Final Exam Review

Risk factors for Alzheimer’s

• Family history of AD or Down Syndrome​

• Advanced age​

• Chemical Imbalances​

• Genetic predisposition, apolipoprotein E​

• Environmental agents or virus (herpes virus, metal, or toxic waste)​

• Previous head injury​

• Assigned female at birth​

• Ethnicity/race (AA or Hispanic)​

• PTSD​

What assessment tools are used for Alzheimer’s

• Mini Mental State Examination (MMSE)​- Is usually conducted over time to have evidence of cognitive decline​

• Set test using fruits, animals, colors, and towns (FACT)​

• Montral Cognitive Assessment Test (MoCA)- The test is a one-page, 30-point test that can be administered in 10 minutes. It assesses short-term memory recall (5 points), visuospatial abilities through clock-drawing (3 points) and cube copy (1 point), and orientation (6 points). Executive function is assessed through modified Trail Making Part B (1 point), phonemic fluency (1 point), and verbal abstraction (2 points).  ​

• Brief Interview for Mental Status (BIMS) ​

• Clock Drawing Test​

Nursing Care for Alzheimer’s

• Initiate bowel and bladder schedules​

• Promote self-care as long as possible​

• Encourage the client and family to participate in an AD support group​

• Avoid overstimulation​

• Reorient patient

• Allow rest periods

• Verbal and Nonverbal communication

• Update white board, have clock visible

• Limit options

• Maintain routine- sleep schedule

  Safety Nursing Care

• Provide frequent walks to reduce wandering

• Remove or secure dangerous items in the clients environment

What is delirium?

A clinical syndrome causing an acute confsional state

Who is at risk for developing delirium

• Advanced age ​

• Hearing or visually impaired ​

• Dehydrated ​

• Malnutrition ​

• Metabolic disorders ​

• ETOH/Drug abuse ​

• Pre-existing dementia ​

• Sleep deprived ​

• Receiving benzodiazepine medications

3 hallmark symptoms of delirium

Inattentiveness​

Confusion/Disorganized thoughts​

Alteration in LOC ​

Types of delirium and clinical presentation of each

Hypoactive- withdrawn/drowsy, more common, harder to detect, higher risk of mortality

Hyperactive-agitated, hallucination, restless, aggressive

Mixed- symptoms of hypo and hyper

Prevention strategies for delirium

General prevention considerations: ​

• Glasses ​

• Hearing aids ​

• Day/night orientation ​

• Method of communicating if barrier  ​

• Board in room with place & date ​

• Clock in view ​

• Noise control ​

• Promote sleep ​

• Cluster care activities​

What screening tools are used for delirium

Richmond agitation sedation scale (RASS): Describes pts alertness and agitation when sedated: goal is -1-0. AND mostly used in mechanically ventilated patients in order to avoid over and under-sedation.

Confusion Assessment method (CAM)

Confusion assessment for ICU (CAM-ICU) used to determine severity, should be used daily

Treatment and management of delirium

Identify reversible causes, avoid benzodiazepines. Psychiatric consult if available

Nursing interventions for delirium

• Prevention ​

• Vigilant early recognition using screening tool​

• Be mindful of the environment ​

• Do not overstimulate ​

  Anticipate and prevent or manage complications​

• Urinary incontinence​

• Immobility and falls​

• Pressure ulcers​

• Sleep disturbance​

• Feeding disorders​

• ​Remove contributing factors causing the client’s confusion​

• Collaborate with interdisciplinary team regarding the client’s plan of care​

• Reorient frequently​

• Speak using a calm voice​

• Consider the use of calming music in the client’s environment​

What is Parkinson’s

Parkinson’s Disease is a progressive degenerative disorder that affects motor function through the loss of extrapyramidal activity

Which neurotransmitter is decreased or loss in this disease process?

