribute to CAD), & substance abuse. -> Non-Modifiable: things you cannot change, such as age, gender, race (African Americans more likely to have CAD), & family history (if your family member has had CAD, then you are more likely to have CAD).
If giving IV heparin, what is the safe dosage range for the amount of units per day?
---> 20,000 - 40,000 units per day is the safe range! -> many facilities have protocols where the dosage is based on pt. weight & PTT values.
Diabetes treatment:
---> 3 main things: -> medication. -> nutritional management. -> exercise. ---> monitoring the blood glucose! Medication -> there are 3 major groups of drugs that we use... 1) Insulin 2) Oral agents 3) Non-insulin injectables --> for Type 1 treatment = we use insulin. --> for Type 2 treatment = we can use insulin/oral agents/non-insulin injectables/exercise/ nutrition/a healthy weight.
Using the scale provided how many units of insulin would you give to this patient before lunch if the blood sugar is 240 and you are following the moderate scale. *** refer to picture ***
---> 8 units
Diabetic Ketoacidosis occurs mainly in which type of diabetes?
---> Type 1 Diabetes. ** DKA occurs mainly in Type 1 Diabetics. DKA is caused by the profound absence of insulin which leads to acidosis. Type 2 Diabetics most often produce some insulin. Their issue can be insulin resistance and the inadequate amount of insulin that they produce.
diabetes mellitus:
---> a chronic disease that affects multiple systems. -> in this disease, the body is either not producing enough insulin, or the body cannot use the insulin that it is producing. - it is the leading cause of adult blindness, end-stage kidney disease, & non-traumatic lower limb amputations. - it is a major contributing factor to heart disease, stroke, & hypertension. - people with diabetes & heart disease have a 2-4 times higher death rate than those with just heart disease. - diabetic pt.s have a 2-4 times higher risk for stroke. - 2/3 of people with diabetes also have hypertension.
what are the signs of increased intracranial pressure?
---> after a stroke, we need to manage our pt.'s intracranial pressure; do not lie them flat, keep the head of the bed elevated!! - change in level of consciousness. - nausea/vomiting. - increased headache. - changes in their pupils. - changes in their BP (widened pulse pressure). - decreased HR. - decreased respirations.
Arterial Occlusive disorders:
---> also known as Peripheral Artery Disease!!! Acute: --> can be caused by thrombus (clot caused y atherosclerotic changes that occur in the blood vessel) or by an embolus (clot or fat embolus that develops somewhere else in the body & moves). - can come on very suddenly. - pt. can lose the extremity or even die if they develop sepsis from it. Chronic: --> progressive narrowing of the arterial blood flow to an extremity; eventual arterial obstruction. - usually in the lower extremities. - slow, progressive symptoms = pain, decreased pulse, pallor, numbness, tingling. how does a pt. develop a chronic arterial problem? -> atherosclerotic changes in the brain/heart/etc. -> risk factors = smoking, high lipids/cholesterol, diabetics, hypertension, etc. -> ischemia is from inadequate oxygenation to peripheral tissues. -> diagnosed with doppler ultrasound, ankle-brachial index (check to see if the BP in pt.'s arm & leg is the same), duplex imaging (to determine the adequacy of blood flow), angiography, & MRI.
If an x-ray is inconclusive, what does the MD order next?
---> an MRI (shows soft tissue) *nursing considerations = is pt. wearing metal; is pt. claustrophobic?
angina:
---> angina pectoris, also known as chest pain. --> this happens when part of your heart muscle is ischemic, & is not getting enough blood flow. --> the heart is demanding, it needs oxygen; if an area of the heart is ischemic & blood flow is not restored within about 20 minutes, the pt. may develop myocardial infarction (death & necrosis of tissue). --> angina is a supply & demand problem: the heart demands a certain amount of oxygen & when the coronary arteries cannot supply that, that is when there are problems. --> an artery is usually at least 75% occluded before the pt. has any symptoms. --> diabetics & women tend to have "silent ischemia", where there are little to no symptoms, or they may just get very tired easily. --> we can reverse ischemia, but we cannot reverse infarction. precipitating factors that lead to angina: --> things that increase cardiac workload include.... - exercise. - extremes of emotions, anything that stimulates the sympathetic nervous system. - eating & having meals. - smoking (causes vasoconstriction, & decreases the available oxygen in the body). - stimulants (caffeine, cocaine, etc). ****if we increase the cardiac workload, we are increasing the demand for oxygen!!! types of angina: 1) Stable (exertional) - predictable; "I always get chest pain after I walk a mile". 2) Unstable - unpredictable, & increases in frequency & severity; "I get chest pain in the middle of the night, or when I'm just resting"; considered an acute coronary syndrome, because if the pain happens when the pt. is at rest that means the artery is getting more & more blocked. 3) Prinzmetal's - rare; due to coronary artery spasm; if the spams lasts long enough & the vasoconstriction lasts long enough, it can cause ischemia. 4) Silent Ischemia - the pt. has no typical symptoms. symptoms: --> classic angina = mid-sternal chest pain that may radiate to the left shoulder/arm, shortness of breath, diaphoresis, dizziness, nausea, anxiety. - pressure, aching. - squeezing, choking. - indigestion, burning. - sub-sternal - radiating. - anxiety. - associated symptoms such as vital sign changes, etc.
what would cause the nurse to suspect osteoporosis? a) loss of height. b) joint pain. c) calcium supplementation. d) obesity.
a) loss of height.
Carcinogens:
---> cancer causing agents. -> just because our body is exposed to a carcinogen, doesn't mean we will develop cancer; sometimes our body is able to excrete these agents from our system! 3 types: 1) Chemical carcinogens - pollutants in the air, water, & soil (Radon). - immunosuppressive drugs & cancer treating agents can be carcinogens because they affect our cells. - estrogen replacement therapy causes a higher risk for endometrial cancer & breast cancer. - Diethylstilbestrol (DES; a synthetic, non-steroidal form of estrogen) = female babies that were exposed to DES in utero are at a higher risk for vaginal cancer later on in their life. - Asbestos exposure can cause lung cancer. - Agent orange exposure can be cancer causing. - crispy brown foods/charbroiled foods can be carcinogens. - BPA plastics. 2) Radiation (2 kinds) -> Ionizing radiation (from an x-ray or nuclear medicine studies); uranium minors & radiologists have a higher risk for brain cancer if they don't wear good protective gear; people are at risk for exposure if they live close to nuclear power plants. -> UV Radiation (from sun); carcinogen that causes skin cancer. 3) Viral carcinogens -> viruses can be carcinogens, & induce the growth of cancer cells. -> the virus goes into the cell & transform the cell, & make it abnormal, which could grow into cancer; these viruses are termed "oncogenic". - Epstein-Barr Virus (EBV) can cause Burkitt's lymphoma-stomach cancer. - Human Immunodeficiency Virus (HIV) can cause Kaposi Sarcoma. - Hepatitis B Virus can cause Hepatocellular carcinoma- liver cancer. - Human Papillomavirus can cause Squamous Cell carcinomas of the cervix.
Infection: chronic diabetes complication
---> diabetic pt.s are more prone to infection, because diabetes causes a defect in mobilization of inflammatory cells & impaired phagocytosis.
nutriton therapy: alcohol
---> diabetic pt.s should only have a moderate amount (1 drink/day for women, 2 drinks/day for men). ---> can cause hypoglycemia; alcohol prevents the breakdown of glycogen to glucose in the liver, so diabetic pt.s need to eat carbs while they are drinking.
nutriton therapy: fats
---> dietary fats provide energy, provide essential fatty acids, & carry the fat-soluble vitamins. ---> diabetic pt.s should limit saturated fats to less than 7% of their total calories. ---> diabetic pt.s should limit cholesterol to less than 200 mg a day. ---> diabetic pt.s should minimize trans fat to basically none. ---> diabetic pt.s should have 2 or more servings of fish per week, because it is a really good source of essential fatty acids.
Anticoagulants & Anti-platelets: Nursing Responsibilities....
---> each dose must be verified by? - 2 RNs for whatever the facility policy is. ---> know which lab values relate to which drug! - PT = Coumadin; PTT = Heparin; Lovenox/others = none, except check pt. platelet count/hemoglobin if the drug can cause thrombocytopenia. ---> assess pt. for signs of? - bleeding. ---> know protocols for therapeutic lab values & dosing for specific facilities!!! ---> pt. teaching? - if pt. is on an anticoagulant, that drug needs to be stopped before pt. undergoes any invasive procedures. - pt. may want to consider using electric razor, softer toothbrush, etc.
diabetic patients: exercise
---> exercise..... - lowers blood glucose (risk for hypoglycemia). - decreases insulin resistance. - aids in weight loss. - lowers triglycerides & LDL levels. - increases HDL levels. - improves BP and circulation. - overall improves physical & emotional health. ---> recommended amount = 30 mins/day for 5 days/week, or 150 mins/week of moderate intensity aerobic exercise. ---> exercise safety rules for diabetic pt.s - need doctor's permission. - wear good shoes. - wear a medical ID. - carry "quick" sugar. - drink plenty of water. - check BG before, during, & after rigorous exercise. - set realistic goals. - snack before exercise; snack in middle of exercise if exercising rigorously. - 150 min/week of moderate intensity, or 90 min/week of vigorous intensity. - 3 days/week with no more than 2 days between; the glucose lowering affects can last up to 48 hours, so we want our pt.s to be consistent in order to help promote consistent BG levels.
Amy is the LPN for Mrs. Banks, who was just admitted to the floor after having surgery to remove a tumor on her ovary. Amy completes a physical assessment on Mrs. Banks. Next, she develops & discusses a plan of care for Mrs. Banks that includes pain management, ambulation on POD #1, advancing diet as tolerated, & teaching regarding care of her JP drain. Are Amy's actions within the scope of practice as the LPN?
---> false
T/F: An Asian man has a higher risk of stroke than a Hispanic man.
---> false *** African Americans have the highest risk, then it is hispanic, then it is asian, then it is Caucasian.
True or False: The Somogyi effect should be treated by increasing the bedtime insulin dose.
---> false. *** In the Somogyi effect, the patient has a drop in blood sugar during the night, around 2-3 am. This causes the release of epinephrine and glucagon that cause gluconeogenesis, which raises blood sugar. Therefore upon awakening, the blood sugar is elevated. It should be treated by decreasing the insulin or adding a bedtime snack.
T/F: Patients with Raynaud's phenomenon should use cold compresses for pain.
---> false. *** raynaud's is an arterial constriction problem!!
T/F: fluid boluses should be used to improve cerebral perfusion after a stroke.
---> false. *** you want to maintain hydration, but you don't want to over hydrate them because we don't want to increase the intracranial pressure.
normal insulin production:
---> for a normal pancreas, this is how insulin in normally produced (refer to picture). -> the blue line is the insulin produced throughout the day; the line never reaches 0, the pancreas is always producing at least a minimal amount. -> the flat, lower part of the line is the "basal rate of insulin" & the large spikes of the line is the "bolus" of insulin which is produced in response to meals.
cardiac output:
---> how much blood the ventricle is pumping out each minute. - it's measured in liters per minute. -> the formula is.... CO = Heart Rate x Stroke Volume *** anything that affects the heart rate or stroke volume will affect the cardiac output!!! - heart rate is primarily regulated by the ANS (autonomic nervous system) !!!!
