NUR 330 Final

Most common and most important side effects of levothyroxine (Synthroid)

** Must take regularly, adherence to life-long therapy ** - Caution patient to avoid sedatives or use lowest possible dose (Synthroid can increase effects) - Monitor for angina and cardiac dysrhythmias - Any chest pain experienced by a patient starting thyroid replacement should be reported immediately and an ECG and serum cardiac enzyme tests must be performed! - Tachycardia - Vomiting - Sweating - Hyperthyroidism - Heat intolerance - Weight loss - Accelerated bone maturation in children

Review the American Nurses Association's (ANA) definition of nursing

- "Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations." - This definition reflects nurses; increasing role in promoting health and wellness and advocating for the recipients of care.

Viral Diarrhea

- 1-8 days - Sx: fever, abdominal cramps, N/V

Parasitic diarrhea

- 2-3 weeks - Giardia lamblia is most common cause in US

Bacterial diarrhea

- 24 hours-7 days - Sx: fever, abdominal cramps, N/V, watery/bloody stools - Staphylococcus: 30 minutes-1-3 days * Mild sx - E. Coli: 60 hour average * Sx: Most common cause of watery/bloody stools in US, fever, N/V, abdominal cramps - C. Diff: Watery diarrhea, fever, nausea, anorexia, abdominal pain

DM Laboratory and Diagnostic Findings

- A1C of 6.5% or higher - Fasting blood sugar over 126 mg/dL - OGTT of 200 or higher with 75g glucose load - If patient has polydipsia, polyuria, and polyphagia with random plasma glucose of 200 or higher

Front-line therapy for HF

- ACE inhibitors - Beta-blockers - Ca channel blockers - Diuretics

NDs for HF patients

- Activity intolerance - Fluid volume excess - Impaired gas exchange - Anxiety - Deficient knowledge

Patients with highest risks of developing a pressure ulcer

- Advanced age - Anemia - Contractures - DM - Elevated body temperature - Immobility - Impaired circulation - Incontinence - Low diastolic BP - Mental deterioration - Neurological disorders - Obesity - Pain - Prolonged surgery - Vascular disease

How to care for a patient with a bilateral adrenalectomy and what is most important

- Assess for hemorrhage (hypotension, tachycardia) * Increased risk due to high vascularity of adrenal glands - Nasogastric tube, urinary cathetery, IV therapy, central venous pressure monitoring, and leg sequential compression devices to prevent emboli - Manipulation of glandular tissue during surgery may release large amounts of hormones into the circulation, producing marked fluctuations in the metabolic processes affected by these hormones * Assess post-operatively (may be unstable due to hormone fluctuations): BP, fluid balance, electrolyte levels - High doses of corticosteroids are administered IV during surgery and for several days afterward to ensure adequate responses to the stress of the procedure (cortisol helps the body manage stress-- when we remove the adrenal gland, we remove the cortisol) * If large amounts of endogenous hormone have been released into the systemic circulation during surgery, the patient is likely to develop HTN * HTN increases the risk of hemorrhage * High levels of corticosteroids increase susceptibility to infection and delay wound healing - Critical period for circulatory instability ranges from 24-48 hours after surgery * Be alert for signs of corticosteroid imbalance * Report rapid/significant changes in: BP, RR, HR - Monitor fluid intake and output to assess for imbalances (hormone fluctuation can mess with fluid balance - Adrenal insufficiency develops if corticosteroid dosage is tapered rapidly - Indications of hypocortisolism (adrenal insufficiency) * Vomiting * Increased weakness * Dehydration * Hypotension - Morning urine levels of cortisol are measured to evaluate effectiveness of surgery

Nursing management for OA

- Assess how the disease is affecting ADLs - Strive to help them get back to doing what they enjoy - Teach pain management, use of assistive devices, nutrition - Correct poor body mechanics

Give examples of each step in the nursing process

- Assessment: Patient states they are in pain due to stage 3 pressure ulcer - Diagnosis: refer to NANDA -Planning: we want to heal the ulcer the best we can, keep skin as clean as possible, and turn the patient in order to attempt to reverse the ulcer

Utilize effective communication skills in providing teaching to patients/caregivers

- Avoid medical jargon-- use words patient can understand - Nonverbal communication is critical to thinking * Relaxed position * Make eye contact * Be eye level with patient - Active listening * Observe patient's nonverbal cues * Do not interrupt * Rephrase and reflect to help clarify - Empathy * Entering into the world of another in a manner that does not judge or correct but to understand * Putting aside own self and stepping into patient's shoes

What to instruct a diabetic patient who is trying to control their blood sugar while sick

- BS increases when sick, so check BS at 4 hour intervals to determine the effects of illness on glucose levels - High blood sugar slows the healing process - Continue with regular meal plan; increase intake of non-caloric fluids - Continue taking oral agents and insulin - Ketone testing if glucose > 240

Tension HA

- Bilateral and bandlike pressure at the skull's base - Constant and squeezing tightness - Cycles for years - 30 minutes- 7 days - Neck and shoulder tension - Treatment: * Aspirin, acetaminophen, NSAIDs all alone or used with sedatives * Muscle relaxants or tranquilizers * Preventative therapy with tricyclic anti-depressants * Topiramate * Divalproex * Mirtazapine

Atonic seizure

- Body stiffens or loses muscle tone and person falls - Consciousness returns by the time the patient hits the ground - Resume normal activity immediately - Greatest risk for head injury

Diagnostic and laboratory findings of OA

- Can detect joint changes with scans-- use of x-rays to see if there is a change or narrowing of space in joint - Bone scans, CT/MRI can detect early; joint space narrowing, bony sclerosis - NO lab abnormalities or biomarkers have been identified for this disease; routine blood tests can screen for related conditions, observation on synovial fluid

Treatment for overflow incontinence

- Catheter to decompress bladder - Implementation of crede or Valsalva maneuver - A-adrenergic blocker - Intravaginal devices to support pelvic floor - Surgery

Diabetic Ketoacidosis

- Cause: deficiency of insulin, ketosis, acidosis, hyperglycemia, dehydration - Occurs most commonly in Type 1 - Pathophysiology: body breaks down fat stores for energy because glucose is in blood, not in the cells; ketones as by product excreted in urine; ketones alter pH making ir more acidic; eventually hypovolemic shock occurs if not treated - S/S: * Poor skin turgor, dry mucous membranes * Kussmaul respirations: deep and rapid to rid CO2 * Fruity breath * Lab findings: glucose greater or equal to 250, pH lower than 7.3, bicarb less than or equal to 15, urine or blood ketones - Treatment: * Initial goal: fluid resuscitation with electrolyte replacement with 1/2 NS or NS (do this in order to get urine output to 30-60 mL/hr) * Then administer insulin (remember, insulin decreases potassium so you want it to be greater than 3.5 before administering insulin) * Once BS gets around 250, administer D5W to prevent rapid decrease in BS (hypoglycemia) * We do not want to decrease BS more than 36-54 mg/dL/hr

Hyperglycemia

- Cause: not enough insulin, excessive carb intake, illness/surgery, stress, corticosteroids - S/S: * Elevated blood glucose * 3 P's * N/V * Blurred vision - Treatment * Continue meds as ordered (insulin, oral agents) * Check BS frequently and monitor urine for ketones * Drink fluids on hourly basis to prevent dehydration from polyuria

Hypoglycemia

- Cause: too much insulin too soon before a meal, excessive amount of oral agent, too little food, or recent exercise - BS less than 70 mg/dL - S/S: * Diaphoresis * Tachycardia * Tremors * Faintness, unsteady gait * Numbness of fingers and/or toes * Hunger * Vision changes * If untreated, seizures and coma - Treatment * Immediately ingest 15 g of simple carb (juice, milk); avoid foods high in fat as fat slows the absorption of glucose! * If that doesn't work, give it again and check BS in 15 minutes * Once it is above 70, check an hour after treatment * If patient is unconscious at home, give glucagon injection (SE is nausea-- Patient could choke, so turn them on their side) * If patient is unconscious in hospital, give 15-20 mL of D50

