Advanced Nursing Skills Module II Exam PDF

Advanced Nursing Skills Module II Exam Chapter 21: Sedatives & Hypnotics (8 questions) ❖ Sedatives vs hypnotics o Sedatives: relaxing/calming; given during the day; DON’T produce sleep o Hypnotics: induces sleep; given at night; DOES produce sleep o Uses: insomnia, con...

Advanced Nursing Skills Module II Exam Chapter 21: Sedatives & Hypnotics (8 questions) ❖ Sedatives vs hypnotics o Sedatives: relaxing/calming; given during the day; DON’T produce sleep o Hypnotics: induces sleep; given at night; DOES produce sleep o Uses: insomnia, convulsions/seizures, preop sedation, conscious sedation o Adverse reactions ▪ Neuro: drowsy, dizzy, headaches ▪ GI: nausea ▪ Older population: RISK FOR oversedation, confusion, ataxia, paradoxical reaction May require smaller doses Sedatives may act like hypnotics o Contraindications: coma, resp issues, drug/alcohol abuse, pregnant or lactating o Additive effect when given with antidepressants, opioids, antihistamines, phenothiazines (antipsychotics), cimetidine, alcohol; even check herbals ❖ Insomnia: affects 30-50% of U.S. population = 40 million people o Causes: medical, behavioral, psych problems, hospitalization ❖ Barbiturates o Uses: insomnia and anxiety (more in past) ▪ Pentobarbital (Nembutal): sedative/hypnotic ▪ Secobarbital (Seconal): hypnotic/preoperative sedation o Action: CNS depression and mood alterations (mild sedations, sleep, deep coma) o IMPORTANT: respiratory depressants due to long half-life; medication stays in body for a longer time (depends on dose) ▪ Discontinuing after prolonged use = fatal or severe withdrawal s/s o Side effects (more severe than non-barbiturates): respiratory depression, N/V/D, constipation, bradycardia, hypotension, syncope, headache o Category D: positive evidence for risk to fetus; benefit may outweigh risk ❖ Non-Barbiturates o Uses: insomnia and anxiety (more in present day) o Action: CNS depression o LESS effect on respiratory rate ▪ Effects will diminish after 2 weeks; less addicting potential ▪ Discontinuing after prolonged use = fatal or severe withdrawal s/s o Side effects (less severe) o Category X: contraindicated in pregnancy; risk to fetus is proven o 2 groups: benzodiazepines and non-benzodiazepines  o Benzodiazepines ▪ Temazepam (Restoril): Hypnotic ▪ Triazolam (Halcion): Sedative or hypnotic o Side effects (both): headache, heartburn, N/V, palpitations, rash, somnolence, weakness, body and joint pain o Non-benzodiazepines ▪ Eszopiclone (Lunesta): Insomnia Side effects: headache, somnolence, taste changes, chest pain, migraine, edema DO NOT EAT WITH HIGH-FAT FOODS (delays action) ▪ Zaleplon (Sonata): transient insomnia Side effects: dizziness, headache, rebound insomnia, nausea DO NOT EAT WITH HIGH-FAT FOODS (delays action) ▪ Zolpidem (Ambien): transient insomnia Side effects: drowsiness, headache, nausea, memory loss/anemia DO NOT TAKE WITH FOOD ▪ ALL are Category C: risk can’t be ruled out ❖ Nursing process o Initial assessments ▪ Sedatives: watch timing, signed consent form, if sedated-take vitals, hold sedative, notify HCP ▪ Hypnotics: consider analgesic instead of hypnotic (if pain is causing insomnia), consider time pt will wake up, if environment is interfering with sleep- dim lights, close door, remove obstacles, cluster care ▪ ALWAYS take baseline vitals before giving any medication ▪ Older adults may need smaller doses o Ongoing assessment ▪ BEFORE admin: vitals, LOC, safe environment, assess pain, scheduling of med PRN: ask HCP for time (2 hrs btwn hypnotic and CNS depressants) ▪ AFTER admin: did hypnotic help with sleep, safe environment-side rails up, call light in reach, stay in bed and call for assistance (educate) o Risk for injury r/t drowsiness or impaired memory ▪ Protect from harm- side rails raised, call light in reach, assist in ambulation (due to hazards of operating machinery and decreased focus/concentration) ▪ Watch for drug hangovers: drowsiness, headache; report to HCP ▪ Reevaluate 1-2 hours after administration; notify HCP if pt can’t sleep, wakes up multiple times, or has adverse