Common final

  1. What is the priority nursing dx for pt in traction
    impaired skin integrity
  2. How often do you assess circulation of pt in traction
    • 30 min after first put on, then Q 1-2 hrs after. 
    • CHART!
  3. To prevent complication of skin breakdown in pt with skeletal traction, what action should be included in plan of care?
    Assess pin site every 8 hrs
  4. When pt in traction is experiencing muscle spasms, what will be done to accommodate for this?
    • Increase weight
    • *make sure to check temp, circulation, for ulcers, pen sites, and that weights are dangling freely
  5. What are the Cranial nerves?
    • Olfactory
    • Optic
    • Oculomotor
    • Trochlear
    • Trigeminal
    • Abducens
    • Facial
    • Acoustic
    • Glossopharyngeal
    • Vagus
    • Accessory
    • Hypoglossal 
    • *Oh Oh Oh To Touch And Feel A Girls Vagina, Always Hot!
  6. Cranial nerve 1
    • Olfactory
    • sensory - sense of smell
    • ask client to close eyes and ID different smells
  7. Cranial nerve 2
    • Optic
    • sensory - Vision 
    • Assess with snellen chart, or ID object 20 ft away
  8. cranial nerve 3
    • Oculomotor
    • motor - muscles that move eye & lid, pupillary constriction and lens accommodation
  9. cranial nerve 4
    • Trochlear
    • motor - muscles that move eyes (obliq or cross-eyed)
  10. cranial nerve 5
    • Trigeminal
    • both motor and sensory - facial sensation, mastication, corneal reflex
    • to assess, alternate btwn sharp & soft objects on face, illicite blink response
  11. cranial nerve 6
    • abducens
    • motor - moves eyes laterally
  12. cranial nerve 7
    • facial
    • both motor and sensory - facial expression, muscle movement, salivation and tearing, taste, sensation in ear
    • assess by asking pt to to different facial expressions, ID varies tastes
  13. cranial nerve 8
    • Acoustic
    • sensory - hearing and equilibrium
    • whisper test or finger clicking
    • balance tested by standing and both eyes closed
  14. cranial nerve 9
    • glossopharyngeal
    • both sensory and motor - taste, sensation in pharynx and tongue, pharyngeal muscles and swallowing
    • Apply salt/sugar on tongue, ID which one; have pt swallow, illicit gag reflex, move tongue side to side
  15. cranial nerve 10
    • vagus
    • both sensory and motor - muscles of pharynx, larynx, soft palate, etc. 
    • sensation in ear, throat, and abd viscera
    • to assess, ask to swallow, assess speech for hoarseness
  16. Cranial nerve 11
    • accessory
    • motor - sternomastoideoustrapeosmus
    • to assess turn head, resist hand, shrug shoulders against hand
  17. Cranial nerve 12
    • hypoglossal
    • motor - chewing/swallowing
    • stick out tongue, move side to side
  18. What is Bells Palsy?
    • Bell's palsy is a form of temporary facial paralysis resulting from unilateral inflammation of 7th cranial nerve
    • Not related to stroke
    • 70% recover completely
    • results in facial distortion/paralysis, decreased lacrimation, painful sensation in face behind ear and in eye, speech difficulties and unable to eat on affected side
  19. Bells Palsy eye protection teaching
    Protect affected eye from injury (lid wont close) by using protective shield and eye ointment at night and close eyelid manually before going to sleep, use moisture drops during day and wrap around sunglasses to decrease evaporation
  20. Bells Palsy teaching
    • Teach to massage face several times daily after sensitivity decreases
    • Do facial exercises - blow out checks, whistling and wrinkling forehead
    • Avoid exposure of face to cold and drafts
  21. Brain abscess priority nursing care
    • Careful neuro assessment!!
