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Exam #3

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)
Created by: crna2b