Heart Failure:
---> the heart is unable to pump blood in sufficient amounts from the ventricles to meet the body's metabolic needs. -> HF is a continuum - it can range from very mild to very severe. -> the most frequent cause of hospital admissions for those other 65; about 5 million people have heart failure any given time; more than half of the cardiac related deaths are attributed to heart failure. -> 20% of pt.s diagnosed with heart failure will die within 1 year of diagnosis; 80% die within 8 years. -> we can manage the symptoms, but we cannot cure heart failure. -> African Americans have higher instances of heart failure, they tend to develop hf at a younger age, and tend to have a higher mortality related to hf. -> African Americans & Asians have more adverse effects to Ace Inhibitors (which are the most common drug used to treat hf); BiDil (combination drug of hydralazine & isosorbide dinitrate) is commonly used in the African American population to treat hf & has shown to improve ejection fraction & exercise tolerance! ---> heart failure is characterized by: -> left ventricular dysfunction!!! - this results in reduced exercise tolerance, diminished quality of life, & shortened life expectancy. risk factors for heart failure: - coronary artery disease & hypertension (2 main risks). - old age. - diabetes. - pt.s with metabolic syndrome have a higher likelihood of developing hf. - smoking. - pt.s with vascular disease. what causes heart failure: -> anything that interferes with anything that has to do with cardiac output....... - preload (having enough volume). - afterload (resistance that the heart has to pump against). - myocardial contractility (ability of the ventricles to contract). - heart rate. - if pt. has chronic hypertension. - if pt. has suffered an MI. - if pt. has cardiomyopathy.
lung cancer:
---> the leading cause of cancer deaths in the US!! - accounts for 28% of all cancer deaths (more than prostate, breast, & colon cancer combined). - smoking is responsible for 80-90% of all lung cancers (10-20% of people who get lung cancer have never smoked). - more common in men than women. - African Americans have the highest incidence of it. - NC ranks 12th highest occurrence of lung cancers that develop. - symptoms don't usually appear right away, so the cancer can grow for a pretty long time before the pt. has symptoms. - it may take the tumor cells 8-10 years to grow into a tumor that is finally a size that's big enough for a Dr. to be able to detect it on a chest x-ray/chest CT. - since most lung cancer pt.s are smokers, it may be hard for them to realize that their cough is a cancer symptom. - the cancer develops more often in the upper part of the lungs, & can grow for a long time & metastasize to the brain or liver before the pt. even has any symptoms that are severe enough to seek medical attention. **** if we determine the pt. has cancer, the next step would be to perform other testing because we want to figure out if it has metastasized!!! signs & symptoms: - cough (most likely symptom). - blood tinged sputum. - chest pain. - dyspnea, hoarseness, anorexia, fatigue. - symptoms are often non-specific & appear late in the disease process. how is it diagnosed: - chest x-ray (most common; smokers over the age of 50 should get yearly chest x-rays). - chest CT (allows us to see the lung tissues closely, & we can see if it has metastasized to the ribs). - sputum cytology (can detect cancer cells, but not always accurate). - biopsy (Bronchoscopy, Thoracentesis, Video-Assisted-Thoracoscopy (VATS); the most definitive way to determine if pt. does have lung cancer). - bone scans, labs, PET scans, CT scans of brain, pelvis, & abdomen (we are looking for if it metastasized). treatment: 1) surgical therapy (most common; a part of the lung is removed). 2) radiation therapy (radiation is used on the lung tissue to radiate all the cancer cells). 3) chemotherapy (used to kill all the cancer cells in the pt.'s body).
Left-Sided Systolic Failure means...
---> the left ventricle is not contracting well, which means it is not ejecting blood out to the rest of the body. -> the most common type of hf. ---> it is a disorder of contractility, where the left ventricle cannot squeeze as hard as it needs to. -> an MI or chronic hypertension can impair contractility. -> there is a decreased ejection fraction (% of blood squeezed out with each beat); < 45% is considered reduced! -> HFrEF = heart failure with reduced ejection fraction.
Left-Sided Diastolic Failure means...
---> the left ventricle is too stiff and cannot relax & fill with blood, which means there will be no blood to be ejected to the rest of the body. ---> the left ventricle has an impaired filling problem because it is so stiff & unable to relax, which results in the "back-up" of blood into pulmonary and/or venous systems. -> can be caused by chronic hypertension, certain cardiomyopathies, or certain diseases of the heart. -> the ejection fraction is still normal, because it's not a problem with squeezing, it's a problem with filling. -> HFpEF = heart failure with preserved ejection fraction.
skin cancer:
---> the most common cause of cancer!! 3 different categories: 1) Basal Cell Carcinoma: -> raised, kinda translucent, pearly looking red bump. - usually on the head, neck, face (around eyes & nose). - usually in an area that gets a lot of sun exposure. - most common in older patients. - usually does not spread beyond the skin, so it's almost always harmless. - the least harmful of all the skin cancers. - it arises from the base cells. 2) Squamous Cell Carcinoma: - arises from the squamous cells in the epidermis. - occurs in areas with lots of sun exposure, or areas where there has been previous sun damage. - it is usually not a problem, but it can be highly aggressive & it does have the potential to metastasize. - can lead to death if not treated early & correctly. - smokers tend to have this around their mouth. 3) Malignant Melanoma: - melanoma is the most deadly type of skin cancer. - it originates from the melanin in the skin. - it is a really dark (blacking/purplish/reddish) abnormal spot, & it gets really dark because the melanin is what produces color in the skin. - it tends to run in families, so there is a genetic predisposition. -> early melanoma detention = ABCD; asymmetrical (not a circle), borders are irregular, color (very dark looking), diameter (it is at least the size of a pencil eraser). - it can occur anywhere on the body, not just sun-exposed areas. - sometimes occurs on the palm of the hand, sole of the foot, under the nails, etc. - it can grow very quickly, & spread to nearby lymph nodes, & start to metastasize to the bone, liver, lungs, or even the brain. - if it is detected early enough, the Dr. will try to remove it with clear margins, & pt. can sometimes even need a skin graft. - if it's found early & less than a millimeter deep, the cure rate for this is 95%.
type 1 diabetes mellitus: the pathophysiology
---> the pancreas stops producing insulin. - there is an insulin deficiency or decreased insulin production by the beta cells in the pancreas. - when this occurs, the onset of symptoms is rapid; the pt. will often present with ketoacidosis & a recent history of weight loss. - this pt. is insulin dependent, so they will be put on an insulin regimen as part of their treatment. - if the glucose is not entering the cells, then there becomes excess glucose in the blood stream, which then extracts a high concentration of fluid into the vascular space; the kidneys then work to excrete that extra fluid (called osmotic diuresis), which causes polyuria. classic type 1 symptoms: - ketoacidosis (body produces high levels of blood acids called ketones, which occurs when the body can't produce enough insulin; ketones are a byproduct of fat & protein metabolism). - polyuria (production of abnormally large volumes of dilute urine; occurs from the osmotic diuresis). - polydipsia (abnormally great thirst; occurs because the pt. is peeing a lot). - polyphagia (excessive or extreme hunger; occurs because even thought pt. is eating, the cells are starving because no glucose is entering them for fuel).
how does the body try to compensate during heart failure?
--> an overloaded heart tries to maintain cardiac output by using........ 1) Neurohormonal Responses 1) Sympathetic Nervous System Activation: -> as cardiac output drops, one of the first things that's activated is your sympathetic nervous system; low cardiac output stimulates the release of epinephrine & norepinephrine (these increase HR, increase myocardial contractility, & causes vasoconstriction). - may help temporarily, but the sympathetic nervous system is the least effective compensatory mechanisms, because it increases the workload on the heart (not good, heart is already being overworked). 2) Renin-Angiotensin-Aldosterone System activation: -> the next thing to happen after the Sympathetic NS. -> decreased cardiac output causes decreased perfusion to the kidneys, so then the kidneys activate the renin system, which results in vasoconstriction & fluid retention (not good because it increases heart workload). 3) Natriuretic Peptides (ANP, BNP): -> next thing to happen after renin system. -> ANP are hormones produced by the atrium, BNP is produced by ventricles, both in response to decreased cardiac output. - these hormones cause vasodilation, diuresis, & they have anti-inflammatory effects (which helps lower cardiac workload, so this is good!!) 4) Nitric Oxide (NO): -> next thing to happen after natriuretic peptides. -> produced by the inner lining of the blood vessels (vascular endothelium). - causes vasodilation, which lowers cardiac workload (good!) **vasoconstriction = high afterload, high resistance, high workload (not good)! **vasodilation = low afterload, Lowe resistance, low workload (good)! 2) Ventricular Dilation -> cardiac chambers dilate, especially the left ventricle. - the heart muscles stretch & increase their contractile force (frank-starling's law), which initially maintains cardiac output. - however, over time the elastic fibers become too strained & stretched out & cannot compensate any longer; can possibly cause Mitral valve regurgitation. 3) Ventricular Hypertrophy -> myocardial hypertrophy is when the heart muscle gets thicker, in response to increased workload. - when the heart muscle gets bigger, it does not contract as well, it's stiffer, & doesn't fill with blood very well; it also then has increased mass so it needs more oxygen. -> also called "remodeling"; is not very helpful for the heart.
complications of arterial occlusion:
--> arterial blood flow stops. --> causes tissue death from the point when blood flow stops, because the tissues are not receiving oxygen. --> can cause death, especially if emboli breaks off & goes to the brain or the pulmonary system (from a DVT).
carpal tunnel syndrome:
--> compression of the median nerve as it passes between the ligament and the bones and tendons of the wrist. -> signs/symptoms: pain, numbness, tingling, weakness in wrist; fine motor movements are affected. - can be treated surgically in order to decompress the median nerve. - can also be treated by wearing a splint/wrist brace to inhibit repetitive motions. *** refer to concept map picture regarding pt. teaching, nursing care/interventions, & what to expect!
the grieving process after an amputation:
--> depression & inability to look at the residual extremity is normal & expected after the initial surgery. --> the pt. needs to be supported during the grieving process. --> the nurse's role: provide support, help identify support systems for the pt.
the heart beat:
--> each heart beat is a cycle of contraction (systole), followed by relaxation (diastole).
T/F: Nodules on the joints is a characteristic of Buerger's disease.
--> false *** Buerger's disease is an arterial problem.
T/F: A patient had a BKA (below the knee amputation) yesterday and has had fluctuations with blood pressure throughout the night. It would be appropriate to delegate the bath and linen change to the NA.
--> false *** if pt. is having fluctuations in BP, he is not stable; he is already at risk for bleeding due to the BKA.
T/F: Your patient has a BP of 208/112. You goal is to lower BP as quickly as possible to 120/80.
--> false. *** if you significantly decrease their blood pressure, it will decrease the perfusion they have in their brain.
what are the signs & symptoms of a fracture?
