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NUR 141 EXAM 1

Erickson stages Middle adult 40-60, achieving a sense of generativity while avoiding self absorption and stagnation.
generativity getting out more, giving of yourself
Stagnation thinking of self
Chinese use holistic, exercise, western/eastern meds, hot/cold therapy, mental illness is unacceptable
common illnesses of the Chinese heart disease, circulatory probs, cancer due to smoking
common diseases of the Chinese due to close living TB, hepatitis A, lactose intolerant
Chinese sick practices very passive, accept care, family makes decisions, very polite, no direct eye contact, very positive, same sex caregivers
Chinese communication no touch, nod/bow in politeness means they understand
Chinese...family is first, pt is second, older family makes decisions, children are not disciplined until age of understanding, children have to study hard
Chinese nutrition white meat, use a lot of oil, sodium
Chinese and death based on ancestor worship, fear death, dont talk about it
Erickson stages older adult over 65, ego integrity vs despair
ego integrity sense of worth, travels, does not fear death, life experiences
despair feels worthless, powerless, focus on past failures, angry, loneliness, irritable, fears death
Maslows 5 levels of needs Basic physiological (pain), safety & security, love & belonging, self esteem, self actualization
local signs of inflammation Redness Heat Pain Swelling Loss of function
How deep does a partial thickness wound extend? extend thru the epidermis into the dermis.
Superficial wounds epidermis only
Full-thickness involve SQ tissue and can extend into the fascia, muscle, tendon, or bone
the three phases of healing for wounds repairing by primary intention 1. initial (inflammatory) 2. granulation (proliferative) 3. maturation/scar formation (contraction)
total separation of wound layers with protrusion of organs through the wound opening. Evisceration
ESCHAR Black necrotic tissue. needs to be removed so that epithelial tissue will grow from wound edges to meet in the middle.
effect of smoking on wound healing? vasoconstriction. higher daily requirement for vitamin C which is essential for collagen formation. impairs oxygenation
most common site for pressure ulcers to develop & tell me why. sacrum. pressure friction & shear positioning moisture
parameters assessed with the Braden scale sensory perception moisture activity mobility nutrition friction and shear
Maceration exposure of the skin to moisture. The skin softens, turns white, and is easily broken down or infected.
characteristics of a stage one pressure ulcer? intact skin with nonblanchable redness
isolation precautions are ordered for a patient with Tuberculosis? AIRBORNE isolation which includes HEPA masks, and negative pressure, door closed, and handwashing.
Which drug is the standard for treatment of latent TB and is included in multi-drug protocols designed to reduce resistance? isoniazid Caution: can damage liver so liver function labs ordered at intervals and teach patient to avoid ETOH.
What nursing intervention should be done both before and after a suctioning pass Oxygenate the patient
Exposure to contaminated soil is a significant risk for which type of respiratory infection? Fungal infections: Histoplasmosis Aspergillosis cryptococcosis
Respiratory defense mechanisms: Air filtration mucociliary clearance system cough reflex reflex bronchoconstriction alveolar macrophages
Restrictive disease: impaired lung or chest wall compliance that creates a problem with lung expansion and reduces lung volumes. Inspiration problem.
Obstructive disease increased resistance in the airways that causes air trapping and increased residual volume. Expiration problem.
orthopnea difficulty with breathing while lying flat.
Name a symptoms that is suspicious for cancer of the larynx that should be referred to a physician immediately persistent hoarseness voice changes “lump” in the throat painless lesions (leukoplakia/erythroplakia
Briefly explain how biologic and targeted therapy drugs work to treat cancer. These classes of medications interfere in some way with cancer cell growth or replication by interfering with a particular biologic signal. Examples: Tarceva inhibits enzyme in GF receptor Avastin inhibits angiogenesis
What is the difference between Chronic Bronchitis and Emphysema? Chronic bronchitis is damage to airways. Emphysema is damage to alveoli.
Asthma obstructive disease. episodic and variable inflammation REVERSIBLE traps air, exhaliation probs
COPD obstructive disease. progressive limitation of expiratory airflow NOT REVERSIBLE traps air, exhaliation probs
What type of sputum test is ordered with suspicion of TB ACID-FAST BACILLI ( need samples 3 days in a row
Anticholinergics block the effect of parasympathetic nervous system . short acting: ipratropium (Atrovent) long acting: tiotropium (Spiriva)
Leukotriene modifiers interfere with inflammatory mediators that cause airway constriction and edema. Prevent bronchospasm and inflammation. montelukast (Singulair) zafirlukast (Accolate
device can be used to monitor disease progression and effectiveness of medications/treatments for pts with obstructive respiratory disease? Peak flow meters measure the exhalation volume.
Corticosteroids medications can be used IV, oral, nebulized, or per MDI to prevent and treat airway constriction and edema?
