NR 226- Exam 2 Study Guide (Patient Care)

NR 226- Exam 2 Study Guide Topics Older Adults 1. Principles for promoting older adult learning Make sure they are ready to learn; are they well enough to learn; sit in front of pt so they can watch your lips move & facial expression; speak slowly & in normal tone; say one idea at a time straight & to the point; give them enough time to answer; minimal distractions w/ proper lighting & comfortable settings; if tired or distracted stop teaching; invite another family to talk; audio, visual & tactile cues to help w/ learning & memory; ask for feedback to know they understand; using past experiences to connect to new learning. 2. Presentation of illness in older adults; acute care, restorative care Presentation of illness – confusion, occurrence & reasons for fall, dehydration, decreased appetite, loss of function, dizziness, incontinence Acute care – (short term hospital stay) risk for delirium, dehydration, malnutrition, nosocomial infections, urinary incontinence & falls. Restorative care - (recovering from acute illness or surgery & support of chronic conditions that effect day-to-day) stabilize chronic conditions, promote health and promote independence w/ ADL’s & IADL’s; prevent, improve, reduce or eliminate problems 3. Comparison of clinical presentation of delirium, dementia and depression; nursing implications Delirium – sudden onset; short fluctuations, worse by night & waking; abrupt progression; last hours to less than month (longer if untreated); consciousness is reduced; alertness fluctuates (lethargic or hypervigilant); attention fluctuates; orientation impaired (severity varies); forgetful; disorganized thinking (speech slow or fast); delusions & hallucinations; psychomotor movements varies; disturbed sleep (reverse). medical emergency & prompt assessment. Bedside 24/7 and ready to recognize development to report. Cognitive impairment reversed once doc identify and treat cause Dementia – slow onset & often unrecognized; long & progressively stable; slow but even progression; last moths to years; consciousness is clear; generally normal alertness; generally normal attention; orientation is normal to person but not place or time; memory impaired; thinking is impaired; misperceptions; normal psychomotor movements (may have apraxia, which is inability to perform purposeful actions); fragmented sleep. Always consider safety, physical & psychosocial needs. Enhance quality of life & maximize functional performance (cognition, mood &behavior) Depression – major life changes, can be sudden or gradual; during day, worse in morning, fluctuations w/ situation; varied progression; last at least 6 weeks or several months to years; consciousness is clear; normal alertness; attention is easily distracted; selective disorientation; sections of intact memory; thinking intact but w/ hopelessness & helplessness; intact perception(delusions & hallucinations in severe cases); varied psychomotor; disturbed sleep (wakes up early). 4. Sexuality in the older adult Changes in reproductive structure & function does not affect libido; still have desires, thoughts & actions for decades. Less activity because illness, death of partner & decreased socialization. Involves love, warmth, sharing and touching. Important role to help maintain self-esteem. understand physical changes in sexual response, provide privacy for discussion of sexuality, be nonjudgmental, ask open-ended questions. Talk about prevention of STI. Touch has many meaning and is an alternative sexual expression. 5. Health concerns; health promotion and maintenance, stroke, smoking, alcohol abuse, safety; nursing implications Health promotion & maintenance – (genetics, good health habits & preventative measures) participate in screenings; exercise regularly; within weight limits; eat low-fat & well balanced diet; low use of alcohol; dental visits; stop smoking; have immunizations. Give info on nutrition, exercise, meds, safety, some med conditions & self-care. Stroke – 3rd leading cause of death; brain ischemia (not enough blood to brain because arterial blockage) or brain hemorrhage; risk factor: hypertension, hyperlipidemia, diabetes, history of ischemic attacks & history of CVA. Impairs functional abilities; inability to be independent. Teach about risk-reduction, to look for early warning