--> fracture symptoms may or may not include..... - swelling. - bruising. - pain. - protruding bones. - crepitation (crunching sound from bone fragments). - muscle spasms. --> some complications from fractures may be..... - malunion (if fracture is not reduced properly, the bone fragments don't grow back together properly). - compartment syndrome (when pressure within muscles builds to dangerous levels; this pressure can decrease blood flow, preventing nourishment & O2 from reaching nerve & muscle cells). - development of blood clots. - risk of infection (especially for open fractures).
insulin pump:
--> goes through the subcutaneous tissue; delivers a certain amount of rapid acting insulin at a time, & then the pt. can program how many additional units to give for their bolus at meals. -> have to frequently monitor blood glucose levels with using the pump.
Osteomyelitis:
--> infection of the bone. -> The infection can occur in 2 ways...... 1) Direct: the infection has occurred because theres a direct opening from the bone to the skin (ex. open fracture). 2) Indirect: the bone infection has occurred because it has spread from an infection from somewhere else in the body (ex. a severe UTI progresses to septicemia, & so that infection travels through the blood & ends up at the bone). * Acute = infection lasts less than 4 weeks. * Chronic = infection lasts more than 4 weeks; sometimes the infection may travel all the way through the surface of the skin where it may be visible. clinical manifestions... - severe bone pain; bone is weakened (at risk for fracture). - swelling, tenderness, warmth. - systemic symptoms (fever, discomfort (malaise), chills, etc.) how do we manage this... - vigorous antibiotic therapy (usually IV) for several weeks. - strict sterile technique with dressing changes. - handle the extremity very carefully = infected bone is weakened bone so at risk for fracture, & the bone is extremely painful. - prevent contracture = perform regular ROM (even though it hurts). collaborative care.... - debridement (removal of dead bone/tissue). - may need negative pressure (wound vac). - hyperbaric oxygen therapy (a very rich oxygen environment may stimulate circulation, & therefore stimulate healing).
A pt. with a fracture will want to know when they can get back to work:
--> it depends on the amount of physical activity required for their job. --> the healing of fractures: - can take up to 24 weeks. - affected by age, site, blood supply, immobilization, implants, infection, hormones, nutrition, systemic disease. - weight bearing is restricted for at least 6-12 weeks.
pre-operative checklist:
--> it's a communication tool for the healthcare team! --> it verifies that the nurse has completed the preparation for the patient.... - consent is signed. - pre-op meds are given. - type & cross match for blood. - NPO status. --> it provides a baseline of current assessment findings. *** examples of checklist items.... - pt. only has a gown on. - make-up/nail polish is removed. - prosthetic devices are removed. - verify patient ID band. - jewelry & valuables are removed.
Venous Thrombosis (VTE: venous thromboembolism):
--> venous blood pools in the lower extremities & is very likely to cause clots. - trauma pt.s have a high likelihood of developing VTE. - according to American heart association, more people have VTE each year than having a MI/stroke; very common. - VTE that progresses to a pulmonary embolism is the #1 most common cause of a preventable in-hospital death. Prevention... *VTE prophylaxis (prevention) is a core quality measure that hospitals must report on!* - compression stockings or SCDs (18 hours a day to be effective). - move fingers, toes, ROM. - prophylactic anticoagulants. (ex. Lovenox). - the best thing you can do for prevention is to get your pt. to ambulate!!! Treatment... *Primary goal is to prevent pulmonary embolus; we don't want a clot to migrate!! - ambulation. - bed rest (maybe; we used to think if pt. already has a clot, walking around may allow the clot to move; however studies show that ambulating with a clot doesn't really help the clot migrate & helps prevent immobility complications). - never massage (could physically dislodge clot & cause it to move). - performing good assessments (not only for clots, but for signs of a pulmonary embolism). - teaching the pt. about prevention & meds. Signs/Symptoms of VTE... - swelling. - warmth. - redness. - may very between pt.s
skeletal muscle relaxants:
--> what questions should the nurse ask before administering this med? - check for allergies? - have you ever had this drug before? how did it work before/did you have any issues with it? - if pt. is on any anti-seizure meds, use skeletal muscle relaxants cautiously. - use this med cautiously if pt. is older or has any renal/hepatic complications. --> what should the nurse teach the pt. about the drug? - these drugs will make you sleepy & drowsy, so higher risk for falls. - tell pt. not to get out of bed without calling the nurse. - can cause dry mouth, blurred vision (don't drive), & GI upset. - monitor pt. vital signs because this drug can cause hypotension & tachycardia.
Pre-Operative Phase:
--> where we're doing the assessment, eduction, & figuring out what the patient's needs will be through this operative process. - not often occurring in the hospital; typically happens in doctor's office, outpatient/inpatient clinics, ambulatory settings, etc. - this phase is critical for the safety & welfare of patients. --> the assessment purpose/goals = - determine current health status. - identify operative risks. - determine impact of surgery on patient & family. - anticipate recovery needs. - establish plan of care. - perform psychosocial assessment. - medical history/medications/allergies. - mental status. - review of systems. - past surgical history (pt. & family). - screening for malignant hyperthermia (deadly disease that can be inherited).
PCA assessment & documentation:
-> Assess: RR, HR, BP, sedation level, & pain score; boluses attempted/delivered & total; the total dose received. -> once the pump is started, we assess all of that every hour for the first 4 hours. -> after those first 4 hours, we assess pca once every 4 hours. -> if the MD makes any kind of change in the pca order, we have assess all of that every hour for the first 4 hours all over again.
compartment syndrome:
-> Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment & oxygen from reaching nerve & muscle cells. -> compression of structures, from swelling & accumulation of fluid, within closed compartments; results in impaired circulation!!! What causes it... -edema causes increased pressure within the closed space. - if there is swelling underneath the fascia that covers the muscles of the extremities, the fascia won't allow for any expansion, which will cause pressure. - circumferential dressing, splint, or cast won't allow for any expansion if there is swelling, so that will cause pressure. Manifestations... - the pain is progressive & will become worse with elevation!! (if you elevate their extremity, the blood flow now has to work against gravity & that will be hard with impaired circulation). - don't ice it (ice will cause vasoconstriction & circulation is already compromised to begin with). - pt. will not be able to actively extend their fingers/toes, & will severely hurt if you try to passively stretch their fingers/toes for them. - as it progresses... compartment will feel tense; loss of sensation/function; paresthesia (numbness, tingling); pt. will turn pale & feel cool; pulses will decrease/become absent (LATE SIGN). Management/Treatment... -> prompt recognition: - ischemia (inadequate blood supply to an organ/ part of the body) may occur in 4-8 hours. - do not elevate extremity. - do not ice extremity. -> relieve source of constriction: - casts, dressings, etc. can be removed (MD removes casts, nurses can remove/loosen splints). - if the muscle fascia is the source of constriction, pt. may need a surgical fasciotomy.
Heparin:
-> IV or subcutaneous anticoagulant. -> action: inhibits the conversion of prothrombin to thrombin. -> antidote: the antidote is Protamine Sulfate, however heparin has a much shorter half life than Coumadin, so we can usually just discontinue the drug if we need to reverse it. * a therapeutic dose is determined by the PTT (partial thromboplastin time; blood test that measures the time it takes your blood to clot). ** a normal PTT is 25-35 seconds; so a therapeutic range for a pt. on heparin would be 46-70 seconds. Dose... -> subcutaneous heparin = 5,000-10,000 units BID for DVT prophylaxis; if being given this way, we typically do not follow PTTs. -> IV heparin = starts with IV push bolus of up to 10,000 units, & then a continuous drip of 20,000-40,000 units/day; if being given this way, we do go off of PTTs. Adverse Effects... - bleeding. - thrombocytopenia (HIT = heparin induced thrombocytopenia)
Metabolic Syndrome:
-> a way of identifying pt.s that are at high risk for developing CAD. -> in order to be diagnosed with metabolic syndrome, the pt. must have 3 or more of the following..... - central obesity (if waist line is > 35 inches in women & > 40 inches in men). - dyslipidemia (elevated cholesterol/triglycerides). - hypertension. - impaired glucose tolerance (elevated blood glucose levels). - type 2 diabetes mellitus.
legal considerations prior to surgery:
-> all required forms must be in chart & completed per facility policy. - Living Will (specific instructions of what the pt. wants to happen in the event that they can't speak for themselves). - Power of Attorney (health care; giving someone else the power to make health care decisions for the pt. in the event that they can't speak for themselves). - Consent forms. - DNR orders (unless pt. says otherwise, DNR orders are suspended during operative phase, & operative phase ends when the pt. leaves the recovery room). *** Surgical Consent Form: - must be voluntarily signed by the pt. - the MD is responsible for explaining all of the info that the pt. needs to know in order to sign the consent form, such as risks/procedure/other options. - the nurse is only responsible for witnessing the pt.'s signature on the consent form, & for verifying the pt.'s knowledge of the procedure. - it is the DR.'s responsibility for legally obtaining the patient's consent!!!!!! (not the nurse) - pt. always has the right to give consent & withdraw consent.
cancer prevention:
-> avoid exposure to = any known carcinogens. -> eat more = fruits/veggies, whole grains, fiber, cabbage family foods, & calcium. -> eat less = fatty foods, brown crispy foods, nitrites, cured meats, preservatives. -> limit intake of = alcohol. -> participate in regular = exercise. -> maintain healthy = weight. -> obtain adequate = rest. -> reduce or learn to cope with = stress. -> have regular = Dr. check-ups. -> know your own = body (moles/lumps). -> follow recommended = screenings (mammograms/colonoscopy/etc). -> know the 7 = warning signs of cancer. -> practice self = examination. -> seek immediate medical care if = you find/notice something abnormal.
If my pt. has a PCA, what are my responsibilities as a nursing student?
-> beginning of shift/summary review: 1) press channel select key & verify settings. 2) press start key. -> access drug event history: 1) press channel select key. 2) press options, then press drug event history. 3) press exit & then press start. - assess my pt. - student responsible for checking pump settings & medication being delivered. - student not to clear out the pump. - student will not set up pump, but may discontinue pump with supervision. - student will document in Cerner if I am documenting on my pt.
the biology of cancer:
-> beings in the stem cell (immature, undifferentiated types of cells, that normally grow into specific types of cells). -> cancer cells are different in 2 ways: they grow differently, & they differentiate differently..... 1) Proliferation (growth): - they lack contact inhibition (normal cells respect each other's space, like lung cells don't grow into bone cells; but cancer cells grow into other cells' spaces). - they grow continuously (normal cells do not grow continuously, they only grow when they need to, like if we have a cut & need more skin cells to heal it; cancer cells don't stop growing). 2) Differentiation: - cancer cells revert to immature state (normal cells start as immature stem cells & then they differentiate to what they are supposed to be, like bone/hung/heart cells; however cancer cells become immature cells & do not differentiate).
how to classify fractures:
-> can be classified by..... - the direction of the fracture line. - the location on the bone (proximal, medial, distal). - displaced (bone fragments are non in proper position) or non-displaced (the bone fragments are still pretty much in the proper position). - open (the skin is broken) or closed (the skin is not broken). * open fractures: higher risk of = infection; collaborative interventions = antibiotics, antibiotic solution may be irrigated into the wound; nursing care/interventions = monitoring the wound, looking for signs of infection as in increased vitals, using strict sterile technique with wound care.
