Nursing 308
Describe the characteristics of an ACUTE illness
rapid onset
short duration
self-limiting
responsive to treatment
complications are infrequent
return to previous level of functioning
Describe the characteristics of a CHRONIC illness
prolonged
does not resolve spontaneously
rarely completely cured, but can be managed
irreversible pathologic changes
residual disability
long term nursing/medical management
Trajectory of a chronic illness
onset -- stable --acute -- comeback -- crisis -- unstable -- downward -- dying
Preventing and managing a crisis, adjusting to changes in the course of the disease, preventing social isolation, and normalizing interactions with others are all what?
tasks of a person with a chronic illness
Give examples of primary prevention
diet, exercise, TLC, immunizations, handwashing, social distancing
Give examples of secondary prevention
screening for early detection of disease
Give examples of tertiary prevention
treatment and limiting disease progression
What should always be included in your plan of care for a patient with a chronic illness?
chronic disease management
What are some differences in assessment for OA?
keeping the pt warm bc they have decreased subcutaneous fat, adapt positioning to physical limitations, perform as many activities as possible in position of comfort for patient, provide a quiet environment for assessment of head and neck because of possible sensory impairments, use caution when palpating the liver bc its readily available (softer and thinner abdominal wall)
Becoming chronically ill is 3x more likely after what age?
45
what are some forms of semi-formal social support?
social groups and religious organizations
what are some forms of formal social support?
in-home professional care giving, adult daycare, assisted living, NHs
What is elder abuse?
physical violence
What is neglect?
withholding food, water, or meds
what is exploitation?
use of OA's money for own gain
A nurse has a duty to do what when abuse, neglect, or exploitation is suspected?
mandatory reporting
what is self neglect?
person is able to meet own needs, but refuses
self neglect increases what?
mortality
What are some care alternatives for OA?
Home health care, adult day care, LTC facilities, PACE, assisted living
What are the requirements for home health?
HCP order, need for skilled care, intermittent acute care, not 24/7 care
What is PACE?
programs for all inclusive care for the elderly. it is needs based care 24/7 in the home; alternative to NH
what are the requirements for assisted living facilities?
must be mostly independent with ADLs
Role of the nurse when caring for OA?
advocate for them, help the pt to communicate their wants to family and providers
Impotants facts to know about the use of restraints?
last resort, ONLY to ensure safety
lest restrictive approach
highly regulated so know your facility, state, and federal guidelines
What is the #1 cause for hospital re-admissions in OA after a transfer of care?
failure to pick up and take meds appropriately
Where do most accidents occur for OA?
in or around the home
What should you do to prevent confusion of OA on admission to hospital?
carefully orient them to the environment
Regarding medication use, what is a common cause of hospitalization and disability or death in OA?
polypharmacy, errors are common
T/F: depression is a normal part of aging?
false
T/F: OA have the second highest rate of suicide?
true
patient who is forgoing treatment of a terminal illness but still needs symptom management would likely benefit from?
hospice care
a patient who is still in treatment for a serious health issue who has a poor quality of life due to their heath issue would likely benefit from?
palliative care
T/F: a nurse is legally and ethically responsive for preparing a patient for discharge?
true
When does discharge planning begin?
on admission and continues through hospital stay
The immediate response to injury or infection that resolves spontaneously or with treatment, healing occurs in 2-3 weeks, and usually has no residual damage is
acute inflammatory response
an inflammatory response that is similar to acute, but lingers for weeks to months would be classified as
subacute
An ongoing response to chronic condition that last months to years is a
chronic inflammatory response
manifestations of local inflammation
erythema, warmth, pain, edema, exudate, loss of function
manifestations of systemic inflammation
increased WBC, malaise, nausea, anorexia, increased pulse, increased respiratory rate, fever
severe inflammation may cause what?
hypovolemia , the fluid shifts from intravascular space to site of inflammation (pts will need to increase fluid intake)
For local injury, what do we do?
RICE - rest, ice (heat after 24-48hrs, compression/immobilization, elevation
What vitamins are used for wound healing?
A, B, C, D
A mild to moderate fever of 103 may be ____________ ?
beneficial, bacteria cannot grow at high temperatures
Although a fever of 103 could be beneficial, we should consider treating the fever if
very young, very old, patient is uncomfortable
Who should you ALWAYS treat a fever in?
immunocompromised
What level of fever should ALWAYS be treated?
