NS 233: Exam 4

What is a Cataract? What causes one?

What is a Cataract? What causes one?

-opacity within the eye, decrease in vision, abnormal color perception, and glare
-age, trauma, smoking, alcohol use, UV light, medications, and comorbidities

What are nonsurgical therapy, preoperative, intraoperative, and postoperative cares regarding Cataracts?

Non surgical therapy:

reading glasses, increasing light for the client when they are working

Preoperative: detailed history and physical report (Do we need to stop any meds before the procedure happens)

Intraoperative: client are given meds to relax them so the provider can complete the operation.

Postoperative: Client spends time recovering after the surgery, to make sure everything did in fact go well. Also to make sure the medications wore off.

What are nursing interventions for cataracts?

-sunglasses
-eat vitamin a & e

What is Glaucoma?

increased intraocular pressure that affects the optic nerve it can cause atrophy and peripheral vision loss.

What are nursing interventions for a client with Glaucoma?

-Teaching risk factors, getting regular check ups, etc.
-Visit opthamologist, noninvasive methods to open outflow channels, and how to detect earlier)

What is breakthrough pain?

A sudden increase in pain that may occur in patients who already have chronic pain from cancer, arthritis, fibromyalgia, or other conditions

Define the following terms:

-Transduction

-Transmission

-Perception

-Modulation

Transduction: Tissue damage that results in the release of a chemical mediator

Transmission: action potential that moves along the nerve fiber to get info back to our brain.

Perception: Pain is percieved

Modulation: The release of a substance that inhibits the transmission of the pain impulses

What is nociceptive pain?

-somatic: originates from receptors in skin, bones, muscles, joints, blood vessels; described as dull, aching, well-localized
-visceral: when internal organ swell or become damaged within the body; described as deep, gnawing, cramping, poorly localized

What is neuropathic pain? What are the causes?

the nerves causing a burning hot, shooting, intense pain, can be short lived
causes: alcohol, trauma, etc.

What assesment findings go along with Multiple Sclerosis?

-Blurred/double vision
-Weakness in muscles causing coordination issues
-Trouble swallowing and speaking
-Urinary incontinence (Leads to UTI)
-Short-term Memory problems
-ADL difficulties

How is Multiple Sclerosis dx?

There are no definitve tests for MS

What are helpful interventions regarding Multiple Sclerosis?

-Identify triggers (CLIMATE or infections (UTI, pregnancy, common cold))
-Manage Symptoms (Decrease pain & therapies)
-Avoid stressful events
-Water activities (aerobics)

What does TRAP stand for regarding Parkinson's Disease?

Tremor : (First sign) Pill rolling fingers prominent at rest

Rigidity : Increase in tension while doing passive range of motion, jerky movements, makes client sore/fatigued/tired

Akinesia : Loss of voluntary movement, slow movements, stooped posture, blank facial expression, and shuffling gait

Postural Instability : Cannot stop themselves from falling forward or backwards

What other illnesses may someone with Parkinson's Disease expireince?

-Depression
-Anxiety
-Pain
-Altered sleep pattern

How many meals should someone with Parkinson's Disease have a day?

-Six small meals daily
-Have a well blanced diet w/ fiber/fruit to reduce constipations

What interventions would you implement to help someone with Parkinson's Disease?

-Encouraging client to walk and move around
-Well balanced diet
-Avoiding complications (ex: Having velcro shoes instead of laces)

When is stiffness and fatigue most prominent in a client with Rheumatoid Arthritis?

In the morning! :)

What are interventions to help someone with Rheumatoid Arthritis?

*<b>Alternate rest with activity</b>*
-Protect joints, take rest breaks, alter routine to put less stress on joints
-Prevent repetitive exercizes (use splints)

How is Rheumatoid Arthritis diagnosed?

-Positive rhematoid factor (RF)
-C-reactive protein (CRP)
-Synovial Fluid analysis

What drugs are used for Rheumatoid Arthritis?

