Nursing Exam 4 Study Guide

• Study notes for Nursing 103 Exam Four include advance directives at the end of life, age-related changes, assessing fluid status, chest pain, COPD diet/effects, interventions for grief, heart disease risk factors, heart failure (left vs right), management of dyspnea/air hunger, grief response, care for the dying and deceased, smoking effects, grief symptoms, pneumonia prevention, BEERS List, antihypertensive side effects, hypoxia symptoms, signs of impending death, heart failure symptoms, energy conservation, grieving timeframe, pulmonary edema symptoms, quality of life related to medicine, and lab values.

Advance Directives at End of Life

• Advance directives let clients state their wishes if they can't communicate.
• A living will outlines preferred treatments.
• A medical power of attorney designates someone to make healthcare decisions.

Age-Related Changes

Pharmacokinetics

• Absorption: Decreased gastric acid, slowed stomach emptying, decreased GI motility and absorptive capacity, decreased blood flow, and reduced subcutaneous fat affects drug absorption.
• Distribution: Decreased total body water increases the concentration of water-soluble drugs like digoxin, lithium, atenolol, and aminoglycosides, requiring dosage adjustments to avoid toxicity.
• Fat percentage increases with decreased lean body mass, extending the half-lives of benzodiazepines and anesthetics.
• Decreased albumin from malnutrition increases levels of highly protein-bound drugs such as warfarin, furosemide, and naproxen.
• Metabolism: Decreased hepatic blood flow reduces drug inactivation before systemic circulation, potentially causing toxicity.
• Excretion: Decreased renal blood flow increases drug half-life, potentially causing toxicity; adjust dose based on GFR and creatinine.

Cardiac Function

• Cardiac output is reduced in older adults.
• Changes in nodal and conducting cells increase the risk of arrhythmia.
• Damaged tissue is replaced by scar tissue.
• Blood vessels constrict, reducing blood flow.
• Blood pools in veins in the lower legs.
• There is a decreased response to stress, with a slow increase and decrease in heart rate.

Respiratory System

• Less gas exchange occurs.
• Breaths become faster and more shallow.
• There is less recoil and more chest wall stiffness.

Fluid Status Assessment in Heart Failure

• Daily weights are crucial.
• 1 liter of fluid equals 1 kg (2.2 lbs).

Chest Pain Assessment

• Determine how long the chest pain has persisted.

COPD Diet

• Eat smaller meals.
• Rest before eating.
• Choose low-fiber foods.
• Avoid drinking too much water before meals.
• Avoid dry foods.

Effects of COPD on the Body

• Barrel chest develops.
• Finger clubbing occurs.
• Activity tolerance is decreased.
• Frequent infections are common.
• Pursed-lip breathing is used.
• There is a chronic cough.
• Accessory muscles are used for breathing.
• It is difficult to lay flat.

Evaluating Interventions for Grief

• A positive sign is when the client starts making plans for the future.

Heart Disease Risk Factors and Modification

• Nonmodifiable risks: Age, gender, family history.
• Modifiable risks:
  • Smoking: Complete cessation is necessary.
  • High blood pressure: Lower blood pressure.
  • High-fat diet (saturated fat): Limit saturated and trans fats to less than 6% of calories.
  • Obesity: Aim for weight loss to a BMI less than 30.
  • Physical inactivity: Engage in 75-150 minutes of aerobic activity and strength training 2 days a week.
  • Stress: Implement stress management, yoga, meditation, or prayer.

Left vs. Right-Sided Heart Failure

Left-Sided

• Decreased tissue perfusion leads to shortness of breath and pulmonary edema.
• Coughing produces frothy sputum.
• Paroxysmal nocturnal dyspnea (worsening SOB or coughing at night) occurs.
• Orthopnea (SOB when lying flat) develops.
• Decreased cardiac output results in cyanosis and activity intolerance.