< 104
T/F: infection may be asymptomatic at times?
true
What kind of precautions are needed for a patient with MRSA?
contact
What kind of precautions are needed for a patient with COVID?
droplet
What kind of precautions are needed for a patient with TB or chickenpox?
airborne
What is cellulitis?
inflammation of the subcutaneous tissue
What kind of abx will be needed for cellulitis? topical or systemic?
systemic
cellulitis often follows what?
skin breakdown
what can cellulitis progress to if untreated?
gangrene
How do we treat cellulitis?
moist heat, immobilization, elevation, abx, hospitilization if severe
T/F: cleansing hands with alcohol based hand sanitizer is sufficient after assessing a client with c. diff?
false, need to wash hands with soap and water, use bleach based disinfectants on equipment
What is sepsis characterized by?
dysregulated patient response along with new organ dysfunction related to infection
manifestations of sepsis?
hypothermia, tachycardia, tachypnea, hypotension, hyperglycemia, AMS, WBC count can be low, normal, or high
When should you get cultures on a wound?
before first dose of abx
what is the nurses job regarding a C&S report?
monitor for results and notify provider
T/F: patient do not need to finish complete dose of abx if their symptoms resolve
false, need to finish COMPLETE dose
T/F: hair should be removed before surgery ONLY if it will interfere with the procedure?
true
you should use clippers or a razor to remove hair before a procedure?
clippers
prophylactic abx should be given when during a procedure?
less than 1 hour before 1st surgical incision
T/F: allergy is an immune response?
true
Characteristics of a Type I latex allergy?
happens withing minutes of exposure, skin manifestations to anaphylaxis
Characteristics of a Type IV latex allergy?
contact dermatitis, delayed response 6-48hrs
What food allergies could also indicate a latex allergy?
avocados, bananas
A pt with an allergy to shellfish could also have an allergy to?
iodine
All patients with allergies should receive a
allergy band
Who should also be notified about a patient's allergy to latex?
dietary
Innate immunity is
present at birth
Acquired immunity is
development of active or passive immunity
Examples of active immunity
illness and immunizations
examples of passive immunity
breast milk, placental transfer, administration of immune globulin
Pt education must be __________ for every patient
documented
Educating a patient on not introducing soap to the vagina, during a bath is an example of what kind of teaching?
informal
Teaching a patient how to use an inhaler for the first time is an example of what kind of teaching?
formal
What is the difference between teaching and learning?
teaching is a nursing intervention, learning is a patient outcome
What are barrier to teaching for the nurse?
time, self-efficacy, disparities
goals for teaching should be SMART, what doe it stand for?
S- specific
M - measurable
A - attainable
R - relevant
T - timely
Who initiates the time out during a surgical procedure?
circulating nurse
When does the pre-op period start?
when the pt is scheduled for surgery
when does the pre-op period end?
transfer to the surgical suite
Whos job is it to tell the pt about the benefits/risks of surgery?
surgeon
Consent must be signed before what?
sedating meds are given
Nurse ALWAYS needs to do what when handling patient valuables before surgery
DOCUMENT - be VERY specific
Patient should do what on call to the OR?
void
in the unrestricted area, what kind of attire is appropriate?
street attire
in the semi-restricted area, what kind of attire is appropriate?
authorized personnel in clean attire
in the restricted area, what kind of attire is appropriate?
strict surgical asepsis
surgical care improvement project says
prophylactic abx 1 hour prior to incisions, warming blankets to prevent hypothermia, SCDs to prevent VTE
Check in, time out, and check out are part of what
WHO surgical safety checklist
a grounding pad and appropriate clothing are used to prevent
fire/burns
postoperative assessment includes
ABCs, neurologic, fluid balance, gastro, surgical site
How should a pt be positioned until they gain conciousness after surgery?
lateral
How should a pt be positioned once they regain conciousness after surgery?
supine with HOB elevated
incentive spirometer should be used ________ every ______ hour(s) while awake
10x; 1 hour
hypothermia is a temp of
< 96.8
example of passive warming
blankets
example of active warming
warm fluids
Malignant hyperthermia is a core body temp over
105
Oral intake should resume once
ordered and gag reflex returns
Positioning a pt on which side can relieve gas pain?
right
A urinary catheter should be removed within ______ hours after surgery unless otherwise indicated
24
DC after an ambulatory sx requires the pt to be
stable, pain controlled, near level of pre-op functioning
can a pt drive after ambulatory sx?