How do we manage post-op pain?
-> convey that you care! -> use analgesic ladder unless otherwise indicated: = 3 step ladder..... 1) NSAIDS, ASA, Acetaminophen (1-3 pain level). 2) Oxycodone, Hydrocodone (4-6 pain level). 3) Opioids - morphine, hydromorphone, demerol, methadone (7-10 pain level). * narcotics are usually used in first 48 hours.
as we age....
-> decreased number of pacer cells will cause arrhythmias (Bradyarrhythmia, slow arrhythmias). -> reduced response to stress causes a longer time for our heart rate to increase/get back to normal. -> blood vessels thicken and become less elastic, which causes an increase in blood pressure (typically systolic rises more than diastolic; creates a wider pulse pressure). -> cardiac valves become stiffer, which causes regurgitation (backward flow of blood when the valve isn't fully closed) & murmurs (valves don't close all the way so blood leaks through). -> meds (antihypertensives) and/or decreased baroreceptor function causes orthostatic hypotension (BP drops when you stand up) & postprandial hypotension (BP drops after you eat).
lipid profile:
-> elevated lipid levels are a risk factor for CAD! = what our "goals" should be. - Total Cholesterol = < 200 - LDL (low-density lipoprotein cholesterol, the "bad" kind; this kind likes to stick to the inner linings of the arteries) = < 70-160, depending on pt.'s risk for CAD; in general, < 100 is good! - HDL (high-density lipoprotein cholesterol, the "good" kind; these carry the lipids to the liver so they can be metabolized, & they don't stick to the arteries) = > 40 men, > 50 women - Triglycerides (fats carried in the blood from the food that we eat) = < 150
PCA nursing considerations:
-> is my pt. too sleepy? -> is my pt. obtunded (not able to arouse with vigorous stimulation)? first thing to do would be: stop pca! call rapid response team. administer narcan as ordered. notify MD! monitor pt. & support as needed. -> is my pt. arousable but over-sedated when unstimulated? we need to: stop pca! administer narcan as ordered. notify MD! monitor pt. closely. -> what is my pt. is still complaining of pain? we need to: assess the pt. first. check the pump. call MD for additional orders.
Non-steroidal anti-inflammatory drugs (NSAIDs):
-> one of the most commonly prescribed group of meds. - anti-inflammatory & provide pain relief. - types: Salicylates (aspirin), Indomethacin (Indocin), Ibuprofen (Motrin), Ketorolac (Toradol), Naproxen (Naprosyn), Piroxicam (Feldene), COX-2 Inhibitors (Celebrex - there is no risk for GI bleeds with this one). -> what should you ask the pt. before administering first NSAID dose? - allergies? - sensitivity to NSAIDs? - history of GI bleeds/stomach ulcers? - what other meds is the pt. on (any anticoagulants?) - 3+ alcoholic drinks a day when taking NSAIDs can increase the likelihood of GI bleeding. - if pt. is taking insulin or other hypoglycemia agents, taking with NSAIDs can increase potential for hypoglycemia. -> what would you teach pt. about NSAIDs? - teach pt. signs & symptoms of GI bleeds (dark & tarry stools). - take with food to minimize GI upset. - monitor long term renal & hepatic functions. - long term NSAID use is associated with cardiac events such as strokes, MI, etc. * all NSAIDs, except for Celebrex, should be stopped at least a week prior to the pt. having surgery, because of that GI bleed risk.
Warfarin (Coumadin):
-> oral anticoagulant. -> action: interferes with synthesis of vitamin K dependent clotting factors; prevents thrombus formation. (the antidote to Coumadin is vitamin K!); Coumadin has a long half-life so it may take a while for the drug to become therapeutic. -> normal dose: 2-10 mg once/day' adjusted per PT (prothrombin time, which is a blood test that measures how long it takes blood to clot). * a therapeutic dose of Coumadin is determined by the PT; a normal PT for the average person is 9-12 seconds. ** PT is reported in terms of INR (International Normalized Ratio), which is our pt.'s PT compared to the normal PT of an average person. *** if our pt. is taking Coumadin, we don't want their PT to be in the normal range, we want it to be 2-3 times the normal; so we want their INR to be 2-3 (therapeutic range for a pt. on Coumadin). EXAMPLE: if a normal pt.s PT is 12 seconds, & meanwhile our patient's PT is 24 seconds, our pt.'s INR would be 2. - pt. is at a high risk for bleeding if their INR is 3-4.5; we would probably stop the drug & maybe even give them the vitamin k antidote. Adverse Effects... - bleeding. - thrombocytopenia (low blood platelet count). Contraindications... - history of bleeding. - allergies. Antidote... -> the antidote is vitamin k. - a diet high in vitamin k will counteract the effects of warfarin (Coumadin), so we need to educate our pt. to moderate their vitamin k consumption & to be consistent in taking their med. - we also need to educate pt. about signs of bleeding & that dark, tarry stools are a sign of GI bleeding. - need to educate pt. that if they miss a dose of their med, don't double up the next day.
Fractures: goals of treatment
-> realignment of bone fragments (reduction). -> immobilization (to maintain realignment). -> restoration of function. Reduction - closed/open reduction. -> if we do an open reduction, that probably included an internal fixation (ORIF), which means we put something inside there to hold the bones back together (pins, nails, screws, wires, etc). -> benefits of ORIF = more stable fix; pt.s can usually ambulate a little earlier. Fixation -> putting something in place to hold the bone fragments back together once it has been reduced. -> Internal Fixation: implanted surgically; wires, pins, screws, plates, rods, nails. -> External Fixation: used outside of the body; casts, bandages, splints, continuous traction, fixators (may be used if the pt. cannot have an ORIF right now due to too much swelling/etc); must complete neurovascular assessments, assess pin sites for signs of infection & check MD's orders for how to clean the pin sites.
Enoxaparin (Lovenox):
-> subcutaneous anticoagulant; typically given in the abdomen deep SQ. -> action: it's a low molecular weight heparin. -> dose: 20-40mg SQ BID or (high dose Lovenox) 1mg/kg SQ BID. -> Lovenox has a much more predictable action in the body, so PT/PTT monitoring is not necessary. Indications... - given for DVT prevention. - given to post-surgical patients. - given to trauma patients. Adverse Effects... - same as heparin!
Oncofetal Antigens:
-> we do a blood test to help determine the amount of cancer cells in the body (undifferentiated, embryonic cells). -> these antigens are found on tumor cell surfaces, inside tumor cells, & fetal cells; known as "tumor markers". -> examples of tumor markers (oncofetal antigens): 1) CEA = elevated if pt. has cancer in their GI tract; normal for CEA to be elevated if we have fetal cells, ulcerative colitis, pt. is a heavy smoker, or has liver cirrhosis. 2) Alfa-Fetoprotein (AFP) = it is monitored in pregnant women because if it's too elevated then that means there is a problem with the baby; it comes from the liver, so it can be elevated with liver cancer, pregnancy, or with viral hepatitis;
Ischemic Stroke:
-> when there is a blockage in a blood vessel, that is causing a problem. -> most common; accounts for at least 85% of strokes. 2 types of ischemic strokes: 1) Thrombotic - most common. - related to atherosclerotic changes. - the narrowing of a vessel, mainly due to diabetes or hypertension. - can be slow to evolve. - there is often symptoms ahead of time (days/weeks/months prior to stroke); such as numbness/tingling or changes in speech. 2) Embolic - second most common. - related to an embolism (blood clot or flat emboli) that happens somewhere in the body, but then travels to the brain & causes a blockage. - disruption in blood flow is caused by a floating particle (fat or blood clot from atrial fib, mechanical heart valves, or oral contraceptives). - usually a very sudden onset, so there may be no warning signs ahead of time.
Hemorrhagic Stroke:
-> when there is bleeding somewhere in the brain that is causing a disruption in the blood flow. 2 types of hemorrhagic strokes: 1) Intracerebral Hemorrhage -> bleeding from within the brain, caused by a rupture of a vessel. - within the brain tissue itself. - hypertension is the most common cause of this. - up to 70% mortality rate in the first 30 days following this type of hemorrhagic stroke. 2) Subarachnoid Hemorrhage -> bleeding in the subarachnoid space caused by an aneurysm (weakened area of a blood-supplying vessel), arteriovenous malformation, trauma, hypertension, or cocaine use. - people can be born with aneurysms. - not in the brain tissue itself, but in the lining that surrounds the brain. - high degree of mortality with bleeds; common rebreeds within 2 weeks of the initial bleed. - pt.s often complain of a severe headache prior to this type of stroke.
OR safety measures:
1) "Time Out": -> basically everyone stops what they're doing & they pay attention to the physician. -> the purpose is the verify the correct patient.... - correct person. - correct procedure. - correct site & side. -> this is done prior to anesthesia. -> the MD is ultimately responsible, however the circulating nurse guides the process & documents the process. -> the circulating nurse is not handing instruments but is ultimately the one who is in charge over the entire patient, & makes sure that everyone has what they need. -> all personnel are present & are introduce, & they all participate. -> the scrub tech is the one who hands the instruments. -> surgeon does the surgery. -> the anesthesiologist is giving anesthesia & monitoring vital signs. ***consequences of poor time out = over 4,000 wrong site surgeries (WSS) occur in the US each year; most common events in 2017 are 1) unintended retention of a foreign body, 2) wrong patient, wrong site, wrong procedure, 3) operative/post-operative complication. 2) Aseptic Technique: -> if surgeon drops their hands below their waist, their hands are no longer sterile. -> the OR has different zones, where some zones require a mask & shoe coverings, while other zones don't. 3) Patient Positioning: -> a pt.'s vitals could be hard to monitor during surgery because of the way they are positioned. -> complications could occur because of the way a pt. is positioned. 4) OR Fires: -> cautery can cause sparking. -> there is flammable material. -> there is a lot of oxygen flowing. 5) Prevention of Hypothermia: -> we don't want the patient to get too cold, as that can cause complications.
insulin injection: site selection & rotation
1) Abdomen = fastest absorption 2) Arms (posterior surface) = second fastest absorption 3) Thighs (anterior surface) = third fastest absorption 4) Hips = least fastest absorption *** caution with exercise; ex: if pt. gets their insulin injection in their thigh & then goes for a walk/run, the exercise of that thigh muscle will cause increased circulation, which will increase the absorption rate of that area & could put the pt. at risk for hypoglycemia. *** we teach pt. to treat each site as a grid (like in the picture), & do each injection an inch away from the last one in the same site area; we want the pt. to use up all the grids in one site before moving to another site location. *** if pt. doesn't rotate the site, the tissue can hypertrophy & get kind of hard, & won't absorb the insulin as well.