reactions ▪ Educate: stay in bed and call for help, no driving  o Ineffective breathing pattern r/t resp depression ▪ BEFORE: assess resp rate depth and quality ▪ Reevaluate 30 minutes-1 hour after administration ▪ Education: avoid alcohol (can cause resp depression and possible death) Remember how these drugs can cause major resp depression o Ineffective individual coping r/t excessive medication use ▪ Best used for less than 2 weeks (to reduce risk of addiction; also become less effective after this period) ▪ If taken for longer periods of time, there’s a risk for dependency ▪ Education: not increasing dose, do not repeat dose if sleep is interrupted, do not discontinue abruptly (gradually reduce dose) ▪ Withdrawal S/S: restlessness, excitement, euphoria, confusion o Implementation ▪ Provide support: backrubs, night lights, quiet and safe place ▪ Educate about avoiding caffeine later in day ▪ Never leave meds at bedside, nurse station, hallway, visitor areas (they’re controlled substances) Chapter 28: Assisting with Respiration and Oxygen Delivery (31 questions) ❖ Upper airway: nose, mouth, pharynx/trachea, bronchi/lungs o Trachea: windpipes; tube air travels through from base of larynx to top of lung ▪ Right and left main bronchi/lungs o Lungs: 3 lobes on right; 2 lobes on left ▪ Pleura: 2 layered protective membrane surrounding each lung ▪ Bronchi: within each lung; divides into smaller branches then bronchioles into alveoli ▪ Alveoli: where oxygen transfer takes place (exchange of CO2 and O2); terminal respiratory units of the lungs; lined with mucous membrane o Inspiration: drawing air into lungs o Expiration: exhaling air from lungs o Diaphragm: major muscle that moves air; moves downward during contraction ❖ Lung changes with aging o Decreased elasticity: thorax and respiratory muscles o Decreased 50% total body water: drier membranes, thicker mucus, harder to cough up secretions ▪ More at risk for pneumonia o Decreased elastic recoil: more difficult to exhale (harder to get CO2 out) o Increased alveolar thickness: decreased gas exchange o Less respiratory reserve: more difficult to meet oxygen demands ❖ Oxygen & hypoxia o Oxygen: needed for all cells  ▪ Pulse oximeter: measures O2 saturation; polish and fake nails decrease effectiveness o Hypoxemia: decreased oxygen in the bloodstream (leads to hypoxia) o Hypoxia: decreased oxygen meets cellular needs (respiratory insufficiency) ▪ Causes Obstructed airway (most common): tongue, mucus, foreign body, aspiration/vomit, near drowning, COPD, burns and inflammation Restricted thoracic cage: abdominal surgeries, chest injuries such as flail chest (broken ribs), pneumothorax (air fills in pleural space and can cause lung collapse; tension pneumothorax is worst), extreme obesity, diseases such as ascites or kyphoscoliosis Decreased neuromuscular function: drugs (sedatives, anesthetic agents, analgesics), brain trauma, CVA/stroke, comas (diabetic, uremic, brain), diseases (multiple sclerosis, myasthenia gravis, poliomyelitis) Disturbed diffusion: diseases (pulmonary fibrosis, emphysema), trauma/contusion, fat/pulmonary emboli, tumors, respiratory distress syndrome Environment: high altitude ▪ Early signs: restlessness (most common), confusion, anxiety, tachypnea ▪ Late signs: cyanosis, retractions, arrythmias o Anoxia: without oxygen-cell metabolism slow down/die o Hypercapnia: increased carbon dioxide in blood ▪ Respiratory insufficiency: body cannot meet its oxygen needs; body cannot remove excess amounts of CO2 in blood ❖ Airway obstruction: due to choking o Heimlich: halfway between xiphoid process and umbilicus o Effective coughing: sit upright (deep breath in nose and hold; exhale through pursed lips) ▪ Huff cough: deep breath with short forcible exhale; 3 low level; then 3 high level coughs while saying word “huff”; moves secretions up bronchi o Sputum secretion: best obtained in morning, increased fluid intake o Postural drainage: drains different lung segments; 5-15 minutes 2-4x per day; rhythmic clapping/cupping hands over thoracic area ▪ Remember hydration is KEY; at least 