Right-Sided

• Profound edema occurs.
• Liver experiences congestion, leading to impaired function.
• GI tract congestion causes anorexia, weight loss, and GI distress.

Management of Acute Dyspnea

• Sit the client up.
• Administer oxygen if needed.

Management of Air Hunger and Choking at End of Life

• Provide oxygen, typically via nasal cannula or simple mask.
• Morphine can reduce air hunger.
• Turn the client to their side if coughing or choking.
• Use anticholinergic drugs like Robinul (IV or oral) or atropine (drops under the tongue) to dry up secretions.

Normal Grief Response to Chronic Loss

• Relief is a normal feeling.

Nursing Care for the Dying and Deceased

• Follow through with care once committed to being with a dying client.
• Turn the client to the side if they are making choking sounds.
• Reassure the family that they should not worry about too much pain medication.
• Answer the client/family’s questions truthfully.
• An impending sign of death is a change in respirations.
• Post-mortem care includes:
  • Putting on a new gown.
  • Cleaning the body.
  • Combing the hair.
  • Putting teeth in.
  • Removing IVs, lines, and tubes.

Physiological Effects of Smoking

• Increases platelet aggregation.
• Increases risk of coronary artery spasm.
• Nicotine increases blood pressure and cardiac demand.
• Inhaling carbon monoxide lowers oxygen levels as it binds more tightly to RBCs.

Physical Symptoms of Grief Response

• Crying
• Tearfulness
• Shortness of breath
• Tightness in throat
• Difficulty swallowing
• Fatigue
• Weight loss or gain
• Hot and sweaty

Preventing Pneumonia

• Stay hydrated by drinking 8 glasses of water a day.
• Elevate the head of the bed.
• Encourage coughing and deep breathing.
• Position the “good” lung down.
• Monitor O2 saturation.
• Administer supplemental humidified oxygen.
• Administer medications as ordered.
• Use incentive spirometry.
• Encourage ambulation.

Purpose of BEERS List

• Identifies drugs with a high risk of adverse reactions in older adults, which should be avoided when possible.
• Weigh the benefits vs. risks of giving these medications.

Side Effects of Antihypertensive Medications

• Thiazide diuretics: Increased urination, risk of dehydration, electrolyte changes.
• Potassium-sparing diuretics: Potassium level too high, avoid salt substitutes, risk of dehydration.
• Beta blockers: Low heart rate, orthostatic hypotension; non-cardio selective ones can worsen asthma.
• ACE inhibitors: Dry cough, angioedema, increased potassium, decreased kidney function.
• ARBs: Increased potassium, decreased kidney function.
• Calcium channel blockers: Worsen heart failure, lower extremity edema.

Signs and Symptoms of Hypoxia

• Early: Increased heart rate, increased respiratory rate.
• Middle: Restlessness, confusion.
• Late: Cyanosis.
• Chronic: Clubbing of fingers, barrel chest.

Signs and Symptoms of Impending Death/End of Life

• Mottling of skin.
• Cheyne-Stokes respirations.
• Periods of apnea.
• Cool extremities.

Symptoms of Heart Failure

• Early: Increased heart rate, increased respiratory rate.
• Middle: Shortness of breath, paroxysmal nocturnal dyspnea (worsening SOB or coughing at night).
• Late: Hypoxia, cyanosis.
• Management of PND involves seeking medical attention.

Teaching Points for Energy Conservation

• Plan activities ahead.
• Sit instead of standing.
• Break tasks into steps with rest in between.
• Rest before and after activities.

Timeframe for Grieving

• No specific timeframe; varies from person to person.

Pulmonary Edema Signs/Symptoms

• Crackles in lungs.
• Cough with white frothy sputum.

Quality of Life and Medicine

• Consider if the side effects of a medicine are worse than the symptoms it relieves.

Lab Values

• Potassium: 3.5-5 (less than 3 or more than 6 is critical).
• Sodium: 135-145.