Diagnosing cancer: diagnostic studies
1) Blood tests - CBC (rbc & platelets may be elevated if pt. has a very large tumor), SGOT (deals with liver enzymes), CA 125 & CA 19-9 (tumor markers; we are looking for if these are elevated), PSA. 2) Stool tests - occult blood (colon cancer). 3) cytology testing - we try to aspirate a piece of the tissue from the tumor (depending on where it is) so we can look at the cells under a microscope & determine how differentiated they are. 4) XR, MRI, CT. 5) Ultrasound. 6) Scopes - fiberoptic instrument. 7) Biopsy - we want to determine what the stage of the cancer is, has it metastasized, what other organs are involved, & what the general health of the patient looks like.
chemotherapy complications:
1) Bone Marrow Suppression: -> treatment-induced reductions in RBCs & WBCs can result in....... - neutropenia (decreased neutrophils, so pt. at higher risk for infection). - infection. - hemorrhage. - overwhelming fatigue. *** WBCs will drop first for chemo pt.s. --> if WBC is below 2,000 we will alter the chemo drugs. NORMAL VALUES: - WBC should be 5,000 - 10,000. - neutrophils should be 2,500 - 8,000. - platelets should be 150,000 - 400,000. - RBCs should be (for man) 4.7-6.1 & for women (4.2-5.4) 2) Thrombocytopenia: -> when platelets are less than 100,000, it is thrombocytopenia. -> monitor platelet count. - < 50,000 is at risk for serious bleeding. - < 20,000 we do a platelet transfusion. - teach pt. NO NSAID USE!! 3) Anemia: -> monitor RBC & HGB. ---> signs & symptoms = fatigue, low BP, racing heart, headaches, pale skin, pale mucous membranes. ----> treatment: RBC growth factors (darbepoetin, epoetin = injection that stimulates the growth of RBCs); transfusions in extreme circumstances. 4) GI Effects: -> nausea/vomiting. - the cells in our intestinal mucosa tract are very sensitive & are replaced ever 2-6 days, & chemo has greatest effect on rapidly dividing cells. - diarrhea. - pt. can even have N/V before receiving chemo, which is called anticipatory nausea & vomiting. - teach pt. to have a light meal before chemo appointments. 5) Mucositis: -> happens to pt.s receiving chemo & radiation. - dry mouth, pain, sore throat. - affects the glands that produce saliva. - decreased teeth cleaning. - decreased food moistening. - loss of taste. - lump in throat. - see dentist before treatment so they can address any problem before hand. - tech pt. not to use mouthwash because the alcohol in them can burn their mouth if they have sores. 6) Anorexia: -> may lead to cachexia ("wasting" disorder that causes extreme weight loss & muscle wasting, & can include loss of body fat). - monitor carefully to avoid weight loss (weigh twice weekly). - recommend small, frequent, high protein, high-calorie meals. - encourage nutritional supplements. - we may give meds (Megace = artificial hormone that stimulates appetite). 7) Skin reactions: -> dry desquamation occurs in pt.s getting radiation. - the skin reaction is progressive, so pt. may start with just erythema & then it turns to dry desquamation (pt. is losing their top layer of skin). - DO NOT treat with temperature extreme measures, such as a heating pad/ice pack. ---> if the rate of cells sloughing off is faster than the production of new epidermal cells, the pt. will have wet desquamation (serous fluid is leaking through the skin). -> hand-foot syndrome (Erythrodysesthesia) occurs in chemo patients; redness & tingling in palms of hands & soles of feet. -> Alopecia occurs in chemo pt.s; hair loss; teach pt. not to shampoo their hair every day in order to slow down hair loss; most of the time hair grows back, but it grows back differently than how it used to look. 8) Pulmonary Effects: -> from both chemo & radiation treatments. - may be progressive & irreversible. - cough, dyspnea, pneumonitis, pulmonary edema. -----> treatment: bronchodilators, expectorants/cough suppressants, bed rest, oxygen. 9) Cardiovascular Effects: -> radiation & chemo can cause lasting effects. - pt.s with pre-existing CAD are more vulnerable. - radiation-induced heart disease is more likely in pt.s given high doses of doxorubicin. - Herceptin is cardiotoxic.
other diagnostic studies:
1) Alkaline Phosphatase: -> an enzyme produced by bone. - it is increased in people who have healing fractures, bone cancers, osteoporosis, or anything that effects bone. 2) Antinuclear Antibody (ANA): -> increased in pt.s who have some sort of autoimmune disorder going on. - used to detect the presence of antibodies that can destroy normal tissue cells. - these levels may be elevated in people with lupus, rheumatoid arthritis, or other connective tissue disorders. - these tests aren't absolutely diagnostic for rheumatoid arthritis, but if we are trying to rule that out, we can use ANA or RF to test for it. 3) Rheumatoid Factor (RF): -> increased in pt.s who have some sort of autoimmune disorder going on. - used to detect the presence of antibodies that can destroy normal tissue cells. - these levels may be elevated in people with lupus, rheumatoid arthritis, or other connective tissue disorders. - these tests aren't absolutely diagnostic for rheumatoid arthritis, but if we are trying to rule that out, we can use ANA or RF to test for it. 4) Arthroscopy: -> when we insert a scope into a joint (usually a knee) to look and see what is going on in there. - the findings sometimes suggest arthroscopic surgery. 5) DEXA Scan: -> a scan that measures the density of bone. - the scan will produce a number, & we can look at that number to determine if the pt. has osteoporosis or reduced bone mass or not.
Emergency situations that can happen in the OR:
1) Anaphylactic Reaction: - the manifestations of this reaction could be masked by anesthesia! - the pt. cannot let you know they are having a reaction, so we must be their advocate & be very vigilant to everything about the pt. (ex. the nurse notices the pt. has a rash on their leg that they did not have before they went into the OR). -> symptoms: hypotension, tachycardia, bronchospasm, pulmonary edema. 2) Malignant Hyperthermia: - this is a rare metabolic disorder; thought to be hereditary. -> characterized by hyperthermia with rigidity of skeletal muscles. - often occurs with exposure to succinylcholine (a paralytic agent), especially in conjunction with inhalation agents. -> symptoms: muscle rigidity (calcium released into muscle cells), exaggerated metabolic increase (RR 45, hypertension, tachycardia range 120-140, increased end tidal CO2 levels, metabolic acidosis); late sign symptom would be extremely high temperature (109) & skin mottling.
tumors can be classified by:
1) Anatomic site: -> the location of the tumor. -> determined by the tissue of origin. - the tissue of origin determines what we call cancers, examples include: - Epithelial tissue = carcinoma (most common). - Connective (bone) tissue = osteosarcoma. - Bone marrow = leukemias. - Nervous tissue = neuroblastoma. - Lymphoid tissue = Hodgkins Lymphoma. 2) Histology: -> where we examine the tissue under a microscope; helps us grade the tumor severity. -> we are looking for the degree of differentiation (differentiation is good, we want that; cancer cells do not differentiate)..... - Grade 1 = cells differ slightly from normal cells. - Grade 2 = cells are moderately abnormal. - Grade 3 = cells are very abnormal. - Grade 4 = cells are undifferentiated; cells of origin are difficult to determine. - Grade 5 = grade cannot be assessed. ***Grade 1 is the best; the more differentiated the cells are, the better it is for the pt; undifferentiated cells do not respond to drug therapy as well. 3) Extent of disease (Staging): -> where we determine the stage of the cancer. - 0 = cancer in situ (cancer is contained in itself & really has not spread at all). - 1 = tumor is limited to tissue of origin (localized tumor growth). - 2 = limited local spread. - 3 = extensive local & regional spread. - 4 = metastasis (determined by doing a PET scan or other diagnostic testing). *** classifying cancers helps us to determine the type of treatment that a patient is going to have, the patient's prognosis (survival or not), & we use the classification info in a statistical way (ex: if a pt. has a certain kind of cancer with a certain type of histology, we can try to determine the best outcome for them based off of smiliar past cases).
complications of angina:
1) Arrhythmias - heart muscle cells that are deprived of oxygen can become irritable, & irritable cells can cause arrhythmias. 2) Decreased Contractility - cardiac output goes down, because myocardial cells that are deprived of oxygen may not contract as well. **** DO NOT drive someone to the hospital if they are having severe chest pain, call 911!!! If they have an arrhythmia on the way to the hospital, you do not have an AED in your car, but an ambulance does!
peripheral artery disease: drug therapy
1) Aspirin - most common antiplatelet medication. 2) Plavix (Clopidogrel) - used for pt.s who cannot tolerate aspirin. - you would NOT combine plavix with aspirin! 3) Trental (Pentoxifylline) - increases erythrocyte flexibility. - reduces blood viscosity. 4) Pletal (Cilostazol) - most common med that is used for pt.s who are having intermittent claudication. - inhibits platelet aggregation. - increases vasodilation. - inhibits smooth muscle cell proliferation. - helps relieve intermittent claudication symptoms.
types of insulin regimens:
1) Basal-Bolus Regimen --> this regimen tries to mimic what a normal pancreas does (large spike in insulin production after eating a meal). -> so rapid or short acting insulin (the bolus) is given before meals, to help breakdown the glucose that's about to be eaten. -> then intermediate or long acting insulin (the basal) is given only once or twice a day in order to act as the "background insulin". 2) Meal-time Insulin (Bolus) --> Rapid Acting (bolus): - Types = Lispro, Aspart, Glulisine. - Onset = 10-30 mins. - Peak = 30 mins-3 hours. - should be injected within 15 mins of meal time. --> Short Acting (bolus): - Types = Regular insulin. - Onset = 30-60 mins. - Peak = 2-5 hours. - should be injected 30-45 mins before the meal. 3) (Basal) Background Insulin --> used to control glucose levels in between meals & overnight; there are 2 options... 1) Long Acting Insulin (basal): - Types = Insulin Glargine (Lantus, Toujeo), Detemir (Levemir), Degludec (Tresiba). -> released steadily & continuously with no peak action. -> administered once or twice a day. -> do NOT mix Glargine or Detemir with any other insulin or solution. 2) Intermediate Acting Insulin (basal): - Types = NPH. -> the duration is 12-18 hours. -> the peak is 4-12 hours. -> can be mixed with short & rapid acting insulins. -> it is cloudy; must be agitated to mix it (don't shake it because that will create air bubbles; just roll the vial around in your hands to mix it). 4) Combination Therapy --> can mix short or rapid acting insulin with intermediate-acting insulin in the same syringe. -> this provides meal time & basal coverage in one injection. -> it comes commercially premixed or may need to be self-mixed (ex: NPH/regular 70/30: Novolin 70/30, Humulin 70/30).
cancer complications:
1) Hypercalcemia - calcium is less than 12. - signs/symptoms: EKG changes, polyuria, exhausted, nocturia, sick, depressed, tired. - kidney stones; bad renal failure. - treatments: fluids; Bisphosphonates (draws CA out of blood & back into the bones). 2) Obstructive Emergencies: 1) Superior Vena Cava Syndrome: -> the tumor/thrombosis is suppressing the S.V.C. & blood cannot flow. - usually in pt.s that have lung/breast cancer & is has spread to lymph nodes. - radiation treatment! - symptoms: face edema, veins distended in head/neck, seizures, headache. 2) Spinal Cord Compression: -> tumor is in epidural space of spinal column. - usually in pt.s. who have lung & breast cancer that has spread. - surgery or radiation treatment! - symptoms: pain in back/neck/legs, weakness in legs, bearing down hurts, pt. can't control bowel/bladder. 3) Infections: --> primary cause of death. - pt.s have lowered immune systems. - usual infection sites = lungs (most obvious because of shortness of breath/adventitious sounds), GI tract, mouth, rectum, peritoneal cavity, blood (from central line catheters). 4) Tumor Lysis Syndrome: --> chemo is rapidly destroying large # of cells & body is trying to breakdown the cancer byproducts. --> a condition that occurs when a large number of cancer cells die within a short period, releasing their contents in to the blood. - occurs 48 hours, 5-7 days after chemo. --> 4 main signs of this = increased Phos & decreased calcium (which both cause renal failure) & increased Uric acid & increased potassium. - treatment = fluids & allopurinol. 5) Pleural Effusion: --> fluid in the lining of the lungs. - diagnose with chest x-ray. - symptoms = dyspnea, cough, chest pain is worse with inhalation, dull lung sounds, thoracentesis (watch fluid at 150-200 ml; 400-500 L is bad!!!)