1500-2000mL/day (keeps pulmonary secretions moist and easier to aspirate) ❖ Oxygen administration (slide 10) o Colorless, tasteless, odorless; combustible (can cause fires), very drying to respiratory tract o Purpose: supplement inspired air  o Must use humidifier (to help reduce drying of the nares) o Must have an order (as it’s a medication) o Methods: ▪ Nasal cannula: low oxygen; 1-6L/min Advantages: pt can move around, eat, and talk; for COPD Disadvantages: can be dislodged easily; risk for skin breakdown ▪ Simple Mask: low to medium oxygen; 5-7L/min Advantages: adequate humidification; delivers O2 for short-term therapy; for nebulizer treatments Disadvantages: risk of pressure necrosis; requires at least 5L/min (less than 5L allows for CO2 to build up in mask) ▪ Partial rebreather mask: high oxygen; 6-10L/min Advantages: reservoir contains 100% oxygen; bag limits CO2 from being rebreathed by allowing it not to build up in mask Disadvantages: risk of pressure necrosis (if long-term use) ▪ Venturi-mask: consistent medium to high oxygen; concentration apparatus; can give 24-50% oxygen Advantages: good humidification; delivers low and precise oxygen Disadvantages: risk of skin breakdown; muffled voice ▪ Non-rebreather mask: highest concentrations; can give 60-90% oxygen Advantages: accurate delivery; prevents rebreathing of CO2 Disadvantages: flow rate must be sufficient to prevent bag from deflating during inspiration ▪ Nebulizer: connected hose to medical air; teach about deep breathing to deliver medication properly into the lungs ❖ Chronic Obstructive Pulomary Disease (COPD) o Pulomary disorder that makes it difficult to exhale air (due to blocked airways- inflammation, mucus, loss of alveoli elasticity) ▪ BIPAP: two way; pressure going in and out (for COPD) ▪ CPAP: one way’ pressure only goes in o Pursed breathing: main manifestation; allows them to eliminate CO2; prolonged expiration creates pressure needed to expel air from alveoli ▪ May also exhibit tripod breathing (toddlers or older populations) ▪ May also be “barrel-chested” o Educate: smoking cessation, conserve energy, eat small and frequent meals (avoid feeling full), nasal cannula set to 2-3L/min (reduced risk of retaining CO2) ❖ Metered-dose inhalers: shake, exhale, and inhale slowly through mouth, then hold breath for 10 seconds o Harmonic-like sound means you inhaled too quickly ❖ Artificial airways: relieve obstructions; also used to protect airway, facilitate suctioning, and provide artificial ventilation o Endotracheal tubes (ET tube): maintains airway when pt cannot ventilate on their own or when they’re unconscious ▪ Replace with tracheostomy after 10 days (prolonged use of ET tubes can damage vocal cords and increase risk for infection) ▪ Patient will not be able to speak o Nasopharyngeal & Oropharyngeal airways ▪ Used with post-op patients ▪ Can breathe independently ▪ Helps maintain airway ▪ Helps keep tongue from falling into throat ❖ Airway suctioning: maintains patent airway by removing any secretions o Suction between 80-120 mmHg o Sterile or aseptic technique o Assess breath sounds before and after; NEVER RESUSE o Oral: use of a yankauer; 14-16 Fr suction catheter; only for a period of 10 secs o Nasopharyngeal: upper air passages of nose, mouth, and pharynx; 8-12 Fr for thin secretions; 14-16 Fr for thicker secretions o Tracheobronchial: deep suctions of trachea and bronchi; sterile technique only; preoxygenate before suction is applied; suction coming up (when removing) ❖ Tracheostomy: surgical opening in trachea that facilitates airway by suction and mechanical ventilation; prevents aspiration; can be temporary or permanent; STERILE o Use after 10 days of endotracheal tube o Trach care: clean half strength peroxide and normal saline; dry inner cannula before reinserting (placed at 12 o’clock until it locks in place); replace Velcro ties whenever soiled; put HOB in high-fowlers; suction before cleaning inner cannula o Always have an obturator at bedside ▪ Facilitates placement and helps guide when inserting a trach tube ▪ Removed after insertion ▪ Emergencies: extra