Final Exam Study Guide/Final Exam Study Guide latet, Exams of Health sciences

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Head to Toe Head & Neck ● Lymph nodes (10) Eyes ● Inspect for color, shape, symmetry, position, & alignment of eyes ○ Corneal light reflex: light appears equally in the same spot on both pupils; strabismus (cross eye) ● Conjunctiva & sclera ○ Bulbar conjunctiva: delicate mucous membrane that covers the exposed surface of the sclera (white) ○ Palpebral conjunctiva: membrane that lines the anterior portion of sclera (uniformly pink) ● Lids: Lacrimal apparatus ○ Nasolacrimal sac: upper dilated end of the nasolacrimal duct; is lodged in a deep groove formed by the lacrimal bone & frontal process of the maxilla ● Confrontation ○ Peripheral vision ○ Pt can see fingers enter visual field (180 degrees) ● CN 2 Optic: S (visual acuity) ○ Snellen (far vision): myopia/nearsightedness ○ Rosenbaum (arms length): hyperopia/farsightedness ○ Ishihara (color vision) ■ od/os/ou ● PERRLA ○ Pupils ○ Equal ○ Round ○ Reactive to Light ■ CN 3 Oculomotor: M ■ Pupillary constriction (bringing light in from the side) ○ Accommodation ■ Constrict & converge (focus on something, then refocus on pen) ● Cardinal Positions of gaze (nystagmus or involuntary rapid eye movements, drifting) ○ CN 3 Oculomotor: M ○ CN 4 Trochlear: M ○ CN 6 Abducens: M ● Cataracts: cloudy or opaque areas in the ocular lens, temporary ○ Risk factors: Increasing age, Diabetes, high BP ● Glaucoma: a group of eye conditions that can cause blindness; often caused by an abnormally high pressure in your eye; permanent ○ Risk factors: having high internal eye pressure (intraocular pressure) ● Terms (exam 4) ○ Wk 9 terms: https://quizlet.com/585839860/week-9-terms- flash-cards/ Ears ● Inspect & palpate auricles for redness, swelling, tenderness ● Inspect external canal for redness, swelling, drainage, cerumen, foreign bodies ● Otitis externa: inflammation of external ear; allergic reaction to beauty/personal care products ● Otitis media: inflammation of middle ear; common in pt’s with environmental/seasonal allergies ● Weber (lateralization) ○ Vibration and sound equal bilaterally ● Rinne (AC>BC 2:1) ○ Pt unable to hear or feel the sensation in one ear during Weber ○ Conduction : air conduction to bone conduction, hear it twice as long as you should be able to feel it ❖ Whisper ➢ Able to identify words Nose ● Inspect nares for symmetry, lesions, tenderness ● Inspect internal nares for inflammation, drainage ➢ Tricuspid: 4th intercostal space L sternal border ➢ Mitral: 5th intercostal space Midclavicular line ■ Bell & diaphragm ■ S1, S2 present, no murmurs, no abnormal sounds ❖ Aortic impulse ➢ 5th intercostal space, midclavicular line or MITRAL (palpate) ➢ Small pulsation is normal only in this location ❖ Pulses ➢ Radial pulse at the same time ➢ Dorsalis pedis pulse at the same time ➢ Or all of them? ■ +2, regular, equal bilaterally ❖ Edema ➢ If pt has, grading (+1 to +4: pitting, non-pitting, brawny, dependent) ■ 1+: 2mm, slight imprint/trace; pulse weak (0 or absent) ■ 2+: 4mm, moderate; pulse normal ■ 3+: 6mm, deep; pulse increased ■ 4+: 8mm, leaves deep imprint that slowly returns to normal; pulse bounding ➢ No edema bilaterally (wk 1) Respiratory ❖ Inspection ➢ Inspect color (cyanosis) & respiratory effort (inspect for ease, distress, cough) ➢ Shape & configuration, AP diameter 1:2 ratio (½ transverse diameter); barrel chested ➢ Clubbing of nailsBulging of the last part of the finger with curved, convex nails ➢ Related to reduced oxygen in blood ❖ Palpate anterior & posterior for lumps, masses, tenderness ❖ Auscultate, anterior & posterior ➢ Adventitious sounds: not normally heard in the lungs & result from air moving through moisture, mucus, or narrowed airways ➢ Diminished: hear to hear, dim, “quiet”; pneumonia ➢ Crackles: bubbling, crackling, popping; low- to high-pitched, discontinuous sounds; auscultated during inspiration & expiration; opening of deflated small airways & alveoli; air passing through fluid in the airways (CHF, pulm edema, bronchitis) ➢ Rhonchi: sonorous or coarse; snoring quality, low-pitched, continuous sounds; auscultated during inspiration & expiration; coughing may clear the sound somewhat; air passing through or around secretions (bronchitis, COPD, cystic fibrosis) ➢ Rub: rubbing or grating; loudest over lower lateral anterior surface; auscultated during inspiration & expiration; inflamed pleura rubbing against chest wall ➢ Noting that all lung fields are clear & the pt was breathing regularly w/ no difficulty or use of accessory muscles ❖ Percussion ➢ Anterior and posterior thoracic region (lean forward, round shoulders) ■ Location, shape, size density of tissues ➢ Resonance: the prolongation & intensification of sound produced by transmission of its vibrations to a cavity during percussion; air filled, normal lung tissue ➢ Hyperresonance: greater than normal resonance (the prolongation & intensification of sound produced by transmission of its vibrations to a cavity), often of a lower pitch, elicited during percussion; pneumothorax ➢ Dull: the sound obtained by percussing over a solid