Complications in the immediate post-operative period:
1) Hypothermia: -> an alteration in thermal regulation. - a core temperature less than 96.8 degrees F. - if pt. gets really cold, they will begin to shiver, & shivering increases oxygen consumption!! Nursing Interventions: temperature check every 15 mins, apply warm blankets or warmers, administer oxygen/warmed oxygen, administer warm fluids. *** patients who get really cold can have arrhythmias, clotting disorders, can affect vital signs, and they don't heal as well. 2) Alterations in Neurological Functioning: - can be tricky because sometimes real neurological issues can be mistaken for when pt.'s are coming out of anesthesia. -> delayed awakening: could be the pt. had a stroke during surgery & that's why they won't wake up, or they could just be extremely sleepy, or the pt. may not process the anesthesia drugs quickly (renal pt.s have prolonged drug actions). Nursing Interventions: supportive measures such as making sure the pt. is oxygenated, pt. airway is open, pt. vitals are good, monitor O2 sats. 3) Emergence Delirium: - pt. goes from sleeping peacefully to waking up from the anesthesia in a very combative and agitated state (ex. pt. is trying to rip out their IV/chest tube/etc). - this may be the case with most pediatric patients, mental health disorder patients, dementia patients, anxiety patients, & older patients. -> may be caused by hypoxemia (so we want to make sure we keep pt.s oxygenated), reaction to anesthesia, pain, bladder distention, or hypothermia. Nursing Intervention: (MD may order a sedative) hold any agitation medication until you're certain it's not from hypoxemia; determine the cause for the emergence delirium before medicating the pt; provide safety for the pt. such as side rails, IV sites, artificial airways. 4) Airway Management: - tongue is the most common cause of airway obstruction (perform head tilt chin lift). - secretions, laryngeal edema, & spasms can also obstruct the airway. -> signs of airway obstruction include: loud snoring respirations, you see the pt.'s abdomen moving up and down while breathing, you put your hand in front of the pt.'s face & you don't feel any air coming out. 5) Hypoxemia: -> PaO2 is less than 60mmHg. - post-op causes of hypoxemia include: atelectasis (complete/partial collapse of entire lung or lobe of lung & occurs when tiny air sacs (alveoli) within lung become deflated/possibly filled with alveolar fluid; pt. in pain won't want to take deep breaths so alveoli deflate) due to hypoventilation, secretions, aspirations, bronchospasm or laryngeal spasm. Nursing Interventions: encouraging coughing & deep breathing, encouraging incentive spirometer use, administering suction, having pt. in side lying position if not contraindicated.
arterial disorders: symptoms
1) Intermittent Claudication - pt. has pain with activity, & eventually progresses to having pain with rest as well. - less pain with legs hanging down/dependent (gravity helps the blood get to the extremities). 2) Paresthesia - numbness/tingling. 3) Pallor with elevation - when pt. puts legs up, they look really pale. 4) Redness with dependent position - when pt. puts legs down, they look really red. 5) Absent/diminished pulses - may need a doppler ultrasound to find the pulse.
Match the signs and symptoms to the correct type of heart failure:
1) Left sided heart failure = restlessness and confusion. 2) Both left and right sided heart failure = anxiety, depression, and fatigue. 3) Right-sided heart failure = jugular venous distension.
Match the medications with the action, side effect, or nursing consideration that applies:
1) Metformin (Glucophage) → Hold medication if undergoing procedure using contrast. 2) Lantus Insulin (insulin glargine) → Has no peak of action. 3) Humalog Insulin (Lispro) → Should be injected within 15 minutes of meal. 4) Glypizide (Glucotrol) → Do not take if patient has sulfa allergy. 5) Precose (Acarbose) → Blocks absorption of starches. 6) Victoza (Liraglutide) → Take with no regard for mealtime.
what are the 6 Ps of acute arterial occlusion?
1) Pain 2) Pallor (will be very pale) 3) Pulselessness (no pulse in the affected extremity) 4) Paresthesia (numbness/weakness/tingling) 5) Paralysis 6) Poikilothermia (cool/cold skin)
Fractures: types of casts
1) Plaster of Paris: - the more layers of wet gauze used, the stronger the cast. - weight bearing when dry (24-72 hours). - since the dry time is so long, you have to be careful not to make any indentations on the wet cast, because that could cause problems to the skin integrity underneath. - as it dries, it emits heat, which can cause that area to swell. 2) Fiberglass: - lightweight. - weight bearing in 30 minutes. 3) Polyester: - weight bearing in 20 minutes.
complications of HF:
1) Pleural Effusion -> if pt. is in left-sided hf & there is leaking from pulmonary capillaries into pleural space, fluid can accumulate in this space & cause a pleural effusion (buildup of fluid between the tissues that line the lungs & the chest). 2) Arrhythmias -> atrial arrhythmias (not usually life threatening) & ventricular arrhythmias (usually life threatening). - up to 50% of hf pt.s may experience sudden cardiac death due to a ventricular arrhythmia. 3) Left Ventricle Thrombus -> if LV is not pumping well, & there is some sedentary blood in the LV, it can cause a clot. 4) Hepatomegaly -> right-sided hf pt.s may have enlarged livers from the swelling. - sometimes this swelling can impact the liver functioning.
3 phases of surgery:
1) Pre-Operative Phase 2) Intra-Operative Phase 3) Post-Operative Phase
types of pre-operative teaching:
1) Sensory Information: - what the pt. will hear/feel/see during the operative phase. 2) Process Information: - what the pt. should expect along the way; ex. telling the pt. that when they get to the holding area, the Dr. will probably start another IV in the pt.'s arm. 3) Procedural Information: - telling the pt. the nitty gritty info of what is actually going to be done; ex. telling the patient that the doctor is going to start a central line in the pt.'s neck.
Sprain & Strain:
1) Sprain - injury to the ligaments that surround the joint. - usually a twisting motion that has caused the injury. - 1st, 2nd, & 3rd degree sprain; the higher the degree, the worse it is. -> signs/symptoms: pain, swelling, decreased ROM, bruising, muscle spasms, non-weight bearing. 2) Strain - over-stretching of the muscle. *** usually for minor sprains & strains, the pt. is back to full functioning in 3-6 weeks. -> nursing interventions: rest, ice (15-20 mins off, 15-20 mins off, needs to be a barrier between ice & pt. skin), compression, elevation (heart level). -> circulation assessment: 5 p's = pain, pulse, pallor (color), paresthesia (sensation; can you feel this?), paralysis (can you move this?)
cancer: treatment options
1) Surgery - most common. - if the pt.'s goal is cure, maybe we can go in & remove the whole or partial tumor. - we want clean, normal tissue margins around what is removed. -> "debulking" = making the tumor smaller, because smaller tumors respond better to chemotherapy. - surgery can be involved with palliative care; ex: if a pt. is terminal with colon cancer, but they have an intestinal blockage that is very painful when they eat, we could give them a colostomy bag to relieve that pain, even though it is not a cure for their colon cancer. 2) Chemotherapy -> chemo drugs are classified by their molecular structure & their method of action. -> 2 major categories of chemo drugs...... 1) cell cycle phase nonspecific = they work during all phases of the cell cycle (while the cell is growing, & while it's resting). 2) cell cycle phase specific = they tend to work while the cell is growing. *** chemotherapy drugs tend to work better while the cell is growing. The effect of chemo on the cells: -> affects all cells in the body. -> most effective on cells that are actively dividing, so cancer cells escape being killed by chemo by staying in the growth 0 phase (or "resting phase"). - as tumors get bigger, more cells become inactive & convert to the growth 0 phase. - if enough cells are in the resting phase, they can actually become drug resistant, & the chemo won't work on them anymore (not good). - the drugs can be irritants (can cause damage to the vessel wall such as hardening; they are vesicants so if they leak outside of the vessel into the tissue, they can cause tissue to die). 3) Radiation -> affects normal cells & cancer cells. -> 2 types.... 1) External (Teletherapy): the site is marked on their skin so we know exactly where to give radiation; pt. is not radioactive. 2) Internal (Bradytherapy): 2 types (temporary & permanent). -> Permanent = radioactive seeds are implanted near the tumor to help kill it; fairly low level of radiation. -> Temporary = pt. is radioactive; double flush commode because of radioactive fluids from pt; don't let kids sit on lap for long time (if radiation was for prostate cancer". 4) Biologic & Targeted Therapy -> is it effective alone, or with surgery/radiation/chemo. ---> biologic therapy = agents alter biological response to tumor cells boost the immune system, & inhibit cancer cell growth; type of immunotherapy; (ex: interferon, interleukin). ---> targeted therapy = it targets & binds to cell receptors that are essential for tumor growth. side effects: - flu-like symptoms. - anorexia, weightless. - fatigue, malaise, weakness. - nausea/vomiting. - photosensitivity. - tachycardia, orthostatic hypotension.
"which drug" practice questions:
1) The primary action to reduce glucose production in the liver ----> Metformin 2) It increases insulin production ----> Sulfonylureas & Meglitinides 3) It causes hypoglycemia ----> Sulfonylureas, Meglitinides & Alpha-Glucosidase Inhibitors 4) Should be taken from 30 mins prior, to right before a meal ----> Meglitinides 5) Should treat hypoglycemia with dextrose instead of cane sugar ----> Alpha-Glucosidase Inhibitors 6) Should withhold prior to and for 48 hours after procedures using contrast medium ----> Metformin
disorders of the veins: venous problems
1) Thrombophlebitis -> an inflammatory process that causes a blood clot to form & block one or more veins, usually in the legs. - the affected vein might be near the surface of the skin (superficial thrombophlebitis) or deep within a muscle (deep vein thrombosis, or DVT). VTE (venous thromboembolism) = a disorder that includes deep vein thrombosis & pulmonary embolism. A pulmonary embolism (PE) occurs when a clot breaks loose & travels through the bloodstream to the lungs. 2) Varicose Veins --> these are dilated subcutaneous veins. - they are caused by increased venous pressure & incompetent valves that allow the blood to back up & travel slightly backwards. - risk factors: pregnancy, obesity, trauma, crossing your legs, etc. - these risk factors cause the vessels walls to become very weak & susceptible to dilation. 3) Venous Stasis Ulcer --> when DVT or chronic venous insufficiency causes the tissue to break down. - goal = promote venous return through positioning. - clinical manifestations = pain with dependent positioning; leathery, brown skin; edema; pain; ulcer is concave, below the skin surface. - treatment = compression boot or stocking; elevate the extremity; prevent infection; dressings; skin grafting if ulcer does not respond to conservative therapy.
the types of diabetes mellitus:
1) Type 1 Diabetes --> the beta cells of the pancreas are destroyed, so they completely stop producing insulin. - absolute insulin deficiency. 2) Type 2 Diabetes --> the pancreas is producing insulin, but it is either not producing enough, or the tissues aren't able to use it (insulin resistance; "the insulin key can fit into the door, but the door is unable to lock, so no glucose can enter the cell"). 3) Pre-Diabetes --> a condition when the glucose levels are higher than normal, but not high enough to be actual diabetes; a warning sign that something is going on with the glucose metabolism. 4) Gestational Diabetes --> a pregnant woman becomes a diabetic during pregnancy; 2-10% of all pregnancies result in gestational diabetes; a woman who has developed gestational diabetes has a higher risk of developing type 2 diabetes later on in life.