Right-sided HF

- Caused by: left-sided HF, backup of blood into right atrium and venous circulation; also caused by cor pulmonale - S/S: JVD, hepato/splenomegaly, vascular congestion of GI tract and peripheral edema - Non-modifiable risk factors: * Age * Gender (white, middle-aged men) * Ethnicity * Family history * Genetics - Modifiable risk factors: * Elevated serum lipids * Elevated BP * Tobacco use * Physical inactivity * Obesity * DM * Metabolic syndrome * Psychological states * Elevated homocysteine level

Describe the prevention and major causes of chronic illness

- Chronic illnesses are preventable: being active, avoiding tobacco or harmful substances, eating health - Primary Prevention: Measures such as proper diet, proper exercise, and immunizations that prevent the occurrence of a specific disease - Secondary Prevention: Actions aimed at early detection of disease that can lead to interventions to prevent disease progression; screenings - Tertiary Prevention: Activities that limit disease progression, such as rehabilitation; rehab programs

Clinical manifestations and goals for a patient with Parkinson's

- Complications: motor symptoms, weakness, neurologic and neuropsychiatric problems, dysphagia, orthostatic hypotension, general debilitation (PNA, UTIs, skin breakdown) - Goals: maximize neurologic functions, maintain independence in ADLs, optimize psychosocial well-being, promote physical exercise and a well-balanced diet

S/S of OA

- Crepitation (grating sensation caused by loose particles of cartilage in joint) - Affects joints asymmetrically (hip, knee, distal interpharyngeal joints, proximal interpharyngeal joints, cervical and lumbar spine, and metatarsopharyngeal) - Heberden's nodes (affect DIP joints, swelling/reddened nodules, do not really affect functional ability) - Bouchard's nodes (affect PIP joints, red/swollen/tender, do not affect functional ability) - Bow-legged appearance due to knee OA (causes changes in gait) - Uneven leg length due to loss of cartilage - Pain worsens with use and falling barometric pressure before bad weather - Referred pain in groin/buttock/medial side of thigh/knee, sitting gets harder, joint stiffness

Explain nursing management of DM

- Decrease symptoms - Monitor BS - Promote well-being - Prevent acute complications - Delay onset and long-term complications - Allow patient to be main participant in care - Teach patient and family

Review the diagnostic tests for COPD patients

- Diagnosis can be confirmed by PFTs - Spirometry-- reduced FEV/FVC ratio and increased residual volume - ABG findings * Decreased PaO2 * Increased PaCO2 * Decreased pH * Increased bicarbonate level (in later phase to compensate for respiratory acidosis) - 6 min. walk test to determine O2 desaturation in the blood with exercise - ECG may show signs of right ventricular failure - Sputum culture

S/S of cor pulmonale

- Dyspnea - Distended neck veins - Hepatomegaly with upper quadrant tenderness - Peripheral edema - Weight gain

Echos vs. ECGs

- Echo: used to determine the EF (Left ventricle function during systole - ECGs: show the electrical activity of the heart

Secondary HTN

- Elevated BP with a specific cause that often can be identified and corrected - 5-10% of adult hypertensive cases - Contributing factors: * Coarctation of aorta * Renal disease * Endocrine disorders * Neurological disorders * Cirrhosis * Sleep apnea

How to treat a patient with Grave's disease that has exophthalmos

- Exophthalmos results from increased fat deposits and fluid (edema) in the orbital tissues and ocular muscles - The upper lids are usually retracted and elevated with the sclera visible above the iris - When eyelids do not close completely, the exposed corneal surfaces become dry and irritated - Serious consequences such as corneal ulcers and eventual loss of vision can occur - Changes in ocular muscles result in muscle weakness causing diplopia (double vision)

How to treat and what you should teach patients on acute decompensated HF

- Failure of the LV manifests as pulmonary edema-- acute life-theratening situation where the lung alveoli become filled with serosangeous fluid - Secondary to CAD * Sx: anxiousness, pallor, cyanotic, clammy/cold skin, dyspnea, orthopnea, RR above 30, wheezing, coughing with pink/frothy sputum, rapid HR - Treat: * Continuous monitoring and assessment in an IC * Monitor ECG and O2 sat * VS and urine output hourly * Hemodynamic monitoring * High-Fowler's position * BiPap * Drug therapy * Ultrafiltration * O2

Manifestations of HF

- Fatigue - Dyspnea - Tachycardia - Nocturia - Skin changes (dusky, shiny, swollen, absent/diminished hair growth) - Behavioral changes - Angina - Weight changes

How do you care for a patient with Parkinson's disease?

- First drug used is a precursor of dopamine and crosses the blood brain barrier (Sinemet) and take 30-60 minutes before eating - Nutritional therapy: malnutrition and constipation may occur, easily chewable food, adequate roughage, bite size pieces, several small meals to prevent fatigue, ample time to eat - Have them do exercises to strengthen muscles of speaking and swallowing - Teach maintenance

Complex Focal Seizures

- Focal with altered consciousness - Dream-like experience, strange behavior

Simple Focal Seizures

- Focal without loss of consciousness - Unusual feelings or sensations

Use of cochlear implants

- For people with severe to profound sensorineural hearing loss in one or both ears - Ideal candidate is one who becomes deaf after acquiring speech and language - Consists of: external microphone behind ear, speech processor and a transmitter implanted under the skin (changes sound into electrical impulses, and a group of electrodes placed within the cochlea stimulate the auditory nerves in the ear)

Stage 4 pressure ulcer

- Full thickness loss extending down to bone - Muscle or supporting structures of tendons - Tunneling may occur

Stage 3 pressure ulcer

- Full thickness loss with damage or necrosis of SQ tissue extending to but not through fascia - Presents as a deep crater with possible undermining of adjacent tissue

Generalized tonic-clonic seizure

- Generalized altered consciousness - Falling and body stiffens (tonic) with subsequent jerking of extremities (clonic) - Medications * Phenytoin * Carbamazepine * Phenobarbital * Divalproex * Primidone

Typical absence seizure

- Generalized altered consciousness - Only in children - Staring spell/"daydreaming"

Myoclonic seizure

- Generalized altered consciousness - Sudden excessive jerking of body and extremities, forceful enough to fall - Medications * ethosuzimide * divalproex * clonazepam

How do generalized seizures differ from partial seizures?

- Generalized seizures involve both sides of the brain and are characterized by bilateral epileptic discharges in the brain from the onset of the seizure - Partial seizures are also referred to as focal; they begin in one hemisphere of the brain in a specific region of the cortex and the symptoms rely on the location

Education regarding the use of hearing aids

- Hearing aid should be restricted to quiet situations in the home so one can adjust to their own voice and house sounds - Patient should experiment with decreasing and increasing volume as situations require - Next, the environment should be expanded to the outdoors - When the aid is not being worn, it should be placed in a dry, cool area - Battery should be removed when not in use - Should be cleaned weekly; toothpicks can be used to clean a clogged ear tip

Risks and Etiologies of DM

- Heart disease - Stroke - HTN - Leading cause of end-stage renal disease, adult blindness, and non-traumatic lower limb amputations

Mild anemia

- Hgb 10-12 - Without or few symptoms (symptoms may develop from underlying disease or compensation to heavy exercise - S/S: palpitations, dyspnea, mild fatigue

Moderate anemia

- Hgb 6-10 - Cardiopulmonary symptoms increased from mild, roaring in ears, with rest and with activity

Severe anemia

- Hgb <6 - S/S: pallor, jaundice, pruritis, retinal hemorrhage, blurred vision, glossitis, smooth tongue, tachycardia, systolic murmurs, angina, HF, MI, tachypnea, orthopnea, dyspnea at rest, HA, vertigo, irritability, depression, impaired thought process, anorexia, hematomegaly and splenomegaly, difficulty swallowing, sore mouth, bone pain, weight loss, lethargy