signs, ways to support pt inn recovery & rehab. smoking – 4th leading cause of death; preventable; if stopped can stabilize COPD & coronary artery disease; stopping after 65 can add 2-3 more yrs of life; within 1 yr coronary heart disease reduced by 50%; if rejects stopping then at least ask to reduce Alcohol abuse – there are two patterns: lifelong heavy drinking or new pattern heavy drinking late in life; causes from depression, loneliness, & lack of social support; suspicion if history of repeated falls & accidents, social isolation, recurring memory loss & confusion, failure to meet obligations, skipping meals or meds, and unable to manage finances. Encourage to be involved in activities of interest & increase self-worth. Safety - drink water when exercising, good support shoes, avoid outdoor exercise if weather is too hot or cold, exercise w/ partner, stop if feeling bad. Teach about different meds, combining& managing. Assess environment for risks at home (temp on water heater, throw rugs, slippery floor) 6. Therapeutic communication; reality orientation, validation therapy, reminiscence Therapeutic communication – respect them, their uniqueness & health expectations Reality orientation – communication technique to make them aware of time, place & person; improving awareness & orientation. Validation therapy – used w/ confused older adults; accepting the time & place the confused pt states it is. Reminiscence – remembering the past; using it to give meaning & understanding to present or resolve current conflicts 7. Older adults in the acute care setting vs restorative care Acute care setting is short term as in hospital stay, they need help adjusting to environment. Risks of delirium, dehydration, malnutrition, health care associated infections, urinary incontinence & falls. Restorative care has two types of on-going care: continued recovery from acute illness or surgery that started in acute care setting and support of chronic conditions that affect day-to-day functions. Can be in private home or long-term care setting. (this is basically a rehab) The Grief Response 1. Types of loss Necessary loss – a part of life; needs to happen & be replaced w/ something different or better Maturation loss – form of necessary loss; happens throughout life span as normally expected (mother sad because kid goes to college) Situational loss – sudden & unpredictable external event (car accident, injured so cant work ) Actual loss – no longer see, hear, feel or know person or object. (death in family, loss of body part, loss of job, loss of home) Perceived loss – defined uniquely by the person that experienced the loss & less obvious to others. (how intensely you feel about the loss) Death is ultimate loss and part of the continuation of life 2. Grief; stages of grief, mourning, bereavement; therapeutic communication, nursing implications Stages of grief – (dying) denial, anger, bargaining, depression & acceptance Grief – emotional response to loss; unique experience per individual; based on personal experience, cultural and spiritual belief. Mourning – outward expression and behavior to the loss; adapting to loss Bereavement – includes both mourning and grief Nursing implications – taking extensive nursing CEU’s to improve end-of-life care and help pt’s and families experiencing loss, grief death & bereavement. One can use research, practice evidence, experience. Show support and give space when needed Therapeutic communication - open heartedness; open-ended questions; active listening (go on, tell me more); learn to be comfortable in silence; empathize; be there for them; intentional &meaningful touch; make sure they know you are available to talk whenever; respectful of privacy; avoid barriers (false reassurance, denying pt’s grief); help family access other resources (spiritual care) 3. Normal grief vs Complicated grief; symptoms, nursing implications Normal grief – normal universal reactions; feelings of acceptance, disbelief, yearning, anger & depression. Complicated grief – prolonged or difficult time moving forward; chronic yearning, trouble accepting death & others, feel excessively bitter, emotionally numb or anxious about future. 