body part that does not resonate, usually obtained over a body part or area containing less air than those parts or organs that do resonate; liver, mass, lobar pneumonia ➢ Flat: the sound obtained by percussion over solid areas such as bone; pleural effusion ➢ Noting terms & sounds flat, dull resonance upon percussion; equal ❖ Wheeze: musical or squeaking; high-pitched, musical, continuous sounds; auscultated during inspiration & expiration; air passing through narrowed airways (asthma, COPD) ❖ Stridor: harsh, loud, high-pitched; auscultated on inspiration; narrowing of upper airway (larynx or trachea); presence of foreign body in airway ❖ Inspect shape & configuration, AP diameter ■ Inspect for cyanosis (blue mucous membranes) ■ Inspect clubbing of nails ■ AP diameter ❖ Lobes ➢ L lung 2 lobes ➢ R lung 3 lobes ➢ Main bronchus branches > secondary bronchi (one to each lobe) > bronchioles ■ Alveoli: small air sacs, site of gas exchange ■ Surfactant: reduces surface tension between moist membranes of alveoli; phospholipid ❖ Terms (wk 4) https://quizlet.com/572069000/week-4-5-terms-flash- cards/ Abdominal ❖ Inspect hair, color, scars, bumps ❖ Inspect contour (flat) ❖ Inspect symmetry ➢ Epigastric: Region of the upper abdomen immediately below the ribs ➢ Umbilical: region that surrounds the area around the umbilicus; contains part of the stomach, the head of the pancreas, the duodenum, a section of the transverse colon & the lower aspects of the left & right kidney ➢ Suprapubic: region of the abdomen located below the umbilical region ❖ Auscultate FIRST: 4 quadrants, clockwise (umbilicus midline) ■ Normoactive bowel sounds in all 4 quadrants ■ Bowel sounds ● Normoactive: High pitched, gurgling noises; Considered normal ● Hypoactive: Heard infrequently ● Hyperactive: loud, high-pitched tinkling sounds occurring frequently; Indicative of diarrhea ● Absent: >2 min, absence of motility, ○ Knee-jerk reflex ● Babinski’s sign ○ The plantar reflex that is a reflex elicited when the sole of the foot is stimulated with a blunt instrument Musculoskeleta l ● Abduction: moving limb away from midline ● Adduction: moving a limb toward body’s midline ● Supination: the assumption of the supine position (laying horizontal) ● Extension: the state of being in a straight line ● Flexion: the state of being bent ● Dorsiflexion: he action of raising the foot upwards towards the shin ● Crepitus: grating sound/sensation produced by friction between bone and cartilage or the fractured parts of a bone ● Contour: outline ● Symmetry: evenness ● Scoliosis: curvature of a portion of the spine to the side, laterally ● Lordosis: curving inward of the lower back ● Kyphosis: forward rounding of the back; hunchback Terms (exam 4) https://quizlet.com/583151111/week-10-terms-flash-cards/ ❖ Cranial Nerves CN S, M, or B? Assessments Description 1. Olfactory S ● Can smell ⅔ odors ● Patency Olfactory bulb located in frontal lobe of brain 2. Optic S Visual Acuity: ● Snellen ● Rosenbaum ● Ishihara Retina (rods & cones) transmit info to optic nerve to process 3. Oculomotor M ● 6 cardinal positions of gaze (nystagmus, ● Muscle function (around eyes) drifting) ● Pupillary reaction to light (PERRLA) ● Pupil response ○ Controls size of pupil ○ Response to light 4. Trochlear M ● 6 cardinal positions of gaze ● Superior oblique muscle ● Eye movement 5. Trigeminal B ● Symmetry of sharp & dull stimuli ● Corneal (light) reflex: sensory ● Clench teeth tightly: masseter & temporalis strength ● Ophthalmic (forehead/scalp/upper eyelids) ● Maxillary (cheeks/upper lip/nasal cavity) ● Mandibular (ears/lower lip/chin) 6. Abducens M ● 6 cardinal positions of gaze Eye muscle movement: ● Lateral rectus movement ● Pons 7. Facial B ● Symmetry of smile, frown, show teeth, puffed cheeks, raised eyebrows ● Sense of taste (sweet, sour, salty) ● Corneal reflex: motor (Q tip) ● Muscle strength Pons of brainstem is complex ● Facial expressions/jaw muscles ● Sense of taste ● Supplying salivary/tear- producing glands ● Sensations to ear 8. Acoustic (Vestibulocochlear) S Cochlear: ● Weber ● Rinne ● Whisper test Vestibular: ● Romberg test Cochlear: ● Hearing ● Pitch/vibrations Vestibular: ● Balance/equilibrium ● Linear & rotational movements of head 9. Glossopharyngeal B ● Soft palate/uvula movement ● Speech quality ● Swallow (stylopharyngeus) ● Gag reflex ● Verbalize taste: sweet, bitter, salty ● Sinuses ● Sense of taste 10. Vagus B ● Soft palate/uvula movement ● Speech quality ● Swallow ● Gag reflex Sensation from ● Ear canal to throat ● Chest & trunk Motor control of ● Muscles in throat ● Stimulation muscles in chest & trunk 11. Accessory M ● Shoulder shrug ● Strength in turning head side to side: sternocleidomastoi d & trapezius muscle ● Controls muscles in neck (rotate, flex, extend) ● Spinal cord: control ● Cranial: medulla oblongata 12. Hypoglossal M ● Ease & equality of tongue movement ● Strength of tongue ❖ Skin ➢ Melanoma ■ A type of skin cancer that occurs when pigment producing cells called melanocytes mutate and begin to divide uncontrollably ■ ABCDE ● Asymmetry ◆ One side does not match other ● Border ◆ Irregular, ragged Ulcerations: If present, toes