no
What kind of wounds are more common in OA?
skin tears
pressure ulcers can be caused by pressure OR
pressure and shear
What are examples of wounds healing by primary intention?
sutured wounds, minor lacerations
What are examples of wounds healing by secondary intention?
margins are gaping and cannot be approximated, healing occurs from margins inward from the bottom upward
What are examples of wounds healing by tertiary intention?
contaminated wounds (a stump following traumatic amputation, surgeon will leave wound open, then go in a close it later)
What are some factors that can delay wound healing?
hyperglycemia, circulatory/vascular disorders, chronic disease states
When should you assess for pressure ulcers?
on admission and every 24hrs during stay
drain management should include
maintaining cleanliness at insertion site, emptying as prescribed/indicated, record drainage amount
Intracellular fluid (ICF) makes up ____ of the body
2/3
Extracellular fluid (ECF) makes up _____ of the body
1/3
what is a good indicator of overall fluid volume loss/gain
sudden body weight changes
what is a good indicator of cardiac output in non-renal failure patients?
hourly urine output
What is the KEY indicator of fluid status?
urine specific gravity
intake > output is a ____ fluid balance
positive
intake < output is a ______ fluid balance
negative
1st spacing
normal distribution of fluid in all compartments
2nd spacing
abnormal excess of fluid in intersitital spaces
3rd spacing
fluid accumulation in areas in which exchange with the rest of ECF cannot easily occur (pleura, pericardial, peritoneal spaces)
insensible water loss
invisible evaporation from lungs and skin
T/F: skin turgor is a good way to check fluid staus in the OA
false - check under tongue
T/F: Cushing's can cause hypervolemia (FVO)
true
labs for FVD include:
oliguria and concentrated urine (urine specific gravity, HCT [increased], Na, BUN, plasma osmolarity)
labs for FVO include:
electrolyte levels, daily weights, I&O
T/F: the HOB should be elevated for pts with FVO
true
sodium imbalances cause
brain changes (loc, seizures)
potassium imbalances cause
heart changes (EKG changes, heart block)
calcium imbalances cause
muscular/bone changes
nurse should monitor what and consult who for pts with electrolyte imbalances?
monitor labs, consult dietary
T/F: acid-base imbalance is a disease
false - its a symptom of underlying causes
Hyperventilation will cause what acid-base imbalance?
respiratory alkalosis (not blowing off the CO2)
hypoventilation will cause what acid-base imbalance?
respiratory acidosis (holding the CO2 in)
what is the mnemonic for acid-base balances
ROME (respiratory opposite, metabolic equal)
Joint Commission requires nutritional screening for all patients within ______ hours of admission and should be done by a ______.
24; registered dietician
starvation related malnutrition:
nutritional needs are not met
Chronic disease related malnutrition:
increased or special nutritional needs due to chronic inflammation
acute disease or injury related malnutrition:
increased nutritional needs due to marked acute inflammation from burns, infection, surgery, trauma
Low pre-albumin indicates acute or chronic malnutrition?
acute
low albumin indicated acute or chronic malnutrition?
chronic
What should the nurse document for a pt with nutritional needs?
% of meal eaten and calorie count
PPN is intended to
supplement oral feedings
can PPN be given through a 20g IV in the right AC?
yes
TPN is
TOTAL parenteral nutrition
TPN must be administered through what kind of line?
central line (PICC)
Patient on PPN/TPN are at risk for what?
hyper and hypoglycemia
what kind of tubing should be used when administering TPN and PPN?
inline filter tubing
How often should the TPN/PPN solution be changed?
Q24hrs
What do you do inf the next bag of TPN/PPN is not ready when the current bag runs out? WHY???
hang dextrose and water solution equal to that of the PPN/TPN until the next bag arrives. To prevent hypoglycemia!!
What is refeeding syndrome?
a complication of parenteral nutrition, fluid retention, electrolyte imbalances
What is the hallmark for refeeding syndrome?
hypophosphatemia
Obese patients are at risk for what complication of anesthesia?
re-sedation
T/F: pain is objective and the pt must have physical manifestations related to pain in order to receive analgesics in order to prevent substance abuse.
