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PVCC NUR151
Exam #3
| Question | Answer |
|---|---|
| Sleep aids are used as a ______. | Last resort |
| What are some safety concerns for patients taking sleep aids? | *Risk for sleep walking *Drowsy upon waking *Avoid alcohol, smoking, caffeine, and other CNS depressants *Keep side rails up or use bed alarms *Assist with ambulation |
| Sleep deprivation decreases... | Immune response |
| Many sleep meds prevent the body from going into... | REM Sleep |
| REM sleep is essential for ____. | Cognitive Restoration |
| Before starting any sleep aids, try nonpharmacologic interventions such as: | *Establish bedtime routine *Avoid caffeine, nicotine, and alcohol *Identify stressors *Relaxation therapy (music, yoga, bath) *promote exercise |
| Melatonin | OTC sleep supplement. Few drug interactions. Commonly used in elders and travelers. Helps control circadian rhythms and promotes sleep. |
| Kava | OTC sleep supplement. Used for anxiety related sleep issues. Allows for relaxation. |
| Valerian | OTC sleep supplement. **Huge drug interactions, can be TOXIC in liver** Used for mild insomnia. |
| Chamomile and Lavendar | OTC sleep supplement. Calming effect. Have mild sedative effects. Allows for relaxation. |
| Sedatives | Produce calming effect, relax patient. |
| Hypnotics | Induce sleep. |
| Sedatives-hypnotics | Combination of both effects. Lower doses result in sedative effect while increased doses cause hypnotic effects. Examples: Barbituates; benzodiazepines |
| Long term use of sleep medications... | Leads to serious sleep disturbances. |
| Use of hypnotic sleep medications result in lack of ____. | REM sleep |
| Signs of lack of REM sleep | *Restlesness *Irritability *Suspicion |
| Potential adverse effects of sleep medications | *Severe allergic reaction *Severe facial swelling *Complex sleep behaviors (i.e. sleep walking) |
| Barbiturates | *Cause a lot of problems *Rx in grains *Prevent nerve impulses on reticular formation; potentiate action of GABA *Easily become toxic in liver *Low therapeutic index *4 Classifications |
| Four classifications of barbiturates | *ultrashort (works within 15 minutes) *short *intermediate *long (takes longer to respond but lasts longer) |
| Examples of barbiturates | *pentobarbital (Nembutal) *phenobarbital (Solfoton) *secobarbital (Seconal) |
| GABA | Prevents constant stimulation and overload of nerve impulses that could cause seizures if unchecked. |
| Indications for Barbiturates | Anesthesia for SHORT procedures *Seizures *Epilepsy seizure prophylaxis *Insomnia (uncommon) |
| Contraindications for Barbiturates | *Allergy *Pregnancy *Significant Respiratory Difficulties *Liver Disease (narrow TI, liver may not metabolize efficiently = toxic) |
| Adverse Effects for Barbiturates | Dizzy, drowsy, lethargy, hypotension, nausea, vomiting, diarrhea, constipation (elderly), respiratory depression, apnea, coughing, toxicity. |
| Barbiturates toxicity and overdose is an immediate emergency and requires: | Gastric lavage, fluids, activated charcol. Support A,B,C's. |
| Barbiturates have an additive effect with: | Alcohol, antihistamines, benzodiazepines, opioids, and tranquilizers. |
| Barbiturates increase the activity of: | Hepatic Enzymes = results in increased drug metabolism and breakdown *makes liver work harder *other meds not as effective |
| Most commonly prescribed sedative-hypnotic | Benzodiazepines |
| Benzodiazepines | *used to relieve anxiety or promote sleep *preferred over barbiturates *Similar MOA as barbiturates except these induce skeletal muscle relaxation and work more in thalamus. |
| True Benzodiazepines | temazepam (Restoril); flurazepam (Dalmane) |
| Pseudo Benzodiazepines | *Do not have same chemical structure, but same MOA and ADEs. Example: zolpidem (Ambien); eszoplicone (Lunesta) |
| Indications for Benzodiazepines | *Sedation *Sleep induction *Skeletal muscle relaxation *Anxiety and agitation relief *Alcohol withdrawal *Seizures and epilepsy *Depression (stimulated by anxiety) *Conscious sedation |
| Contraindications for Benzodiazepines | *Allergy *Glaucoma (these meds dilate pupils) *Pregnancy *Avoid use in elderly |
| Adverse Effects of Benzodiazepines | Headache, drowsiness, paradoxical excitement or nervousness, dizziness or vertigo, cognitive impairment, lethargy |
| Symptoms of Benzodiazepine overdose include: | Somnolence, confusion, coma, diminished reflexes |
| Overdose of benzodiazepine with alcohol or other depressants leads to: | Respiratory depression and hypotension |
| If overdose is severe, may be treated with... | Flumazenil |
| Order of treatments for overdose of sleep aids | *Less evasive first* 1st = support ABCs, 2nd = may give bicarb to help pull drug out with urine 3rd = activated charcoal, gastric lavage Last = flumazenil |
| Benzodiazepine drug interactions: | Significant and intense |
| Benzodiazepines have _____ effect with other CNS depressants. | *additive effect* 90% change of causing adverse drug reactions when combined with other drugs affecting CNS |
| Benzodiazepines have herbal interactions with: | Kava and valerian |
| Foods to avoid when taking benzodiazepines | Grapefruit and other significantly acidic foods (drug likes basic environment) |
| Pre-therapy assessment for sleeping medications | *Allergies *Use of other meds *Health hx *Mental status *Age *SLEEP DIARY *Baseline vitals (supine & erect) *HEAD TO TOE ASSESS and FOCAL ASSESS *Lab tests (CBC, Liver enxymes, BUN, Creatinine) |
| Benzodiazepines have a high affinity for... | P-450 enzymes |
| When should sleep meds be given? | 15-30 minutes before bedtime for maximum effectiveness in inducing sleep |
| Most sleep medications cause... | REM rebound and tired feeling next day |
| REM Rebound | There is not enough REM sleep when on medication. When patient is taken off medication abruptly, patient will have vivid nightmares. *More severe with barbiturates* |
| Rebound insomnia may occur for ___ after a 3-4 week regimen is discontinued | For a few nights |
