Term
| Cardiovascular Effects of Immobility |
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Definition
blood pools in the thorax and increases pressure
decrease in circulating blood volume
increase workload on heart: decrease SV and CO
orthostatic hypotention |
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Term
| Respiratory Effects of Immobility |
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Definition
-risk for pneumonia
-decrease in:
--tidal volume
--residual volume
--forced vital capacity
-structural changes
--risk for atelectasis
-restricts free movement of ribcage and diaphragm
-decrease air exchange
-Pooling mucous, thickened mucous |
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Term
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Definition
-venous stasis/pooling
-hypercoagulability (clotting factors increase b/c of decrease in liver function
-blood vessel damage |
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Term
| Why is hypercalcemia a risk in immobility? |
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Definition
| bones soften, osteoclasts decrease and calcium moves to blood |
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Term
| What are common assessment findings in immobile patients? |
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Definition
-decreased ROM
-body alignment changes
-activity intolerance
-decreased UO and bowel output
-gait changes
-alertness changes |
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Term
| ABG Interpretation: PH - 7.51 pCO2 - 39.4 pHCO3 - 31.3 pO2 - 77.3 |
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Definition
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Term
You are caring for a patient with possible fluid overload. Which is your priority for assessment?
a. skin turgor
b.urine output
c.lung sounds
d.mucous membranes |
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Definition
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Term
You are caring for a patient on fluid restriction. What statement made by the patient would indicate need for further teaching?
A.I will not add jello as a dessert to my meals
B.I will not drink more than 4 8oz glasses a day
C.I will eat ice cream as alternative dessert
D.I will notify doctor of developed edema |
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Definition
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Term
A patient is admitted to Med/Surg. for dehydration. Patient has altered mental status. Patient presents with dry mucous membranes, edema. What condistion would you suspect?
A. Hyperkalemia
B. Hypernatremia
C. Hypokalemia
D. Hyponatremia |
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Definition
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Term
Patient is being treated with Lasix. Which condition is not assoicated with this medication?
A. Assess decreased in blood pressure
B. Assess for increase in urination
C. Monitor for increase in potassium
D. Monitor for hypokalemia |
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Definition
| C. Monitor for increase in potassium. |
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Term
| What are the manifestations of fluid volume overload? |
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Definition
-edema
-bounding pulse
-jugular vein distention
-increased weight
-increased urine output
-crackles in lungs |
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Term
| What are the manifestations of fluid volume deficit? |
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Definition
-Tachycardia
-Dry mucous membranes
-flattened neck veins
-decreased urine output
-Serum osmolality >300
-Serum electrolyte levels may increase
-decreased skin turgor
-Alterations in mental status |
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Term
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Definition
Groans: GI: constipation, nausea, anorexia
Moans: Neuromuscular: depression, weakness, and confusion
Bones: Bone pain, risk for fractures
Stones: renal calculi |
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Term
| What is the priority intervention for hypercalcemia? |
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Definition
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Term
| Alkalosis, shallow respirations, irritability, confusion, weakness, lethargy, abdominal distention and thready arrhythmias are symptoms of? |
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Definition
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Term
| What are interventions to promote sleep? |
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Definition
-Create a restful environment
-Promote comfort/relaxation
-Avoid napping if at all possible
-Establish periods of rest/sleep |
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Term
| What are changes in the older adult sleep cycle? |
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Definition
-REM cycles shorten
-Decreases in stages 3 and 4
-frequent waking, longer to fall asleep
-chronic illness can be a factoring cause |
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Term
| What is the proper diet for diabetic kidney disease? |
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Definition
-no potassium
-low sodium
-avoid citrus, dry foots, nuts, leafy greens, chocolate and mushrooms
-quinoa, tofu, eggs, lean meats (protein)
-avoid cola and dark pops |
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Term
| What is the proper diet for a cardiac patient? |
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Definition
-sodium restriction
-DASH diet: decreased saturated fat, total fat, and cholesterol; increase potassium, calcium, magnesium; increase fruits, vegetables and fiber |
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Term
| What are the manifestations of left sided heart failure? |
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Definition
-Paroxysmal nocturnal dyspnea
-Pulmonary congestion
-Restlessness
-Confusion
-Orthopnea
-Tachycardia
-Exertional dyspnea
-Fatigue
-Cyanosis |
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Term
| What are the manifestations of right sided heart failure? |
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Definition
-fatigue
-increased peripheral venous pressure
-ascites
-Enlarged liver and spleen
-Jugular vein distention
-weight gain
-dependent edema |
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Term
| What are the physiological signs of pain? |
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Definition
-increased HR
-increased BP
-increased respiration |
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Term
| What are behavioral and psychosocial signs of pain? |
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Definition
-behavioral: grimacing, guarding and moaning
-psychosocial: social withdrawal, depression and anxiety |
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Term
| What is the theory of gate control? |
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Definition
| Using non-painful input to block pain impulse before it reaches the brain. |
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Term
| What are examples of using the gate control theory? |
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Definition
-massage
-TENS
-heat/cold therapy
-acupuncture |
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Term
| What would you tell a patient taking levothyroxine? |
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Definition
-Take 30-60 minutes before meals or 2 hours after meals
-Increase risk for bleeding if paired with anticoagulants
-Monitor HR before taking, if lower than 60 hold dose and contact HCP.
-Do not take with proton pump inhibitors.
-Increase fiber in diet but do not take supplements.
-This medication is lifelong |
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Term
| How would you take care of a hypoglycemic patient? |
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Definition
-Assess blood sugar and recheck if necessary.
-Give glucagon if unconscious, turn on side
-Supply snack (milk or crackers_
-Follow facility protocol |
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Term
| If the HbA1C is above 6.5%, this indicates...? |
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Definition
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Term
| What are the signs and symptoms of peripheral venous insufficiency? |
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Definition
-lower leg edema
-aching constant pain
-cyanosis with dependence
-brown, leathery color on legs
-ulcer development: around ankles or medial/anterior aspect of leg
-dermatitis |
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Term
| How would you educate a patient on HTN meds? |
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Definition
-monitor weights daily
-monitor intake and output
-take diuretics in the AM
-safety precx
-monitor for edema |
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Term
| How would educate a patient on ACE inhibitors? |
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Definition
-avoid grapefruit juice
-better absorbed on empty stomach
-doesn't work well on African Americans
-1st dose hypotension
-Report to HCP if you experience a nagging cough |
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Term
| How would you educate a patient on ARBs? |
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Definition
-Monitor for upper respiratory infection
-1st dose hypotension |
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Term
| What is pursed lip breathing and how does it help COPD patients? |
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Definition
| Pursed lip breathing is breathing in through the nose for 2 seconds and out through the mouth for 4 seconds. It helps COPD patients keep the pressure up in their airways and prevent the large airways from collapsing. It prevents air trapping and eases the feeling of shortness of breath. |
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Term
| What are nursing interventions for acute pneumonia? |
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Definition
-*priority: manage hypoxia, provide O2 if needed.
-incentive spirometer, TCDB
-provide plenty of rest periods
-prevent sepsis
-provide a high calorie/carb diet and increase fluids to thin secretions. |
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Term
| What are nursing interventions for O2 therapy? |
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Definition
-Monitor pulse ox closely.
-Assess for skin breakdown every 4 hours(face, nose , ears)
-Document every shift
-No petroleum jelly or smoking around oxygen
-Add humidifier to oxygen above 4L |
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