66 Final Exam PDF

Week 1: Ethics and Health Care Law **Nursing Contraindication/Action for patient seclusion - Contraindicated when the client is: - Medically unstable - Has delirium/dementia - Severe SI tendencies - Used as a punish...

Week 1: Ethics and Health Care Law **Nursing Contraindication/Action for patient seclusion - Contraindicated when the client is: - Medically unstable - Has delirium/dementia - Severe SI tendencies - Used as a punishment - Used for convenience of staff - Patient’s (client’s) rights regarding SECLUSION - The right to treatment, right to refuse, right to least restrictive measurements - Seclusion: involuntary confinement, physically prevented from leaving - Used to manage violent/self-destructive behavior AFTER other less restrictive measures have failed - Written order expires every 24hr → need new written order q24hr - RN can initiate seclusion but pt must be evaluated within 1hr - RN responsibilities: assess pt behabior, safety & physical needs (circulation, vitals, toileting), offer food and fluids, document q15-30 min - Seclusion must end when the client demonstrates behavior that no longer poses a risk. - *Restraint: manual device restricting the ability to move arms, legs, body freely - Chemical restraint: drug used to manage behavior, restrict movement - Not standard treatment - Policy per hospital policy: q15min F2F observation w/ documentation Week 3: Communication COMMUNICATION IN NURSING Therapeutic Communication Methods Active Listening: Engaging without interruption. with Psychological Clients Empathy: Reflecting the patient’s emotions. Open-Ended Questions: Encouraging dialogue (e.g., "How are you feeling today?"). Clarification: Asking questions for understanding (e.g., "Can you explain what you mean by...?"). Non-Therapeutic Communication Giving Advice: Can undermine autonomy. Methods to Avoid Judging or Criticizing: "You shouldn’t feel that way" is invalidating. Offering False Reassurance: "Everything will be fine" can diminish trust. Changing the Subject: Dismissing the patient’s concerns. Therapeutic Strategies in Mental Cognitive Behavioral Therapy (CBT): Identifying and changing negative thought Health Settings patterns. Reality Orientation: Reinforcing time, place, and person (often used in dementia care). Relaxation Techniques: Deep breathing, and guided imagery for anxiety. Supportive Listening: Non-judgmental space for patients to express feelings. Behavioral Interventions: Reinforcing positive behavior. Week 4: Inflammation/Infection Sepsis vs. SIRS SEPSIS SIRS: Systemic Inflammatory Response Syndrome Definite organism causing infection + 2 SIRS With or without infection criteria **Criteria: - Needs to be diagnosed in the first hour - Temp: 38C **Labs/Diagnostics: - HR: >90bpm - Lactic acid - Tachypnea: >20RR or PaCO2 10% immature band - 3hr: Lactate, blood cultures x2 BEFORE forms ABX, broad spectrum ABX administered, QSOFA: IV fluids:.9% NS 30mL/kg bolus if SBP 22 (score 1) or Lactate >4.0 - Systolic BP: 2.0 (advanced) HOLD MED AND NOTIFY MD for both - Early sx: N/V, diarrhea, thirst, polyuria, slurred speech, muscle weakness - Advanced sx: coarse tremor, GI upset, mental confusion, slurred speech, incoordination, stupor, hypotension, bradycardia, renal failure, gastric lavage hemodialysis - Severe toxicity: >2.5mEq/L SEIZURE COMA DEATH - Education: - 2-6 week onset - Take it at the same time as prescribed - Safety labs: BMP, lithium levels - Must have a primary care physician! - Family needs to educated and mentally stable to help patient Week 8: Psychosis Psychosis: hallucinations (auditory, visual, tactile, olfactory), delusions (paranoid, grandiose, bizarre, somatic), disorganized thinking, disorganized/abnormal motor behavior, impaired insight, irritability/aggression, anxiety/feat Schizophrenia Symptoms Positive: symptoms that ADD experiences beyond normal functioning, lessens w/ medication - Hallucinations, delusions, bizarre behavior, catatonia, formal thought disorder, clang associations Cognitive: impairment in memory, disruption in social learning, inability to reason, solve problems, focus attention - Most debilitating symptoms Negative: symptoms that reduce normal functioning, less responsive to medications - apathy, lack of motivation, anhedonia, blunted or flat affect, poverty and speech, social withdrawal, alogia, absence of intonation in speech Mood: depression, anxiety, demoralization, suicidality, excitability, agitation - Increase the risk of SI and substance abuse Other sx: paranoia, bizarre behavior “odd”, clothing overly sexual, repetitive or ritualistic, odd speech patterns Nursing Assessment: 1. Rule out medical/substance induced psychosis 2. Assess for command hallucinations (DTO/DTS) a. Plan to follow the command? b. Able to resist the command? c. Do you believe the voices are real? d. Do you recognize the voices? 