Types of anticoagulants:
1) Vitamin K Antagonists - Warfarin (Coumadin); given oral. 2) Thrombin Inhibitors - Heparin; given IV or subcutaneous; measured in units. - Enoxaparin (Lovenox); given IV or subcutaneous. 3) Factor Xa Inhibitors - Fondaparinux (Arixtra). - Rivaroxaban (Xarelto). - Apixaban (Eliquis).
practice questions:
1) What is the main difference between type 1 & type 2 diabetes? type 1 does not produce any insulin at all; type 2 can produce some insulin but they are more insulin resistant. 2) What is a type of basal insulin you could use? Lantus 3) When should you withhold a bolus dose of insulin? If the pt. is NPO 4) Describe the difference between the Somogyi & Dawn phenomenon: with somogyi, the pt. will be hypoglycemic in the middle of the night but will wake up with hyperglycemia; with dawn, the pt. is just hyperglycemic. 5) Can all oral agents cause hypoglycemia? No 6) What are some signs/symptoms of hypoglycemia? shakiness, clammy, cold, altered level of consciousness, etc.
If you were first on the scene, how would you treat a patient with a fracture (in correct order)?
1) airway/breathing/circulation. 2) neurovascular assessment of the injured extremity (5 Ps). 3) elevate the affected limb (if possible! be very careful not to manipulate the bone ends that are broken). 4) apply compression bandage unless it's dislocated. 5) apply ice. 6) immobilize the extremity in the position that you first found it in, don't try to straighten it (could further damage the blood vessels/nerves in that area). *** repeat neurovascular assessment repeatedly because the cardiovascular status could change.
You receive a patient from PACU following a total hip replacement. Put the interventions in order:
1) assess vitals. 2) assess for bleeding. 3) auscultate lungs. 4) assess neurovascular status of affected leg.
the effectiveness of the heart as a pump depends upon:
1) its ability to generate & conduct electrical impulses. 2) its ability to fill & empty properly. 3) the strength with which it can contract.
clinical manifestations of heart failure:
Acute Decompensated HF -> "pulmonary edema" = as pulmonary congestion increases, fluid moves into the interstitial spaces & surrounds alveoli, causing very poor gas exchange. - this situation is considered an emergency & can become life-threatening very quickly. -> symptoms include... - agitation. - pallor. - cyanotic. - skin is cool & clammy. - dyspnea. - wheezing. - crackles. - productive cough. - tachycardia. - BP fluctuations. ---> how to care for this patient: - typically these pt.s will be in an ICU if they are unstable, or maybe a step-down telemetry unit. - monitor their heart rhythms & oxygen sat continuously, frequent vital signs & monitor unitary output every hour. - O2 ventilation/support; help with gas exchange. - have pt. in high-fowler's position, maybe with feet hanging off the bed (helps decrease venous return, which decreases the amount of venous blood going back to the ventricle, which then decreases preload, which then decreases the overall cardiac workload). - ultrafiltration (removing fluid). - balloon pump/LV assist devices (machines that mechanically take over the workload of the left ventricle). -> drug therapy: diuretics, vasodilators, morphine, inotrope agents (work to increase contractility).
drug therapy for stroke patients:
Antiplatelets - Aspirin (most common), Plavix, Ticlid. - ASA used prophylactically in high-risk patients. Thrombolytics - TPA (Tissue Plasminogen Activator) = a blood clot buster; given IV, & will dissolve all clots in the body. - a major risk (7% risk) for TPA is that it can change an ischemic stroke into a hemorrhagic stroke. - TPA must be administered as quick as possible; at most, 3-4 hours after the pt. starts having symptoms, in order to be effective. - pt.s who've just undergone surgery or extensive injuries, or who are at risk for bleeding/hemorrhaging are NOT candidates for TPA. Anticoagulants - they serve to prevent any new blood clots from forming, & to prevent an existing clot from getting bigger. - heparin, lovenox, Coumadin (INR 2-3). Calcium Channel Blockers - decreases the effects of vasospasm. - used before or after an aneurysm clipping. - subarachnoid hemorrhage stroke pt.s may be on these, because having an aneurysm clipping procedure done may cause vasospasm. Seizure Prophylaxis - recommended after hemorrhagic strokes. - given after ischemic strokes, only if there is seizure activity.
arterial vs venous problem:
Arterial Problem --> the blood has a hard time flowing to the extremities. Venous Problem --> the blood has a hard time flowing back from the extremities.
Match the medications to the correct statements:
Calcium -> appropriate dose is at least 1,000 mg/day. Estrogen -> not used as primary treatment for osteoporosis due to risks. Raloxifene (Evista) -> mimics the effects of estrogen with fewer side effects. Bisphosphonates, such as -> inhibits breakdown of alendronate (Fosamax bone by osteoclasts. Teriparatide (Forteo) -> stimulates new bone formation by osteoblasts.
The nurse is caring for a patient on an antihypertensive medication. In preparing to administer the medication, the nurse checks the BP and obtains a reading of 90/46. What is the most appropriate action for the nurse to take? A. Give the medication and notify the physician. B. Withhold the medication and clarify the order with the physician. C. Give the medication. D. Hold the medication and recheck the BP in one hour.
Hold the medication and recheck the BP in one hour.
diabetes: diagnostic lab criteria
REFER TO PICTURE FOR NORMAL VALUES!!! ---> basically we measure the glucose amount in the blood stream. - the majority of the glucose is supposed to be inside of the cells being used for fuel; so if most of it is outside of the cells & in the bloodstream, there is a problem. the diagnostic tests include..... 1) A1C ---> the percentage of total hemoglobin that has glucose attached to it. - once a glucose attached to an RBC, it remains attached for the life span of that RBC. - an RBC has a lifespan of roughly 120 days, so an A1C result basically gives you an idea of what a pt.'s glucose level has been over the preceding 2-3 months. - this test also gives you the estimated daily glucose. 2) FBG (fasting blood glucose) ---> the amount of glucose in the blood stream after having fasted. - this may not be the most reliable because how do we know if our pt. actually fasted? 3) OGTT (Oral Glucose Tolerance Test) ---> pt. will drink a sugary drink, & then measure their glucose levels 2 hours later to see if it is high enough to be diagnosed as diabetes. - 2 hour post-prandial = after pt. eats. - often used for pregnant women to determine if they have gestational diabetes. 4) RBG (random blood glucose) ---> testing the glucose of the pt. during their every day day-to-day routine, without having them fast or anything.
RN vs LPN roles:
RN roles - assesses the pt. - plans, initiates, delivers, & evaluates appropriate nursing actions. - teaches, delegates to, or supervises other personnel. - collaborates with other health care providers. - implements the treatment and pharmaceutical regimen prescribed by the MD. - teaches & counsels the pt. - reports & records the plan of care, nursing care given, & pt. response to that care. LPN roles - participates in the assessment of the pt. - participates in implementing the health care plan developed by the RN and/or MD. - participates in the teaching & counseling initiated by an RN or MD. - reports & records the nursing care rendered & the pt's response to that care.
Ordered: heparin bolus 2800 units IV push. Available: heparin 1,000 units/mL, 5mL vial. How much heparin (ml) will you administer? (Round to the tenth place and include only numbers in your answer)
Remember: units supplied = units/H desired mL supplied mL/H desired Remember the rules of rounding: if your answer is more than one ml, round to the nearest 10th (one decimal place). If your answer is less than one ml, round to the nearest 100th (two decimal places). 1000 = 2800 units 1 X ml 1000X = 2800 X = 2.8 ml
500 ml NS with 50,000 units heparin is infusing at 19ml/H. What is the dose of heparin (units/H) this client is receiving?
Remember: units supplied = units/H desired mL supplied mL/H desired 50,000 = X units/hour 500 19 ml/hour 500X = 950,000 X = 1900 units/hour
500 mL D5W with 50,000 units heparin is infusing at 20 ml/H. What is the dose of heparin (units/H) the client is receiving?
Remember: units supplied = units/H desired mL supplied mL/H desired 50,000 = X units/hour 500 20 ml/hour 500X = 1,000,000 X = 2000 units/hour
1000mL NS with 75,000 units heparin is infusing at 1500 units/H. What is the rate (ml/H) for this drip?
Remember: units supplied = units/H desired mL supplied mL/H desired Remember: continuous drips: give your answer in whole numbers. 75,000 = 1500 units/hour 1000 X ml/hour 75,000X = 1,500,000 X = 20 ml/hour
A patient is taking Meglitinide (Prandin) for Type 2 Diabetes. The patient reports to you that they have had several glucose readings under 70 during the past week. What would you do next for this patient? a. Instruct the patient to take their medication 30 minutes before meals and to not take the medication if they skip a meal. b. Question the patient about other medications they are taking since Prandin does not cause hypoglycemia. c. Discuss with the physician whether this medication should be discontinued. d. Ask them to bring their meter to the next visit to have it calibrated.
a) Instruct the patient to take their medication 30 minutes before meals and to not take the medication if they skip a meal. *** Prandin increases insulin production so it can cause hypoglycemia. It should be taken 30 minutes prior to a meal and not taken if the meal is skipped. Skipping meals and taking the Prandin is the most likely cause of hypoglycemia. Bringing the meter in to be calibrated is a good idea, but not the most immediate concern for this patient.
Which statements are true of exenatide (Byetta), a GLP-1 agonist? a. It mimics the action of one of the incretin hormones. b. It promotes weight loss by causing the patient to feel full (satiety). c. Oral medications must be taken one hour prior to this medication. d. This medication is used for patients with type 1 diabetes only.
a) It mimics the action of one of the incretin hormones. b) It promotes weight loss by causing the patient to feel full (satiety). c) Oral medications must be taken one hour prior to this medication. *** Rationale = GLP-1 agonists simulate, or mimic, the effects of one of the incretin hormones, thus causing insulin release and inhibit glucose production by the liver. They decrease gastric emptying and increase satiety, thus promoting weight loss. Oral medications must be taken one hour prior to injecting this drug to prevent interference with absorption of the oral meds. It is only prescribed for patients with type 2 diabetes, as the patient has to be able to secrete insulin.