| Patient education regarding sleep medications | *Keep sleep journal *Try non-pharmacologic methods first *Check with Dr. before taking OTCs *Take meds as Rx *SAFETY FIRST *Tapper off meds *Short-term basis use *Hangover effect may occur *DO NOT smoke in bed |
| Drugs affecting the Upper Respiratory System | -Antihistamines -Decongestants -Antitussives -Expectorants |
| Drugs affecting the Lower Respiratory System | -Bronchodilators -Mucolytics (Block 2) |
| Anaphylaxis and severe allergic reactions | -Release of excessive amounts of histamines - smooth muscle constriction - Increase in body secretions - Vasodilation and increased capillary permeability |
| H1 receptors (Antihistamines) | Mediate smooth muscle contraction and dilation of capillaries |
| H2 receptors (H2 Antagonists) | Mediate acceleration of heart rate and GASTRIC ACID secretion |
| Properties of Antihistamines (H1) | -Blocks H1 receptors - Blocks ACh receptors -Produces calming effect |
| Examples of Antihistamines | -diphenhydramine (Benadryl) -chlorpheniramine (Chlor-Trimeton) - fexofenadine (Allegra) |
| Antihistamines compete with histamine for ______ | Unoccupied receptors *Cannot push histamine off the receptor if already bound* |
| Antihistamines are more effective... | for prevention of histamine effects rather than reversing them. |
| How soon should a patient stop taking an antihistamine before allergy testing? | four days |
| Antihistamine Indications | -nasal allergies - allergic reactions - motion sickness - sleep disorders (traditional meds cross blood-brain barrier) -PALLIATIVE |
| Contraindications for Antihistamines | -Drug allergy -Acute asthmatic attack -Glaucoma -Cardiac disease - Kidney disease - Hypertension -ASTHMA (dry secretions which irritates = inflammation = blocks airway) |
| Traditional Antihistamines | -Older and work both peripherally and centrally (cross blood-brain barrier) -Have anticholingeric effects |
| Examples of Traditional Antihistamines | -diphenhydramine (Benadryl) -chlorpheniramine (Chlor-Trimeton) |
| Non-Sedating Antihistamines | -Work peripherally to block the actions of histamine thus fewer side effects *Longer duration of action which increases compliance (usually taken once a day) -decrease drying effects |
| Examples of Non-Sedating Antihistamines | -fexofenadine (Allegra) -loratadine (Claritin) -cetirizine (Zyrtec) |
| Nursing assessment for Antihistamines | -allergy -breath sounds -BP, HR -Hx |
| Antihistamines are best tolerated when.. | Taken with meals, although this decreases absorption |
| If dry mouth occurs with anitihistamines, instruct patient to: | Perform frequent mouth care, chew gum, or suck on sugar-free hard candy |
| Patient Education for Antihistamines | -Report excessive sedation, confusion, or hypotension -Avoid driving -Do not consume alcohol or other CNS depressants -Do not take with other prescribed or OTC meds before checking with Doc |
| Three groups of decongestants. | Adrenergics, Anticholinergics, Corticosteroids |
| Adrenergics | Largest group of decongestants, sympathomimetics (mimic sympathetic nervous system) |
| Anticholingerics | Less common decongestant, Parasympatholytics (Prevent parasympathatic nervous system) |
| Decongestants are often combined with... | Antihistamines |
| Decongestants taken PO have a .... effect | systemic |
| Decongestants taken by spray or drops have a ... effect | Topical |
| Topical decongestants can have a ... effect. | Rebound |
| Pharmacotherapeutics for decongestants | Relieves nasal congestion of colds, sinusitis, and allergies. (reduce swelling) |
| Oral Decongestants | -less potent than topical -NO REBOUND CONGESTION -EXCLUSIVELY ADRENERGICS -prolonged decongestant effects, but delayed onset. |
| Example of an oral decongestant | pseudoephedrine (Sudafed) |
| Topical Adrenergics | Potent with prompt onset (within minutes) -Sustained use for several days causes rebound congestion |
| Rebound Congestion | Occurs when topical nasal adrenergics are used for several days. Body adapts to use and when stopped, causes extreme inflammation. |
| Example of a topical adrenergic | phenylephrine (Neo-Synephrine) |
| Pharmacokinetics of decongestants | -Absorbed by GI (PO) or localized mucosa (topical), metabolized in liver, and EXCRETED in FECES. |
| Pharmacodynamics of decongestants | Adrenergics stimulate the SNS, which causes upper airway blood vessels to constrict. |
| Mechanism of Action for Decongestants | -Shrink engorged nasal mucous membranes and relieve nasal stuffiness. -Constrict small blood vessels that supply upper respiratory tract which facilitates nasal drainage. |
| Contraindications for Decongestants | -Glaucoma, cardiac disorders (increase BP, HR), diabetes (glucose is released), prostatitis (decreased urine output), hypertension. |
| Side Effects of Decongestants | *Running from Dinosaur* -tachycardia, hypertension, dysrhythmias, tremors, insomnia, headache, dizziness, seizures, dry nose and mouth. |
| Drug interactions for Decongestants | Sympathomimetic drugs- leads to additive effect |
| pseudoephedrine (Sudafed) | Very common. Avoid using before bed. Monitor VS for effects of sympathetic nervous system (increase in BP, HR, RR). |
| What are some major teaching factors for pseusdoephedrine (Sudafed) | Teach pt. to notify physician of altered heart beat, dyspnea, seizure activity. Avoid caffeine. Report fever, cough, or other symptoms lasting longer than one week. |
| When are antitussives used? | NON-productive coughs and in cases where coughing is harmful. |
| Antitussives | Stop or reduce coughing. |
| Opioid Antitussives | Suppress the cough reflex by DIRECT action on the cough center in the medulla. |
| Examples of Opioid Antitussives | -codeine (Robitussin, Dimetane) -hydrocodone |
| Non-Opioid Antitussives | Suppress the cough reflex by NUMBING STRETCH RECEPTORS in respiratory tract and prevent stimulation of cough reflex. |
| Examples of non-opioid antitussives | -benzoatate (Tessalon, Perles) -dextromethorphan (Vicks Formula 44, Robitussing DM) |
| MOA for dextromethorphan is similar to opioid antitussives, therefore it works... | directly on the cough center in the medulla. |
| Adverse effects for dextromethorphan | -dizziness, drowsiness, nausea |