Pre-HTN

- Identified if at least one of the following is occuring: * SBP of 120-139 mmHg * DBP of 80-89 mmHg

Hypertension

- Identified if at least one of the following is occuring: * SBP of 140 mmHg or more * DBP of 90 mmHg or more * Current use of anti-hypertensive medications - Two stages: * Stage 1: 140-159/90-99 * Stage 2: >160/>100

ND for Parkinson's and bradykinesia

- Impaired physical mobility r/t S/S - Impaired swallowing r/t neuromuscular impairment - Impaired verbal communication r/t dysarthria, tremor, and bradykinesia

Diastolic HF

- Inability of the ventricles to relax and fill during diastole, resulting in decreased stroke volume and CO - HF with normal EF - Result of left ventricular hypertrophy (most common) from HTN

What to teach a patient about anti-thyroid medications with newly diagnosed Grave's disease

- Inhibit the synthesis of thyroid hormones - Propylthiouracil (PTU) and methimazole (Tapazole) - P in propylthiouracil = plenty (must be taken 3 times a day) - M in methimazole = mono (single daily dose) - Improvement usually begins 1-2 weeks after the start of drug therapy - Good results usually appear in 4-8 weeks - Therapy is continued 6-15 months to allow for spontaneous remission - Emphasize importance of adherence to drug regimen - Abrupt discontinuation can result in return to hyperthyroidism

Stage 1 pressure ulcer

- Intact skin with non-blanchable redness - Warm skin - Edematous/spongy tissue - Painful - May appear red, blue, or purple in dark skin tones

Urge incontinence

- Involuntary urination is preceded by urgency - Overactive bladder symptoms of urgency and frequency - Large amounts of urine frequent/periodic - Caused by uncontrolled contraction or overactivity of detrusor muscle - Reflexive contractions from CNS disorders (Parkinsons, Alzheimers, tumor) - Bladder disorders (radiation effects, carcinoma in situ) - Interference with spinal inhibitory paths (malignant growths)

Define nursing process, assessment, data analysis, nursing diagnosis, planning, implementation, and evaluation

- It is nursing driven. We are at the bedside taking care of the patient. It covers all grounds of the patient to help us achieve patient safety and good outcome. - Assessment: gather subjective and objective data - Diagnosis: assessment data is analyzed and a judgment is made about the problem (NANDA) - Planning: patient outcomes/goals are developed for the diagnosis and interventions are identified to accomplish the outcomes (NOC and NIC) - Implementation: nursing interventions are performed, putting the plan into action (includes delegation or doing it yourself, when to delegate, who to delegate what to) - Evaluation: determine whether the patient outcomes were met as a result of the interventions

Importance of pursed lip breathing and how to teach a patient on doing it and when

- Keeps airway open by maintaining positive pressure and abdominal breathing to slow the RR - Use when short of breath - Inhale through nose and slowly exhale through the mouth (exhale 3X longer than inhale; smell the roses, blow out the candles) - Do 8-10 reps 4 times daily

Treatment of stress incontinence

- Kegel exercises - Weight loss if obese - Smoking cessation - Topic estrogen products - External condom catheters - Surgery - Support devices

What is cor pulmonale?

- Late manifestation of COPD - Hypertrophy (muscle build up) of right side of heart resulting from pulmonary HTN * The right ventricle also enlarges, which pumps blood less effectively than it should. The ventricle is then pushed to its limits, by trying to make up for its inability to get enough blood out, and eventually fails - Eventually causes right-sided HF

Systolic HF

- Left ventricle loses its ability to generate enough pressure to eject blood forward through the aorta - Hallmark finding: decreased left ventricular ejection fraction (normal being 50-60% and less than 45% usually signals HF)

What to teach a patient with newly diagnosed HTN

- Lifestyle modifications * Weight loss of 22 pounds may decrease SBP by 5-20 mmHg * DASH eating plan * Dietary sodium reduction * Moderation of alcohol consumption * Physical activity * Avoidance of tobacco products * Management of psychosocial risk factors - Drug therapy * Primary goal is a BP less than 140/90 mmHg * Reduce SVR and reducing volume of circulating blood * Patient and caregiver teaching related to drug therapy: Identify, report, and minimize SE such as: orthostatic hypotension, sexual dysfunction, dry mouth, and frequent urination

Foods high in iron and education on why anemic patients still need supplements

- Liver, muscle meats, eggs, dried fruits, legumes, dary green leafy vegetables, whole-grain and enriched bread and cereals, potatoes - Continuous blood loss requires supplements more than just in one's diet; to replenish the iron stores, it needs to be taken 2-3 months after the Hgb level returns to normal

Functional incontinence

- Loss of urine from cognitive, functional, or environmental factors - Older adults have problems with balance and mobility

How to care for a patient incontinent of urine

- Maintain and enhance dignity - Maintain privacy and self-worth feelings - Scheduled voiding regimens - Timed voiding - Habit retraining - Prompted voiding - Bladder retraining - Kegel exercises - Vaginal weight training - Biofeedback - Catheters - Pads and briefs

Hgb values in men and women

- Men: 13.2-17.3 - Women: 11.7-15.5

Hct levels for men and women

- Men: 39-50% - Women: 35-47%

RBC levels for men and women

- Men: 4.7-6.1 million - Women: 4.2-5.4 million

Treatment of functional incontinence

- Modify environment to facilitate regular bathroom use and easy access

Explain collaborative care for self-management of DM

- Monitor BS - Inspect hands and feet daily - Take insulin or oral agents as needed - Monitor carb intake - Exercise - Patient/caregiver follow up

What to teach a diabetic patient about exercising and controlling blood glucose levels

- Monitor BS before and after exercise (check during exercise if hypoglycemia is suspected) - Bring snacks in case it gets low - Eat carb snack Q30min - 150 minutes/week of regular, consistent exercise - Weight loss from exercise decreases insulin resistance and helps medication reach target blood glucose goals - Can help reduce triglycerides and LDLs, increase HDLs, reduce BP, improve circulation - Strenuous activity can cause release of counterregulatory hormones and temporarily elevate BS - Warm up, cool down, start gradually and increase slowly - Best after meals when BS is rising

Left-sided HF

- Most common - Prevents normal forward blood flow and causes blood to back up into left atrium and pulmonary veins - S/S: pulmonary congestion, edema

Focus on tonic-clonic seizures

- Most common; AKA "grand mal" - S/S: cyanosis, excessive salivation, tongue or cheek biting, incontinence, muscle soreness, fatigue and no memory of the seizure - Medications: * phenytoin * carbamazepine * phenobarbital * divalproex * primidone

Primary HTN

- No known cause - 90-95% of all cases of HTN - Contributing factors * Increased SNS activity * Overproduction of sodium-retaining hormones and vasoconstrictors * DM * Increased sodium intake * > Ideal body weight * Tobacco use * Excessive alcohol consumption

Magnesium: Normal value and HF value

- Normal: 1.5-2.5 - HF: above 2.5

Phosphate: Normal value and HF values

- Normal: 2.4-4.4 - HF: above 4.4

BNP: Normal value and HF value

- Normal: below 100 - HF: 100-300

What are the first things you do for someone who is having a seizure?