or trauma on feet Develops at sides of ankle Gangrene: May develop Does not develop Medications ➢ Beta Blockers ■ -olol ■ Decreases blood pressure ■ Side effects ● Fatigue ● Weakness ● Erectile dysfunction ● Bradycardia ● HF ● Pulmonary edema ➢ Benzodiazepines ■ -zepam ■ CNS depressant; controls anxiety; sedative ➢ ACE Inhibitors ■ -pril ■ Decreases blood pressure; treats HF ➢ ARB Blockers ■ -artan ■ Decreases blood pressure ➢ Calcium Channel Blockers ■ -dipine ■ Decreases blood pressure; treats chest pain; treats migraines ➢ Thrombolytics ■ -ase/-plase ■ Dissolves blood clots ➢ Corticosteroids ■ -sone ■ Treats asthma, arthritis, cancer, autoimmune disorders ➢ Bronchodilators (Beta2-agonists) ■ -terol ■ Treats asthma, COPD ➢ DPP4 inhibitors ■ -gliptin ■ Decreases blood sugar ■ Sitagliptin ● Side effects ◆ Pancreatitis ◆ Anaphylaxis ◆ Angioedema ◆ Exfoliative skin conditions (Stevens-johnsons syndrome) ● Interactions ◆ Risk of hypoglycemia when also on insulin, glyburide, glipizide, glimepiride ➢ Incretin mimetics ■ -tide ■ Decreases blood sugar ➢ Leukotriene antagonists ■ -ast ■ Treats asthma & allergies ➢ Proton pump inhibitors (PPI’s) ■ -prazole ■ Treats GERD, peptic ulcers & H. pylori ■ Take 30 minutes before meals ➢ Sulfonylureas ■ -ide ■ Decreases blood sugar; treats type 2 diabetes ➢ Biguanide ■ Metformin ■ Decreases blood sugar ➢ Anticoagulant ■ -arin ■ Prevents blood clots ■ Warfarin ● Side effects ◆ Calciphylaxis ◆ Bleeding ● Avoid foods high in vitamin K ◆ Broccoli ◆ Cauliflower ◆ Cabbage ◆ Brussel sprouts ◆ Kale ◆ Spinach ➢ Statins ■ -statin ■ Lipid-lowering medication; lowers cholesterol ■ Avoid grapefruit when taking ● Atorvastatin ● Lovastatin ● Simvastatin ■ Take at night ➢ Stool Softeners ■ Docusate, Senna ■ Prevents constipation ■ Take at night ➢ NSAIDs ■ Aspirin, ibuprofen, diclofenac ■ Relieve pain, reduce inflammation, brings down temperature ➢ Loop Diuretics ■ Bumetanide, furosemide, torsemide ■ Increases flow of urinal removes sodium & chloride from body in urine ➢ Anticonvulsants ■ -zepine/-in ■ Decreases incidence/severity of seizures ■ Gabapentin ● Side effects ◆ Suicidal thoughts ◆ Confusion ◆ Depression ◆ Dizziness ◆ Drowsiness ◆ Anaphylaxis ◆ Angioedema ◆ Multiorgan hypersensitivity reactions ● Take 2 hours after antacid (if you’re on one) ● Can interact with benzos Labs ➢ Na ◆ Respiratory distress ◆ Decreased cardiac contractility ◆ EKG changes ◆ Reflexes (hyper/hypo) ● Symptoms: nerve conduction changes, paralysis, murder ● Causes - MIKA ◆ Meds ➢ Supplements, ACE inhibitors, Beta blockers, NSAIDs, K+ sparing diuretics ◆ Intake ➢ Excessive intake of bananas, spinach, yogurt, high K+ foods ◆ Kidney ➢ Impaired ability to secrete fluid ◆ Acidosis ➢ Result of an increase in acid components or an excessive loss of bicarbonate ● Assessments ◆ Labs, VS, I&O, reflexes ● Interventions ◆ VS monitoring, ECG, labs, meds ➢ CO2 ■ 23 -29 mEq/L ■ Symptoms: headache, lightheaded, change in LOC, cyanosis, pain during expiration/inspiration, barrel chested, hyperventilating, clubbing, cap refill > ● Heart: organs unable to perfuse d/t < O2 resp ● Lungs: SOB, hyperventilation, AKI, trauma, infection ■ Labs: Na, CO2, GLU, Hgb, Hct, WBC ■ Diagnosis ● Alterations in Oxygenation; ineffective airway clearance, ineffective breathing pattern, impaired gas exchange ■ Outcome identification & planning ● Oxygenation problem ● The patient will: ◆ Demonstrate improved gas exchange in the lungs by an absence of cyanosis or chest pain ◆ Pulse oximetry <95% ◆ Exercise ◆ Demonstrate self-care behaviors that provide relief from symptoms and prevent further cardiopulmonary problems. ■ Implementing ● Promote/control coughing, suction, med administration, supplemental oxygen, manage chest tubes, artificial airways, CPR, teaching ■ Teach ● Vaccination, smoking cessation/environment, nutrition, reducing anxiety, positioning, fluid intake, incentive spirometry, breathing techniques, coughing meds, chest physiotherapy oxygen, chest tube, CPR ■ Meds ● Bronchodilators ● Liquefy or loosen thick secretions ◆ Reduce inflammation in airways ● Metered dose inhaler ● Nebulizer ● Dry powder inhaler ➢ Cl ■ 95-105 ■ Anion ■ ECF ■ Hyperchloremia ● Major causes ◆ Metabolic acidosis, head trauma, increased perspiration, decreased GFR ● Tachypnea, weakness, lethargy, decreased awareness, hypertension, decreased cardiac output, dysrhythmias, coma ■ Hypochloremia ● Major causes ◆ Vomiting/diarrhea, drainage of GI tube, metabolic alkalosis, diuretics, burns ● Hyperexcitability, tetany, hyperactive DTRs, weakness, muscle cramps ➢ BUN ■ 7-24 mg/dL ■ Backs up Cr findings ■ Formed in liver from ammonia ■ Excreted by kidneys ● Can be used to assess nutritional status ■ Evaluates kidney function & aids in diagnosis of renal or liver disease ■ Assessment of ● Hydration ● Effectiveness of dialysis ■ Symptoms: seizures, altered LOC, swelling, chest pain, tachycardia, BP changes, dyspnea, crackles, oliguria/anuria ● Heart: cardiac enlargement, HF, HTN ● Lungs: COPD, respiratory failure ● Kidneys: AKI, CKD ● GI: meds, obesity ■ Labs: Na, K, BUN, Cr, GLU, WBC, Mg, Phos ■ Cells overfilled ➢ Cr ■ 0.7-1.4 mg/dL ■ Provides a more