Summary Final Exam Study Guide NUR 2790: Professional Nursing III

Final Exam Study Guide NUR 2790: Professional Nursing III MODULE 1: CELLULAR REGULATION Cancer • Primary vs. Secondary prevention Primary CA prevention: removal of “at risk” tissue, chemoprevention, vaccination (HPV) Secondary CA prevention: regular screening • Risk factors/warning signs (CAUTION mneumonic) C: change in bowel/bladder function A: a sore throat that does not heal U: unusual bleeding T: thickening lumps I: indigestion/difficulty swallowing O: obvious change in mole N: nagging cough/hoarseness • Treatment types, side effects/complications (& treatment/nursing care of side effects/complications) Surgery: can be prophylactic, diagnostic, curative, palliative SE/complications: removed organs and tissues lose function, removal of organs does not necessarily rid cancer Radiation: destroy cancer cells with minimal damaging effects of surrounding normal cells SE/complications: radiation dermatitis, altered taste/fatigue, atherosclerosis, coronary artery disease, fibrosis, scarring, bone marrow suppression Nursing care: provide accurate info, skin care (wash gently with soap and water, avoid scrubbing), do not remove temporary ink markings, provide nutritional support, care of xerostomia (administer saliva substitutes, lozenges, mouth rinses), reduce risk for bone fracture, encourage exercise and sleep interventions to treat fatigue Chemotherapy: treatment of cancer using antineoplastic drugs (cytotoxic systemic therapy) SE/complications: dosage and scheduling (dose-limiting side effects may impact), extravasation and vesicants, bone marrow suppression (neutropenia, anemia, thrombocytopenia), mucositis (inflammation of oral mucosa) alopecia (hair loss), chemo brain, chemo-induced peripheral neuropathy, fatigue Nursing care: epo-alfa/Epogen, blood products, no flossing, soft toothbrush, no razors, no NSAIDS, treat nausea (peppermint oil, Zofran, fluids, room temperature food, alcohol swabs) Immunotherapy: enhances and alters pt’s biological response to cancer cells via direct antitumor activity SE/complications: fluid shifts/inflammation, decreased LOC and other neuro changes, fever, chills, malaise Photodynamic therapy: selective destruction of cancer cells via chemical reaction triggered by last light which destroys or shrinks tumors Hormonal manipulation: changing usual hormone responses to slow tumor growth to certain cancer types SE/complications: masculinizing affects in women, feminizing effects in women (gynecomastia), fluid retention, acne, hypercalcemia, liver dysfunction, VTE Bone marrow transplants: transplant of bone marrow from a matched individual (self or other) SE/complications: nausea, vomiting, graft vs. host disease, infection, organ damage Complementary & Alternative Medicine (CAM) • Types of CAM (mind-body therapy, tai chi, chiropractic care, herbal meds, etc.), goals of use, and interactions Mind-body therapies: biofeedback, guided imagery, intercessory prayer, meditation, relaxation exercise Biologically-based therapies: herbal therapies (chamomile, garlic, gingko, ginseng, peppermint, ’s wart, vaerin) Manipulative and body-based therapies: acupuncture, acupressure, chiropractic, massage, rolfing, shiatsu, tai chi, yoga Energy therapies: reiki, therapeutic touch Alternative medical systems: homeopathy (tx of disease with minute drug doses to activate and illness that then stimulates the body’s normal defense system to eliminate disease; remedies without chemically active ingredients), naturopathy (the practice of assisting in the health of patients through the application of natural remedies), osteopathy (embracing the full spectrum of medicine, including the use of medications and surgery, in addition to manipulative techniques) MODULE 2: END-OF-LIFE CARE Chapter 10: Principles of Emergency and Disaster Preparedness • Palliative vs. Hospice care (goals of each, differientation) Palliative care: can be any stage of serious or chronic illness, care may be provided concurrently with curative therapies, care not limited by time periods, care provided by PCP with potential follow-up vistis Hospice care: prognosis of less than 6 months to live, initiated when curative tx stops, 60-90 day periods of care, care provided by RNs, social workers, chaplains, and volunteers • Ethical/legal considerations r/t dying (AD’s, living will, euthanasia, etc.) • Durable power of attorney for health care (DPOAHC): makes decisions about pt’s healthcare when MD determines pt does not have capacity to make decisions (pt does not receive info, pt does not evaluate, deliberate and mentally manipulate info, pt does not communicate a tx preference) Living will: discusses CPR or code status (must be initiated unless and DNR order exists, may be violent and painful), intubation/artificial ventilation, artificial nutrition/hydration “Five wishes”: identification of decision maker (DPOAHC), identification of treatments the pt