- Note time and all other aspects (events preceding seizure, when it occurred, how long each phase lasted, what occurred in each phase - Be sure patient has a patent airway - Protect head - Turn to side - Loosen clothes - Ease to floor - No restraints - Nothing in patient's mouth

Components of the Tanner's clinical judgment model

- Noticing-- focused observation of a change in the clinical situation, assess context/background/relationship, gather data * Ex: Patient's IV is burning and red - Interpreting-- analyzing the data, understanding the situation, setting priorities, determining appropriate responses * Ex: You now know that you need to take it out because it is not safe for the patient - Responding-- deciding on most appropriate course of action and intervention; decide whether to carry it out or do nothing * Ex: Take IV out, apply warm pack - Reflecting-- evaluation and analysis of choices and decisions made in clinical performance, assessing for effectiveness, ongoing improvement * Ex: Try to better IV insertions since you now know what to do when an IV site looks like that * (Reflection-in-action: assessment of patient's response to nursing intervention and an adjustment of that based on the assessment) * (Reflection-on-action: experience contributes to ongoing action, how can you apply this to other situations)

Collaborative management of patients with HF

- O2 administration - Physical and emotional rest - Intraaortic balloon pump: * Increases myocardial O2 perfusion while at the same time increasing cardiac output - Ventricular assist device: * Mechanical device that replaces the function of the heart - Destination therapy * "Bridge to transport" stays in place until heart transplant is then removed - Drug therapy - Nutritional therapy: weight reduction, DASH, sodium restriction, daily weights

Hyperosmolar Hyperglycemia Syndrome

- Occurs in patients over 60 with Type 2 - S/S: * Glucose greater or equal to 600 * NO ketones in urine * Increased serum osmolarity - Treatment: requires more fluid replacement than DKA, but the rest of therapy is similar to DKA treatment

Clinical manifestations for anemia

- Pallor - Palpitations - Dyspnea - Fatigue - Roaring in ears - Blurred vision - Tachypnea - Orthopnea - HA - Hemorrhage

Stage 2 pressure ulcer

- Partial thickness loss of dermis - Shallow, open ulcer with pink wound bed - Intact or ruptured blister ***

Explain the characteristics of a chronic illness

- Permanent impairments or deviations from normal - Irreversible pathological changes - Residual disability - Special rehab required - Need for long-term medical and/or nursing management

Complications of HF

- Pleural effusion - Dysrhythmias - Left ventricular thrombus - Hepatomegaly - Renal failure

What do you want to teach a patient with COPD about exercising and nutrition and what things they should do before, during, and after?

- Prepare foods in advance - Eat 5-6 meals a day to avoid bloating and early satiety - Cold foods cause less fullness - Avoid foods that increase amount of chewing and gas forming foods - High calorie, high protein diet - Hydrate between meals - Modify ADLs to conserve energy - Walk 15-20 minutes a day at least 3 times a week with gradual increases - Can have oxygen on during exercise - Avoid exercise at least 1 hour before and after eating - Some benefit from taking SABA 10 minutes before exercise - Check HR after walking: it should not exceed 75-80% the maximum HR (age in years subtracted from 220) - Instruct patient to wait 5 minutes after completion of exercise before using the B2-adrenergic agonist to allow a chance to recover

Overflow incontinence

- Pressure in overfull bladder overcomes sphincter - Distended bladder and palpable - Bladder or urethral outlet obstruction or underactive detrusor muscle caused by myogenic or neurogenic factors (herniated discs, diabetic neuropathy) - After anesthesia or flaccid bladder

Tasks of people with chronic illness

- Preventing and managing a crisis trying to prevent acute exacerbation for the chronic illness (diabetic patient becomes hyperglycemic) - Carry out prescribed treatment regimen-- varies in degree of difficulty and impact on patient - Controlling symptoms: so patient can do desired activities, good quality of life - Reorder time: reorganize patient's time for chronic illness to adjust to lifestyle changes - Adjust to changes in course of disease-- develop personal identity to include chronic illness - Prevent social isolation-- withdrawals due to chronic illness - Attempt to normalize interactions: manage symptoms to hide disability or disfigurement

Diagnostic/laboratory tests and findings for HF

- Primary goal: determine and treat the underlying cause - EF below 45% - BNP over 100 - Chest XR - ECG - Hemodynamic assessment - Echocardiogram - Stress testing - Cardiac catheterization

How would you educate a patient about taking anti-seizure medications?

- Primary goals: prevent seizures with a minimum of toxic side effects - Begin with a single drug and increase if needed or add another - 1/3 of patients need a combination regimen for control - SE: diplopia, drowsiness, ataxia, mental slowness, nystagmus, decreased hand and gait coordination, cognitive functioning, altered alertness - Do not abruptly stop medications-- this may preciptate seizures

Know what evidence-based practice (EBP) is and how important it is to nursing practice

- Problem-solving approach to clinical decision making, involving the best available evidence (research findings, data, professional standards, in combination with clinical expertise and patient preferences and values to achieve desired patient outcomes). - It is something we refer to when we need more research on a certain patient's situation, what is best to use when we are "stumped" in a situation. - (Use the PICOT method in step 1: * Patients/population, intervention, comparison, outcomes, time)

Give examples of the role of the nurse in patient teaching

- Promotion, prevention, management, appropriate selection and use of treatment - Teach caregiver and patient in appropriate methods of learning for the individual, offer written info, determine how they learn best and when the best time to teach is, evaluate their health literacy and cultural considerations

Know how to care for a patient with blindness or hearing difficulties

- Provide emotional support - Allow patient to express anger or grief - Help them comply with therapies to prevent further vision or hearing loss - Face the patient when speaking - Teach them about their assistive devices - Sight-guided technique for visually impaired (in front and to side, offer elbow)

Clinical manifestations and patient education regarding thyroidectomy

- Reasons: no response to drug therapy, tracheal compression by goiter, malignancy, not a candidate for RAI - Teach: turn, cough, deep breathe, leg exercises, head support with turning, neck ROM-- may have speaking difficulties - Monitor for tetany for 72 hours (Trousseau's/Chvostek's signs = hypocalcemia) - Nutritional therapy: high cal diet before and without surgery for hunger and preventing tissue breakdown (avoid caffeine, high seasoned/fiber foods); after surgery, decrease calories

Isolated systolic hypertension (geriatric HTN)

- SBP > 140 mmHg with DBP < 90 mmHg - SBP increases with age - DBP rises until approximately age 55 then declines - Control of ISH decreases the incidence of stroke, HF, and death

Mixed Systolic and Diastolic Failure

- Seen in disease states such as dilated cardiomyopathy - Extremely low EF (<35%) - High pulmonary pressures - Biventricular failure (ventricles dilated and have poor filling and emptying capacity

Describe the role of the nurse in health promotion, disease prevention, and managing the special needs of older adults

- Serve as patient advocate - Base goals off of patient's strengths and abilities - Providing safety is always the first goal - Modify approach based on patient's physical and mental status - Health promotion: * Reduce diseases and problems * Increase participation in health promotion activities * Increased target services that reduce health hazards

Best position for taking a BP for a patient and why

- Sitting upright with arm at heart level - BPs vary at different positions, and our BP tends to drop when we stand-- not reflecting the true value

Unstageable pressure ulcer

- Slough (black or yellow eschar) present and preventing one from seeing the base of the ulcer

Atypical absence seizure

- Staring spell with warning - Peculiar behavior during - Confusion after

Stress incontinence

- Sudden increase in intraabdominal pressure causes involuntary passage of urine - Can occur when coughing, laughing, sneezing, or heavy lifting and exercise - Mostly in women with relaxed pelvic floor muscles from delivery, instrumentation use in vaginal delivery, multiple pregnancies or medication use such as ACT inhibitors (-pril), a-adrenergic receptor agonists (-zosin)

How do you measure for anti-seizure medication toxicity?

- Therapeutic range for each drug indicates the serum level above which most patients experience toxic SE and below which most continue to have seizures - Monitor serum drug levels

Treatment of urge incontinence

- Treat underlying cause - Biobehavioral interventions like retraining, decrease in dietary irritants, bowel regularity and kegels - Anti-cholinergic drugs - Ca-channel blockers - Containment devices - Vaginal estrogen creams - Pads

What equipment would you need for a patient in status epilepticus?