| Adverse effects for benzonatate | -dizziness, headache, sedation, nausea, and others... |
| Adverse effects of Opioids... | -Sedation, nausea, vomiting, lightheadedness, constipation. |
| Nursing implications for antitussives | -Perform respiratory and cough assessment -allergies -instruct pts to avoid driving -patients taking chewable tablets or lozenges should not drink liquids for 30 to 35 mins afterward. |
| When is a cough assessment performed? | Only with nonproductive coughs |
| Patients taking chewable tablets or lozenges should not drink liquids for ... afterward. | 30-35 minutes |
| Expectorants | Aid in coughing up and spitting out excessive mucus. Reduce viscosity of secretions and disintegrate and thin secretions. |
| Examples of Expectorants | -guaifenesin -iodinated glycerol -potassium iodide |
| Expectorants are used for what type of coughs? | Productive coughs |
| Two MOAs for Expectorants | -Reflex stimulation -Direct stimulation |
| Reflex stimulation MOA | Loosen and thin secretions in response to irritation of GI tract (example: guaifenesin) |
| Direct stimulation MOA | Stimulation of secretory glands in REPIRATORY tract (example: iodine glycerol and potassium iodine) |
| Contraindications for expectorants | -allergy -hyperkalemia (Don't want to give more potassium based drugs) -lithium -antithyroid drugs -potassium containing drugs (potassium saving diuretics) |
| Adverse effects of expectorants | -Nausea, vomiting, gastric irritation (due to more mucus production) |
| What is the best expectorant | WATER |
| Be careful using expectorants in the ... and ... | elderly and those with asthma or respiratory insufficiency (more mucus) |
| COPD includes... | Chronic bronchitis and Emphysema |
| When is use of albuterol (Proventil) indicated? | relief of bronchospasm r/t asthma, bronchitis, and other pulmonary diseases. |
| Mechanism of action for albuterol... | *beta-2 adrenergic* -Dilate airways by stimulating beta-2 adrenergic receptors located throughout lungs. |
| When is use of albuterol contraindicated? | -allergy -uncontrolled cardiac dysrthymias (if dose stimulated beta-1 = increased vasoconstriction which effects heart), -risk of stroke, -hypertension |
| Drug interactions of albuterol | -additive hypertensive effect with other sympathomimetics (sudafed) -increased risk of cardiac toxicity with xanthines and digoxin -hypokalemia with some diuretics |
| When should the oral form of albuterol be taken? | with meals |
| Patient education for beta-agonists. | -call immediately with SOB, chest pain, dizziness, etc. -avoid OTCs, caffeine, smoking -GET VACCINATED for flu and pneumonia -Teach use of inhalers -adequate fluid intake |
| Indications for anticholinergics | PREVENTION of bronchospasm. NOT for management of acute symptoms |
| MOA for anticholinergics | -Block ACh receptors on bronchial tree to prevent bronchoconstriction; indirectly causing airway dilation. |
| Contraindications for anticholinergics. | -allergy (atropine and peanut) |
| Example of a anticholinergic | ipratopium (Atrovent) |
| Teaching points for use of MDI or nasal spray anticholinergic. | -Rinse mouth -Good oral care -Lozenges or hard candy for dryness *Don't use more than prescribed* **AVOID during acute bronchospasm** |
| MOA for Xanthine Derivatives | -Cause bronchodilation by increasing levels of energy producing substance cAMP. -Increase blood flow to heart and kidneys (increase HR = increase urination) |
| Indications for xanthine derivatives | -Used to dilate airways in pt with asthma, chronic bronchitis, or emphysema. |
| Example of xanthine derivative | -theophyline (Theo-Dur) **narrow therapeutic index, A LOT of drug interactions** |
| When is use of xanthine derivatives contraindicated? | -allergy -cardiac problems -seizures -peptic ulcers -cautious with liver disease |
| Adverse effect of xanthine derivatives | -N/V -anorexia -seizures -tremor -anxiety -tachycardia |
| Xanthine derivatives have many interactions with ... | food, herbs, and other drugs. |
| Theophylline is broken down into ... derivatives which increases stimulation. | caffeine |
| Nursing implications for xanthine derivatives | -monitor HR, BP, neuro status, labs -give oral with food |
| Teaching for xanthine derivatives | -take ONLY prescribed dose -increase fluid intake -avoid OTC meds, especially cold meds (decongestants) -NO SMOKING -Avoid foods containing caffeine. |
| MOA for Anti-leukotriene drugs | Prevent leukotrienes from attaching to receptors on cells in the lungs and in circulation -inflammation in the lungs is blocked and asthma symp. are relieved. |
| Indications for anti-leukotriene drugs | -used for PROPHYLAXIS and long-term treatment of asthma. -Some used to treat allergic rhinitis -NOT for ACUTE asthma attacks. |
| Example of anti-leukotriene | motelukast (Singular) |
| Anti-leukotriene drugs are __% protein bound. | 99% |
| Adverse effects of anti-leukotriene drugs | -**headache** -liver dysfunction -fatigue -nausea *Specific meds = few ADEs* |
| Drug interactions for Anti-leukotriene drugs | Phenobarbital may decrease drugs effect as they work on the same enzyme. |
| Anti-leukotriene drugs are excreted in | bile/feces |
| Anti-leukotriene drugs can increase risk of ... | depression and suicide |
| Rescue inhalers | -Short-acting meds for immediate relief of acute respiratory distress ex: albuterol |
| Maintenance inhalers | -Used on daily scheduled basis to prevent acute respiratory distress ex: Atrovent |
| Order to use maintenance, steroid, and bronchodilator inhalers. | 1st-bronchodilator 2nd-maintenance inhalers 3rd-steroids last and then wash mouth out. |
| When using inhaler, how long should you educate the patient to hold there breath? | 10 seconds then slowly exhale |
| Special storage and use for dry powder inhalers... | Do NOT store in moist environment, get wet, or shake. |
| When should patient refill inhaler medications? | 7 to 10 days before it runs out |
| What meds are delivered using a Small Volume Nebulizer or SVN? | -Bronchodilators and mucolytics |
| Moisture through nebulization improves... | clearance of pulmonary secretions. |
| Circadian Rhythm | pattern of seep and wakefulness that follow a cyclic pattern |