Dopamine

What are the risk factors associated with Parkinson’s disease

• Clients assigned male at birth​

• Genetic predisposition​

• Exposure to environmental toxins and chemical solvents​

• Chronic use of antipsychotic medications​ (chlorpromazine)

What are the 4 cardinal symptoms

TRAP

Tremors

Muscle rigidity

Akinesia

Postural instability

What is the goal of anticholinergic medication in the treatment of Parkinson’s disease

Reduce tremors, drooling, and rigidity​

What should the nurse monitor for if a client is taking a dopamine agonist?

Monitor for orthostatic hypotension, dyskinesia, and hallucinations​

What is deep brain stimulation and what should the nurse monitor for post operatively?

Targeted area receives mild electrical stimulation to reduce tremors and rigidity ​

• Typically reserved for patients who do not respond to medications​

Post op:

• monitor for infection

• brain hemorrhage

• stroke like findings

List the nursing actions associated with caring for a client with Parkinson’s

Administer medications as prescribed​

Implement safety precautions​

• Falls​

• Sleep deprivation​

• High-risk tasks (ex. driving)​

Facilitate nutritional intake​

• Risk for aspiration and decreased oral intake ​

Elevate HOB​ (45-90)

Suction equipment at bedside​

Stool softener + fluid intake

Encourage self care

Interprofessional collaboration (PT,OT, Speech, Neurology, diet)

Communication Strategies

Acid/Base Ranges

pH A ←A 7.35-7.45 B→

PaCO2 ←B 35-45 A→

HCO3 ←A 22-26 B→

Solve Acid/Base Imbalance

pH: 7.26

PaCO2: 35

HCO3:16

pH is acidic

PaCO2 neutral

HCO3 acidic

Uncompensated metabolic acidosis

Solve Acid/Base Imbalance

pH: 7.30

PaCO2: 58

HCO3:30

pH is acidic

PaCO2 acidic

HCO3 basic

partially compensated respiratory acidosis

Solve Acid/Base Imbalance

pH: 7.52

PaCO2: 26

HCO3:22

pH is basic

PaCO2 is basic

HCO3 is neutral

Uncompensated Respiratory alkalosis

Solve Acid/Base Imbalance

pH: 7.36

PaCO2: 48

HCO3:24

pH is neutral, but closer to being an acid

PaCO2 is acidic

HCO3 is neutral

Compensated respiratory acidosis

Compensation rules

if pH is normal and

• PaCO2 and/or HCO3 are abnormal, then the pt is compensated

If pH is abnormal and

• either PaCO2 or HCO3 are abnormal, then the patient is uncompensated

If pH is abormal and

• PaCO2 and HCO3 are both abnormal, then the pt is partially compensated

What does Peripheral arterial disease (PAD) do?

PAD affects vessels that carry blood away from the heart

Risk factors for PAD

• Hypertension​

• Hyperlipidemia​

• DM​

• Smoking​

• Obesity (BMI over 30)​

• Sedentary Lifestyle ​

• Genetics​

• Female sex​

• Advanced age (over 50)​

• Elevated C-reactive protein

• Hyperhomocysteinemia​

​

Expected clinical findings for PAD

• Burning, cramping, and pain in the legs during exercise (intermittent claudication)​

• Numbness or burning pain primarily in the feet when in bed ​

• Pain relieved by placing legs at rest in a dependent position​

• Bruit over femoral and iliac arteries​

• >3 sec cap refill​

• Decreased or nonpalpable pulses​

• Loss of hair on legs​

• Dry, scaly, mottled skin​

• ​Thick toenails​

• Cold and cyanotic extremity​

• Pallor of extremity with elevation​

• Rubor of the extremity in dependent position​

• Muscle atrophy​

• Ulcers and possible gangrene of toes​

Positioning the client with PAD

Positioning for a client with PAD would include elevating the legs but not above the heart

What is compartment syndrome

A medical emergency for clients with PAD

6 P’s

• Pain

• Paresthesia- pins and needles

• Pulselessness- state of having no pulse

• Pallor- pale

• Poikilothermia- cool extremities

• Paralysis- loss of ability to move

What does PVD affect?