sensitive measure of renal damage than BUN levels ● Stress on kidneys ■ Waste product from breakdown of tissue ■ Assessment of ● Glomerular filtration ● Renal damage ■ Symptoms: seizures, altered LOC, swelling, chest pain, tachycardia, BP changes, dyspnea, crackles, oliguria/anuria ● Heart: cardiac enlargement, HF, HTN ● Lungs: COPD, respiratory failure ● Kidneys: AKI, CKD ● GI: meds, obesity ■ Labs: Na, K, BUN, Cr, GLU, WBC, Mg, Phos ■ Cell overfilled ➢ GLU ■ 60-110 mg/dL ■ Symptoms ● Retinopathy, changes in LOC, dizziness, sweaty, tremors, HTN, palpitations, infection, renal failure, nephropathy, obesity, hunger, changes in urine, neuropathy ● Heart: blood vessel contraction, risk for CAD, HTN ● Lungs: reduced lung function, infection ● Kidneys: acute renal failure, nephropathy ■ Transports carbon dioxide from organs back to lungs ● How many RBCs do we have to carry O2 & CO2? ■ Main indicator of general bleeding; specific/localized ● <8 big deal (.1 increments not a big deal) ■ Measures ● Severity of anemia ● Polycythemia (too many RBC) ◆ Causes: ➢ Bone marrow produces too many RBCs → cancer ➢ Autoimmune disorder ● Response to therapy ● Baseline prior to surgery/invasive procedures/treatments ◆ Have we tried some sort of treatment like giving RBCs or iron? ◆ Have we done something to determine the reason why we don't have enough RBCs? ◆ Determine the underlying reason why our RBC is low/low production ➢ GI bleed → colonoscopy to determine where the bleed ➢ Hematoma ➢ Aneurysm ◆ Surgery is invasive (blood loss) ➢ Male patient hemoglobin is 10-11 before surgery and then after surgery it is 6-7 ● Distribution of oxygen to organs & tissues ➢ WBC ■ 5,000 to 10,000/mm3 ■ Respond to infection in the body ■ Symptoms: febrile, change in LOC, confusion, dizziness, swollen lymph nodes, high HB (to compensate), sweaty, pain, BP changes (hypotension), body aches, oliguria/anuria (dehydrated), burning, increase RR, diarrhea ■ Labs: Na (high, dehydrated), K (low, laxatives to get rid of K, 5Ds), BUN, Cr, GLU, WBC ● Heart: tachycardia, HF, MI ● Lungs: pneumonia (tachypnea) ● Kidneys: UTI ● GI: diverticulitis ■ Cell is dehydrated ➢ Plt ■ 145-450K/uL ■ Non-nucleated, cytoplasmic, round or oval disks formed by budding off large, multinucleated cells ■ Essential in coagulation, hemostasis, blood thrombus formation ● Platelets move to vessel injury, hemostasis, bind to fibrinogen causing platelets to stick together, forming a plug ■ Thrombocytopenia ● ↓ platelet count ● When body’s need for platelets exceeds the rate of production ◆ Congenital, cancer, bone marrow diseases, cirrhosis, bleeding disorders (disseminated intravascular coagulation), sepsis, medications ■ Thrombocytosis ● ↑ platelet count ● Causes ◆ Hemorrhage, infectious disorders, iron deficiency anemia, splenectomy, inflammatory disorders ■ Purpose of platelet count ● Evaluate platelet production ● Assess effects of chemotherapy & radiation therapy ● Diagnose & monitor severe thrombocytosis or thrombocytopenia ➢ Ca ■ 8-10 mg/dL ■ Cation in ECF ■ Plays role in blood coagulation and transmission of nerve impulses ■ Regulates muscle contraction/relaxation ■ Hypercalcemia (“The body is WEAK”) ● Weakness of muscles ● EKG changes ● Absent reflexes ● Kidney stone formation ■ Hypocalcemia (CRAMP) ● Confusion ● Reflexes (hyperactive) ● Arrhythmias ● Muscle spasms (tetany) ● Positive Trousseau’s sign ➢ Mg ■ 1.5-2.5 mEq/L ■ Cation in ICF ■ Hypomagnesemia ● Symptoms: STARVED ◆ Seizures ◆ Tetany ◆ Anorexia ◆ Rapid HR ◆ Vomiting ◆ Emotions ◆ Deep tendon reflexes ● Weakness, muscle cramping, rhythm changes ● Risk factors: poor intake, poor GI absorption, GI losses, Alcohol, meds ● Assessment: neuro status, VS, ECG changes, labs, I&O ● Interventions: VS, I&O, meds, seizure precautions ■ Hypermagnesemia ● Symptoms: RENAL ◆ Reflexes decreased ◆ ECG changes ◆ Nausea/vomiting ◆ Appear flushed ◆ Lethargy ● Low muscle & nerve activity, bradycardia, change LOC ● Risk factors: renal failure, endocrine disorders, mag-antacids or laxatives, meds ● Assessments: neuro status, VS, ECG changes, labs, I&O ● Interventions: VS, I&O, meds, seizure precautions ➢ Phos ■ 3.5-4.5 mg/dL ■ Anion in ICF ■ Muscle and RBC function ■ Hyperphosphatemia ● Causes ◆ Impaired kidney excretion, hypoparathyroidism ● Tetany, anorexia, nausea, muscle weakness, tachycardia ■ Hypophosphatemia (can’t pump what body needs), BP changes, enlarged heart (tachycardia, palpitations) Lungs: wheezing Kidney: failure (excessive urination) GI: bloating Hypertensi on >130, >80 Headache, fatigue, vision changes, chest pain, difficulty breathing, palpitations, confusion Effects: Heart: enlarged ventricles, HF, MI, Stroke (sleep apnea, irregular heartbeat) Kidney: failure (blood in urine) GI: DM2, Obesity, high cholesterol, salt calories K, Mg, Na, BUN, Cr, GLU, Ca, Troponin Beta blockers Diuretics CCBs ACE ARBs DASH diet Diet Exercise Sedentary lifestylePai n manageme nt Stress VS monitori ng, I&O, diet, weights, labs Race, age sleep apnea, DM, obesity, HLD, alcohol consumptio n Cell full Hypotensio n <90, <60 Dizziness, tachycardia, pallor, sweating, blurred vision, nausea, confusion Effects: Heart: dehydration, hemorrhage, HF, arrhythmias K, Mg, Na, BUN, Cr, GLU, Ca, Troponin Fluids Vasopress ors Midodrine ↑ sodium Diet Exercise Sedentary lifestyle Pain manageme nt Stress Further imaging VS monitori ng I&O Diet Disease process, meds, hemorrhage , athletes Cell isn’t full Kidneys: dialysis GI: diabetes r/t, hypoglycemia Lung Disease Symptoms Labs Meds Diet Pt education Nursing interventio n Risk factors COPD Emphysem a & chronic bronchitis (88%-92% may be their normal) Shallow, rapid breathing, dyspnea, sputum, barrel chest, clubbing of nails, wheezes, rhonchi Effects: Heart: chest pain (chest pressure), perfusion, fatigue Lungs: Resp infections, dyspnea, lack of O2, wheezing (dry or wet cough) GI: malnourished CO2, ABGs, O2 level, WBC, Na Bronchod ilator, steroid, oxygen therapy Small meals , ↑ calor ie, high prote in Breathing techniques , pace activities, hydration, smoking cessation Respiration s, VS, O2, ABGs, O2 application, breathing techniques, pace activities, diet changes, ambulation , incentive spirometry Smoking, pollution Asthma Inflammati on, swelling, extra mucus Use of accessory muscles, wheezing, dyspnea, chest pain, cough Effects: Heart: tachycardia, tachypnea, chest tightness, Lungs: wheezing, dyspnea, sputum, production, frequent resp infections GI: meds WBCs, O2 Bronchod ilatorSter oid inhalersO xygen therapy Small meals , ↑ calor ie Meds, exercise changes, allergies/p ollution Incentive spirometry, resp assess, VS, O2, pace activities, identify triggers Air pollution, triggers, meds, family history, smoker, allergies Cell empty Pneumonia Wheezing, crackles, WBC, Antibioti Small Lifestyle Standards Age, Is it HAP, CAP VAP, or aspiration? phlegm production, fever, shaking, chills, dyspnea, chest pain Effects: Change in LOC/mental status Heart: tachycardia, fluid overload?, tachypnea, chest tightness Lungs: sputum, decrease oxygenation Kidneys: infection? GI: meds CO2, other labs correlat e w/ underly ing cause cs, albuterol oxygen, treat underlyin g cause meals, high calorie modificati ons, diet changes, medicatio ns, precaution s of precaution, VS, O2 therapy, I&O medication s, asthma, COPD, smoking, immunoco mpromised , pollution, alcohol, HF Cell empty ➢ Kidney Diseases ■ KF Symptoms (BATSOC) ● Blood pressure changes ● Altered level of consciousness ● Tachycardia ● Seizures ● Oliguria/anuria ● Crackles ■ KF Causes: MESH3 ● M: Metabolic acidosis ◆ ↓ pH & ↓ HCO3- ◆ Lactic acid ◆ ↑ Glucose ◆ Dehydration ◆ Hyperkalemia ◆ Hypernatremia ● E: Electrolyte imbalance ◆ Sodium ↓ ◆ Potassium ↑ ◆ Magnesium ↑ ● S: Sepsis ◆ Symptoms ➢ Febrile ➢ Diabetes Mellitus ■ Type 1 ● Absence of insulin production by the pancreas resulting from autoimmune destruction of beta cells ◆ The pancreas does NOT produce insulin ● Affects metabolism → hyperglycemia ● Causes ◆ Genetics ◆ Viruses (Coxsackie virus, mumps, rubella), toxins ◆ Infant weight ■ Type 2 ● Combination of resistance to insulin action & impared insulin secretion ◆ Causing hyperglycemia & other complications ➢ Microvascular: retinal & renal ➢ Macrovascular: coronary & peripheral vascular ➢ Neuropathic conditions ◆ Pancreas still produces insulin ➢ Insulin secreted is either not enough or the body is resistant to the insulin ■ Retinopathy ● Microvascular ● Corneal abnormalities, glaucoma, iris neovascularization, cataracts, neuropathies ● Advances stages include floaters, distortion, blurred vision ■ Nephropathy ● Microvascular ● Leading cause of CKD ● Considered after routine urinalysis & screening ● Albuminuria, decline in GFR, elevated arterial BP ■ Neuropathy ● Most common complication of DM ● Presence of symptoms of peripheral nerve dysfunction ◆ Sensory ◆ Motor ◆ Autonomic ■ Macrovascular ● Coronary and peripheral vascular ■ Labs ● Glucose, ketones, pH, Na, BUN/Cr, WBC, HgA1C ■ Meds ● Insulin, oral agents (Metformin, Januvia, Gliptizide, Glyburide) ■ Diet ● Carb control ■ Education ● Diet control, exercise, urine, symptoms ■ Nursing interventions ● VS, blood sugar, urinalysis, exercise, meal planning, med administration ■ Risk factors ● Genetics, age, obesity, meds, toxins ❖ Ostomies/Elimination ➢ Ostomies ■ Stoma’s appearance ● Pink, moist, rounded ■ Diet considerations ● Resume regular diet ● Avoid foods that cause loose stools ● Adjustments for antibiotic therapy ● Low fiber ● Avoid foods that are difficult to digest ● Eat foods that thicken stool ● Foods to avoid: ◆ Stringy, high fiber foods (gas producing) ◆ Membranes on citrus fruit ◆ Fruits & vegetable skins ◆ Peas, popcorn, spinach, dried fruits, nuts, pineapple, seeds ◆ Fish, eggs, beer & other carbonated beverages ■ Emotional ● Body image/sexuality ■ Indications for ostomy surgery ● Congenital anomalies: spina bifida ● Cancer: bladder, colon, rectal ● Inflammatory bowel diseases: Crohn;s, ulcerative colitis ● Ureter obstruction ● Abdominal wounds ➢ Elimination ■ Types of incontinence ● Stress Urinary Incontinence ◆ ↑ in intra-abdominal pressure ● Urge Urinary Incontinence ◆ Urine lost during abrupt & strong desire to void ● Mixed Urinary Incontinence ◆ Symptoms of urge & stress incontinence present ● Overflow Urinary Incontinence ◆ Over distention & overflow