| REM Sleep | Vivid, full-color dreaming. Usually begins about 90 minutes after sleep starts. Most Restful stage of sleep. |
| Loss of REM sleep can lead to: | -feeling of confusion or suspicion -alterations in body function -alterations in immune function -more accidents |
| Insomnia | -Chronic difficulty falling asleep -Frequent awakenings from sleep or short sleep or nonrestorative sleep. |
| Comfort measures for patients with GERD in relation to sleep pattern: | -Have small meals, -Don't eat directly before bed, -Pillows to raise HOB |
| Comfort measures for patients taking Diuretics. | Give diuretic a couple hours before bed so patient is not up every hour to go to bathroom. |
| Sleep Apnea | Lack of airflow through nose and mouth for 10 seconds or longer during sleep. |
| Most common sleep apnea | Obstructive sleep apnea |
| Related causes of sleep apnea | Excessive ETOH, Obesity, Family Hx, Smoking |
| Signs and symptoms of sleep apnea | excessive daytime sleepiness, morning headaches and increased BP common. (Body is not getting adequate oxygen. BP increased in effort to better circulate blood and O2) |
| Treatment for sleep apnea | -CPAP (Continuous positive airway pressure) -Good sleep hygiene -Weight loss -Surgical procedure |
| Sleep requirements in elderly | -quality deteriorates -REM shortens -Tendency to nap increases with age -Changes may be due to changes in CNS or medications |
| What natural protein is found in foods that may help induce sleep? | L-tryptophan. Found in foods such as mild cheese and meats |
| Sources of sleep assessment | Client (sleep journal). Bed partner |
| Assessment of sleep history includes: | -nature of problem -s/s -onset & duration -severity and predisposing factors -effects on client **SLEEP-WAKE LOG** |
| BPH | Benign prostate hyperatrophy |
| Therapeutic communication focuses on | The patients ideas, experiences, and feelings. Help patient examine self-defeating behaviors and test alternatives; promote self-care and independence |
| Values clarification (3 processes) | 1)emotional 2)cognitive 3)behavioral |
| Types of communication | verbal, nonverbal, intrapersonal, group |
| Phases of Nurse/Patient realtionship | Preorientation phase, Orientation phase, Working phase, and Termination Phase |
| What are the best types of questions to ask patients.. | Open ended *Don't Ask WHY Questions* |
| Referent communication | one person communicates with another |
| Interpersonal variables | Factors within the sender and receiver that influence communication. I.e: Perception, education, gender, sociocultural background. |
| Strategies for communicating with older adults. | *Check for hearing aids and glasses. *Reduce environmental noise and distractions. *Do not chew gum. *Rephrase rather than repeat if misunderstood. *Face client with mouth visible. *Speak in normal tone. *Use at least 14-point font. |
| Strategies for communicating with clients who are unresponsive. | *Call client by name during interactions. *Communicate verbally and by touch. *Explain all procedures and sensations. *Avoid saying things the client should not hear. |
| Strategies for communicating with clients who cannot speak clearly. | *Listen attentively, be patient, and do not interrupt. *Ask simple questions. *Allow time for understanding and response. *Communication aids: magic slate, pen & paper; Communication board with pictures, words;call bells; sign language; eye blinks. |
| Ethno-geriatrics | Specialty area of providing culturally competent care to ethnic elders. i.e culture specific: mexican |
| Elder abuse | Acts of commission |
| Elder neglect | Acts of ommission |
| First sign of hypoxia | Anxiety |
| Primary stimulus for breathing | CO2 retention in blood |
| COPD patient adjust to higher ___ levels. | CO2. Their breathing is controlled with hypoxic drive. |
| Do not over-oxygenate ____ patients. | COPD (emphysema, bronchitis). Stimulus comes from hypoxic drive. Increased O2 with stop stimulus to breathe. O2 levels prescribed by Dr. |
| Ventilation-Perfusion | (Ventilation) airflow - (perfusion) blood flow |
| Efficient gas exchange depends on balance between ____ | Ventilation and perfusion. Normal VQ ratio is 0.8 |
| Reasons why areas may be ventilated but not perfused. | *"dead space" due to gravity, anatomy, pathology. *PE, blocked blood flow *High pressure in alveoli may collapse capillaries |
| Reasons why ventilation is reduced | *Fluid in alveoli *Mucus plug (common with chronic bronchitis) *Bronchospasm and constriction. |
| Inspiration | Air flows from area of higher pressure to lower pressure when diaphragm moves down |
| Expiration | Elastic recoil of chest wall and lungs allows chest to passively return to normal position |
| Diffusion | Process of moving oxygen and carbon dioxide across the alveolar capillary membrane |
| Hypoxemia | Reduced oxygenation of ARTERIAL BLOOD caused by respiratory alterations |
| Hypoxia | Reduced oxygenation of the CELLS or TISSUES; may be caused by hypoxemia, low CO, cyanide poisoning, or anemia |
| S/S of Hypoxia | Anxiety (first), change in LOC, dizziness, cyanosis (late stage), increased pulse rate, and increased rate and depth of respiration. |
| Best place to assess for cyanosis | Mouth |
| Oxygenation | oxygen level at the cell |
| Ventilation | Inspiration and expiration |
| Perfusion | Circulation of blood through tissue |
| Dyspnea | Difficulty breathing |
| Opioids and pain meds effect what body function... | Respiratory |
| Antidepressant effect... | Respirations |
| Diuretics effect... | Blood volume (decreased), dehydration |
| Neuro conditions that effect respiratory status | Dementia, Parkinson's, CVA |
| Bronchiectasis | Large bronchiole tubes |
| What details do you document on coughs? | *PQRST *Sputum? *If so...color, thickness, amount, how often, when it started. |
| When is the best time to get a sputum sample. | In the morning |
| Eupnea | Normal, quiet breathing |
| Orthopnea | Condition in which the client uses multiple pillows when lying down or must sit with arms elevated and leaning forward to breathe. |