PVD affects vessels that carry blood to the heart

Expected findings for a client with a DVT- deep vein thrombosis

• Client can be asymptomatic​

• Calf or groin pain, tenderness, and a sudden onset of edema in the extremity​

• Warmth, edema, and induration and hardness over the involved blood vessel​

• Changes in size (circumference) to affected leg​

• !! SOB and CP can indicate that the embolus has moved to the lungs (PE)!! ​

Labs and diagnostics for DVT

D-Dimer (blood specimen)​

• Measures fibrin degradation present in the blood produced from fibrinolysis​

• Positive test indicates a thrombus has formed​

​DVT & Thrombophlebitis​

• Venous duplex USN​

• Doppler flow​

Explain what a Pulmonary embolism (PE) is, the clinical manifestations, and nursing interventions associated with caring for a client with a PE

The complications of a pulmonary embolism include

• Thrombus is dislodged→ embolus → lodges in pulmonary vessel​

• Leads to obstruction of pulmonary blood flow, decreased systemic O2, hypoxia, and death​

• Manifestations: Dyspnea, CP, apprehension, “feeling of impending doom”, hemoptysis​

• Nursing interventions: NOTIFY the provider, assist client to comfortable position, O2, ABG, admin anticoag​

• Nursing actions: Assess for Tachypnea, crackles, friction rub, S3 or S4, diaphoresis, petechiae over chest and axillae, and decrease SaO2​

What is Raynaud's disease

Vasospasm that causes narrowing of the arteries

Primary Raynaud’s disease

• Idiopathic

• Exposure to cold temp

• stress

• blood vessel vasospasm

Secondary Raynaud’s Disease

• Complication from comorbidity

• Scleroderma​

• Lupus Erythematosus​

• Rheumatoid Arthritis​

• Arterial Disease​

• Carpal Tunnel Syndrome​

What Client Education would you provide to someone with raynaud’s

• Medication side effects​

• Smoking cessation​

• Exercise​

• Stress Reduction​

• Limit caffeine​

• Avoid cold temperatures​

What is cellulitis

A local bacterial infection in the subcutaneous tissue

• Cellulitis may appear as a swollen, red area of skin that feels hot and tender​

Risk factors for cellulitis include

• Older client​

• Weak immune system​

• Break in the skin (first defense)​

• IV drug use​

• DM​

Clinical Manifestations include

• Tenderness, inflammation​

• Skin sore or rash that spreads quickly​

• Tight, glossy appearance of the skin​

• Abscess w/ pus formation​

• Fever, elev WBC’s ​

Medical Management includes:

• IV antibiotics

• Analgesics​- Acetaminophen/Ibuprofen for pain​

What are 3 primary symptoms of COPD

Chronic cough, sputum production, dyspnea

What happens if you over oxygenate a client with COPD

They will lose their drive to breath

What type of chest would a patient with COPD have

Barrel shaped chest

What should a client with COPD be instructed to perform

Pursed lip breathing

What diagnostic tools are used for COPD

ABGs

Chest x-rays

Spirometry is used to measure lung volumes and air flow. The two tests used are:​

Forced Vital Capacity (FVC) - maximum volume of air exhaled during a forced expiration​

Forced Expiratory Volume in 1 second (FEV1) — Volume of air exhaled in the first second of a maximal expiration after a maximal inspiration ​

Complications of COPD

• Respiratory insufficiency and failure​

• Pneumonia​

• Chronic atelectasis​

• Pneumothorax​

• Right-sided Heart Failure (cor pulmonale)​

What acid/base balance would you expect this client to have? Why?

Respiratory Acidosis, because they have chronically increased PaCO2 levels

What is asthma

Asthma is a chronic condition that worsens based on triggers. Allergy is the strongest predisposing factor