3. Review the patient's belief system for fragmentation, organizations, unsupported by reality a. Fragmentation, organization: are they in their own reality? 4. Assess concurring conditions such as depression, anxiety, and substance abuse a. Draw a UA– toxicology screen 5. Inventory patient’s medication and check for compliance 6. Determine the family's response to increased symptoms 7. Assess the way patient and family interact 8. Review the support system Week 10: Addiction Risk factors: genetics, peer pressure, community, culture, societal norms, elderly - Opioids: CNS depressant - Sx: pinpoint (small) pupils, slurred speech, incoordination, drowsy, ↓ V/S, unsteady gait - CNS withdrawal: N/V, ↑ V/S, sudden diaphoresis, anxiety, agitation, tremors, insomnia, seizures, delirium, T/A/V disturbances - Administer oxycodone, fentanyl, methadone to prevent withdrawal? - OD effects: CV, respiratory depression/arrest, coma, shock, convulsions, death - Give dat hoe NARCAN - ETOH withdrawal (last 48-72 hours): ↑ BP, pulse, temperature, diaphoresis, N/V, diarrhea, tremors, seizures, agitation, disorientation, anxiety, hallucination, paranoia - Symptom onset depends on how long you have been drinking and how much you drink - Begins 6-12 hours after last drink - Peak symptoms: 24-48hr - ETOH withdrawal/delirium tremens is a medical emergency - Screening tool: CIWA-AR - Medications: benzodiazepines on fixed schedule, B vitamins, folic acid, anti seizures, barbiturates - Medications that promote sobriety: - Substance use disorder:  - Disulfiram: prevents impulsive drinking - When mixed with ETOH, can cause violent physical reaction (pounding chest, hypotension, N/V) - Naltrexone (Revia/Vivitrol): reduces “high” by blocking release of endorphins/blocks cravings - Considerations: is the patient eating, may lead to malnutrition - Acamprosate (Campral): helps reduce anxiety, decreases ETOH craving - Methadone: alleviates withdrawl sx and cravings without producing intense euphoria/high w/ drugs like heroin - Buprenorphine: alleviate withdrawal sx, reduce cravings, block the effects of illicit opioids - Tobacco use disorder: - Varenicline (Chantix): reduces craving and withdrawal sx associated w/ nicotine - Bupropion (Wellbutrin, Zyban): smoking cessation aid; helps reduce craving and withdrawal sx associated w/ nicotine Week 10: Gas Exchange/TB - Symptoms of TB - Latent TB: do NOT have symptoms but w/o treatment they can develop active TB disease (you were only exposed), can’t spread the disease - Active TB: have the symptoms, need to get treatment for a longer period - Sx: cough that lasts 3 weeks or longer, chest pain, coughing up blood/sputum, weakness/fatigue, rapid weight loss, loss of appetite, chills, fever, night sweats - Skin test: what diameter would you be concerned about? - >/=5 mm: positive for people at high risk (ex: HIV+, recent TB contact, organ transplant recipients) - >/=10 mm: positive for moderate-risk individuals (ex: recent immigrants, healthcare works, people with certain medical conditions) - >/=15 mm: positive for individuals with no known risk factors - Components necessary to diagnose TB vs screening TB - Screening: Blood test and skin test, CXR, questionnaire, sputum samples - For the symptomatic pt… - Acid-fast bacilli (AFB) Smear - detects presence of TB, takes 4-6wks to confirm TB species through culture - Can’t be done on children under 5y/o - (+) smear does not confirm a dx of TB - Need 3 specimen 8 hrs apart - Preferably 2 specimens collected early AM - PCR (1-2 weeks) detects DNA of TB complex - TB pt suspected or confirmed: what kind and when are transmission precautions needed - Airborne, NEGATIVE AIR pressure rooms  - RN should wear n95, patient wears surgical mask - **Those with Latent TB cannot spread TB; do not need precautions - TB meds: what info would you need for PT teaching - Pt Ed is done by the Health Department prior to D/C - Cause of TB, transmission, dx, tx plan, how to take medication, side effects, how to prevent spread - With all TB meds, monitor liver function (hepatotoxicity), renal function (nephrotoxicity), CBC - RIPE: rifampin, isoniazid, pyrazinamide, ethambutol, rifapentine, moxifloxacin - R: orange discoloration of body fluids and use contraceptives - I: take w/ Vitamin B6 to prevent peripheral neuropathy - P: increase fluid intake - E: report visual disturbances - Streptomycin: hearing loss/tinnitus – regular hearing checks Week 13: Cognition - **Delirium: acute state of confusion (associated with polypharmacy) - Assessment: illusions, hallucinations (tactile/visual), wandering, falling, changes in sleep patterns, hypervigilance, dramatic changes in mood, labile (quick, changing) moods - Fast onset, underlying cause, RESOLVES - Elderly patients take longer to metabolize medications - **How to care for this person: - Fall precautions: bed alarm, yellow non-slip socks, bracelet, place in a room close to the nurses station, explain to family that Benzodiazepines (medications) can make the situation worse - Interventions: - Identify and address cause: infection, dehydration - Ensure safety: fall precautions, agitation-related injuries - Use calm communication: reassure pt w/ clear, gentle explanation - **Dementia: chronic and progressive decline - Irreversible; mild - severe - Impairs a person’s daily functioning - Interventions:  - Cognitive engagement: puzzles, familiar tasks - Memory aids: calendars, clocks, labeled items - Have a routine - Always identify yourself, call the person by their name every time - F2F contact, speak slowly using short, simple, words and phrases - 1-2 arms length - Talk to the patient about familiar things, encourage reminiscing about happy times - When pt is delusional, acknowledge feelings and reinforce reality. - Do not argue or refute delusions - If there is an argument with another, separate them. After 5 mins, explain intervention - If verbally aggressive, acknowledge patient’s feelings and shift topic - **Depression: gradual with exacerbation during crisis/stress - Defense behaviors: - Denial: cover up - Ex. “my cat scratched me” to explain a burn mark - Confabulation: making up answers in unconscious attempt to maintain self esteem - Ex. Will make up a story of who the person is if they do not remember them, “I haven’t seen you in 20 years, remind me of your name again” - Preservation: repetition of phrases or behavior - Ex. “i cooked yesterday it is your turn today” - Avoidance of questions **Stages of Alzheimer’s: why are the stages important to a RN - Stage 1 (mild): forgetfulness, possible depression, aware of the problem - Priority: maintain a daily routine - Stage 2 (moderate): confusion, memory gaps, self care gaps, apraxia (difficulty speaking), labile mood, withdrawn from social activities, increased depression, commonly needs daycare - Priority: - Stage 3 (moderate to severe): unable to identify familiar objects or people; advanced agnosia and apraxia, ADL deficit, not willing to bathe, loss of reasoning, self absorbed, reduced stress threshold - **Priority: safety, helping with ADLs, self-care deficit - Stage 4 (late): may not recognize self/family, forgets how to eat, mute, loss of ability to write (agraphia), sucking reflex, put objects in your mouth (hyperorality); excessive attentiveness to visual stimuli w/ a tendency to touch every such stimulus regardless if its history or reward value (hypermetamorphosis) - **Priority: nutrition (feed them until their plate is >75% done) Medications that help slow the progression - There is no medication to cure! - Cholinesterase inhibitors (for mild to moderate stages) - Galantamine hydrobromide (Razadyne): enhances cognitive function - Rivastigmine tartrate (Exelon): available as oral or transdermal patch - GI distress is a common side effect - Donepezil hydrochloride (Aricept): improves memory, awareness, and thinking - NMDA Receptors Antagonists (for moderate to severe stages)  - Memantine hydrochloride (namenda): regulates glutamate to improve memory and attention - Delay and prevent symptoms from worsening for a limited time - Useful in mild-moderate - Prevent breakdown of acetylcholine and stimulate nicotinic receptors to release more acetylcholine - SSRI: low side effect profile; well tolerated - Trazodone and mirtazapine: facilitates sleep and