| Hyperventilation | State of ventilation in excess of that required to eliminate the CO2 produced. (Occurs with fever, fear, PE, Shock, OD on aspirin) |
| Hypoventilation | Occurs when alveolar ventilation is inadequate to meet the body's oxygen demand or to eliminate sufficient CO2 (occurs with atelectasis) |
| Biot's Respirations | 3-4 normal breaths with irregular periods of apnea |
| Cheyne-Stokes | Regular pattern of inc. respirations followed by progressively more shallow respirations until apnea occurs |
| Crackles | Early inspiratory crackles in obstructive disease (COPD) late inspiratory in restrictive disease (pneumonia, CHF). Not cleared by cough. |
| Wheezes | Due to narrow airways. Most common on expiration |
| Rhonchi/Gurgles | Coughing may clear. Heard primarily during expiration. |
| coccidiomycosis | Valley fever |
| Lung Scan | Nuclear Medicine. Determine V/Q and Dx or R/O PE |
| Bronchoscopy | Examine tissue, biopsy, remove mucous plugs, collect sputum. Patient is NPO until Gag reflex returns. NEED INFORMED CONSENT. |
| Pulmonary Function Tests | (PFTs) Volumes of airspeed and ease of airflow. Strength of respiratory muscles. |
| Infectious Rhinitis | Common Cold |
| Sinusitis | Sinus infection |
| (URI) Upper Respiratory Infection causes: | *Bacteria/virus invades upper airway which triggers the immune/inflammatory response (swelling of tissue, increased mucous). Self-limiting |
| Possible complications of URIs | Sinusitis, ear infections, bronchitis, pneumonia |
| Nursing interventions for all URIs | *Rest (helps body fight infection, use pillows for support) *Fluids & Nutrition (increased fluids loosens mucous) *Meds (DON'T RECOMMEND SPECIFIC) Decongestant *Humidifier |
| S/S Influenza (URI) | Increased temperature, malaise, sore throat |
| Complications of Influenza | Pneumonia, sinusitis |
| Who should get a yearly flu shot? | Elderly, Young, Healthcare Workers, Patients who are immunocompromised or have cardiovascular issues. |
| Pharyngitis | Could be viral, bacterial, or fungal. Acute inflammation of the pharynx. (UPPER AIRWAY) |
| S/S of Strep throat | Redness/inflammation, sore throat, white patches in throat |
| Complications of untreated strep throat | rheumatic fever which leads to rheumatic heart of kidney disease |
| Interventions for Pharyngitis/Strep throat | *Warm salt water gargles *lozenges *throat culture (antibiotics if bacterial only) |
| C&S | Culture and sensitivity test (sputum) |
| Laryngitis | Inflammation of larynx (voicebox) usually caused by a virus; self-limiting (UPPER AIRWAY) |
| S/S of Laryngitis | Hoarseness, sore throat, nasal congestion, headache |
| Nursing interventions for laryngitis | *voice rest *fluids *humidified air |
| Complication for laryngitis | Excessive drooling caused by edema and obstructed airway |
| Acute Sinusitis | Frequently develops as a result of an URI (particularly viral). Can also be caused by bacteria, or dental infections. (UPPER AIRWAY) |
| S/S of acute sinusitis | Pressure, pain and tenderness over sinus area, fever, and purulent nasal secretions. |
| Complications of acute sinusitis | If left untreated can cause meningitis, brain abscess and/or osteomyelitis (infection in bone) |
| Medical Management for acute sinusitis | Treat infection, shrink nasal mucosa, relieve pain: C&S, Antibiotics (Augmentin & Ampicillin), decongestants, analgesics (pain relief). |
| Nursing interventions for acute sinusitis | Hot showers (break up congestion), increase fluid, warm/moist packs, sleeping positions (increase HOB) |
| Teaching points for acute sinusitis | Teach to recognize early s/s and see MD. (malaise, fever = meningitis) |
| Infectious lower airway disorders | Pneumonia, TB, Valley Fever |
| Obstructive lower airway disorders | Asthma, COPD: chronic bronchitis, emphysema |
| Post-op respiratory complications | PE, Atelectasis, Pneumothorax |
| IS | Incentive spirometer |
| Atelectasis | Collapse of alveoli with retained mucous secretions |
| S/S of Atelectasis | Increased RR, dyspnea, fever, crackles, productive cough |
| Cause of Atelectasis | inadequate lung expansion due to anesthesia, analgesia, immobilization, pain |
| What can nurses do to decrease risk of atelectasis? | **Turn, cough, deep breathe** 10 deep breaths per min. Adequate fluids, IS. |
| Pneumonia | Acute infection of lungs caused by bacteria, virus, fungus, aspirations, Legionella, Pneumocystis carinii (HIV) Can be community of hospital-acquired. |
| Pneumonia can damage... | lung tissue due to inflammation, immune response. |
| S/S of Pneumonia | Fever, chills, increased RR, dyspnea, fatigue, crackles (base), wheezes (upper), productive cough. Sputum (pink, yellow, green, rust), Chest pain if pleura inflamed. |
| Nursing interventions for pneumonia | Antibiotic, O2 (if ordered), increase fluids, tripod position, rest, limit activity, humidifier, shower. |
| Assessment for pneumonia | Respiratory rate and rhythm, lung sounds (crackles, wheezes), sputum, fever, fatigue, best position for respiratory effort (tripod) |
| Prevention of pneumonia | Turn, cough, deep breathe, IS, move, |
| Tuberculosis | Cause by mycobacterium tuberculosis. Lower airway. Colonizes in respiratory bronchioles or alveoli. Bacillus implants in lung tissue, causing immune/inflammatory response. |
| Identifying TB | CXR not definitive, need sputum smear x3 for acid-fast bacilli (cultures take 6-8 weeks) |
| QuantiFERON-Tb | Newer rapid test for TB. Blood sample exposed to mycobacterial antigens. Lymphocytes will secrete y-interferon if TB infection present. |
| Increased rate of TB in... | HIV, Homeless, Immunocompromised, High density housing (Prison), Travelers. |
| Spread to TB | By inhalation of droplets of ingested in unpasteurized milk (not highly infectious, usually requires repeated contact) |
| S/S of TB | Fatigue, malaise, weight loss, low-grade fever, night sweats, cough with mucopurulent sputum (white/green sputum) **Hemoptysis and dyspnea NOT common** |
| Precautions for TB infections | Airborne (special mask, negative pressure room, gloves, gowns) |
| Diagnostic tests for TB | TB skin test (PPD), CXR, Sputum smear, and C&S |
| Drug therapy for TB | 6-12 months of therapy. Must take meds accurately (in maricopa, must be witnessed by public health nurse) |