    • Results from increased ICP and brain shift
  22. Creutzfeldt-Jakob disease dx
    • Mad cow disease
    • Dx by EEG - characteristic pattern
    • Immunologic assessment - detects a protein kinase inhibitor
    • MRI scanning
  23. Encephalitis med treatment
    • Antiviral agents (Acyclovir or Ganciclovir)
    • No specific meds for arthropod borne-symptom management
    • Antifungal agents (fluconazole, amphotericin b)

    *recall 3 types: herpes simplex, arthropod-borne (mosquito), and fungal
  24. Encephalitis nursing care
    • Comfort to reduce HA
    • Dim lighting, reduce noise & visitors
    • grouping nursing interventions
    • pain management (use opioids cautiously - may mask neuro sx)
    • Address pt and family anxieties
  25. Meningitis manifestations
    • HA and fever initially - remains high
    • Neck immobility
    • Positive Kernig's sign (Severe stiffness of hamstrings causes inability to straighten leg when hip is flexed to 90 degrees)
    • Positive Brudzinski's sign (When neck if flexed, flexion of knees & hip is produced)
    • Photophobia
    • Rash-bacterial
    • Disorientation/memory impairment
    • Seizures
  26. Neuropathy manifestations
    • *Peripheral neuropathy - disorder of peripheral motor and sensory nerves
    • Usually begin in hands or feet
    • Loss of sensation 
    • Muscle atrophy and weakness
    • diminished reflexes
    • pain and paresthesia (tingling, needles)
  27. Neuropathy teaching
    • Protect limb from injury: inspect LE for skin breakdown, check temp of bathwater and make sure footwear is accurately sized 
    • Assistive devises for risk of falls
    • Driving may be limited or eliminated
  28. Trigeminal neuralgia teaching
    • *5th cranial nerve - painful twitching in eye
    • Factor that can aggravate pain: food too hot or cold; Jarring pt bed or chair; washing face, combing hair or brushing teeth
    • Provide cotton pads & room temp water for washing face
    • Instruct to rinse w mouthwash after eating
    • Do personal hygiene during pain free intervals
    • Food and fluids at room temp that are soft
    • Chew on unaffected side - soft foods
    • Treat anxiety, depression and insomnia
  29. Trigeminal neuralgia tx complications
    • Antiseizure agents (Tegretol)
    • serum levels must be monitored for bone marrow depression during long term therapy
  30. What is CEA
    • Carotid Endarterectomy
    • Plaque is surgically removed from carotid artery
  31. CVA: ischemic or hemorrhagic???
    Ischemic = block = usually from uncontrolled HTN

    Hemorrhagic = bleeding = usually from smoking
  32. CVA aphasia nursing care
    • Gain pt attention, speak slowly and keep language consistent
    • One instruction at a time-allow time to process
    • Don't complete thoughts or sentences of pt
    • Consistent schedule, routine & repetition
    • Communication board - pics of common needs and phrases
  33. CVA emotional responses cause
    • Depression!!
    • They just lost self control, are frustrated with change in function and communication
  34. CVA exercises
    Do passive exercises to affected extremities through full ROM 4-5 times a day
  35. CVA family teaching
    • Encourage family participation in recovery
    • safe home environment
    • depression is common and serious prob
    • Pt may tire easily, may become irritable & upset by small events & may be less interested in events - often associated with speech dysfunction
    • Community based stroke support groups!
  36. CVA hemianopsia nursing care
    • *loss of half of visual field
    • Approach pt on unaffected side so they will see you
    • Place extremities in field of vision
  37. CVA nursing care
    • Do passive ROM exercises 4-5x daily
    • Correct positioning (pillow in axilla & under arm w arm placed in neutral position, fingers barely flexed & slightly supination) change position q 2hr
    • Prepare pt for ambulation
    • Encourage pt to participate in personal hygiene
    • Encourage family participation
  38. CVA nursing dx
    • Impaired sensory perception
    • Risk for falls
    • Risk for skin integrity  
    • Etc...
  39. CVA risk reduction (modifiable risk factors)
    • Uncontrolled HTN
    • A-fib
    • Dyslipidemia
    • DM
    • Smoking
    • Carotid stenosis
    • obesity
    • periodontal disease
    • excessive alcohol consumption
  40. Prevention of CVA
    • Healthy lifestyle
    • dietary approaches to stop HTN (DASH diet)
    • heath screenings (cholesterol)
    • Aspirin - low dose
    • Coumadin for A-fib (INR 2-3)
    • Statins (esp w diabetes)
    • CEA
  41. CVA safety during mobilization
    • ASAP assist pt out of bed
    • First sitting - learn to maintain balance
    • Standing - learn to maintain balance
    • Ready to walk as soon as standing balance is achieved
    • A chair or wheelchair should be readily available for dizziness or fatigue
  42. Addison's disease
    • *A disorder in which the adrenal glands don't produce enough hormones.