- Treat with rapid acting IV lorazepam or diazepam followed by long-acting drugs - Rail padding

Parkinson's S/S

- Tremors** - Rigidity** - Bradykinesia** - Others included are: depression, anxiety, fatigue, pain, constipation, sleep problems, short term memory loss, impotence

Cluster HA

- Unilateral - Radiating up or down from one eye - Severe or bone-crushing - Months or years between attacks and occur in clusters over period of 2-12 weeks/5 minutes=3 hours - Nocturnal and awakens patients from sleep - Facial flushing or pallor - Ptosis and rhinitis and pain in cheeks - Triggers: alcohol, strong odors, weather, napping - Treatment: * CT scan, MRI, MRA may rule out aneurysm, tumor, and infection * Lumbar puncture rules out disorders with similar conditions * Drug therapy not always helpful since it is quick to form and then go away * 100% O2 6-8 L for 10 minutes - Relief: * Meditation, yoga, biofeedback, CBT, relaxation training, acupuncture, acupressure, hypnosis

Migraine HA

- Unilateral (60%); may switch sides and are commonly anterior - Throbbing/pulsating - Periodic with cycles lasting several months to years; 4-72 hours - Prodrome first, onset after awakening and gets better with sleep - N/V, irritability, sweating, photo/phonophobia, prodrome of sensory/motor/psychic phenomena - Family history - Without aura (bright lights, scotomas, distortions, smells, weakness, paralysis) is most common - Triggers: menstruation, head trauma, physical exertion, fatigue, stress, missed meals, weather, drugs, chocolate, cheese, oranges, tomatoes, onions, MSG, aspartame, and alcohol (red wine) - Treatment: * "Hibernate" -- go away from noise, light, odors, people and problems * NSAIDs, aspirin, caffeine-containing combination analgesics * Triptans are first line therapy for moderate-severe migraines--> produce vasoconstriction (take at onset of migraine or in aura; preventative topiramate (antiseizure), botox is effective for those that do not respond to others

What nursing actions will be important to teach a patient with Grave's disease experiencing exophthalmos?

- Use artificial tears - Tape eyelids shut - Elevate HOB to allow for drainage - If severe: * Corticosteroids * Radiation of retro-orbital tissues * Orbital decompression * Corrective lid or muscle surgery

How to treat and evaluate a patient with asthma before and after therapy

- Use baseline to compare - Monitor rate, rhythm, depth, and effort of respirations - Observe chest movement, auscultate sounds - Allow to recover from exhaustion - Keep in stimulus free, calm area - Make sure patient is comfortable to maximize chest expansion - Educate on use of pursed lip breathing

What are the common clinical manifestations of Cushing's Syndrome?

- Weight gain (truncal obesity, generalized obesity) - "Moon face" - Buffalo hump (on cervical vertebrae) - Thin extremities - Purplish/red striae on abdomen, breasts, and/or buttock - Acne - Hyperglycemia (causes delayed wound healing) - Protein wasting (leads to weakness) - Loss of collagen (makes skin weaker and thinner, more easily bruised - Insomnia - Mood disturbances

Risks of Osteoarthritis

- Women (decrease in estrogen) - Aging (can begin between 20-30, affected by 40) - Occupational injury - Obesity (more weight on joints) - Genetic factors - ACL injury in football players can lead to knee OA - Regular moderate exercise decreases risk

ABG normal values

- pH: 7.35-7.45 - PaCO2: 35-45 - Bicarb: 22-26 - PaO2: 80-100 - O2: >95%

Explain the physical and psychological effects of unrelieved pain

-Unnecessary suffering -Sleep disturbances -Decreased mobility -Decrease in cognitive function -Decreased immune response -Unrelieved acute pain leads to chronic pain -Unrelieved pain can lead to depression and anxiety -May be more sensitive to other stimuli -Urinary retention -Increased HR and output leading to HTN -Longer hospital stays, re-hospitalization, visit to outpatient clinics and ED

Describe nursing interventions to assist chronically ill older adults

-Use of Complementary and Alternative Medicine (CAM) -Non-drug therapy -Pharmacological agents (medications)

PLTS levels

150,000-400,000

WBC level

4,000-11,000

Describe the composition of the major body fluid compartments

50-60% of body weight is water (need 2000-3000 mL) ICF (intracellular fluid) - Inside the cell - Main cation: Potassium - Main anion: Phosphate ECF (extracellular fluid) - Outside the cell - Intravascular (plasma) = 1/3 - Interstitial (in between the cells and in the veins) = 2/3 - Transcellular (cerebrospinal fluid, in GI tract, pleural, synovial, peritoneal, intraocular, and pericardial fluid) - Main cation: Sodium - Main anion: Chloride

Serum glucose range

70-110 mg/dL (from capillary)

Oral glucose tolerance test (OGTT)

<140 mg/dL is normal 140-199 mg/dL = pre-diabetes >200 = DM

Pathophysiology of DM

Absent or insufficient insulin production by B-cells in pancreas or poor utilization of insulin

Differentiate between assessment and treatment of acute and chronic pain. Remember that chronic pain may not be able to be a goal of < 3.

Acute: sudden, cause of pain known, <3 months or normal healing, decreases over time and goes away - Pain from trauma, post-op - Assessment: patient knows the onset - S/S: increased HR, RR, BP, pallor, anxiety, urine retention, diaphoresis, confusion - Treatment (pain control with eventual elimination) * Pain control to extent possible * Focus on enhancing quality of life Chronic: lasts longer than 3 months, could have started as acute - Assessment: ask for duration rather than onset; patient probably cannot remember when it began; cause may not be known/original cause may differ from mechanisms that maintain pain - S/S: periods of increasing and decreasing pain, flat affect, decreased physical activity, fatigue, withdrawal from social isolation - Treatment: Pain control to extent possible, focus on enhancing quality of life

How to assess a patient with pre-HTN and what you would teach them about it

Assess - Physical exam, including: * BP in both arms * Family history * Risk factors of HTN * Co-morbidities such as atherosclerosis - Pre-HTN: 120-139/80-89 Educate - Modifiable risk factors, including: * Diet change * Weight loss * Increasing amount of exercise * Avoiding tobacco * Limiting alcohol intake * Limiting sodium intake

Explain your role and responsibility in pain management

Assess pain and communicate with others to ensure adequate management and relief measures Evaluate effectiveness of interventions and advocate for those in pain Believe all reports of pain, communicate concern and affirm commitment to patient Act as planner, educator, patient advocate, interpreter, and supporter of patient and family * Use holistic approach * Every patient deserves to have their pain treated * ASSESS * Base treatment plan on patient's goals * Use drug and non-drug therapies * Look for non-verbal cues * Effective communication-- builds patient trust

How to assess and treat a patient having an acute asthma attack

Assess: - Anxiety - Increased BP, HR (>120 bpm), RR (>30 breaths/min) - Diminished lung sounds or silent chest (severe obstruction) - O2 status - Cough or wheeze Treat: - SABA inhaler (most effective for relieving acute bronchospasms - Tripod position - Oral corticosteroids - Intubation if necessary - Take 2-4 puffs of albuterol Q20 min. 3 times to gain rapid control of symptoms

Explain nursing management of patients with HF, including assessment, diagnosis, planning, implementation, and evaluation

Assessment - Past health history - Functional health patterns - Medications - Physical exam Diagnosis - Activity intolerance - Fluid volume excess - Impaired gas exchange - Anxiety - Deficient knowledge Planning - Decrease symptoms and peripheral edema - Increase exercise tolerance - Compliance with medical regimen - No complication r/t HF Implementation - Patient education (lifelong adherence to medication, taking HR, knowing when to withhold medication and call doctor) - Home BP monitoring - Signs of hypo/hyperkalemia - Energy conserving and efficient behaviors Evaluation - Respiratory status - Fluid balance - Activity tolerance - Anxiety control - Knowledge of disease process

NDs appropriate for asthma and COPD

Asthma - Ineffective airway clearance - Deficient knowledge - Anxiety COPD - Ineffective airway clearance - Impaired gas exchange - Imbalanced nutrition: less than body requirements - Risk for infection - Insomnia