of bladder ● Functional Urinary Incontinence ◆ Caused by factors outside the urinary tract ● Reflex Urinary Incontinence ◆ Emptying the bladder w/o sensation of need to void ● Total Urinary Incontinence ◆ Continuous, unpredictable loss of urine ● Urinary Retention ◆ 3000-4000ml urine ◆ Temporary ◆ Common after surgery ◆ May result from mechanical obstruction ■ Assessment of urine ● Color, consistency, duration, severity, precipitating factors ● Patient’s perception of their urine ● Self-care ● Meds ● Pain, intake & output ➔ Costovertebral tenderness (kidneys) ➔ Palpate & percuss bladder ➔ Bladder scanner ➔ Urethral meatus assessment for infection, discharge, odor ➔ Skin, color, texture, turgor, excretion of wastes ➔ Urine- color, odor, clarity, sediment ➔ Stool- color, consistency, amount ➔ Abdominal pain, tenderness ➔ Rectum- hemorrhoids, bleeding, open skin ● Characteristics of Urine ◆ Color ◆ Odor ■ Headache ■ Weakness (not enough O2 to muscles) ■ Dizziness (brain isn’t receiving enough O2) ■ Palpitations (heart isn't receiving enough O2) ■ Bruising (not perfusing O2) ● Trying to keep as much as it can in internal organs, first priority ● Long time to heal (skin is last priority) ➢ Dyspnea (lungs aren't receiving enough O2) ➢ Epistaxis ➢ Pica ➢ Physical findings: ■ Dull, thinning hair ■ Pallor, ecchymosis, petechiae ■ Occult blood in stool (melena - blood is sticky) ■ Splenomegaly ➢ Patient history ■ Hemorrhage ● Menstrual cycle ■ Chronic Renal Disease ■ Bone Marrow Suppression ■ Poor Nutrition ■ Fluid retention (dilution of blood) ■ COPD (long term) ❖ Hyperthyroidism ➢ Overactive thyroid ➢ Signs/symptoms ■ Intolerance to heat (HOT) ■ Weight loss ■ Changes in menses; short menstrual pattern with scant flow ■ Fine, straight hair; bulging eyes, tachycardia, high systolic BP, localized edema, diarrhea, tremors, finger clubbing ❖ Hypothyroidism ➢ Underactive thyroid ➢ Signs/symptoms ■ Cold intolerance ■ Weight gain ■ Increased frequency & flow of menses ■ In extreme cases: bradycardia and dyspnea from low cardiac output ■ Receding hairline/hair loss, facial & eyelid edema, dull-blank expression, extreme fatigue, thick tongue-slow speech, anorexia, brittle nails & hair, apathy, dry skin (coarse, scaly), muscle aches/weakness, constipation ❖ Pain ➢ Assessing pain ■ Ask ● Simple questions ■ Numerical rating scale ■ Observational tool ● PAINAD ■ Wong-Baker FACES ■ Utilize low doses ➢ Recognize that each person holds various beliefs about pain and that pain is what the patient says it is ➢ Respect the patient’s right to respond to pain in one’s own fashion ➢ Never stereotype a patient’s responses to pain based on the patient’s culture ➢ Be sensitive to nonverbal signals of discomfort, such as holding or applying pressure to the painful area or avoiding activities that intensify the pain ❖ Aging Adult ➢ Sensory changes ■ Vision ● Presbyopia ◆ Decrease focus on near objects and light adaptation ● Decrease in dark adaptation, upward gaze, pupil size, visual field ● Increased eye dryness ■ Eardrum thickens ■ Presbycusis ● Loss of high frequency hearing acuity ■ Hair fibers in ear canal less able to help with earwax removal and protect canal ➢ Taste & smell ■ Fewer taste buds, less saliva, dry mouth, oral conditions, decreased sense of smell, medications, disease, tobacco use ● Xerostomia ◆ Dry mouth ● Burning Mouth Syndrome ● Hyposmia ◆ Reduced ability to smell ● Anosmia ◆ Loss of ability to detect one or more smells ● Parosmia ◆ Odors are distorted ● Phantosmia ◆ Smelling something that isn't actually there ➢ Speech ■ NOT a normal part of aging ■ May be a result of medical procedures ■ Majority related to stroke or TIA ■ Smaller percentage due to Alzheimer’s or Parkinson’s ■ Aphasia ● Impaired expression or comprehension of written or spoken language ● Stroke or TIA ■ Dysarthria ● Disorder of speech production that results from weakness, slowness, or lack of coordination of speech motor control ● Damaged nervous system System Physical changes General Status ● ↓ efficiency of physiologic processes ○ Fragile balance ○ Difficult to maintain homeostasis ● Physical/emotional stressors make them more vulnerable from ↓ physiologic reserves ● Modified pace during activities & frequent rest periods ● Eardrums thicken Integumentary ● ↓ skin elasticity ○ Wrinkling, sagging of skin, dryness, scaling ● Balding, thinning of hair ■ Cluttered pathways ❖ Legal/Ethical ➢ Bioethics ■ Encompasses a number of fields “life sciences” ➢ Clinical ethics ■ Concerned with ethical problems “at bedside” ➢ Nursing ethics ■ Formal study of ethical issues that arise in the practice of nursing ■ Analysis used by nurses to make ethical judgments ➢ Utilitarian ■ The rightness or wrongness of an action depends on the consequences of the action ➢ Deontologic ■ An action is right or wrong independent of its consequences ➢ Principles of bioethics ■ JANB ■ Fidelity: keep promises ■ Veracity, accountability, privacy, confidentiality ➢ 2 types of ethical problems ■ Ethical dilemma ● Two or more clear moral principles apply but support mutually inconsistent courses of action ■ Ethical distress ● The nurse knows the right thing to