4. Grief considerations in the older adults No different because of age, response is related to nature of loss experience; increased age means increased loss in life; they recover quickly (others can learn to from their courage); can have complicated grief from multiple losses (depression, loneliness, functional decline); physical decline because of illness leads to grief over health, functions & roles; pain is undertreated (mostly w/ dementia pt’s); benefit from same therapeutic techniques as other age groups; goals for grieving relieving depression & maintaining physical function. 5. Coping strategies, client education life experiences shape the persons way to deal w/ loss; emotional disclosure (talking about feelings, venting); always positive & optimistic emotions to better cope; writing letters or in a journal leads to accomplishment. 6. Palliative care vs Hospice care Palliative care – prevention, relief, reduction or soothing of symptoms of disease or disorder throughout entire time; include care of the dying & bereavement follow-ups for family; achieve best possible quality of life; advanced or chronic illness, any age, any diagnosis, any time, any setting Hospice care – care for the terminally ill; managing pain & symptoms; comfort; attention to all needs; less than 6-12 months to live; home, hospital, extended care or nursing home 7. End of life care; Promoting comfort in the terminally ill client Pain - Skin & mucous membrane discomfort – skin care as needed, lotion on skin, dry clean linens Mucous membrane discomfort – oral care every 2-4 hrs w/ soft toothbrush or swab and nonabrasive toothpaste or water, light lip balm, topical analgesics to oral lesions Corneal irritation – eye drops or optic lubes, warm water to remove crust Fatigue – balance activity & rest periods according to pt’s priorities & preferred time of day, conserve pt’s energy Anxiety – address cause, provide calm & supportive environment, active listening, use benzodiazepines for acute anxiety. Nausea – give antiemetic or promotility agents, stop meds or foods that cause it, oral care atleast 2-4 hrs, liquid diet & ice chips, no liquids that increase stomach acidity Constipation – laxatives w/ opioids, change diet as tolerated, increase fluid if tolerated Diarrhea – fecal impaction?, ask doc to change meds if that the cause, moisture barrier on skin Urinary incontinence – dry clothes and linens, foley or condom cath for comfort & skin protection Altered nutrition – smaller portions of pt-preferred foods, do not force food, treat anorexia if pt wants to eat Dehydration – mouth care as least every 2-4 hrs, ice chips or moist cloth to lips. Keep lips & tongue moist Ineffective breathing patterns – treat or control cause, position for comfort & maximal breathing, supplemental oxygen, reduce anxiety or fever, pain management, fan for air movement, stimulate 5th nerve on cheek to decrease dyspneic sensation; give anxiolytics, bronchodilators, inhaled steroids or opioids to suppress cough & ease breathing Noisy breathing (death rattle) – elevate head for postural drainage, turn side to side to mobilize & drain, stop oral intake, avoid suction (discomfort & ineffectiveness), anticholinergic meds sometimes helpful 8. Care of the body after death; cultural considerations Fed & state laws require to have policies for requesting organ or tissue donation, performing autopsy, certifying and documenting how death happened, providing safe and postmortem care. Each culture is different in how they handle their dead. Give compassion, maintain privacy & dignanity and respect for pt and pt’s family members cultural beliefs & practices. African American – large extended family and church family there at time of death, mourning period short, memorial service & public viewing (wake) before burial. Organ donation & autopsy allowed. Chinese –Same respect as living. Buried w/ food & stuff. Extended family stays w/ body for up to 8 hrs. oldest son or daughter bathes body under direction of older relative or temple priest. Organ donation & autopsy are uncommon. Hispanic – special objects like amulets or rosary beads, alternative healing practices & prayer. Grief expressed openly. Religious rituals are essential in end of life. Death is gods will. Native American – Navajos do not touch body after death. Cleansing body, painting the face, dressing in clothing and attaching an eagle feather to symbolize a return home. mourners cleanse their bodies. Dead buried in deceased homeland. Islamic – body ritualistically washed, wrapped, cried over, prayed for and buried as soon as possible. Eyes & mouth closed and face turned toward mecca. Same gender prepare the body. Body is burned not cremated. Autopsies interfere w/ quick burial so ask w/ sensitivity. Soul stays w/ body until It is buried. Organ donation is permissible by some quran interpretations. Buddhist – believe in afterlife, death preferred at home & state at time of death in important. Minimal emotion expression & maintain peaceful compassionate atmosphere. Male family members prepare the body. Recommend not touch body after death so they can transition smoothly into afterlife. Prayer and standing & touching by head of dead. Body not left alone after death. Respects after death & before cremation. Hindu: body placed on floor w/ head facing north. Same gender handles body. Yes to autopsy, bodies cremated Jewish – a member stays w/ body until burial. Burial w/in 24 hrs but not on the Sabbath. Some avoid cremation, autopsy, embalming. Sleep 1. Factors influencing sleep Drugs – many meds cause different effects like sleepiness, insomnia & fatigue Lifestyle – daily routine messes w/ sleep patterns, like a night shift work schedule. Also unaccustomed heavy work, late night social life, and changing in evening mealtime. Emotional stress – worrying at night about personal problems, hard to fall asleep & awakens in the middle of night. Environment – good ventilation is needed to sleep, position & firmness of bed, accustomed to sleeping with someone else in the bed. Noises disrupt sleep. 2. Stages of the sleep cycle Stage 1: NREM – few mins; lightest sleep; gradual fall in vitals & metabolism; noise easily arouses; if awoken feels like daydreaming Stage 2: NREM – 10-20 mins; sound sleep; relaxation progresses; body functions continue to slow; aroused remains easily Stage 3: NREM – 15-30 min.; first stages of deep sleep, muscle completely relaxed; vitals decline but regular; difficult to arouse & rarely moves Stage 4: NREM – 15-30 min; deepest state; if sleep loss has happened then stays in this stage most of night; vitals lower than waking hours; sleepwalking & enuresis (bed-wetting) sometimes occur; very difficult to arouse REM sleep – usually 90 min after sleep begun; duration increases w/ each cycle & averages 20 min; vivid, full-colored dreams(less vivid in others); fluctuating heart, RR, bp(or increase), loss of skeletal muscle tone & increased gastric secretions; very difficult to arouse. 3. Sleep deprivation symptoms Physiological: Ptosis (blurred vision), fine-motor clumsiness, decreased reflexes, slowed response time, decreased reasoning & judgement, decreased auditory & visual alertness, cardiac arrhythmias Psychological: Confused & disoriented, increased sensitivity to pain, irritable, withdrawn, apathetic, agitated, hyperactive, decreased motivation, excessive sleepiness. 4. Assessment of sleep disorders Ask certain questions to try and understand the characteristics of the pt’s sleep problem; try to pinpoint the disorder; get a sleep history of 1-4 wks; bed partners or parents of children provide info also on sleep patterns; 5. Sleep apnea; nursing implications, client education Lack of airflow through nose & mouth for 10 secs or longer; if having surgery have to monitor because analgesics my increase risks of having airway obstructed; often have to be on ventilators to avoid respiratory complications postop; Client education - lifestyle changes; good sleep hygiene; alcohol moderations; stop smoking; lose weight; elevate head of bed & use side or prone position to sleep; use pillows to prevent supine; use Continuous Positive Airway Pressure (CPAP) device at night to sleep. 