does/does not want, comfort level expectations, how they want to be treated, what the pt wants loved ones to know Active euthanasia: use of medications or tx that purposefully causes pt’s death (physician assisted suicide) Passive euthanasia: discontinuation of one or more therapies that may prolong life Voluntary stopping of eating and drinking (VSED): refusal to eat or drink in order to hasten death by competent pt with terminal illness • S/Sx of end-of-life Lack of heartbeat, absence of spontaneous respirations, irreversible brain dysfunction Weakness, anorexia, changes in cardio function (cool, mottled cyanotic extremities, decreased BP, heart rate will increase-irregular-brady-asystole), dyspnea (cheyne- stokes), changes in GU (incontinence, decreased UO), changes in LOC (sleeping, restless, anxiety, lethargy) MODULE 3: TISSUE INTEGRITY Chapter 10: Principles of Emergency and Disaster Preparedness • Traditional triage vs. Mass Casualty triage Traditional triage: most critical pt’s are seen first(emergent/immediate threat to lfie, urgent/major injuries, nonurgent minor injuries) Mass casualty triage: emergent (red tag) pt’s seen first, urgent (yellow tag), nonurgent (green tag), expectant or allowed to die (black tag) • Internal vs. External events Internal events: power outage, active shooter, explosion External: tornado, volcano, hurricane, wild fires, epidemics Chapter 26: Care of the Patient with Burns • Classifications of burn injury (superficial, partial-thickness, etc.) Superficial-thickness burns (1st degree): least damage; epidermis is only part of skin injured (sun burn, flash exposures) Partial-thickness burns (2nd degree): Superficial partial-thickness: injury to upper third of dermis, pink moist blanchable, blister formation, heals within 10-21 days without scarring Deep partial-thickness: extend deep into the dermis, red dry with slow blanching, no blisters, edema, heal within 2-6 weeks with scarring Full-thickness burns (3rd degree): destruction of entire epidermis and dermis, skin does not regrow, characterized by; eschar, edema, waxy-white, deep-red, yellow, brown, or black appearance, may have no blood supply, reduced/absent sensation, healing takes weeks to months • Rule of 9’s • Phases of burn injury (time periods, priority assessments, etc.) Resuscitative/emergent phase: 24 to 48 hours Goals: secure airway, support circulation (fluids), pain relief, prevent infection, maintain body temp, provide emotional support Assessment: direct airway injury (hoarseness, brassy cough, drool, tachypnea, wheezes, stridor), smoke poisoning, pulmonary edema (SOB, crackles), CO poisoning (cherry-red coloring, headache, nausea, drowsiness, irritiable), thermal airway injury (ulcerations, redness, edema), hypovolemia, decreased CO, decreased BP with increased HR, EKG changes with direct heart damage, fluid shifts, decreased UO, concentrated urine Diagnostics: increased Hgb, Hct, increased BUN, glucose, potassium, decreased sodium, protein and albumin Interventions: maintain airway, fluid resuscitation, manage pain, preventresp distress Acute phase: 36-48 hours Debridement, dressings (biologic, biosynthetic, synthetic), surgical wound management (grafting), minimizing weight loss, support self-esteem Rehabilitative phase: years to lifetime Wound closure, emphasis on; prevention of scars, psychosocial adjustment, resuming pre-burn activity • Immediate burn care (Education for patients) Remove cause of burn, check of breathing, administer CPR if needed, lukewarm water to cool skin around burn unless wound is open, remove any loose debris, remove jewelry, cover burned area with clean dry cotton, raise burned area above level of heart • Parkland formula 2-4mL/kg/%BSA burned (over 1st 24 hours), half of total volume over 1st 8 hours, half over next 16 hours MODULE 4: GAS EXCHANGE Chapter 8: Principles of Emergency and Trauma Nursing • Triage (Definition, How does it work?, Where is it used? Etc.) Triage: an organized system for sorting and classifying pt’s into priority levels, depending on illness or injury severity o Pts with highest acuity need the quickest eval and tx, ED nurses act as the gatekeeper, three-tiered system, disposition of pt’s in the ED o 3 options: admit to hospital, transfer to specialty care center, discharge home Chapter 32: Care of Critically Ill Patients with Respiratory Problems • S/Sx of respiratory distress* Dyspnea, orthopnea, increased RR, decreased SpO2, restlessness, irritability, confusion, increased HR, decreased LOC, headache, weak peripheral pulses • Who is at risk for impaired gas exchange? Pt’s with pulmonary embolism (PE), venous thromboembolism (VTE), acute respiratory failure (ARF), acute respiratory distress syndrome (ARDS), chest trauma • Chest Trauma (pneumothorax, rib fractures, etc.) types & treatment measures Pulmonary contusion: common chest injury caused by rapid deceleration during MVA, may lead to ARDS, asymptomatic at first s/sx: bloody