-DMARDS
-biologics
-Corticosteroids
-NSAIDS

Rheumatoid Arthritis attacks what size of joints first?

small joints yo

What are the risk factors for cogntition problems?

Age, comorbities, past trauma, and genetics

What are most seisures caused by?

old age

What are the four phases of seizures?

Prodromal phase: Signs or activity that warns a symptom is about to happen This can be a sign hours before a seizure begins. Symptoms include: overly affectionate, depressed, have random headaches
Aural Phase: a sensory warning (happens a few minutes to a few seconds before a seizure begins)
Ictal Phase: seisure activity
Postical phase: the period of recovery

What are assesment findings of seizures?

-Aura
-status epilepticus
-loss of conciuosness
-bowel/bladder incontinence
-tachycardia/diaphoresis
-cyanosis
-muscular rigidity with jerky movements

A seisures should not exceed __ minutes

5, or brain damage can occur

What can be done to protect a client that is prone to seizures?

-having bed in lowest position
-pads on floor to stop them from hitting floor
-clients can wear helmet while moving around

What should the nurse be doing during a seizure?

-ictal: note what makes the seizure onset
-monitor note observe how long the seizure is happening
-maintain patient safety
-get vitals after seizure
-maintain airway

What are the risk factors for bacterial and viral meningitis?

-Depending on season (late fall, winter, and early spring)
-Older adults who are in close living quarters

What are the assesment findings of bacterial and viral meningitis?

-fever/headache
-N/V
-Severe nuchal rigidity (neck stiffness)
-Photophobia
-Decreased LOC, Increased ICP

What is the diagnostic tests for bacterial and viral meningitis?

-CT scan (locates obstructions)
-Lumbar puncture (identify which organism)
-Body fluid cultures (mucus)

What complications arise regarding bacterial and viral meningitis?

-Increased ICP
-Headaches that last months after dx

What are Interprofessional cares for bacterial and viral meningitis?

-Rapid dx is CRUCIAL (100% fatal if not treated)
-When meningitis is suspected, antibiotic therapy is started after sample of CSF is collected AND before diagnosis is confirmed

What are nursing interventions for bacterial and viral meningitis?

-Educate why the patient needs to get vaccines (flu, meningococcal, treat ear/respiratory infections immediately)
-Provide a calm and safe enovirement for the patient
-(A full recovery is expected)

What happens to a person with bacterial and viral meningitis?

They are placed in isolation (droplet precautions) until thier cultures are negative

Should the head of the bed be flat or raised for a client with bacterial and viral meningitis?

The head of the bed should be up so the ICP decreases via gravity

What are risk factors for Alzheimer's disease?

-Genetics/Family hx
-More prominent in women
-Existing cardiovascular problems ( Diabetes, HTN, smoking, high cholesterol)
-Head truma (ever been dx w/ major brain injury)

What are the ealy signs of Alzheimer's disease?

-memory loss that effects job
-difficulty performing familair tasks
-Disorientated to time and place-poor judgement
-misplacing keys
-changes in mood/behavior/personality
-loss of initiative

As Alzheimer's disease progress what symptoms appear?

-Decreased personal hygenie/concentration/attention
-Unpredictable behavior
-Delusions and hallucinations

How is Alzheimer's disease diagnosed?

There are no definitve tests

What are nursing interventions for Alzheimer's disease?

-Encourage client to stay active and eat healthy diet
-Support patient and family
-Asses pain related to behavioral problems
-Ensure not too much stimulation happening around client
-prevent infection
-MONITOR EATING AND SWALLOWING TROUBLES

What are the risk factors for fluid volume deficit?

-Fever
-Fuerosemide (Diuretics)
-Hemorrhage
-Vomiting, NG suction, diarrhea
-Burns and intestinal obstructions

What are the assessment findings for someone with a fluid volume deficit?

-Dry Mucous Membrane
-Increased pulse
-Decreased urine output
-Postural Hypotension
-Weight loss
-Restless/Drowsy

What are the risk factors for fluid volume excess?