6. Drugs and their effects on sleep: hypnotics, diuretics, alcohol, nicotine, narcotics; nursing implications, client education Hypnotics – interfere reaching deeper sleep; provide temp (1wk) increase in quality of sleep; hangover during day, drowsiness, confusion, decreased energy; makes sleep apnea worse in older adults Diuretics – wake up at night to pee Alcohol – fast to fall asleep; reduces REM; awakens in the middle of the night then cant fall back asleep. Nicotine – decrease total sleep & REM time; wake up from sleep; difficulty staying asleep Narcotics – suppress REM sleep; daytime drowsiness Fluid, Electrolyte, and Acid-Base Balance 1. Laboratory Normal Values for Adults; Complete Blood Count (CBC), Basic Metabolic Panel (BMP) Sodium Na+ - 136-145 mEq/L Potassium K+ - 3.5-5.0 mEq/L Chloride Cl- - 98-106 mEq/L Total CO2 – 22-30 mEq/L Bicarbonate (HCO-3) – arterial 22-26 mEq/l , venous 24-30 mEq/L Total calcium Ca2+ - 8.4-10.5 mg/dL Ionized calcium Ca2+ - 4.5-5.3 mg/dL Magnesium Mg2+ - 1.5-2.5 mEq/l Phosphate PO3-4 – 2.7-4.5 mg/dL Anion gap – 5-11 mEq/L 2. Laboratory Normal Values for Arterial Blood Gases (ABG) Ph: 7.35-7.45 paCO2: 35-45 mmHg PaO2: 80-100 mmHg O2 saturation: 95%-100% Base excess: -2 to+2 mmol/l 3. Acid-Base Imbalances; ABG interpretation (compensating/non-compensating) Acid base Ph 7.35 – 7.45 Co2 45 – 35 Hco3 22 – 26 Metabolic acidosis – hyperventilation to compensate Metabolic alkalosis – hyporventilate to compensate Respiratory acidosis - hypoventilation Respiratory alkalosis – hyperventilation 4. Fluid Imbalances: Hypovolemia, ECV deficit, ECV excess; physical assessment Hypovolemia – decreased vascular volume; used when talking about ECV deficit ECV deficit – when there is not enough isotonic fluid in extracellular compartment ECV excess – too much isotonic fluid in extracellular compartment; intake of isotonic sodium has exceed fluid output. ECV deficit – sudden weight loss; hypotension or orthostatic hypotension; lightheaded; pulse rate rapid & thread; neck veins collapse when inhaling supine; sluggish capillary refill; small urine output (dark yellow); dry mucous membranes; skin turgor test fail; thirst; restlessness & mild confusion; ECV excess – sudden weight gain; pulse bounding; neck vein full or distended when upright; crackles or rhonchi w/ progressive dyspnea; edema; 5. Intravenous Solutions; isotonic, hypotonic, hypertonic- Isotonic – same effective osmolality as body fluids; used to treat ECV deficit. Hypertonic – effective osmolality greater than body fluids; increases osmolality and pulls water out of cells making it shrivel. Hypotonic – effective osmolality less then body fluids; diluting body fluids & moving water into cells 6. Electrolyte Imbalances; related causes and sign/symptoms of the imbalances Hypokalemia – bilateral muscle weakness that starts in quads & may go up towards respiratory muscles; abdominal distention; decreased bowel sounds; constipation; cardiac dysrhythmias; signs of digoxin toxicity at normal digoxin levels. (decreased K intake: excessive use of potassium-free iv; shift of K from ECF to cell: alkalosis, treatment of diabetic ketoacidosis w/ insulin; increased K output: aldosterone excess, polyuria, use of potassium wasting diuretics, glucocorticoid therapy, acute or chronic diarrhea, vomiting or other GI losses) Hyperkalemia – bilateral muscle weakness in quads, transient abdominal cramps & diarrhea, cardiac dysrhythmias, cardiac arrest (increased K intake: iatrogenic administration of large amounts of IV potassium, repid infusion of stored blood, excessive ingestion of K salt substitutes; Shift of K from cells into ECF: massive cellular damage like from trauma or cytotoxic chemotherapy, insufficient insulin, some types of acidosis; decreased K output: acute or chronic oliguria (end-stage renal disease), use of potassium-sparing diuretics.) Hypocalcemia – positive Chvostek’s sign(contraction of facial muscles when facial nerve is tapped), positive Trousseau’s sign(carpal spasm w/ hypoxia), numbness & tingling in fingers and circumoral (around mouth) region, hyperactive reflexes, muscle twitching and cramping, tetany, seizures, laryngospasm, cardiac dysrhythmias (decreased Ca intake: calcium-deficient diet, vit D deficiency (end-stage renal), chronic diarrhea, laxative misuse, steatorrhea (pancreatitis); shift Ca from ECF into bones or inactive: hypoparathyroidism, rapid administration of citrated blood, hypoalbuminemia, alkalosis, hyperphosphatemia (end-stage renal disease); Increased Ca output: steatorrhea, chronic diarrhea) Hypercalcemia – anorexia, nausea & vomiting, constipation, fatigue, diminished reflexes, lethargy, decreased level of consciousness, confusion, personality change, cardiac dysrhythmias, possible flank pain from renal calculi, shift of calcium from bone: pathological fractures, signs of digoxin toxicity at normal digoxin levels (increased Ca intake: milk- alkali syndrome; shift of Ca from bone into ECF: prolonged