Clinical manifestations of asthma

• Dyspnea, chest tightness, anxiety or stress​

• Physical Assessment Findings:​

• Cough, productive or not​

• Generalized wheezing​

• Mucous production ​

• Use of accessory muscles ​

• Prolonged exhalation ​

• Hypoxemia and central cyanosis ​

• Tachypnea ​

​

Medications that treat asthma

Quick-relief medications​

• Short-acting Beta2-adrenergic agonists (SABAs)​

• Anticholinergics​

Long-acting medications​

• Corticosteroids​

• Long-acting beta2-adrenergic agonists (LABAs)​

  ​

​​

Most accurate diagnostic tool for Asthma

Pulmonary function test

Clinical manifestations of Pneumonia

• Fever​

• Shortness of breath ​

• Tachypnea ​

• Pleuritic chest pain (sharp)​

• Productive cough ​

• , blood-tinged, purulent, and/or rust-colored ​

• Crackles, wheezing​

• Hypoxia​

• Dull chest percussion over areas of consolidation  ​

What lab and diagnostic tests are used for pneumonia?

Laboratory Tests:​

• Sputum culture and sensitivity ​

• CBC​

• ABG​

• Blood Culture ​

• BMP​

Diagnostic tests

• Chest x-ray​- May lag by up to 72 hours​

• CT Scan (chest) ​- More accurate in early stages ​

What is CAP- Community associated Pneumonia

• Diagnosed in community or early in hospital admission (less than 48 hours)​

• Most common type ​

• Often occurs as a complication of influenza ​

What is HCAP- healthcare associated pneumonia

• Non-hospitalized patients that have extensive contact with healthcare personnel ​

Often caused by Multidrug resistant (MDR) pathogens​

• More likely to be resistant to antibiotics ​

• Linked to higher mortality ​

What is HAP? Hospital acquired pneumonia

Develops 48 hours or more after hospital admission​

Patients can be exposed to pathogens from different sources​

• Medical equipment​

• Provider contact​

• Shared facilities​

Caused by various pathogens​

​

What is VAP? Ventilator associated pneumonia

• Sub-type of HAP​

• When the condition manifests greater than 48 hours after the client is intubated ​

What nursing care would be provided to a client with pneumonia? Write the rationale next to each intervention

• Assessment ​

• Administer breathing treatments and medications​

• Administer O2 therapy​

• Monitor for skin breakdown  ​

• Position​- high fowler’s = 90 degrees to maximize ventilation (unless contraindicated)​

• Mobility ​

  Promote adequate nutrition and fluid intake ​

• Nutrition: increased work of breathing requires additional calories ​

  Fluid intake: encourage 2-3L/day to promote hydration and thinning of secretions (unless contraindicated) ​

• Provide rest periods ​

• Provide reassurance ​

What members of the interprofessional care team would be consulted for a client with pneumonia? Write the rationale next to each consult

RT: inhalers, breathing treatments, suctioning, O2 monitoring and therapy, draw ABGs as needed ​

Nutritional: weight loss or gain related to medications or diagnosis ​(dietician)

Rehab: can be consulted for prolonged weakness and mobility assistance ​(PT/OT)

What nursing interventions would you provide to prevent aspiration?

• Keep HOB elevated >30 degrees​

• Use as few sedatives as possible​

• Confirm tube placement before enteral feedings​

• Avoid stimulation of gag reflex with suctioning or other procedures​

• Thickened fluids for swallowing problems​

Fasting blood glucose range

Dm: Greater than or equal to 126 mg/dL

Prediabetes: 100-125 mg/dL

Hemoglobin A1C range

DM: Greater than or equal to 6.5%

Prediabetes: 5.7-6.4

What does an A1C meausre?

the glucose average from the past 3 months

What does the fasting blood glucose measure

Blood glucose levels, make sure pt doesn’t eat for 12 hours prior

What is the patho of DMT1

Absolute lack of insulin

What is the patho of DMT2

Insulin resistance

Clinical manifestations 3P’s

Polyuria: Excessive peeing

Polyphagia: excessive eating

Polydipsia: excessive thirst

Where is DKA usually found?

Diabetes type 1

Clinical manifestations of DKA

• Polydipsia

• Polyphagia

• Lethargy

• Stupor

• Blurred vision

• Breath has smell of acetone, fruity breath due to blowing off ketones

• Kussmaul breathing (hyperventilation)

• Nausea- trying to get rid of acid by compensating and getting rid of excess CO2

• Vomiting

• Abdominal pain

• Polyuria

• Glycosuria- glucose in urine due to having too much, first spills in kidneys then urine

What specific diagnosis/ lab testing is associated with DKA?