-Excessive IV fluid administration
-Heart/Renal failure
-SIADH (syndrome of innapropriate antidiuretic hromone)

What are the assesment findings for someone with fluid volume excess?

-Peripheal edema
-Bounding pulse
-Increased BP
-Polyuria
-Dyspnea and crackles
-Weight gain

If you restrict sodium what increases in the body?

Water

What are the assesment findings of Hypernatremia?

Nuerological changes

What are the nursing interventions for Hyponatremia?

-Correct underlying problem
-Monitor sodium level
-Fluid restrictiom
-Sodium replacement (Increase sodium in diet)

Hypernatremia can cause what? Hyponatremia can cause what?

-Fluid volume deficit (hypovolemia), due to the inverse relationship sodium has w/ water -Fluid volume excess (hypervolemia)

What are the risk factors for Hypernatremia?

-Excessive sodium intake (IV, tube feedings)
-Inadequate water intake
-Excessive water loss (diarrhea)

What are the assesment findings of Hyperkalemia?

cardiac changes

What are nursing interventions for Hyperkalemia?

- Stop IV fluid infusions of potassium
- Monitor ECG
- Correct underlying problem
- Monitor potassium levels

What are the risk factors for Hypokalemia?

-GI loss
-Diuretics use
-Diaphoresis
-Dialysis/starvation

What loop diuretic is used to treat Hyperkalemia?

Furosemide, increases renal excretion of water, potassium, and calcium

What are the adverse effects of Furosemide?

Hypokalemia, dehydration, and hypovolemia

What are the nursing implications for Furosemide?

-Asses fluid status
-Asses potassium level/renal labs
-Monitor BP before administering
-Monitor for dysrhytmias

What are the risk factors for Hypercalcemia?

-Certain cancers
-Malignances
-Prolonged immoblility
-Calcium containing antacids

What are the risk factors of Hypocalcemia?

-Renal insufficiency
-Hypoparathyroidism
-Diarrhea/Malnutrition

What assesment finding is prominent regarding Hypocalcemia?

-Laryngeal or bronhcial spasm
-Chvostek's/Trousseau's sign

calcium inbalances cause __________ complications

Neuromuscular

Hypercalcemia: nerves and muscles less excited

Hypocalcemia: nerves and muscles more excited, HOORAY

What are the diagnostic tests for impaired Oxygenation?

-Arterial Blood gasses (ABGs)
-Complete Blood count (CBC)-Sputum test
-PFT

What are the consequences of impaired Oxygenation?

-Fatigue
-Increased RR/HR
-Respiratory acidosis
-Cellular ischemia/necrosis

What are interventions for somone with impaired Oxygenation?

-Oxygen masks
-Oxygen tube placment
-Tripod position!
-Rest periods between activities

What are the risk factors for asthma?

-Nose/sinus problems
-Respiratory infections
-Allergens
-Cigarette/Pollutants
-Exercixe
-GERD
-Immune response

What are the assesment findings of asthma?

-Wheezing
-Breathlessness
-Chest tightness
-Cough/Dyspnea
-Hyperventilation/status asthmaticus

What bronchodialtor is used for asthma? What position should someone going through an asthma attack be in?

-albuterol
-high fowlers/tripod

What is the use of being perscribed short-term glucocorticosteriods?

-reduces inflammation

What are the risk factors for COPD?

-Tobacco use
-Infections
-Asthma/air pollution
-Chemical use
-Age
-Genetics

What is the assesment of COPD?

-Chronic cough
-Sputum production
-Dyspnea
-Angina
-Wheezing
-Prolonged expiratory phase
-Barrel chest
-Fatigue/Weight loss

What are the nursing interventions for COPD?

-Teach about COPD
-Bronchodialators
-Pulmonary rehab/breathing retraining
-Activity considerations
-Promote sleep
-Keep O2 above 90%

What is the incubation period for influenza? What precautions are they put into?