do but factors make it difficult to follow the correct course of action ➢ Ethics (JANB) ■ Justice ● Fairly allocating benefits and burdens of healthcare delivery ■ Respect for Autonomy ● Supporting patient exercise of self determination ● Right to consent to and refuse treatment ■ Nonmaleficence ● Avoiding actions likely to cause harm ■ Beneficence ● Promoting patient well-being while protecting from harm ❖ Cultural Competence ➢ Subculture ■ Large group of people who are members of a larger cultural group; members have certain ethnic, occupational, or physical characteristics not common to the larger culture ➢ Cultural assimilation (acculturation) ■ Minorities living within a dominant group lose the characteristics that made them different; values replaced by those of dominant culture ➢ Culture shock ■ Feelings a person experiences when placed in a different culture; may result in psychological discomfort or disturbances. ➢ Cultural imposition ■ Belief that everyone should conform to the majority belief system ➢ Cultural blindness ■ Ignores differences & proceeds as if they did not exist ➢ Culture conflict ■ People become aware of differences and feel threatened; Response: ridiculing beliefs & traditions of others to make themselves feel more secure ➢ Ethnocentrism ■ Belief that one’s ideas, beliefs, & practice are the best or superior or are most preferred to those of others ➢ Cultural influences on healthcare ■ Physiologic variations, reactions to pain, mental health, gender roles, language & communication, orientation to space & time, food & nutrition, family support, socioeconomic factors ➢ Culture of poverty ■ Feelings of despair, resignation, & fatalism; day-to-day attitude toward life, no hope for future; unemployment & need for financial or government aid; unstable family structure, possibly characterized by abusiveness & abandonment; decline in self-respect & retreat from community involvement ➢ Guidelines for providing culturally competent nursing care: ■ Develop cultural self-awareness ■ Develop cultural knowledge ■ Accommodate cultural practices in health care ■ Respect culturally based family roles ■ Avoid mandating change ■ Seek cultural assistance ➢ Cultural assessment ■ Beliefs, values, traditions & practices of a culture; culturally defined, health-related needs of individuals, families, & communities; culturally based belief systems of the etiology of illness & disease & those related to health & healing; attitudes toward seeking help from health care providers ❖ Standard Precautions ➢ Standard ■ Precautions used in the care of all hospitalized patients regardless of their diagnosis or possible infection status ■ Guidelines ● Hand hygiene ● Don non sterile gloves ● Wear PPE ● Follow respiratory hygiene/cough etiquette ● Avoid recapping used needles ● Use safe injection practices ● Wear face mask ● Handle used patient care equipment that is soiled with blood or identified body fluids, secretions, and excretions carefully ● Use adequate environmental controls ● Review room assignments carefully ➢ Transmission-Based ■ Airborne (Tuberculosis) ● Patient must be in private room with door closed ● Must wear respirator when entering room ● Only transport pt out of room when necessary; use mask on pt ■ Droplet (Influenza) ● Private room; door may stay open ● PPE for all interactions that involve contact with pt ● Only transport pt out of room when necessary; use mask on pt ● Visitors must stay 3 ft away from pt ■ Contact (C. Diff) ● Private room ■ Long-term regulation ● Regulate extracellular fluid volume through kidneys ■ Systolic (top number) ● Normal pressure 120 ● Systolic pressure – ventricular contraction ■ Diastolic (bottom number) ● Normal pressure 80 ● Diastolic pressure – lowest pressure present on arterial walls ■ Pulse pressure: difference between systolic and diastolic pressures ■ What causes BP changes? ● Age ● Circadian rhythm (gender, diet/intake) ● Med/drugs (weight, emotions) ● Position (ethnicity, exercise) ➢ Pain ■ 0-10 ❖ Nursing Process ➢ ADPIE ● Assess ◆ Gather data ➢ Vitals ➢ Labs ● Diagnose (Nursing) ◆ How we communicate things to the patient ➢ Awareness ➢ Outcomes ● Plan ◆ Steps you will take ◆ Goals need to be SMART ● Intervention ◆ Doing the task ● Evaluate ◆ Reassess after steps have been taken ◆ Was it effective? ■ SMART ● Specific ● Measurable ● Applicable; Attainable ● Relatable; Relevant ● Time ❖ Maslow (Hierarchy of needs) ➢ Human needs vs. priorities of care ➢ Physiologic ➢ Safety and Security ➢ Love and belonging ➢ Self-esteem ➢ Self-actualization ❖ SBAR ➢ Situation ■ What is going on with the patient? ■ Initial assessments ➢ Background ■ Mental Status ■ History (medical, social, etc) ➢ Skin Assessment ■ What is the problem? ➢ Recommendation ■ What needs to happen? ■ From who? ❖ Sepsis ➢ Potentially life-threatening condition that occurs when the body's response to an infection in its own tissues ➢ Symptoms ■ Fever or low temperature and shivering ■ Altered mental status ■ Difficulty breathing/rapid breathing ■ Increased heart rate ■ Weak pulse/low blood pressure ■ Low urine output ■ Cyanotic or mottled skin ■ Cold extremities ■ Extreme