Which statement about the basal bolus insulin regimen is correct? a. It most closely mimics the endogenous (physiologic) insulin production b. It requires only two insulin injections per day. c. Rapid or short acting insulin is used for the basal insulin. d. Intermediate or long acting insulin is used for the bolus insulin.
a) It most closely mimics the endogenous (physiologic) insulin production. *** Rationale = The basal bolus method provides good glycemic control for many patients because it most closely mimics the endogenous (physiologic) insulin production. It requires at least three or more injections each day. Rapid or short acting insulins are used for bolus injections with each meal. Intermediate or long acting insulins are used for basal injections once or twice daily.
The nurse is teaching a patient with heart failure about Captopril (Capoten). What information should the nurse include? a. It will reduce the workload on your heart by lowering fluid levels and decreasing resistance. b. You need to use Ibuprofen (Motrin) or another NSAID for mild pain while taking this medication. c. Monitor your blood pressure daily, as this medication can cause fluid retention and increase your blood pressure. d. A dry cough is a rare side effect of this drug that should be reported to the physician immediately, as it may become permanent
a) It will reduce the workload on your heart by lowering fluid levels and decreasing resistance.
My PACU patient has a BP of 175/87, HR of 134, and temp. of 105. What is my patient experiencing? a) Malignant Hyperthermia. b) Over-sedation. c) Allergic reaction. d) Distended bladder.
a) Malignant Hyperthermia.
The surgical unit nurse has just received a patient with a history of hypertension from the post-anesthesia care unit. Which medication order should the nurse question? a) Morphine 10 mg IV push q2h PRN pain. b) Zofran 4 mg IV push PRN pain. c) Benadryl 12.5 mg IV push PRN itching. d) Narcan 0.2 mg IV push PRN respiratory rate less than 8.
a) Morphine 10 mg IV push q2h PRN pain.
The nurse is caring for a patient who has been just admitted with an ischemic stroke. The patient is lethargic, has dysphagia, and has right hemiparesia. Which nursing intervention should the nurse perform first? a. Position the patient with head elevated. b. Perform range of motion exercises on the affected side. c. Apply a foot drop boot and hand splint on the affected side. d. Perform a bedside swallowing evaluation.
a) Position the patient with head elevated. *** The priority during the acute phase after a stroke is respiratory management. This patient has dysphagia so is at risk for aspiration pneumonia. Positioning with head elevated is an important intervention to prevent aspiration. Preventing musculoskeletal complications with ROM exercises, foot drop boot, and hand splint are appropriate but respiratory issues are higher priority. Bedside swallow evaluations are typically conducted by a speech therapist.
What action would be most effective in reducing the risk of developing peripheral arterial disease? a. Stop using tobacco products b. Inspect and lubricate feet daily c. Avoid soaking the feet d. Keep heels free of pressure
a) Stop using tobacco products
select all of the following that are correct about a transient ischemic attack (TIA). a) TIAs are caused by a temporary decrease in blood flow to the brain. b) A TIA is a warning sign that an impending stroke may occur. c) TIAs produce signs & symptoms that can last for several weeks to months. d) TIAs don't require medical treatment.
a) TIAs are caused by a temporary decrease in blood flow to the brain. b) A TIA is a warning sign that an impending stroke may occur.
A patient has been diagnosed with an ischemic stroke and thrombolytic therapy has been ordered. What finding should prompt the nurse to withhold the thrombolytic and notify the physician? a. The patient's BP is 190/110. b. The patient is on a beta blocker for angina. c. The patient states his symptoms began 3 hours ago. d. The patient had a cholecystectomy six months ago.
a) The patient's BP is 190/110. *** Due to the risk of bleeding, the patient's BP must be less than 185/110 in order to receive thrombolytic therapy. Beta blockers and a history of angina are not contraindications for thrombolytic therapy. Thrombolytics must be started within 3 - 4.5 hours after the onset of symptoms. Major surgery is a contraindication if it has occurred within 14 days. Other contraindications are recent history of GI bleed, stroke, or head trauma within the past three months.
A surgical patient's premedication regimen includes midazolam (Versed). What are the most likely desired effects of this medication? a) monitored anesthesia care & amnesia. b) potentiates volatile agents to speed induction. c) analgesia & prevention of intra-operative vomiting. d) relaxation of skeletal muscles & facilitation of endotracheal intubation.
a) monitored anesthesia care & amnesia.
A patient is being discharged on Victoza (liraglutide). What instructions will you give this patient? select all that apply. a. This drug will increase your insulin levels b. This drug may make you hungrier c. You will need to inject this drug subcutaneously. d. Do not mix this medication with insulin.
a) This drug will increase your insulin levels. c) You will need to inject this drug subcutaneously. d) Do not mix this medication with insulin. **** Exenatide (Byetta) and liraglutide (Victoza) simulate glucagon-like peptide-1 (GLP-1) (one of the incretin hormones), which is found to be decreased in people with type 2 diabetes. • These drugs increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, decrease gastric emptying, and reduce food intake by increasing satiety. A subcutaneous injection. Given with no regard to meal times. • It is not a type of insulin and is prescribed only for Type 2 patients. Patients must be able to produce and secrete insulin. GLP-1 is a satiety signal and slows gut emptying, • These drugs may be used as monotherapy or adjunct therapy for patients with type 2 diabetes who have not achieved optimal glucose control with oral agents. • Exenatide and liraglutide are administered by subcutaneous injection with a prefilled pen. • The delayed gastric emptying that occurs with these medications may affect the absorption of oral medications. Advise patients to take fast-acting oral medications at least 1 hour before injecting liraglutide. • Acute pancreatitis and kidney problems have been associated with its use.
A patient has been diagnosed with a TIA and asks the nurse what this means. What is the best response? a. This is a sign that you may be developing blockages in the blood vessels in your brain. b. This means that an area of your brain has lost blood supply and those cells have died, similar to a heart attack. c. This means that you have developed a blood clot that could travel to your lungs or other vital organs. d. The symptoms you are experiencing may resolve if we act quickly to give you a "clot-busting" medication.
a) This is a sign that you may be developing blockages in the blood vessels in your brain.
Avoiding grapefruit is advisable for patient's taking which drug? a) Verapamil (Calan). b) Lisinopril (Prinivil). c) Terazosin (Hytrin). d) NTG.
a) Verapamil (Calan)
which patients are candidates for tissue plasminogen activator (TPA) for the treatment of stroke? a) a pt. who is showing signs & symptoms of ischemic stroke. b) a pt. with a CT scan that is negative. c) a pt. that has had symptoms for past 12 hours. d) a pt. that had a colon resection 1 week ago.
a) a pt. who is showing signs & symptoms of ischemic stroke.
select all the signs/symptoms that occur with a left sided stroke: a) aphasia. b) right sided hemiparesis. c) depression & anxiety. d) left sided neglect.
a) aphasia. b) right sided hemiparesis. c) depression & anxiety.
what nursing intervention would be most effective in preventing deformity in a patient having a stroke? a) apply a night splint to affected extremity. b) encourage pt. to perform their own self care. c) encourage pt. to get out of bed for meals. d) position fingers in a flexed position with a hand roll.
a) apply a night splint to affected extremity. *** we want to encourage pt. to use their affected extremity as much as they can during the day, but when they're not using it at night, we can apply a splint.
How can you best communicate with your patient who has expressive aphasia? a) ask questions that require simple responses. b) write out questions for the pt. to study. c) have important conversations before bedtime. d) fill in the words that the pt. has difficulty with.
a) ask questions that require simple responses.
What medication must be stopped at least one week prior to total joint replacement surgery? a) aspirin b) Metoprolol (Lopressor) c) Furosemide (Lasix) d) antibiotics
a) aspirin
Your patient has a peripheral artery bypass for peripheral arterial disease. The nurse will make it a priority to do what? a) assess the surgical site for bleeding. b) apply compression stockings. c) elevate the lower extremity above heart level. d) assess & grade lower extremity pulses bilaterally.
a) assess the surgical site for bleeding.
which action is most beneficial for patients with varicose veins? a) avoid crossing their legs. b) avoid weight loss. c) perform stretches before bedtime.
a) avoid crossing their legs
What intervention is most appropriate for a patient with an external fixator? a) clean pins more frequently if drainage is noted. b) slight amount of drainage from pin sites is expected. c) use a diluted hydrogen peroxide solution to clean around pins. d) apply antibiotic ointment to pin sites twice daily.
a) clean pins more frequently if drainage is noted.
Amy (LPN) is caring for 4 pt.s during this shift that all require 0900 medications. Amy needs help getting Mrs. Smith bathed before PT arrives. Amy asks Sarah, a nurse aide 1, to assist Mrs. Smith with her bath this morning. This is an example of: a) delegation b) assigning c) supervision
a) delegation
What are the best interventions for a pt. with a venous stasis ulcer? select all that apply. a) elevate legs to decrease swelling. b) begin walking program when ulcer is healed. c) encourage use of pressure stockings. d) avoid standing for long periods of time.
a) elevate legs to decrease swelling. b) begin walking program when ulcer is healed. c) encourage use of pressure stockings. d) avoid standing for long periods of time. *** these are all correct! We want to promote healing with these ulcers.
A patient is due for a dose of warfarin (Coumadin). INR is 2.8. What is the most appropriate action? a) give the Coumadin. b) hold the med. & notify the MD. c) check the PT result. d) check the PTT result.
a) give the Coumadin.
A pt. with PVD complains of burning & tingling of the hands & feet & cannot tolerate touch of any kind. Which of the following is the most likely explanation for these symptoms? a) inadequate tissue perfusion leading to nerve damage. b) fluid overload leading to compression of nerve tissue. c) sensation distortion due to psychiatric disturbance. d) inflammation of the skin on the hands & feet.
a) inadequate tissue perfusion leading to nerve damage.
Pletal has which actions? a) inhibits platelet aggregation. b) increases erythrocyte flexibility. c) increases vasoconstriction. d) increases blood viscosity.
a) inhibits platelet aggregation. *** normally given to pt.s with peripheral arterial disease.
Which interventions can help to decrease uric acid levels in a patient experiencing gout? select all that apply. a. Limit intake of alcohol b. Increase intake of purine-rich foods c. Take colchicine (Colcrys) daily as prescribed d. Take allopurinol (Zyloprim) daily as prescribed
a. Limit intake of alcohol d. Take allopurinol (Zyloprim) daily as prescribed
Your patient receives a prescription for doxazosin (Cardura) for hypertension. Which medication would be most concerning for them to combine with doxazosin? a. Sildenafil (Viagra) b. Warfarin (Coumadin) c. alendronate (Fosamax, Binosto) d. Aspirin
a. Sildenafil (Viagra)
the effects on the body from right-sided heart failure:
backwards: fluid overload in systemic circulation -> right ventricle is not pumping blood effectively, so blood backs up from right ventricle into the right atrium, & then into the systemic venous circulation. forwards: decreased cardiac output -> regardless of where, if the blood is being ineffectively pumped, you are going to have reduced cardiac output, so all the tissues in the body will have decreased perfusion.