immobilization, hyperparathyroidism, bone tumors, nonosseous cancers that secrete bone- reabsorbing factors. Decreased Ca output: use of thiazide diuretics Hypomagnesemia – positive Chvostek’s & trousseau’s signs, hyperactive deep tendon reflexes, insomnia, muscle cramps & twitching, grimacing, dysphagia, tachycardia, hypertension, tetany, seizures, cardiac dysrhythmias, signs of digoxin toxicity at normal digoxin levels (decreased Mg intake: malnutrition, chronic alcoholism, chronic diarrhea, laxative misuse, steatorrhea; shift of Mg into inactive: rapid administration od citrated blood; increased Mg output: aldosterone excess, use of thiazide or loop diuretics, steatorrhea, chronic diarrhea or other GI lossses Hypermagnesemia – lethargy, hypoactive deep tendon reflexes, bradycardia, hypotension; acute elevation in Mg levels: flushing, sensation of warmth; severe hypermagnesemia: flaccid muscleparalysis, decreased rate & depth of respirations, cardiac dysrhythmias, cardiac arrest. (decreased Mg outout: end-stage renal disease, adrenal insufficiency; increased Mg intake: excessive use of Mg containing laxatives & antacids, parenteral overload of magnesium) 7. Medical History: Recent surgeries, GI output, Acute illness/trauma, respiratory issues Recent surgeries – 2 to 5 days postop there is increased aldosterone, glucocorticoids,& ADH cause increased ECV, decreased osmolality and increased potassium. GI output – chronic or acute diarrhea or vomiting can cause ECV deficit, hypernatremia, dehydration & hypokalemia by increasing sodium & potassium. Diarrhea also causes hypocalcemia & hypomagnesemia. Acute illness or trauma – imbalances caused by respiratory diseases, burns, trauma, GI alterations & acute oliguric renal disease. Respiratory disorder – can lead retaining carbon which is Increasing Paco2 which causes respiratory acidosis. 8. Daily weights and fluid intake and output measurements/calculations; oz to mL, kg/lbs to fluid retained/lost 1Kg – 2.2Lbs ; 1oz – 30mL 9. Blood transfusions; nursing implications pre, during, and post administration 1. To increase circulating blood volume after surgery, trauma or hemorrhage 2. Increasing the number of RBC’s & maintaining hemoglobin levels in pt’s w/ severe anemia 3. Providing selected cellular components as replacement therapy (clotting factors, platelets,albumin) Safety is priority, pt assessment, verification of health providers order & verification of correct blood product for correct pt. Make sure pt knows the reason for blood, if they’ve had a transfusion or a reaction. Explain the procedure and tell the pt to notify if there are any side effects. Make sure consent is signed. Get vitals before starting. Verify: right blood ordered, that the right blood bag is the same type of blood on med record, and right pt receives blood. Two RN’s or 1 RN & LPN checks product against record and pt id number. If minor error do not give. Prime the tube w/ saline. Stay for 15 mins to make sure there is no reaction, monitor vitals, record findings. Cant be given for more than 4 hrs because risk of bacteria. If reaction stop transfusion immediately, change tubing, turn both off, notify health care provider immediately, remain w/ pt observing signs & symptoms, prepare to give emergency meds, prepare for CPR, save blood containers w/ labels & tubing and give to blood bank, get blood and urine samples if ordered. 10. Complications of intravenous therapy: circulatory overload, infiltration or extravasation, phlebitis- assessment findings, nursing implications Circulatory overload – receiving solution too fast or too much fluid; shortness of breath, ECV excess w/ Na isotonic fluids, hyponatremia w/ hypotonic fluid (confusion, seizures), hypernatremia, hyperkalemia (cardiac dysrhythmias, Exam Items Representation: 60 questions total; 52 multiple choice 3 select all that apply, 5 Med Calc and/or alternate format Items Hyponatruima – confusion, gi loss, seize, fluid overload, Hypernatrurim – dehydration, decrease fluid intake, diabetes insipidus Hyperkalimia – renal failure,(metabolic acidosis), cardiac, muscle. Kaexcalate enema Hypokalimia – always give on pump, Hypermagnisma – low phosphate, renal failure Hypomagnisms – malnutritrun , alcoholics Hypocalcemic – parathyroid, high phosphate Hypercalcemia – Hypocalcemia- Crn16259 t & t 8:00 16278 vicente Friday Show Less