BMP: Normal value and HF values

BUN - Normal: 6-20 - HF: above 20 CO2 - Normal: 23-29 - HF: above 29 Creatinine - Normal: 0.6-1.3 - HF: above 1.3 Glucose - Normal: 70-110 - HF: above 110 Serum chloride - Normal: 96-106 - HF: below 96 Serum potassium - Normal: 3.5-5.0 - HF: above 5 Serum sodium - Normal: 135-145 - HF: above 145

Metabolic Acidosis

Base bicarbonate deficit which occurs when an acid other than carbonic acid accumulates in the body, or when bicarbonate is lost from body fluids. Compensation: increases CO2 excretion which results in Kussmaul respirations (deep, rapid breathing) and the kidneys excrete acid Types of patients: - DKA, renal failure, shock, sepsis, salicylate OD, diarrhea S/S: drowsiness, confusion, dizziness, HA, coma, decreased BP, dysrhythmias, warm/flushed skin, N/V/D, abdominal pain, deep/rapid respirations (Kussmaul) Management: Need to call doctor to get orders; interventions (O2) will not fix it

Metabolic alkalosis

Base bicarbonate excess caused by gain of HCO3- Compensation: decreased respiratory rate to increase plasma CO2 and renal excretion of HCO3- Types of patients: - Prolonged vomiting/gastric suctioning, overuse of antacids, potassium-wasting diuretics S/S: dizziness, light-headedness, confusion, tachycardia, dysrhythmias, N/V, anorexia, tetany, tremors, muscle cramps, hypertonic muscles, seizures, hypoventilation

Foods high in fiber

Beans (legumes), whole-grain products, fruits, veggies, bran

Identify the processes to maintain acid-base balance

Buffers (reacts immediately)-- Changes strong acids to weaker ones, or binds to neutralize them Respiratory (takes minutes to hours) - Increased respirations, increased CO2 expelled (purpose is to get rid of acid) - Decreased respirations, decreased CO2 expelled (purpose is to increase acid) Renal (takes 2-3 days)-- Excretion of weak acids

Respiratory Alkalosis

Carbonic acid deficit caused by hyperventilation blowing off too much CO2 Compensation: rarely occurs because of aggressive treatment to treat causes of hypoxemia Types of patients: - Anxiety - High altitude - Pregnancy - Fever - Hypoxia - Excessive tidal volume in vented patients - Initial stages of pulmonary emboli S/S: dizziness, light-headedness, confusion, HA, tachycardia, dysrhythmias, N/V, epigastric pain, tetany, numbness, hyperreflexia, seizures, hyperventilation Management: breathe into bag (breathe CO2 back into body)

Respiratory Acidosis

Carbonic acid excess caused by hypoventilation; respiratory depression or failure Compensation: kidneys conserve HCO3- and secrete H+ into urine Types of patients: - Drug OD, chest trauma, pulmonary edema, COPD, airway obstruction, neuromuscular disease S/S: drowsiness, confusion, dizziness, headache, coma, decreased BP, V-fib, warm/flushed skin, seizures, hypoventilation Management: get orders, give O2

Describe common problems of older adults related to hospitalization and acute illness and the role of the nurse in assisting them with selected care problems

Care Transitions - Safe, effective, and efficient care transitions are most likely to occur when interdisciplinary team members work together to coordinate care - Many older adults are in unstable condition Rehabilitation - Help older adults adapt to or recover from disability - Acute inpatient rehabilitation or long-term care settings - Reducing disability through geriatric rehabilitation is important to the quality of life of older adults - Factors that influence rehabilitation potential: preexisting problems associated with reaction time, visual acuity, fine motor ability, physical strength, cognitive function, and motivation Assistive Devices - Dentures, glasses, hearing aids, walkers, wheelchairs, adult briefs or protectors, adaptive utensils, elevated toilet seats, and skin protective devices can decrease disability - Provide instruction on use Safety - Higher risk for accidents; normal sensory changes, slowed reaction time, decreased thermal and pain sensitivity, changes in gait and balance, and medication effects - Most accidents occur in or around the home - Hypothermia and hyperthermia occur more often Medication Use - Requires thorough and regular assessment, care planning, and evaluation - Drug half-life is increased in older adults, leading to drug toxicity and adverse drug reactions --> drugs metabolize slower - Polypharmacy, overdose, and addiction to prescription drugs are major causes of illness Depression - Not normal part of aging - Arises from low self-esteem and may be related to life situations Use of Restraints - May only be used to ensure person's safety or safety of others - Least restrictive restraint is required Sleep - Decrease in deep sleep and are easily aroused - Altered sleep pattern

Explain the needs of special populations of older adults

Chronically ill older adults - Most common chronic illness in older adults are HTN, arthritis, HD, cancer, stroke, DM - Others include: Alzheimer's disease, vision and hearing deficits, osteoporosis, hip fractures, stroke, Parkinson's disease, and depression Older adult women - More likely to live alone - Less likely to have health insurance - Lack of formal work experience--> lower income - Cares for ill spouse - Higher incidence of chronic health problems: arthritis, HTN, stroke, DM - More likely to rely on Social Security as major source of income - Poverty rates highest among minority women--> more likely to live in poverty - Loss of spouse is more common Cognitively impaired - May experience memory lapse or benign forgetfulness that is not related to cognitive impairment (age associated memory impairment) - Declining physical health - Older adults experiencing sensory loss, HF, or cerebrovascular disease may show a decline in cognitive functioning - Encourage older adults with memory loss to be evaluated by PCP and use memory aids, attempt recall in a calm and quiet environment, and actively engage in memory improvement techniques Rural older adults - 5 barriers: transportation, limited supply of healthcare workers and facilities, lack of quality health care, social isolation, and financial limitations Homeless older adults - Often relates to having a low income, reduced cognitive capacity, living alone, and lack of affordable housing - Mortality rates are 3 times higher than for older adults who have housing - Have more health problems and appear older - Requires interdisciplinary approach that links shelters with outreach, primary care clinics, Medicare and Medicaid offices, and pharmacies Frail older adults - S-- Sadness or mood change - C-- Cholesterol, high - A-- Albumin, low - L-- Loss or gain of weight - E-- Eating problems - S-- Shopping and food preparation problems - Frailty is a geriatric syndrome in which 3 or more of the following are present: advanced age, unplanned weight loss, weakness, poor endurance and energy, slowness, and low activity levels - Risk factors: disability, multiple chronic illnesses, and dementia

Hypervolemia

DECREASED ECF - Too much water - HF patient - Renal failure - Interstitial to plasma shift - S/S: HA, edema, polyuria, increased BP, jugular venous distention, weight gain - Treatment: * Diuretics (Furosemide-- can cause tinnitus if pushed too quickly; Spironolactone/K+ sparing diuretic-- eliminates fluid without depleting potassium) * Remove fluid without change electrolyte balance or osmolality of ECF - Nursing management * Monitor I&O * Monitor CV and respiratory change * Daily weight * Skin assessment * Neurological function: LOC, muscle strength * Renal monitoring to make sure it can excrete all the fluid

Foods that contain phosphates

Dairy, meat, fish, nuts, beans

Nursing actions for patients with anemia

Diagnoses: - Fatigue - Altered nutrition: less than body requirements - Ineffective self-health management Goal: - Assume normal ADLs - Treat underlying disease to correct the cause - Maintain adequate nutrition - Develop no complications r/t anemia Implementation: - Blood or blood product transfusions with packed RBCs - Drug therapy with medications like erythropoietin and vitamin supplements - Volume replacement - Dietary and lifestyle changes (increased iron intake, nutritional therapy, oral or occasional parenteral iron supplements - O2 therapy - Patient teaching of nutrition and compliance with safety precautions