sputum, decreased breath sounds, crackles or wheezes, dullness on percussion tx: may resolve on own, good lung down positioning, maintain oxygenation Rib fractures: often from blunt trauma, risk for deep chest injury, pt often splints chest with breathing tx: maintain adequate gas exchange, splint rib cage when breathing/coughing, analgesics, fractured ribs reunite spontaneously Flail chest: results from fractures of two or more ribs in two or more places causes paradoxical chest wall movement s/sx: chest goes in during inspiration and out during expiration, dyspnea, cyanosis, increased HR, decreased BP tx: intubation with positive-pressure ventilation, analgesics Pneumothorax: air in pleural space (open=exposed to air, closed= spontaneous) s/sx: reduced or absent breath sounds on affected side, hyperresonant percussion, tracheal deviation to unaffected side types: traumatic (r/t trauma), spontaneous (not from trauma) tx: provide oxygen, relieve pain/anxiety, correct acid-base imbalance, minimize further damage, remove air (needle thoracostomy) Hemothorax: bleeding into the pleural space (simple is less than 1000mL, massive is greater than 1000mL) s/sx: reduced or absent breath sounds on affected side, dull percussion • Mechanical Ventilation (settings, complications, etc.) Support pt until lung function is adequate/episode has passed to improve gas exchange and decrease WOB Controls: o Tidal volume (Vt): volume of air the pt receives with each breath (6-8mL/kg) o Rate (f): ventilator breaths delivered per minute o Positive end-expiratory pressure (PEEP): positive pressure exerted during expiration (prevents atelectasis, usually 5-15cm H2O) o FiO2: oxygen level delivered to pt, ranging between 21-100% o Peak inspiratory pressure (PIP): pressure used by ventilator to deliver a set tidal volume at a given lung compliance, highest pressure reached during inspiration • ETT vs. Tracheostomy (purposes, differentiation, etc.) ETT: intubation with a long PVC tube that is passed through the mouth and into the trachea, most often required for pt’s with hypoxemia and progressive alveolar hypoventilation with resp acidosis, utilized for 10-14 days max, performed by CRNA or RT Tracheostomy: intubation with PVC tube that is surgically placed into the trachea, utilized when pt cannot wean from ETT after 10-14 days to improve comfort and decreased risk for pneumonia MODULE 5: PERFUSION Chapter 33: Cardiac Function and Hemodynamics • Hemodynamic measures (CO, SV, CVP, MAP) Blood pressure (BP): pressure contained within the walls of the arteries Mean arterial pressure (MAP): average pressure contained within the arterial system SBP + 2(DBP) / 3 = MAP Cardiac output (CO): HR x SV = CO Stroke volume: mL of bleed ejected with each heartbeat, affected by contractility, preload and afterload, normal is 60-100 mL • Preload, afterload, & contractility (What affects these? How do we fix alterations?) Preload: the degree of the end-diastolic stretch of myocardial muscle fibers, volume of blood in ventricles just prior to systole, comparable to pt’s fluid volume status, measure central venous pressure (CVP, normal CVP = 3-8 mmHg) Contractility: inotropic state of the muscle, measured by ejection fraction 55-70% (normal) Afterload: resistance left ventricle must overcome to circulate blood, increased in hypertension and vasoconstriction (increased afterload = increased cardiac workload), determined by BP, SVR = 80 x (MAP - CVP) / CO • Vasopressors vs. Vasodilators Vasopressors: epinephrine, norepinephrine (Levophed), phenylephrine (Neo- synephrine), dobutamine, dopamine, vasopressin Epinephrine activates a1, a2, b1, b2 Norepinephrine activates a1, a2, b1 Phenylephrine activates a1 Dopamine activates dopaminergic, b1 Dobutamine activates b1 Vasopressin activates ADH Vasodilators: nitroglycerin, clevidipine/cleviprex Chapter 34: Care of Patients with Dysrhythmias • Cardiac Electrical Anatomy (What are the areas involved? What do they look like on EKG?) SV node: the pacemaker, 60-100 bpm = P wave AV junction: consisted of transitional cell zone, AV ndoe, and bundle of his, lies below right atrium endocardium (AV node is the area in which impulses are slowed or delated before moving to ventricles) = PR segment Purkinje cells: responsible for rapid conduction of electrical impulses through ventricles, which leads to ventricular muscle contraction = QRS complex • Parts of a rhythm (P, QRS, T, U, PR segment, QT interval, etc.) • Rhythms/Dysrhythmias (NSR, SA, ST, SB, SVT, PVC’s, AV-blocks, VT, VF, Paced rhythm, PEA, etc.) o Be able to differentiate between o Nursing interventions and treatment (medications, skills, etc.) NORMAL SINUS RHYTHM (NSR) SINUS ARRHYTHMIA (SA): changes in intrathoracic pressure with breathing, digitalis, morphine causes: exercise/anxiety, pain, fever, anemia, hypoxemia, hyperthyroidism, epinephrine, atropine, caffeine, alcohol, nicotine, cocaine tx: rest, avoid causative substance, stress management