decreases agitation - Seroquel: reduces agitation without leading to a decline in cognitive function Family Teaching for newly diagnosed dementia pt: - Be patient and supportive - Simple language, nonverbal communication - Avoid arguing - Home safety - Establish a routine, encourage independence, encourage cognitive simulation (reading, puzzles, short walks) - Provide nutrition and hydration - Manage caregiver stress, support groups, community resources Week 15: Leadership Leadership - Delegation: if you do not know a person's scope of practice, ask. Prioritization: 1. ABCs (Airway, Breathing, Circulation) a. Always assess issues related to ABCs FIRST – critical for patient survival. b. Airway: RR, O2 c. Breathing (gas exchange): RR d. Circulation: pumps, pipes, plasma i. BP, HR, O2, RR e. If your patient is not compensating how you would expect…. Ask WHY? i. Meds? Age? 2. Maslow’s Hierarchy of Needs a. Helps prioritize patient needs from the most basic (physiological needs) to higher-level needs (safety, love, esteem, and self-actualization). Ensures the most essential needs are met first 3. Acuity and Intensity Tools a. Helps assess the severity of a patient’s condition (acuity) and the amount of care required (intensity). High-acuity and high-intensity patients need more immediate and frequent care 4. Time Management Techniques a. Effective time management is crucial for prioritizing tasks: creating to-do lists, setting goals, and using “brains” can help organize tasks and manage time efficiently  5. Clinical Judgement and Critical Thinking: a. Essential for prioritizing care. Practice assessing patient conditions, identifying potential risks, and making informed decisions about which tasks to tackle first. Prioritize Principles in Client Care - Prioritize acute before chronic - Recognize and respond to trends vs. transient findings - Recognize indications of medical emergencies and complications vs. expected findings Mr. L’s Section Week 1 & 2: Perfusion/EKG Cardiopulmonary System Perfusion: oxygen delivery to the tissues - Shock: inadequate amount of perfusion Flow of blood through the heart - Deoxygenated blood → R atrium → R ventricle → lungs → L atrium → L ventricle →aorta - L ventricle: systemic - R ventricle: pulmonary Cardiac Conduction: SA node → AV node → bundle of HIS → Bundle branches → Purkinje fibers - PR interval: helps determine types of heart blocks! | atrial depolarization - P wave: atria contract - QRS: represents ventricular depolarization (contractions of the ventricles) + atrial repolarization (NOT VISIBLE) - T wave: beginning of ventricular repolarization (relaxation) EKG Strips: V-Tach: 100-250 bpm (life threatening) torsades will make u die - Sx: awake, chest pain, lethargy, anxiety, syncope, palpitations - No cardiac output → low oxygen - Causes: MI, electrolyte imbalances, dig toxicity, stimulants (caffeine and methamphetamine) - Tx: - With pulse: O2, amiodarone (stabilizes rhythm), synchronized cardioversion (in sync w/ QRS wave)  - Without pulse: CPR, ACLS protocol for defib, possible intubation, drug therapy: EPI, AMIO, vasopressin SVT: 151-200bpm - Sx: palpitations, lightheadedness, chest pain, SOB, abrupt onset/ending - HR >180 → decreased cardiac output and stroke volume - Tx: vagal stimulation (bear down), synchronized cardioversion, drug tx: adenosine (stops heart), b-blocker, Ca+ blocker V-fib: unknown bpm DEFIB THE VFIB - Sx: loss of consciousness, may not have pulse or BP, respirations have stopped, cardiac arrest and death - Causes: cardiac injury, medication toxicity, electrolyte imbalances, untreated VTACH - Tx: CPR, O2, Defib, possible intubation, drug tx: epi (vasoconstriction), antiarrhythmic (amio, lidocaine), magnesium A-fib: usually >100bpm - Sx: commonly asymptomatic, fatigue, malaise, dizziness, SOB, tachycardia, anxiety, palpitation - Causes: open heart surgery, HF, COPD, HTN, ischemic heart disease - Tx: - Stable pt: O2, drug tx: beta blocker, Ca+ channel blockers, digoxin, amio - Anticoagulants to prevent clots: the atria is quivering → pooling in the blood → increase risk for clots = MI, PE, CVAs, DVTs - Unstable pt: O2, synchronized cardioversion (in sync w/ QRS wave) Cardiac Labs: - 12 Lead ECG - Troponin: indicate myocardial injury, rise at 3-4 hours after injury - 0-0.03ng/mL - Creatine Kinase (CK-MB): elevated values = myocardial injury or infarction - 0-5ng/mL - Electrolytes (K+, Mg): levels influence cardiac electrical activity - K+: 3.5-5.0 - Mg: 1.5-2.5 (hypomagnesemia: increased risk of torsades) - Both hypo levels increase risk of deadly arrhythmias (Vfib) Week 3: Perfusion/MI Stable: “predictable”, occurs w/ EXERTION, emotional stress, after large meal - Sx: substernal pressure or tightness, pain can radiate to left arm, neck, jaw, or back, mild SOB w/ exertion, fatigue/discomfort, diaphoresis - Tx: NTG, stop activity that causes it, b-blocker, ca+ blocker, ASA - NTG: causes vasodilation Unstable: “preinfarction”, occurs at REST Priority: pain relief, NTG MI: - Sx: SOB, N/V, diaphoresis, pale/dusty skin, heartburn, pain felt in left arm, mid back/shoulder - Women: fatigue, shoulder blade discomfort, SOB - Prioritize: EKG, reperfusion (angiogram) SEND DAT HOE TO CATH LAB - Dx: ECG (ST elevation, ST depression, T-wave inversion), Troponin levels, Stress Test - Tx: - Immediate: MONA (morphine, O2, NTG, ASA) - Cath Lab/clot buster: thrombolytics (-teplase, -ase), surgery (PCI, CABG) - Prevention & rest: heparin IV, NTG, b-blockers, ca+ blockers - Decreased renal perfusion as they are furthest from the heart → decreased urine output Week 5: Perfusion r/t clinical judgement - Sx a person needs CPR: unresponsiveness, pulseless, no normal breathing, cyanotic - Always assess your patient… they could be sleeping - Why they are in cardiac arrest: Vfib, V Tach, Asystole, PEA - Cardiac Medications: - Epi: 1st line medication to increase blood flow (vasoconstriction, increase HR and contraction force) - Use in Vfib, V TACH, asystole - Amio: blocks specific ion channels, stabilizes cardiac rhythms and prolongs the refractory period → restore normal rhythm - Use in Vfib, V Tach - Adenosine: slows conduction through the AV node → temporarily blocks AV node - Use in SVT, PSVT - Atropine: blocks the parasympathetic effects of the heart → increased HR by blocking vagal influence on the SA node - Use in symptomatic bradycardia or AV block Week 6/7: F/E, Acid-Base Imbalances, ABG Acid (acidosis) Base (alkalosis) less than 7.35 over 7.45 Respiratory - Low RR → CO2 is retained - High RR → ↑ CO2 elimination Metabolic - Cause: DKA, shock, lactic acid - Cause: vomiting, gastric decompression accumulation, diarrhea ABG Normal Values - pH: 7.35 - 7.45 - PaCO2: 35-45 mm Hg - HCO3 (bicarb): 22-26 - PSaO2: over 80% - Is the patient compensating?  - Uncompensated: 1 value normal - Partially compensating: all abnormal - Fully compensating: Both values abnormal, normal pH Metabolic Alkalosis: low pH, low HCO3 - Dx: ABG, serum electrolyte levels, physical exam (muscle twitching, dizziness, arrhythmias - Causes: vomiting, NG tube suction, ingesting too much sodium bicarb (tums), Cushings - Sx: hypoventilation, hypokalemia (dysrhythmias, muscle cramps/weakness, vomiting), tetany, tremors, EKG changes - Tx: identify and address the underlying cause, replace electrolytes, adjust medications Metabolic Acidosis: low pH, high HCO3 - Causes: DKA, diarrhea, malnutrition, acute kidney injury - Sx: Kussmaul breathing (high RR), muscle twitching, warm/flushed skin, hypotension, hyperkalemia (muscle twitching, weakness, arrhythmias), confusion - Tx: - if DKA= insulin, anion gap 20 - Tx: paper bag breathing if you know the cause, encourage good breathing patterns. Anti-anxiety medications/sedatives Respiratory Acidosis: body is retaining CO2 → slow RR - Causes: COPD, hypoventilation, asthma exacerbation, PNA, ETOH, OD, opioids - Sx: anxiety, SOB, wheezing, warm/flushed skin, hypotension, restlessness - Tx: treat the problem - non rebreather mask to reduce amount of CO2, narcan DKA: BG >250, not enough insulin produced - Sx: N/V, fruity scented breath (from ketones), excessive thirst, Kussmal breathing (to blow off CO2) polyuria, confusion, excessive hunger, cachectic in poorly controlled diabetics – wasting away - Priority: give fluids and give insulin Week 8: Elimination Interventions: - Stage 1&2: focus on BP control, glycemic control (DM), lipid management and lifestyle changes changes (diet, exercise) to slow progression - Stage 3-4: medications to manage HTN, diuretics for edema, ESAs for anemia, prep for possible dialysis/transplant - Stage 5: dialysis is necessary to manage waste and fluid retention or kidney transplant Week 9: Gas exchange/Anemia Anemia: body is lacking hemoglobin, impaired perfusion - Low or ineffective hgb - Hgb