• Blood glucose level greater than 250 mg/dL​

• Ketonuria (ketones in the urine)​

• Arterial pH of less than or equal to 7.30​

• Serum bicarbonate level of less than or equal to 18 mEq/L​

• Positive anion gap​

What is the treatment for DKA

• Fluid replacement with isotonic normal saline​

• Correction of electrolyte imbalances, focusing on monitoring and correction of decreased potassium level if necessary, prior to insulin administration​

• Insulin administration, usually by intravenous delivery​

• REGULAR INSULIN​

What is the patho of DKA

• Inadequate insulin for cells to obtain adequate glucose for normal metabolism​

• Body tries to get energy by the rapid breakdown of fat stores, releasing fatty acids from adipose tissues.​

• The liver converts the fatty acids into ketone bodies, which can serve as an energy source in the absence of glucose.​

• The ketone bodies, however, have a low pH, resulting in metabolic acidosis.​

Where is HHS found?

Usually in diabetes type 2

Common causes of HHS

• Infection

• Most commonly in older adults in response to stress or infection

Specific clinical manifestations include?

Profound dehydration

Alteration in levels of consciousness

What specific diagnostic/lab testing is associated with HHS

• Blood glucose greater than 600mg/dL​

• pH greater than 7.4​

• Serum bicarbonate levels greater than 15 mEq/L​

• Absence of ketones in urine ​

• Serum osmolality greater than 320 mOsm/kg​

• Negative anion gap​

• Profound dehydration ​

• Alteration in level of consciousness  ​

What is the treatment for HHS

Fluid replacement with isotonic normal saline​

Treatment for altered mental status ​

• Airway management ​

Insulin administration, usually by intravenous delivery​

• REGULAR INSULIN​

What is the patho of HHS

• occurs when there is sufficient insulin to prevent rapid fat breakdown and ketone release​

• there is not enough insulin to prevent severe hyperglycemia​

• extreme hyperosmolality leads to osmotic diuresis​

Contributing factors for GERD

• Obesity ​

• Older age​

• Sleep apnea​

• Nasogastric tube  ​

​Excessive ingestion of foods that relax the LES:​

• Chocolate, caffeine, fatty and fried foods, peppermint, spicy foods, tomatoes, citrus fruit, alcohol ​

• Prolonged or frequent abdominal distention (from overeating) ​

Increase abdominal pressure​

• Constrictive clothing​, obesity, pregnancy, bending at the waist, ascites ​

• Medications that can relax the LES or cause increased gastric acid​

• Hiatal hernia ​

• Gastritis due to Helicobacter pylori  ​

• Lying flat ​

Clinical Manifestations for GERD

• Report of dyspepsia (indigestion) after eating an offending food or fluid​

• Radiating pain (neck, jaw, or back)​

• Report of feeling of having a heart attack​

If having either of the 2 symptoms above further diagnostic testing should be done to rule out an MI