| Asthma | inflammation and spasms of bronchiolar smooth muscle caused by hyper-responsiveness to irritating stimuli |
| s/s of asthma attack | Hear wheezing, diminished breath sounds in bases, mucus, dyspnea, anxiety, coughing, shallow rapid breathing, accessory muscle use. |
| Complications of Asthma | Status asthmaticus (cannot be reversed with drugs) |
| Nursing interventions for asthma | Prevent exposure to allergens, evaluate severity (PFTs, monitor peak flow, pulse ox), calm patient, use bronchodilators and anti-inflammatories. |
| COPD | Progressive airflow obstruction which decreases ability of lungs to perform ventilation. (emphysema, chronic bronchitis) |
| If wheezing stops during or immediately after meds are given for an asthma attack: | bronchioles have closed off...REALLY BAD!! No O2=dead patient. After meds are given, wheezing should get louder due to more air passage. |
| S/S of COPD | Dyspnea on exertion, <70% on Pulmonary function tests, may or may not have more mucus production |
| Hereditary COPD | Alpha1 antitrypsin deficiency. Accounts for less than 1% of COPD. treated with IV Prolastin. |
| Chronic Bronchitis | Chronic productive cough lasting 3 months for 2 consecutive years. May develop hypoxemia and hypercapnia. |
| Causes of chronic bronchitis | Excessive mucous production, chronic inflammation of small airways, recurrent infections. |
| Emphysema | Permanent hyperinflation of alveoli, destruction of alveolar and capillary walls, narrowed, tortuous small airways and loss of elasticity. Able to inhale, but air is TRAPPED ON EXHALATION. "Barrel Chest" |
| Bronchiectasis | PERMANENT, abnormal distension of one or more large bronchi; associated with recurrent bacterial infections. |
| Complications of COPD | Cor Pulmonale, Recurrent Infections (increased mucus), Pneumonia (increased fluid), Acute Respiratory Failure, Peptic ulcer & GERD, Depression/anxiety. |
| Treatment of COPD | Promote improved ventilation, reduce secretions, slow disease progression, reduce risk of complications, promote pt. comfort and participation in care, improve quality of life. |
| Nursing interventions for COPD | Relaxation techniques, music, TT, meditation, positioning, support group. Deep breathing, Cough, hydration, Respiratory therapy (due by RT), plan activities. |
| Nursing assessment for COPD | See: increased RR and cap refill, Barrel chest, diminished breath sounds, crackles, SOB, dyspnea, decreased O2 sat, pain excessive mucus. Signs for infection. |
| Lab tests for COPD | VS, PO2, AGBs, PFTs, CXR |
| Always use ______ first to open airways, wait five minutes, then administer other meds. | bronchodilators |
| Coccidioidomycosis | Valley Fever: caused by coccidioides immitis which is a fungus that lives in soil, spores inhaled when dry soil is disturbed. Inhaled spores change into spherule which grow and bursts, releasing endospores. |
| S/S of Valley Fever | 60% have no symptoms. If present first see (1-4 wks after exposure): fever, chills, cough, fatigue. This can last for months. |
| Complications of Valley Fever | Less than 1% develop disseminated cocci disease that spreads outside the lungs to form abscesses in SC tissue, brain, spinal cord, bone. |
| Dx of Valley Fever | Fungus found in SPUTUM (most common), pus, urine, cerebrospinal fluid, or in biopsies of skin lesions or affected organs, skin tests or blood test. |
| Treatment of Valley Fever | Mild resolve w/o treatment. If developed into disseminating cocci = could be fatal untreated. Treat with anti-fungal meds. |
| Positions for respiratory patients | Best: Tripod Other: semi-fowler's and "good lung down"(this will give bad lung chance to drain. |
| Chest physiotherapy | Involves postural drainage, chest percussion, vibration to mobilize secretions. Used for patients with atelectasis or there is over 30mL of sputum/day. |
| Nutrition for respiratory patients | *Adequate water 2-3L/day (loosens mucus); Don't drink water with meals (fluid will fill tummy, need nutrition); Need high Cal/High Protein foods to maintain weight. Thickened liquids (less aspiration risk). |
| When should liquid supplements (Ensure, Boost) be given? | Between meals. Do not supplement for a meal. Ask Dr. for best supplement. |
| Meal/snack frequency for Respiratory patients. | Small, frequent meals; avoid full stomach, avoid lost of chewing; rest 30-60 minutes before/after eating; use bronchodilator before eating; use O2 during meal, NO STRAW! |
| Aspiration precautions | No straw; 90 degrees while eating; sit during meals; feed slow on unaffected side; small amounts; check for pocketing; refer to speech therapist. |
| Micturation | Process of emptying the bladder |
| Ability to control micturation can be affected by what types of injuries? | Brain and spinal chord injuries. |
| Nephrons | Functional part of kidney, does not regenerate |
| After d/c of foley, patient needs to void within ____ hours | 4-5 hours |
| In 7th decade, _____% of glomeruli have lost function | 30-50% |
| BPH | enlarged prostate gland, occurs with age and results in hesitancy, retention, slow stream, and UTI's. |
| CMP | Complete metabolic panel = assess for electrolyte imbalances |
| 24 hour urine sample | 1st urination starts time (dump first sample); collect urine over 24 hours; keep urine in special jug over ice; put signs everywhere (If pts voids without saving urine, have to start over) |
| Assessing bladder distension | first palpate lightly then use bladder scanner |
| Urinary retention | accumulation of urine in the bladder |
| Causes of urinary retention | Enlarged prostate, urethral restriction, trauma (childbirth), meds, scar tissue |
| S/S urinary retention | Discomfort, pain, pressure, dribbling,inability to start micturation *voiding small amounts of urine at one time but using bathroom more frequently** |
| Promoting normal voiding habits | Toilet schedule, privacy, position, hygiene (prevent infection) *promote fluid intake 2000-2500 cc/day *strengthen muscle tone *acidify urine (cranberry juice) |
| oliguria | decrease in output, can be caused by hemorrhage, kidney disease, or dehydration |