False - pain is SUBJECTIVE. EVERYONE has the right to adequate pain management
what is nociceptive pain?
damage to somatic or visceral tissue
somatic pain comes from where?
joints, bone, muscle, skin, connective tissue, can be superficial or deep and it is localized
visceral pain comes from where?
visceral organs - can also have referred pain
What is neuropathic pain?
damage to peripheral nerve or CNS
what are the cahracteristics of neuropathic pain?
numbing, burning, shooting, stabbing, or electrical in nature
T/F: acute pain has a sudden onset, less than 3 months, increase in HR, RR, BP
true
T/F: chronic pain has a gradual or sudden onset, last for more than 3 months, characterized by waxing and waning but does not go away, and can cause social withdrawl
true
T/F: pt should wait until pain is unbearable to take analgesics to prevent addiction
false
can the nurse push the button on a PCA pump for a patient if the patient asks them to?
no - ONLY the patient may press the button
what should be educate our patients on PCA pumps about?
that the pump is programmed and they cannot overdose themselves
What is end-dose-failure
pain that occurs at or near the time of next dose - may need another analgesics prescribed for breakthrough pain
T/F: after a nurse prescribed pain meds, they need to document that administration, reassess the patient in 1 hours, document the reassessment
true
Hypotension is a BP of
<100/<60
symptoms of hypotension
weakness, dizziness, confusion, organ dysfunction
T/F: HTN is modifiable
true
hypertension is also called what?
"silent killer"
does HTN incidence increase with age?
yes - atherosclerosis
manifestations of HTN?
silent killer, fatigue, reduced activity tolerance, dizziness, palpitations, angina, dyspnea
what category is a blood pressure of < 120/< 80?
normal
what category is a blood pressure of 120-129/<80?
elevated
what category is a blood pressure of 130-139/80-89
HTN stage I
what category is a blood pressure of >140/>90
HTN stage II
to be classified as having HTN you must have
sustained elevation of BP for 2 or more readings, both arms, separate occasions OR currently use any anti-HTN medications
primary HTN is
elevated BP without an identified cause
90-95% of all cases of HTN are primary or secondary?
primary
secondary HTN is
elevated BP with a specific cause, identify and treat underlying cause to reverse HTN
does cushing's disease cause seconary HTN?
yes
Almost everyone who has DM also has ______
HTN
What are some lifestyle changes that can modify HTN?
weight loss, restrict sodium, moderate alcohol consumption, (1/day for women, 2/day for men), tobacco cessation, manage stress
You should always monitor labs before administering BP drugs, but which labs especially?
electrolytes
what should always be documented with a BP reading?
site it was taken at
T/F: position affects BP
true
what affect does supine positioning have on BP?
increased SBP, decreased DBP
what affect does a sitting position have on BP?
decrease SBP, increased DBP
When would you hold BP medication?
hypotension, abnormal labs [esp. K or renal function]
T/F: nurse does not need to notify provider when a drug is held
false - always notify provider when holding a drug
How do you calculate MAP?
(SBP + 2DBP)/3
what is the minimum MAP?
60
what should you do if a pt has a map < 60?
call rapid response
how do you calculate pulse pressure?
SBP-DBP
what is a normal pulse pressure?
40
pulse pressure is _________ in pts with atherosclerosis
increased
pulse pressure is _________ in pts with HF and hypovolemia
decreased
T/F: it is okay for patient to stop taking BP drugs if they make them feel bad
false - no abrupt cessation
we should always educate our pts that therapy for HTN _________, it is not a _______
controls; cure
T/F: follow up appointments are not important for BP control
false - follow up are crucial in achieving BP goals
T/F: pts should bring their home BP monitoring device with them to their appointments
true - devices should be checked regularly for accuracy
A BP of what is classified as hypertensive urgency?
>180/110
T/F: hypertensive urgency has no signs of target organ damage and is treated with oral anti-HTN meds
true
What BP is classified as hypertensive emergency?
above 220/140
T/F: hypertensive emergency has signs of target organ damage, and is treated with IV anti-HTN drugs
true
What is the most common reason for hospitalization for people over the age of 65?
heart failure
How is heart failure classified?
according to phase of cardiac contraction and according to side of the heart
What is the overall result of heart failure no matter the classification?
decreased cardiac output
left sided systolic heart failure is the inability of the heart to do what?
L ventricle to EMPTY adequately [can't squeeze hard enough]
left sided diastolic HF is the inability of heart to do what?
L ventricle FILL adequately
what will the heart muscle look like in someone with systolic failure?
weak/floppy
what will the heart muscle look like in someone with diastolic failure?
stiff/thick
Clinical manifestations of LHF?