    • Also called Adrenocortical insufficiency
  43. Addison's disease manifestations
    • Muscle weakness, fatigue, emaciation
    • Anorexia & GI sx
    • Dark pigment of mucous membranes & skin
    • Hypotension
    • Low BS & sodium
    • High potassium
    • Depression, emotional lability, apathy, confusion
  44. Adrenocortical insufficiency causes
    Therapeutic use of corticosteroids is most common cause (sudden cessation)
  45. Aldosteronism nursing assessment
    • *profound decline in K and hydrogen ions
    • *Muscle weakness, cramping and fatigue (caused by hypokalemia)
    • *Sodium is normal or elevated
    • Hypertension is most prominent and universal sign.
    • Polyuria (serum abnormally concentrated)
  46. Corticosteroid therapy administration teaching
    • Best time of day for dosing is 7-8 am (when natural secretion of cortisol)
    • will minimize cushing effects
  47. Corticosteroid therapy pt teaching
    • Increased risk for infection
    • slowly taper to prevent adrenal insufficiency - DO NOT STOP SUDDENLY
  48. Corticosteroid therapy sequalae
    • Increases risk for infection
    • suppresses inflammation and autoimmune reactions
    • Adrenal insufficiency
    • Prevents transplant rejection
    • controls allergic reactions
  49. Cushing syndrome lab testing
    • *a condition the occurs from exposure to high levels of cortisol for a long time
    • Serum cortisol
    • Urinary cortisol
    • Low dose dexamethasone suppression test: overnight test to dx pituitary/adrenal causes. Dex administered late in evening & cortisol level obtained at 0800. If cortisol level is low, the hypothalamic-pituitary-adrenal axis is functioning
  50. Cushing syndrome nutrition/diet
    • High protein diet to minimize muscle wasting
    • Need adequate calcium and vit D, d/t osteoporosis
  51. Cushing syndrome psychosocial issues
    • Major nursing dx is psychologically disturbed body image
    • Have central type obesity with buffalo hump and thin extremities
    • Irritable mood and depression are common
    • decreased quality of life and impairment can also occur
  52. DI vs DM
    Diabetes Insipidus is a disease where kidneys are unable to conserve water.

    Diabetes Mellitus is characterized by high levels of sugar in the blood
  53. DI lab results
    • Fluid deprivation test
    • withhold fluid for 8-12 hrs & weighed throughout
    • continues to excrete large volumes of urine w low specific gravity and weight loss
    • test terminated if tachycardia, excessive weight loss or hypotension develops
  54. Hyperthyroidism interventions
    • improve nutritional statue: appetite is increased, need several small size meals. Rapid movement of food through GI tract: high calorie & high protein. Monitor weight and dietary intake. 
    • Reassurance that emotional reaction are result of disorder
    • Maintain normal body temp
  55. Hypoparathyroid nursing assessment
    • Goal is to increase serum calcium level to 9-10 mg/dL
    • results in hypocalcemia and hyperphosphatemia (decreased renal excretion of phosphate)
    • sx include hyper irritability, tetany, numbness, tingling and cramps in ex, stiffness in hands and fee
    • May lead to bronchospasm, laryngeal spasm, dysphagia and dysrhythmias
  56. Hypothyroidism nursing assessment
    • Can affect all body functions
    • extreme fatigue
    • hair loss, brittle nails, dry skin
    • menstrual disturbances
    • subnormal body temp & pulse rate
    • myxedema coma - hypothermic & coma
  57. Hypothyroidism prevention
    • Can't be prevented
    • But you can watch for s/s and get early tx
  58. hypothyroidism tx complications
    • Oral thyroid hormones interact w many other meds
    • Thyroid hormones may alter required doses of digitalis, anticoagulants
    • With small IV doses, benzodiazepines may reduce profound somnolence lasting longer than anticipated - narcosis = respiratory depression
  59. Pheochromocytoma surgical intervention complication
    • *benign tumor of adrenal medulla. definitive tx is surgical removal of tumor
    • A hypertensive crisis from release of stored epinephrine and norepinephrine
    • Hypotension and hypoglycemia may occur because of sudden withdrawal of excessive amts of catecholamines
  60. Pituitary tumor removal nursing care
    Make sure to watch pt blood sugar and blood in stools
  61. SIADH nursing dx
    • Syndrome of Inappropriate Antidiuretic Hormone - can't excrete dilute urine, retain fluids