body pain or discomfort (5-7) ❖ Pharmacology ➢ Pharmacokinetics ■ Refers to the kinetics of drug absorption, distribution & elimination (metabolism & excretion) ■ ADME (the time course of the drug concentration in the body) ● Absorption: entry of molecules into blood ● Distribution: movement of molecule between water, lipid & protein constituents of the body ● Metabolism: process of alteration in structure of molecule in the body ● Excretion: removal of drug molecules or metabolites from the body ■ What the body does to the drug ➢ Pharmacodynamics ■ The relationship of drug concentration to pharmacologic effects; what the drug does to the body ➢ Bioequivalence ■ Two pharmaceutical equivalents w/ similar bioavailability ➢ Biotransformation ■ Drug metabolism ■ The chemical alteration of drug structure (mostly in liver) ➢ Bioavailability ■ The rate & extent at which therapeutically active drug reaches systemic circulation in the intact form ➢ Safety ■ Staying aware of ● Potentiative effects ◆ When a pt is taking two medications, one drug may intensify the effects of the other ➢ Beneficial or detrimental ● Inhibitory interactions ◆ Interactions that result in reduced drug effects ➢ Beneficial or detrimental ● Allergic reactions ◆ When the immune system overreacts to a harmless ■ Reduce condition such as obesity, HTN, hyperlipidemia/hypercholesterolemia ■ Carbohydrates ● Our body uses sugar for energy → causes blood sugar to ↑ ● Carbs should be limited & regular ■ Protein should be limited to lean meats, fish, eggs, beans, soy, nuts/seeds ■ Saturated & trans fats can ↑ risk of heart disease ■ Salt should be monitored for heart disease complications ■ Alcohol can ↑ blood sugar levels ■ Exercise ➢ Clear liquid ■ Broth, bouillon, coffee, tea, carbonated beverages, clear fruit juices, gelatin, popsicles ➢ Full liquid ■ Clear liquids + smooth-textured dairy products, custards, refined cooked cereals, vegetable juice, all fruit juices ➢ Pureed ■ Full liquid + scrambled eggs, pureed meats, vegetables, fruits, mashed potatoes and gravy ➢ Mechanical soft ■ Pureed + ground/finely diced meats, flaked fish, cottage cheese, rice, potatoes, pancakes, light breads, cooked vegetables, cooked/canned fruits, bananas, soups, peanut butter ➢ Regular ■ No restrictions ➢ Soft/low residue ■ Low-fiber, easily digestible foods, pastas, casseroles, moist tender meats, canned cooked fruits and vegetables, deserts without nuts or coconut ➢ High fiber ■ Addition of fresh uncooked fruits, steamed vegetables, bran, cornmeal, dried fruits ➢ Modified fluid consistency/Altered thickened ■ For patients with dysphagia ■ Nectar consistency, thicker than water but can be sipped through straw, including nectar, vegetable juice, cream soups, honey consistency, can be eaten with spoon but does not hold shape, honey, tomato sauce, yogurt, pudding consistency ❖ Stress/Adaptation ➢ Role exhaustion (stage of exhaustion) ■ Results when adaptive mechanisms are exhausted Body either rests and mobilizes its defenses to return to normal or dies ➢ Caregiver burden, neglect, crisis ❖ Death/Dying/Spirituality ➢ Kubler Ross stages of grief (DABDA) ■ Denial ● Avoidance; confusion; elation; shock; fear ■ Anger ● Frustration; irritation; anxiety ■ Bargaining ● Struggling to find meaning; reaching out to others; telling one’s story ■ Depression ● Overwhelmed; helplessness; hostility; flight ■ Acceptance ● Exploring options; new plan in place; moving on ➢ MOLST ■ A physician order and patient/surrogate consent form that conveys a patient’s wishes regarding cardiopulmonary resuscitation (CPR), mechanical ventilation & other life sustaining treatment ➢ HCP ■ A document in which a patient with decision-making capacity appoints a person to make decisions about medical care in the event that the patient subsequently becomes incapable of making those decisions ➢ Living Will ■ Document in which a person with decision-making capacity expresses his/her wishes to receive or not receive certain life-sustaining treatments in the event that he/she becomes terminally ill & loses decision-making capacity in the future ➢ Hospice ■ Makes life comfortable & prepares patient and family for end of life ■ Treatment of illness is not pursued ■ Does not use life prolonging medication ➢ Palliative Care ■ Focuses on relief from physical suffering; patient may be treated for a disease or be living w/ a chronic disease ■ Uses life prolonging medication ■ Addresses patient’s physical, mental, social, & spiritual well-being ➢ Sources of data ■ Primary: the client ■ Secondary: family members, caregivers, support people, health records lab and diagnostic test results ❖ Subjective vs. Objective ➢ Subjective ■ Information perceived only by the affected person; this data cannot be perceived or verified by another person ➢ Objective ■ Observable and measurable data that can be seen, heard, felt, or measured by someone other than the person experiencing them ❖ Communication ➢ Explain progression of dying process ➢ Do not encourage unrealistic hope ➢ Describe procedures and care the patient is receiving ➢ Invite family to participate in patient care ➢ Maintain quiet/calm environments