| Foley typically kept in ____ days after surgery. | 1 or 2 days |
| Irrigating catheter | Only when Dr. orders! |
| Bladder training | Used with catheters. Clamp tubing and release at scheduled intervals. Retrains bladder to expand and hold urine |
| Impact of catheterization | Increased risk for infection, decreased sphincter and muscle tone, can decrease stimulus for voiding (if let in too long) |
| Peristalsis is under control of the ____ system | nervous |
| BRAT diet | Bananas, rice, apples, toast. For diarrhea |
| High fiber foods | apples, whole grains, veggies, fruit |
| Constipating foods | cheese, lean meat, eggs, pasta |
| Foods with laxative effect | fruits, veggies, bran, chocolate, alcohol, coffee |
| Gas producing foods | onions, cabbage, beans, cauliflower |
| Patients at risk for constipation | immobile, depressed, dehydrated, medicated (esp. pain), CNS disease, |
| Interventions for constipation | BEST: High fiber diet, exercise Others: laxatives, enemas, suppositories, digital removal of impacted stool |
| Colace | stool softener usually given after surgeries |
| Impaction | feces wedged in rectum that cannot be expelled. Seen in debilitated, confused, or unconscious patients. |
| S/S of impaction | No stool for several days, oozing of diarrhea stool, loss of appetite, distention, cramping, rectal pain |
| Interventions for impaction | digital removal (DR. ORDER), diet, meds, regular bowel pattern. |
| Patients at risk for diarrhea | Those taking certain meds, especially antibiotics; GI infections, gets rid of good flora. |
| Interventions for diarrhea | remove cause when possible, skin care, hygiene, diet |
| Two main causes of diarrhea in Nursing Homes | C-Diff and E-Coli |
| S/S of flatulence | fullness, pain, distention, cramping |
| Causes of flatulence | decreased motility, medications, anesthesia, immobilization |
| Nursing interventions for flatulence | Decrease pain meds, increase mobility |
| Ileostomy | In small intestine. Stools will be watery and frequent |
| Colostomy | In the large intestine |
| Endoscopy | Radiology test to assess upper GI. Put light down mouth. |
| Colonoscopy | Assess lower GI |
| Exercises for bedridden patients that help will bowel function | 1=lie supine, tighten abdominal muscles, hold three secs. 2=Flex and contract the thigh muscles by raising one knee slowly toward chest. Repeat five times |
| Promoting regular bowel habits | timing, positioning, privacy, fluid/nutrition, exercise, hygiene |
| Bowel Training Programs | Diet, fluid, activity. Manipulate factors within the patient's control. |
| Differential diagnosis | tests to rule out a diagnosis |
| Examples of procedures needing informed consent | INVASIVE: Blood transfusions, thoracentesis, biopsy, IVP (Intravenous pylogram), cytoscopy, Renal BX, arteriograms. |
| Hematology | Examination of actual blood cells |
| Chemistry "metabolic" | Series of tests of the chemical composition of plasma. i.e CMP, BMP, SMAC |
| Two categories of blood tests | Hematology and chemistry |
| Normal value of WBCs (Leukocytes) | 5,000-10,000 cells per cu mm |
| Significance of elevated/decreased WBC value | Elevated= Bacterial infection Decreased= impaired immune system |
| WBC Differential | Dived all WBCs into specific groups Leukocytes = Granulocytes or Agranulocytes = Neutrophils, Eosinophils, Basophils, Monocytes, or Lymphocytes |
| Granulocytes include | Neutrophils (Segs or bands), Eosinophils, Basophils (mast cells) |
| Agranulocytes include | Monocytes, Lymphocytes (B cells, T cells) |
| Neutrophils are ____ responder. Key to _________ infection. | first responder. Key to bacterial infection. |
| Increased neutrophils (Leukocytosis) | Bacterial infection. Called a shift to the left. |
| Decreased neutrophils (Leukopenia) | Viral infections |
| Left shift = | Increased WBC count with more than normal neutrophils. |
| WBC values in bacterial infection | Increased neutrophils, decreased lymphocytes. |
| WBC values in viral infection | Increased lymphocytes, decreased neutrophils. |
| Normal RBC values | 4.5-6 million cells per cu mm (variations in men/women, decrease with age) |
| Normal HgB values | Hemoglobin - 12-16 gm/100mL |
| If RBC or HgB is low = | Patient will not have enough O2 in tissues. |
| Hematocrit (HCT) | Concentration of cells in plasma. Shows adequacy of RBCs and fluid balance. |
| Normal HCT value | 40-50% |
| HgB and HCT are often ordered and interpreted together in a ____ ratio | 3:1 ratio. 3 HCT to 1 HgB |
| When a patient is dehydrated, the % or plasma will _____, causing the % of RBCS to change because: | The % plasma will decrease, causing the RBC % to change because there is an increased concentration of RBCs |
| Platelets (Thrombocytes) | Smallest cells. Aid in quicker blood clot time and decrease bleeding. |
| Normal Platelet value | 150,000 - 400,000 cells per cu mm (Usually leave off last 3 zeros) |
| CMP or BMP | Basic metabolic panel or chemical metabolic panel |
| Normal Na+ levels | 135-145 |
| Normal K+ levels | 3.5-5.5 |
| When Na+ is decreased = _____ is decreased | Chloride |
| BUN and Creatinine reflect : | Kidney function |
| BUN normal value | Blood urea nitrogen 9-25. |
| BUN significance | Increased reflects altered renal function, Decreased can show impaired liver function. |
| Creatinine normal value | 0.6-1.3 mg/dl |
| Significance of creatinine | increased shows altered kidney function |
| Normal Albumin Value | 3.4-5 |
| Significance of albumin values | Relfects nutritional state and hepatic function. |
| Watch ____ to monitor effects of meds | Albumin. Decreased albumin = more effect of high protein bound drugs. |
| When albumin is low, look for.... | Third spacing |
| Normal acid/base values | pH of blood=7.4, HCO3=24, PCO2=40 |
| Normal Respiratory Function values | O2 saturation=95-100%, PO2=74-100 mmHg, PCO@=35-45 mmHg |
| FBS and normal value | Fasting blood sugar. Normal=70-100 |
| GTT | Glucose Tolerance Test |
| HbA1c | Glycosylated HgB |
| HbA1c significance | Shows glucose levels over 6-8 wk period. 7% or less desired. Shows patient's actual glucose control. |