    • fluid overload or  risk for electrolyte imbalance (hyponatremia)
  62. ADA dietary recommendations
    • 50-60% of cal should be carbs
    • 20-30% fat
    • 10-20% protein
  63. Diabetes 2 primary tx
    weight reducation
  64. diabetes ed re exercise
    decreases need for insulin
  65. diabetes manifestations
    • Polyuria (frequent urination)
    • Polydipsia (excessive thirst)
    • weight loss
    • vision changes
    • fatigue
    • ketones in urine
    • *recall ketones are byproducts from fat breakdown signaling deficiency of insulin in type 1 diabetes
  66. Diabetes types pathophysiology
    • Type 1 = pancreatic beta cells are destroyed
    • Type 2 = Insulin resistance and impaired insulin secretion (pancreas is giving up on your fat ass)
    • Gestational - effects of hormonal changes during pregnancy
  67. Evaluation before beginning diabetes teaching
    • Assess for readiness to learn: 
    • when first dx, often go through stages of grief
    • Assess coping strategies
    • Assess social situations (literacy level, financial resources & insurance, family support, daily schedule & cultural beliefs)
    • Assess neuro defects
    • ask about fears or concerns
  68. Evaluation for nutrition
    Have pt keep food diary
  69. Foot care rationale
    with peripheral neuropathy (tingling) at risk for infection
  70. foot care teaching
    • Inspect and wash feet daily - use as emollient
    • food exam yearly by HCP
    • see HCP quickly if injured
    • Always wear shoes and socks
    • Avoid hot water bottles and heating pads
  71. hyperglycemia causes
    food, stress, illness, infections
  72. Hypoglycemia tx
    15/15 rule (15 carbs q 15 mins), unconscious=D50 or glucagon, conscious=simple sugar followed by slower form
  73. Insulin teaching
    watch them draw and inject insulin. Teach site rotation, timing
  74. Ketonuria pathophysiology
    • ketones are by product of fat breakdown
    • ketonuria signals deficiency of insulin in type 1 diabetes
    • body breaks down fats for energy instead of carbs
  75. meal planning benefits
    • including food groups and timing of meals:
    • pts who adhere to meal plan and schedule are most likely to experience glucose control
  76. Metformin side effects
    hypoglycemia, lactic acidosis NEPHROTOXIC
  77. peripheral neuropathy risks
    • most common cause is poor glycemic control
    • *risk for infection!
  78. Sick day rules
    • continue to take insulin/oral meds
    • check sugars and ketones q 3-4 hrs
    • eat small amounts of carbs (may need to be liquid)
    • report dehydration
    • If you take insulin, may need supplement doses every 3-4 hrs
  79. survival skills topics
    • Pathophysiology
    • Treatment modalities - admin of insulin or oral antidiabetic meds, meal planning, monitor of BS and urine ketones, and foot care
    • Recognition, tx, and prevention or acute complications
    • Pragmatic info- where to buy and store insulin, syringes and glucose monitoring; how and when to contact doc
  80. Types of oral antidiabetic meds
    • Alpha glucosidase inhibitors
    • Biguanides
    • Thiazolidinediones
    • DPP4 inhibitors
    • Sulfonylureas
    • Meglitinide
    • SGLT2 inhibition
    • *A Big Thick Dick iS My Satisfaction 
    • (Don't judge me. I bet you'll remember it too)
  81. Alpha glucosidase inhibitors
    • oral hypoglycemic med
    • Ex: Miglitol, Acarbose
    • decrease glucose absorption in large intestine
  82. Biguanides
    • oral hypoglycemic med
    • Ex: metformin
    • decreases hepatic glucose output
    • also makes muscle tissue more sensitive to insulin so glucose can be absorbed
    • *nephrotoxic
  83. Thiazolidinediones
    • Oral hypoglycemic med
    • Ex: rosiglitazone, pioglitazone
    • increase peripheral glucose uptake via fat/muscle
  84. DPP4 inhibitors
    • oral hypoglycemic med
    • ex: sitagliptin, saxagliptin, linagliptin
    • increase and prolong action of incretin - decreased glucagon secretion and increased insulin secretion in small intestine
  85. Sulfonylureas
    • oral hypoglycemic med
    • ex: glipizide, glyburide, glimepiride
    • stimulate beta cells to secrete insulin in pancreas
  86. Meglitinide
    • oral hypoglycemic med
    • ex: repaglinide, nateglinide
    • stimulate pancreas to secrete insulin
  87. SGLT2 inhibition
    • oral hypoglycemic med
    • ex: canagliflozin, dapagliflozin
    • reduces renal glucose reabsorption and increases urinary glucose excretion (kidneys)
Card Set
Common final
Common final