trach tube and obturator at bedside ❖ Chest tubes: flexible tube that drains blood, fluid, air around lungs, heart, and esophagus; between ribs in the space between outer and inner lining of chest cavity o Purpose: removes air (pneumothorax, hemothorax, chest surgery) o Connects to a drainage device; may require suction/gravity for drainage ▪ Watch for bubbling (means there’s an air leak) o Removal: immediately place an occlusive Vaseline-based dressing (3 sides covered); also do this if tube accidentally comes out ▪ Hemothorax: collection of blood in pleural cavity ▪ Pneumothorax: collapsed lung  o Interventions: medicate before insertion and removal; make sure tubing is not looped, kinked, obstructed, or clamped (which interferes with negative pressure system, deters proper drainage, and can cause tube to become dislodged) ❖ Incentive spirometer: educate pt about taking 10 slow and deep breaths every hour they’re awake o Used with post-op patients (also teach about splinting after surgery and deep breathing to reduce risk of respiratory insufficiency problems) Chapter 31: Sleep & Oxygenation (9 questions) ❖ Healthy people 2030 objectives o Reduce rate of moto vehicle crashes due to drowsy driving o Increase number of adults with sleep apnea symptoms to get evaluated o Increase number of adults who get enough sleep o Increase number of high school students who get enough sleep ❖ Functions of sleep o Influences: memory/cognition, mood hormones, immunity, temperature, and kidney function o Promotes: adequate rest, illness recovery, pain control o Inadequate: daytime drowsiness and fatigue, irritability, depression, impaired concentration and memory, accidents and illness ❖ States of sleep o NREM (non-rapid eye movement) stage 1: transition, light sleep, muscles relax o NREM stage 2: deeper sleep; brain waves activity lengthens, electrical activity bursts o NREM stage 3: delta sleep, slow-waves, high voltage, respirations and HR slow, become immobile o REM sleep 4: deepest stage, difficult to arouse o REM stage 5: brain waves become active; almost feels like you’re awake, vivid and active dreams, 25% of night is this stage ❖ Sleep requirements (sleep is needed for muscle growth) o Newborns: 16 hours; 80% REM sleep; brain growth/maturation occurs o 2-3 months: 50% REM sleep o 1 year: 12-14 hours o Preschool: 11-13 hours o School-age: 10-12 hours; REM decreases o Adolescents: 9-10 hours; growth hormone is secreted during sleep; changes of circadian rhythms o Adults: 7-7.5 hours; deep sleep decreases; REM 20% o Senior adults: naps; advanced sleep onset ❖ Sleep disorders o Insomnia: difficulty in getting to sleep or staying asleep  ▪ Transient insomnia: short term; due to stress, excitement, change of environment ▪ Chronic insomnia: medical, behavioral, psychiatric problems; requires treatment from HCP o Sleep apnea: when one stops/pauses breathing for brief periods during sleep ▪ Obstructive: most common; due to relaxed soft tissues and bony structures obstructing airway; visible respiratory effort but cannot move air past obstruction Treatment: CPAP, dental appliance to reposition tongue/jaw, surgery to correct obstruction ▪ Central: less common; due to failure of brain to communicate with respiratory muscles; causes a cessation of breathing with no observable respiratory effort; breathing is resumed once oxygen saturation gets low Treatment: needs a specialist (CPAP doesn’t work) ▪ Mixed: combo of both o Narcolepsy: sudden onset of recurrent, uncontrollable episodes of sleep during normal hours of wakefulness; lasts few seconds to 30 minutes ▪ Treatment: drug and behavior therapy; exercise and sunlight exposure ▪ Teach about sleep logs and diaries ▪ Cataplexy: medical condition which strong emotion or laughter causes one to collapse o Snoring: vibration of air passages at back of mouth or nose; due to poor muscle tone, excessive tissue, or deformities; colds and allergies; can indicate apnea ▪ Treatment for mild snoring: exercise to develop good muscle tone and lose weight ▪ Treatment for moderate-severe: specialist referral ***2 dosage calc***