Left=Lungs so, problems with the lungs
What is the primary cause of RHF?
LHF
Clinical manifestations of RHF
right = venous congestion
What is a great indicator of cardiac output?
urine output
Class I heart failure
no signs
Class II heart failure
little symptoms with increased activity
Class III heart failure
starting to struggle with ADLs
Class IV heart failure
cannot even lay in bed without symptoms
T/F: HF patients can move classes with treatment
true
Acute decompensated Heart Failure manifests as what?
pulmonary edema
What does the diet of a pt with HF look like?
Na restriction (2-3g/day), increase K, fluid restriction
Nurse should do what 2 things with patients who have heart failure?
monitor I&O and daily weights (should stay withing 1-2lbs of baseline weight)
What position is best for pts with HF?
semi or high fowlers
Nurse should discourage what in patients with HF
valsalva maneuver
Palliative and end-of life care are indicated in patients with what stage HF
D
Class IV HF with life expectancy of < 6 months ---- pt would benefit from?
hospice
PAD - does incidence increase with age?
yes - can occur at younger age in pts with DM
Most commonly affected areas for PAD?
carotid, coronary, lower extremities
Risk factors of PAD
smokine, CKD, DM, HTN, sedentary lifestyle, obesity, advanced age, stress
Clinical manifestations of PAD
intermittent claudication
intermittent claudication causes
pain with activity, relief with rest
complications of PAD
atrophy of skin and underlying muscles, delayed wound healing, infections, tissue necrosis, arterial ulcers of bony prominences like feet, toes, lower legs, gangrene leading to amputation
assessment findings of PAD
thing, shiny, taut skin, loss of hair on lower legs, pulselessness, pallor when legs are elevated, resting pain that is worse at night and aggravated with elevation
Critical Limb Ischemia
end stage of PAD, chronic ischemic pain at rest lasting more than 2 weeks
Diagnostic studies for PAD
segmented BP; ankle brachial index (ABI)
How do you do segmented BP?
at thigh, below knee, and ankle with pt laying supine
A drop in BP greater than ______ indicated PAD - segmented BP
30
ABI of what indicated PAD?
<0.9
T/F: ABI should only be used for basic screening bc results can be skewed
true
What medications are critical for PAD patients to reduce risk of CVD?
antiplatelets and ACE inhibitors
what is the goal for a patient experiencing intermittent claudication?
improve pain-free walking distance
diet for pts with PAD
reduce cholesterol and triglycerides, lower BG, reduce Na to < 2g/day
what kind of exercise should pts with PAD do?
a supervised program of 30-45 mins of walking or cycling 3x/week for at least 3 months
What is the most common surgical approach for pts with PAD?
peripheral artery bypass
T/F: in the beginning stages of PAD, pt will have pain with exertion and in later stages pts will also have pain at rest
true
PRE-op care of leg with CLI
protect limb from trauma, dependant positioning, NO ice, NO elevation, NO compression
What position can be beneficial for pts with PAD?
reverse trendelenberg
POST-op care of leg with CLI
check extremity q15 initially, then hourly, monitor for the 6 P's, discourage prolonged sitting with legs in dependent position, even walking short distances is desirable
if edema occurs in a pt post-op from CLI, what should you do?
position the pt supine and elevate the leg above the heart level, early ambulation
Risk factor for PVD
chronic venous congestion, obesity, sedentary lifestyle
treatment for PVD includes?
compression, elevation, fluid restriction, diuretics
if you suspect a venous thrombosis what should you do?
compare the size of the affected extremity with the other one
T/F: pts with PVD may be on bedrest initially?
true
What drugs would you expect a PVD pt to be on?
anticoagulants
what should PVD pts avoid?
prolonged sitting, nicotine and oral contraceptives
T/F: COPD is chronic and progressive?
true
T/F: COPD is preventable and treatable
true
A deficiency of what is genetically linked to COPD?
AAT
T/F: COPD develops rapidly
false
Disgnostic study for COPD?
spirometry is gold standard
What is the goal O2 sat for a pt with COPD?
> or equal to 90%
What kind of diet is recommended for COPD pts?
high calorie, high protein
What is important to note about meals for pts with COPD?
they should eat 5-6 SMALL meals a day to conserve energy, should avoid meals that require a lot of chewing, should avoid treatments and exercise for 1 hour before and after treatment, should rest for 30 minutes before eating
T/F: energy conservation is VERY important for COPD patients
true
diet for pts with PAD