• Pyrosis (burning sensation in the esophagus)​

• Odynophagia (pain when swallowing)​

• Pain that worsens with position​

• Pain that occurs after eating and lasts 20 min- 2 hours ​

• Throat irritation (chronic cough, laryngitis) ​

• Increased flatus and eructation (burping)​

• Pain is relieved by drinking water, sitting upright, or taking antacids ​

• Chest congestion and wheezing ​

• Dental caries ​

Preferred diagnostic test for GERD

EGD/Upper endoscopy

Nursing management/patient education for GERD

• Avoid eating immediately prior to going to bed ​

• Avoid foods and beverages that decrease LES pressure ​

• Exercise regularly​

• Maintain a healthy weight ​

• Elevate HOB ​

• Avoid straining or excessive vigorous exercise ​

• Avoid wearing clothing that is tight around the abdomen ​

Risk factors for peptic ulcer disease

• H. Pylori infection ​

• excessive secretion of stomach acid​​

• chronic use of NSAIDs/ Corticosteroids​​

• Excessive alcohol​ consumption ​

• Blood type O​​

• Rare: Zollinger-Ellison Syndrome ​​

• Rare: Gastrin Secreting Tumor​​

Clinical manifestations for a peptic ulcer

• dull aching pain ​​

• ​burning in the mid-epigastrium area or back​​

• heartburn and vomiting may occur​​

• Bleeding is possible​

Diagnostic tests for peptic ulcer disease

• Upper endoscopy​​

H. pylori testing (95% of non-NSAID PUD patients are positive) ​​

• Biopsy- with endoscopy ​​

• Fecal Antigen test​​

• Urea breath test​​

• Serological antibody​​

• Stool culture​​

Bleeding ulcer​​

• Periodic CBCs​​

• Fecal Occult blood​

What are the specific clinical manifestations of perforation or penetration?

• Signs include severe upper abdominal pain that may be referred to the shoulder,

• vomiting and collapse

• tender board-like abdomen

• symptoms of shock or impending shock​​- tachycardia and hypotension

What is the difference between primary and secondary osteoporosis

Primary OP: Genetic or environmental

Secondary: R/T comorbidities or chronic medication use

Clinical manifestations of OP

• Reduced height 5-7.5 cm (2-3 in)​

• Acute back pain after lifting or bending ​

• Restriction in movement and spinal deformity​

• History of fx (wrist, femur, thoracic spine)​

• Kyphosis of dorsal spine​

• Pain upon palpation over affected area​

What Diagnostic test is used for a client with OP?

Bone density tests (DEXA scan)

What medications are used to treat OP?

Calcium and vitamin D

What are the clinical manifestations of RA

• Seven S’s​​

• Sunrise Stiffness (severe pain) GREATER than 30 minutes​​

• Soft, tender, and warm in joint​​

• Swelling in the joint (warm)​​

• Symmetrical​​

• Synovium (affected and inflamed)​​

• Systemic (affects not only the joint feels aches, tired, lungs, heart, anemia etc.)​​

• Stages (synovitis, pannus, anklyosis)​

What are the surgical interventions of RA?

Total joint Arthroplasty or replacement​

• Used when least invasive measures fail, used to relieve pain and improve mobility and quality of life, uncontrolled diabetes or htn can cause major postop complications​

• Synovectomy (removal of the synovium), if not there, therefore cant be inflamed ​

​

What medications are used to treat RA?

• NSAIDs​​

• Corticosteroids​

• Disease modifying anti-rheumatic drugs (DMARDs)​

What members of the interprofessional care team would be consulted for a client with RA?

• PT- assist with comfort therapies

• Dietician- assist with meal planning

• Case manager (Social Work)- set up a home nurse to determine home modifications

• OT- assess the need for assistive and adaptive devices, mobility aids, clothing with velcro closures, feeding

What is the main pathological problem in OA?

Deterioration/destruction of what?

Nonsystemic, Noninflammatory ​deterioration of the articular cartilage of the bones (cartilage destruction)​​

Clinical Manifestations of OA

• “Osteo”​​

Outgrowths on Hands: Nodes (bony outgrowths) on fingers from bone spurs:​​

• Heberden’s Node (more common): found on the distal interphalangeal joint​​

• Bouchard’s Node: found on the proximal interphalangeal joint​​

• Stiffness​ and joint pain​

• Tenderness when touching the joint site with bony outgrowths.​​

• Experience grating (crepitus) of the bone​​

• Only the joints: Asymmetrical/Uneven, limited to joints​

Surgical interventions of OA?

• Intra-articular injections: steroid injections ​

• Glucocorticoids are used to treat localized inflammation​

• Osteotomy: bone realignment…like a knee osteotomy to help alleviate weight on affected knee​

​

What is included in the nursing care/management of an client with OA?

• Determine the psychosocial impact ​

• Assess the need for assistive or adaptive devices​

• Balance activity w/ rest​

• Heat v cold therapy​

• Healthy weight​

• Adhere to exercise regimen consistently​

• Interprofessional care​