Describe drug and non-drug methods of pain relief

Drug: using medication - Opioids: potent, no analgesic ceiling, several routes of administration, often combined with non-opioids to relieve pain * Morphine, codeine, hydrocodone * Naloxone (narcan) reverses their sedation effect-- must use carefully since it could take away pain effects - Non-opioids: have analgesic ceiling (increased dose does not increase analgesic effects, harms liver) * Aspirin (used for HA, arthritis) * Acetaminophen (used for pain and fever, no more than 4g/day, or 1000 mg Q6H) * NSAIDs (for inflammation, pain, swelling; ibuprofen, Aleve, Motrin) - Adjunct therapy: used in conjunction with opioids and non-opioids * Corticosteroids for inflammation and pain * Anti-depressants help with neuropathic pain * Anti-seizure are used for diabetic neuropathy and pain - Non-drug therapy: without medication * Possibly alters the ascending nociceptive input or stimulates the descending pain modulation * Lowers risk for addiction and tolerance * Guided imagery * Acupuncture * Meditation * Massage * Relaxation

Understand how to communicate with a hearing impaired patient and functional blindness

Functional blindness - Communicate in normal tone - Address patient, not caregiver - Make eye contact - Face the patient Hearing impaired - Use visual aids - Use interpreter if they use sign language - Speak normally and slowly - Use simple sentences - Do not over enunciate - Do not shout - Speak in normal voice into BETTER ear - Avoid covering mouth or chewing gum - Maintain eye contact

Collaborative care of OA

Goal: decrease pain, prevent disability, improve joint function Main treatment is non-pharmacological Balance of rest and activity-- do not immobilize joint more than 1 week Encourage regular ROM exercises Stiffness from immobilization-- morning after sleep, use heat Inflammation due to injury or not enough rest-- use cold treatment Warm up before exercise-- Tai-chi CAM (complimentary alternative medicine-- guided imagery, acupuncture, yoga, massage Drug therapy: - Acetaminophen - Capsaicin cream - NSAIDs: sometimes works better than others; start at low dose, increased risk for GI bleed - Corticosteroid-- inject into affected joint to help subside inflammation - Hyaluronic acid-- normally found in joint fluid; contributes to viscosity and elasticity of synovial fluid

Primary risk factors for HF

HTN and CAD

HA1C

Hemoglobin in the RBCs, sees how much glucose is binded to it Normal-- 4-6% Pre-diabetes-- 5.7-6.4% DM-- >6.5%

Differentiate among the care alternatives to meet the needs of older adults

Housing - If health declines, one can make adaptations to their home Community-Based - Adult daycare programs: provide social, recreational, and health-related services to individuals in a safe, community-based environment - Home health care: can be a cost-effective alternative for older adults who are home-bound, have health needs that are intermittent or acute, and have supportive caregiver involvement Long-Term Care Facilities - Rapid patient deterioration - Caregiver inability to continue to care due to burnout - Loss of family support system Case Management - May use if family is out of town and needs facilitator

Hypovolemia

INCREASED ECF - Abnormal loss of body fluids (V/D, hemorrhage) - Inadequate intake of water - Plasma to interstitial shift -S/S: drowsiness, confusion, thirst, decreased skin turgor, urinary retention, weight loss, increased respirations and HR, weakness, seizures, coma - Treatment: Replace water and electrolytes with IV solution (Lactated Ringer's or NS); treat underlying cause (older patients have decreased thirst mechanism)

What essential nutrient should a patient with anemia take?

Iron

Review different teaching strategies

Lecture-Discussion - Used when group of patients and caregivers can benefit from basic information - Lecture portion is short - Discussion ("teach-back") follows lecture * Ex: Basic principles of cardiac rehab (exercise, nutrition) Demonstrate/Return Demonstration ("show-back") - Teach patient and caregiver to perform a skill - Through return demonstration ("show-back") can evaluate patient's ability to perform skill * Ex: Dressing change, injection Role play - Used when patients need to examine attitudes and behaviors, understand viewpoints of others, or practice carrying out ideas or decisions * Ex: Wife who rehearses how to talk with husband about the need to quit smoking Learning Materials - Use of audiovisual materials to supplement teaching including: printed materials, CDs/DVDs - Hospital-based TV - Internet-based programs

Cor pulmonale: management and what the nurse will monitor the patient for

Management - Continuous low-flow O2 and diuretics are generally used to prevent more damage on the heart Monitor - BP, O2 status, RR, edema, I&O, presence of neck vein distention, lung sounds (crackles usually present)

Magnesium imbalances

Normal range: 1.5-2.5 - Regulates calcium balance, helps with myoneural junction, cardiac function Hypermagnesemia - Causes: increased dietary intake, kidney disease/failure - S/S: loss of deep tendon reflexes, respiratory depression/eventually cardiac arrest - Treatment: decrease dietary intake, give CaCl to reverse it, give fluids to promote urinary excretion Hypomagnesemia - Causes: decreased intake, starvation, chronic alcoholism, fluid loss from GI without supplementation, diuretics - S/S: Hyperactive deep tendon reflexes, cardiac dysrhythmias - Treatment: increase dietary intake, oral supplements, IV or IM if severe enough

Sodium imbalances

Normal range: 135-145 -Sodium lives outside of the cell and helps with nerve transmission Hypernatremia - Causes: too much sodium, loss of water, making sodium solute higher than actual water, cellular dehydration, decrease thirst (geriatric) - S/S: increased thirst, seizures, CNS deterioration, increased IF, decreased turgor, seizures, coma - Treatment: Give hypotonic solution (D5), diuretics, decrease sodium intake, treat underlying cause Hyponatremia - Causes: not enough intake, too much water, vomiting, diuretics, HF (way more water retained than compared to salt) - S/S: Irritability, confusion, CNS deterioration, N/V, seizures - Treatment: hypertonic solution, increase salt intake, limit water intake (most likely to go NPO), vasopressin (antidiuretic if losing too much salt and water)

Phosphate imbalances

Normal range: 2.4-4.4 - Helps with RBCs, nerve impulses, muscles Hyperphosphatemia - Causes: chemo, increased intake, renal failure, vitamin D - S/S: tetany (constant muscle contraction), calcified depositions - Treatment: decrease intake, treat underlying cause Hypophosphatemia - Causes: malnourishment, alcohol withdrawal, use of phosphate binding antacids - S/S: CNS dysfunction, osteomalacia (bone weakness, deterioration), muscle weakness, dysrhythmias, cardiomyopathy

Potassium imbalances

Normal range: 3.5-5 - Important for cardiac rhythm, cellular growth, and helps with muscles Hyperkalemia - Causes: increased dietary intake, renal failure (cannot excrete it), cellular destruction from trauma (potassium in cell, ruptures and leaves cell) - S/S: EKG changes, anxiety, cramping, weakness in lower extremities, v-fib from renal failure, paralysis of skeletal muscles Hypokalemia - Causes: decreased intake, diuretics, V/D - S/S: EKG changes, soft/flabby muscles, bradycardia, shallow respirations - Treatment: oral supplement, monitor I&O so we know that potassium can be excreted - Do not exceed more than 10 mEq/1 hour for IV - NEVER IV PUSH PURE POTASSIUM-- NEEDS TO BE DILUTED

Calcium imbalances

Normal range: 8.6-10.2 - Helps with formation of bones and teeth, clotting, inverse relationship with phosphorous, cardiac function (helps muscles contract) Hypercalcemia - Causes: increased intake, overactive parathyroid gland, vitamin D overdose, malignancy, prolonged immobilization (calcium is used for muscle contraction-- if it is not being used, it will build up) - S/S: fractures (due to prolonged immobilization), depressed reflexes, psychosis, thirst, CNS deterioration (memory decreased, increased IF, caused by hyperparathyroidism) Hypocalcemia - Causes: blood transfusions, pancreatitis, alkalosis - S/S: tingling in extremities and around the mouth, Chvostek's sign (twitching of the facial nerve while tapping it), Trousseau's sign (BP cuff over arm causing carpal spasm), tetany, CNS and ECG changes