-1-4 days
-contact and droplet precautions

What are the assesment findings of influenza?

-fever
-Headache
-Cough/fatigue
-muscle soreness
-exhaustion

What are the two BP ranges of Hypertension?

HTN Stage 1: Systolic: 130-139
Diastolic: 80-89
HTN Stage 2: Systolic: 140+
Diastolic: 90+
(If BP is mixed, go with higher stage!)

What are the assesment findings for Hypertension?

Little to no symptoms (SILENT KILLA)

What are interprofessional cares for Hypertension?

-Lifestyle modifications
-Weight reduction
-DASH diet (low fat increased fruits & veggies)
-Reuce sodium/alcohol

What are the risk factors for Peripheal Artery Disease?

-Tobacco use
-Diabetes/Hyperlipidemia
-Age

What are the assessment findings of Peripheal Artery Disease?

Intermittenet claudation: ichemic pain caused by exercize, relived with ten minutes of rest caused by lactic acid
-Shiny, taut and thin skin
-Dimished lower extremity pulses
-Rest pain

What three factors cause thrombus formation? (VTE)

-Venous Stais
-Damage to endothelium
-Hypercoagability

What are the risk factors for a Venous Thromboembolism?

-Age
-Comorbidites
-Obesity/pregnancy
-Cancer
-Hip/Knee replacement
-Tobacco use

What are the assesment findings of Venous Thromboembolism?

-Pain/Tenderness w/ palpations
-Dialated superficial veins
-Sense of fullness in calf
-Erythema/Warm skin
-Paresthesia

What are interprofessional cares for Venous Thromboembolism?

-Walking, Turning patient, Flex and extend feet, TED HOSE, and compression devices

What Vitamin K antagonist is used for a VTE?

Warfarin (Coumadin): Come in weekly to get PT/INR checked

What are the risk factors for Atrial Fibrillation?

-CAD
-Vascular Heart Disease
-Hypertension/Heart Failure
-Cardiomyopathy

What are the assessment findings of Atrial Fibrillation?

-Palpitations
-Fatigue from fast heart rate
-Chest pain/Dyspnea
-Hypotension/Irregular pulse

What are the diagnostic tests for Atrial Fibrillation?

-12 lead ECG
-Complete H & P
-Chest X-ray
-Stress test
-Holter monitor

What medication is used for Atrial Fibrillation?

-Warfarin (Coumadin)

What does Warfarin (Coumadin) interfere with?

-hepatic synthesis of vitamin K dependent clotting factors

What are you assesing for Warfarin (Coumadin)?

-Asses for bleeding!
-Check labs, PT/INR
INR: 2.5-3.5 range

What is the antidote for Warfarin (Coumadin)?

Vitamin K

What are nursing implications of oxycodone and morphine?

-Hold for respiratory depression
-Monitor for constipation

What are the consequences of impaired protection?

immunosuppression: Increased risk of infections by bacteria or viruses
-exaggerated immune response: autoimmune disorders

What are the diagnostic tests for protection?

-labs
-allergy testing
-organ function test
-disease testing
-blood test/imaging

What are some examples of primary prevention regarding protection?

-vaccines
-standard precautions
-modify risk factors
-hand hygiene
-reduce injury risk

What are some examples of secondary prevention regarding protection?

-HIV testing
-STI testing

What are the assesment findings of suppressed immune function?

-malnourished
-fatigue
-impaired wound healing

What is inflammation?

Immunologic defense against tissue injury, infection, or allergy

What are some consequences regarding altered-protection?

-chronic inflammation
-sepsis
-multisystem organ failure

What is the chain of infection in order

infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, susceptible host

What are the consequences of sepsis?

-changes vascular permeability makes fluid shift out

-nervous system compensates and vasoconstricts

-heart compensates by increasing HR

-compromised circulation to organs

-results in muti-system failure

What is the pathophysiology of pneumonia

an acute infection of the lung parenchyma