| SBGM | Self blood glucose monitoring. Capillary glucose testing. ACX or BGM |
| PT | Prothrombin time (used with coumadin therapy) |
| INR | International Normalized ratio. Compares PT with a control value |
| PTT | Partial thromboplastin time. Used with Heparin Therapy |
| Lipid profile | Cholesterol:LDL, HDL, Triglycerides |
| CK or CPK | Creatine kinase or creatine phosphokinase. ELEVATEs with muscle damage. Isoenzymes to point to specific muscle types. |
| CK-MM | Skeletal muscle |
| CK-MB | Cardiac Muscle |
| CK-BB | Brain and lung |
| Troponin | Released from damaged cardiac muscle |
| Specific gravity normal value | 1.010-1.030 |
| Chemical tests on urine (Blood, acetone, glucose, bilirubin, protein) | Most are "O" |
| Most effective time for urine analysis | Morning |
| 24 urine samples reflect... | kidney function and cortisol levels |
| AFB | Acid-fast bacillus, Screens for TB |
| Tomography | X ray |
| CXR | Chest X-ray |
| GI Series | UGI, BE (Barium enema) |
| CT | computed tomography. CAT:computed axial tomography (clear, layered pics) |
| PET | Positron emission. Pt swallows radioactive glucose. (Angiography with contrast medium; cancer takes glucose fast =look bright; brain function = areas light up) |
| MRI | NO radiation, magnetic resonance imagry |
| Sound waves | No radiation, ex: ultrasound, echocardiogram, doppler studies |
| Electrical imagery | EKC, EEG |
| % of plasma in HCT | 55% |
| Hypotensive actions of diuretic drugs | Decrease fluid vol.=decrease BP; cause vasodilation of arterioles; decrease peripheral vascular resistance; decrease extracellular fluid volume, plasma volume, and cardiac output. |
| Loop Diuretics | Act on ascending loop of Henle. Block Chloride and Na+ resorption. Active prostaglandins |
| Prostaglandins | Involved with inflammation response. Triggers vasodilation = decreased BP resistance. |
| Indications for loop diuretics | Edema associated with heart failure or hepatic/renal disease. Control hypertension |
| Difference between swelling and edema | Swelling is just water, Edema must have Na+ retention. |
| Loop diuretics have rapid onset of action and: | Long duration of action = more compliance. GIVE IN AM. |
| ADEs for loop diuretics | "rollercoaster" Nausea, vomiting, dizziness, blurred vision, headache, TINNITUS, Hyperglycemia, hypokalemia, hyperuricemia (build up of uric acid) |
| Toxic effects of loop diuretics | Electrolyte loss, dehydration, circulatory failure. |
| Contraindications of loop diuretics | Drug allergy, sulfa allergy, severe electrolyte loss |
| Drug interactions for loop diuretics | Decreased effectiveness with NSAIDS. Additive toxic effect with neurotoxic and nephrotoxic drugs. Additive effect with other diuretics |
| Why does loop diuretics have a decreased effectiveness when taken with NSAIDS? | NSAIDS prevent release of prostaglandins, while diuretics aim to stimulate prostaglandin release |
| Loop diruetic example: furosemide | Lasix. Structurally related to sulfonamide antibiotics (Call Dr. if allergy to sulfa) |
| Primary uses for Lasix | Heart failure, hypertension, renal failure, pulmonary edema, cirrhosis of liver |
| Osmotic diuretics | Act on entire nephron to increase osmotic pressure in GFR = pulls water into renal tubules. Minimal loss of electrolytes |
| Indications for mannitol (osmotic) | Acute renal failure (NOT CHRONIC), high intraocular or intracranial pressure, drug intoxication. |
| Contraindications for osmotic diuretics | drug allergy, severe renal disease or anuria, pulmonary edema, active intracranial bleed, severe dehydration |
| ADEs for mannitol (osmotic) | Convulsions (due to rapid fluid loss), pulmonary congestion (increased blood volume so if kidney fails, fluid pools), HA, Tachycardia, blurred vision. IV FORM ONLY |
| Potassium sparing diuretics | Act in collecting ducts and distal tubules, interfere with Na+ and potassium exchange, less potent than loop diuretics. Given with thiazide or loop diuretics |
| Indications for K+ sparing diuretics | Hypertension and to reverse potassium loss caused by potassium wasting diuretics. Protective cardiac benefits (Na+/K+ pump) |
| Contraindications for K+ sparing diuretics | Allergy, hyperkalemia, severe renal failure, anuria |
| Example of K+ sparing diuretic: spironolactone | Aldactone |
| ADEs for Aldactone | Dizziness, HA, cramps, N/V, diarrhea, weakness, hyperkalemia, irregular menses |
| Drug interactions for K+ sparing diuretics | K+ supplements and ACE inhibitors have additive hyperkalemic effect. Lithium toxicity, Decreased effectiveness with NSAIDS |
| Thiazide Diuretics | MOA= ACt in distal tubule to inhibit resorption of Na+, K+, and chloride. relaxes arterioles, decrease in renal function = decrease in drug efficiency.(because it acts in distal tubule) |
| Indications for thiazide | treatment of edema, hypertension, heart failure. |
| Contraindications for thiazide | allergy, severe renal disease, anuria |
| ADEs for thiazide diuretics | Dizziness, HA, N/V, diarrhea, impotence, decreased libido, rash photosensitivity. Decreased potassium , increased calcium lipids, glucose, and uric acid. |
| Toxicity of Thiazide drugs = | hypokalemia, treat with electrolyte replacement |
| S/S of hypokalemia | Anorexia, nausea, lethargy, muscle weakness, confusion, hypotension. |
| Drug interactions with Thiazide diuretics | Steroids: additive hypokalemic effect. Digoxin + hypokalemia = dig toxicity. Decrease effect of oral hypoglycemics. |
| Ex of Thiazide diuretics: hydrochlorothiazide | HydroDIURIL. Safe, effective, and inexpensive. Used in combo with other antihypertensives. Ceiling effect at 50 mg/day |
| Thiazide-like diuretic | metolazone (Myknox): potent in patient with renal dysfunction. Creatinine clearance can be 10 mL/min. |
| Metolazone is give in combo with what other diuretic in treatment of heart failure. | loop diuretics. |
| metolazone is available in what form | Oral |
| Safety concerns with diuretics | *Diet (K+ or not), Daily weights, change positions slowly (orthostatic hypotension), monitor diabetics glucose carefully, monitor for signs of dig toxicity, report N/V (concern about fluid loss) |
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