Know how to write a proper ND

Nursing diagnosis (problem) r/t ____ AEB ____ - Ex: Impaired skin integrity r/t restricted mobility AEB skin breakdown

Know different routes to give pain medications and know which is quickest

PO (route of choice for the person with a functioning GI system) Rectal (unable to take PO or has N/V) Parenteral = IV (quickest), SQ, IM Epidural, intrathecal Transmucosal/buccal/sublingual, transdermal, intranasal (highly vascular mucosa and avoids first-pass effect) Intraspinal, implantable pumps, PCA

Fasting/impaired fasting plasma glucose range

PREFERRED METHOD OF DIAGNOSIS 100-125 = pre-diabetes >126 = DM

Assessment details and tips

Pain is considered the 5th VS-- ask with the pain scale and OLDCARTS. Elements = direct interview, observation, diagnostic studies, physical exam Breakthrough pain, anxiety/fatigue/depression can worsen pain Physiological and behavioral signs are not reliable for pain; but facial expressions, breathing, and body movement/tension can help

Understand use of PCAs

Patient controlled analgesia-- acute pain, cancer and post-op pain; taper off PCA eventually by increasing dose of oral drug and slowly decreasing PCA analgesic ONLY PUSH WHEN HAVING PAIN Patient can press green light when ready, but educate that only the patient can press it Patient cannot OD, but respiratory depression may still occur Bolus is delivered once button is pushed

Evaluate the influence of one's own knowledge, beliefs, and attitudes about pain assessment and management

Patients have different beliefs and attitudes toward pain. Assess for attitudes that can hinder pain management. - Some believe that opioids result in addiction so they try to live with their pain

State principles of adult education applied to patient/caregiver

Physical characteristics: age, gender, pain, tired, ill, mental status, vision/hearing, medication S/S Psychological characteristics: anxiety, depression, self-efficacy Sociocultural characteristics: health literacy, cultural considerations, socioeconomic considerations Learner characteristics: learning needs, readiness to learn, learning style (reading, listening, doing) Prior experience: motivation is increased when one knows already, identifying past knowledge/experiences help find familiar ground to increase confidence Learner's self-concept: patients need control and self-direct to maintain sense of self-worth; they do not learn when treated like children and told what they need to do

Define the pain dimensions

Physiologic: genetic, anatomic, and physical determinants-- influence how stimuli are recognized and described Affective: anger, fear, depression, anxiety (negative emotions impair the patient's quality of life), suffering in states of severe distress and loss are eased by pain relief and spirituality, treating depression can help relieve pain Behavioral: facial expressions, socially withdrawn, less physically active, using relaxation, taking medication Cognitive: beliefs, attitudes, memories, and meaning attribute to pain and influence the responses so they must be incorporated into the comprehensive treatment plan Sociocultural: demographics, support systems, social roles and culture; age, gender, and education influence beliefs and coping; asses without stereotypes

Trans-theoretical Model of Health Behavior Change

Pre-contemplation - Patient Behavior: not considering a change, not ready to learn - Nursing Implication: provide support, increase awareness of condition; describe benefits of change and risks of not changing Contemplation - Patient Behavior: thinks about a change, may verbalize recognition of need to change; says "I know I should," but identifies barriers - Nursing Implication: introduce what is involved in change the behavior; reinforce the stated need to change Preparation - Patient Behavior: starts planning the change, gathers information, sets a date to initiate change, shares decision to change with others - Nursing Implication: reinforce the positive outcomes of change, provide information and encouragement, develop a plan, help set priorities, and identify sources of support Action - Patient Behavior: begins to change behavior through practice; tentative and may experience relapse - Nursing Implication: reinforce behavior with reward, encourage self-reward, discuss choices to help minimize relapses and regain focus; help patient plan to deal with potential relapses Maintenance - Patient Behavior: practices the behavior regularly; able to sustain the change - Nursing Implication: continue to reinforce behavior; provide additional teaching on the need to maintain change Termination - Patient Behavior: change has become part of lifestyle; behavior no longer considered a change - Nursing Implication: evaluate effectiveness of the new behavior; no further intervention needed

Causes of HF

Primary causes: - CAD, HTN, rheumatic heart disease, congenital heart defects, cardiomyopathy, hyperthyroidism, myocarditis, valvular disorders Precipitating causes: - Anemia, infection thyrotoxicosis, hypothyroidism, dysrhythmias, bacterial endocarditis, pulmonary embolism, Paget's disease, nutritional deficiencies, hypervolemia - Increase the workload of the ventricles resulting in an acute condition and decreased heart function

How to write a NANDA

Problem related to etiology as evidenced by signs and symptoms

CBC: Normal values and HF values

RBC - Normal: 3.8-5.7 - HF: below 3.8 Hgb - Normal: 11.7-17.3 - HF: below 11.7 Hct - Normal: 35-50% - HF: below 35%

Know how to teach patients distraction techniques

Redirect attention away from pain onto something else. Watch TV/movie, converse with the patient, music, play a game It is important to match the activity with the patient's energy level and ability to concentrate.

Pathophysiology of OA

Slowly progressive, asymmetrical non-inflammatory disorder of the diarthrodial joints; new joint tissue is formed as old cartilage is broken down, causes spurs and loose cartilage pieces and decreased fluidity of joint space; secondary synovitis may result. Usually seen in DIP, PIP, MCP (all 3 finger/thumb joints), hips, MTP (toes), cervical/lower lumbar vertebrae

Define pain

Subjective, whatever the person experiencing it says it is, unpleasant sensory and emotional experience associated with actual or potential tissue damage

Interpret the subjective and objective data that are obtained from a comprehensive pain assessment

Subjective: health history (OLDCARTS, expression of pain, past treatments, review of health care utilization r/t pain problems); medications (Rx, OTC, illicit, herbal products, alcohol use - Functional health patterns * Health perception/management (social and work history, mental health, smoking effects of pain on emotion, relationships, sleep and activities, interview family, records from psychiatric treatment r/t pain) * Elimination: constipation r/t opioids * Activity-exercise: fatigue, limits, pain r/t muscle use * Sexuality-reproductive: decreased libido * Coping-stress tolerance: psychological evaluation to examine coping style, depression, and anxiety Objective - Physical exam including evaluation of functional limitations - Psychosocial evaluation of mood

Heart Failure

The heart is unable to provide sufficient blood to meet the O2 needs of the tissues. It involves inadequate pumping and/or filling of the heart.

Cardiac enzymes: Normal value and HF value

Troponin - Normal: <0.1 - HF: above 0.1 CK - Normal: 20-200 - HF: above 200 CKMB - Normal: <4-6% - HF: >4-6%

Differentiate between DM Type 1 and Type 2

Type 1 - Absence of endogenous insulin (T-cells kill B-cells) - Insulin-dependent for life - Occurs gradually as disease is present for months to years before S/S occur - Most end up in DKA if not monitoring blood sugar - Usually diagnosed before the age of 40 - S/S: weight loss, 3 P's, fatigue Type 2 - Presence of endogenous insulin (major distinction between Type 1 and Type 2) - Most common - Insufficient insulin production or poor utilization of insulin by tissues - Nutrition and exercise can reverse it - Obesity is main risk - Four major metabolic abnormalities * Insulin resistance: receptors are insufficient in number or unresponsive * Inappropriate glucose production by liver * Decreased ability to produce insulin because B-cells are tired from the compensatory over-production of insulin * Production of hormones and cytokines by adipose tissue (adipokines, which play a role in glucose and fat metabolism, are believed to cause chronic inflammation that is involved in insulin resistance) - Usually diagnosed around age 35

S/S of DM

Type 1 - Polydipsia - Polyuria - Polyphagia - Weight loss - Fatigue - Ketoacidosis when untreated Type 2 - Non-specific - Sometimes 3 P's - Recurrent infections - Fatigue - Recurrent yeast infections - Prolonged wound healing - Visual changes