Aspiration pneumonia develops most often in the dependent portions of the right lung as the right bronchi is straighter.
What techniques can be taught to patients with COPD that can increase the length of expiration and reduce resp rate and airway collapse? Pursed lip breathing
Structural changes of aging decreased expiratory muscle strength stiffening of chest wall (↓compliance) ↑AP diameter of the chest (barrel shape) decreased elastic recoil decrease in functioning alveoli spinal changes (↓compliance)
family in later life accepting shifting of generational roles, maintain intereests in spite of physiological decline, retirement, deal w losses.
NS intervention for family in later life indentify and support caregiver, explore respit care, meals
sandwich generation middle adult, meet needs of younger/older adults
primary disease prevention true prevention, preceeds any disease, good nutrition, immunizations, excerise, stop smoking/drinking, safe sex, seat belts, gloves, washing hands
secondary prevention early detection and treatment
tertiary prevention rehab and restoration, had problem and now minimizing the effects of
what can prevent UTI vit C
to absorb b12 you need acid in stomach and intrinsic factor
no intrinsic factor equals.... anemia
60 yo needs a varivax shot to prevent shingles
exercise for 50yo female 3-5xwk x30 min, wtb to raise P and R.
exercise for 80 yo male ask dr first, walk, pool therapy, wtb x5-10 min
vacs for middle adult Tdap q 10 yrs, Hept B series x3, pneumovac, flu, hept A
vacs for elder adult Tdap q 10 yrs, flu, pneumovac x5-10yrs
medicare part A inpt procedures
Medicare part B physician services and equip
Medicare part D drugs
sequential reaction to cell injury inflammatory response
inflammatory response roles neutralizes/delutes inflam agent, removes necrotic material, establishes environment for healing and repair
inflammatory mediators that cause vasodilation and inc capillary permiability cytokines, histamines, prostaglandins, leukotrienes
clinical manifestations to response vasoconstriction, inc WBC with shift to left of neutrophils, exudate forms, malaise, N and anorexia, inc P/R, fever
signs of local response of inflammation redness, heat pain swelling, loss of function
wound classification the cause, duration, depth
superficial depth involves epidermis
partial thickness wound goes into dermis
full thickness wound involves the subcutaneous tissue and may extent into fascia, muscle, tendon and bone
replace lost tissue with same type regeneration (liver)
replace with connective tissue, various types repair
type of healing that occurs when wound margins are approximated primary intention= surgical incisions, paper cuts
3-5 days approximation, migration, fibrin meshwork initial phase (primary intention)
5 days to 3 weeks, fibroblasts, surface pink vascular, edges begin to regenerate and migrate granulation phase (primary intention)
collagen organized/remodeled avascular scar forms maturation and scar contraction (primary intention)
repair secondary intention healing of wounds with large amounts of exudate, wide irregular margins, excessive tissue loss, edges cant b approximated
secondary intention wounds related to trauma, ulceration, infection, more inflam, granulation from edges inward, bottom upward
tertiary intention wound contaminated, healing occurs w delayed suturing of wound, larger/deeper scar
collection of blood underneath tissues hemmorrhage
skin/tissue separate due to poor wound healing dehiscence
separation of wound layers w protrusio of viceral organs evisceration-cover w sterile towel soaked in NS, NPO status
abnormal passage between 2 organs or organ and outside of the body fistula
complications of healing hemorrhage, infection, dehiscence, evisceration, fistula
factors delaying healing corticosteroids-impair WBC and fibroblast function, dec granulation and contraction
vit A and zinc aids in process o9f epithelialization
vit B coenzymes for metabolic reactions
vit C promotes formation of collagen fibers and capillary develpment
protein provides amino acids for tissue repair
carbohydrates inc metabolic energy
fats aids in synthesis of fatty acids and trglycerides
inc fluids loss from perspiration and exudate
multidrug resisitant pathogens MRSA-methicillin resisitant Staph aureus; VRE-vancomycin resistant enterococci
contact precautions private room, HW entering/leaving room, visitor same thing
best for cleaning wounds NS
secondary intention red wounds granulating, protect wound, sterile dressing
secondary intention yellow wound slough or soft necrotic tissue, dressing to absorb exudate
secondary intention black wound necrotic tissue called eschar, wet to dry
peroxide kill granulation tissue
injury over boney prominence from pressure, sheer/friction, secondary intention pressure ulcers
most common site for pressure ulcers sacrum, heels
stage one pressure ulcer intact skin w nonblanchable redness
stage 2 partial thickness loss of dermis w red-pink granulation, may have serum filled blister, popped blister
stage 3 full thickness tissue loss, subQ fat may b visible, undermining/tunneling
stage 4 full thickness tissue loss w exposed bone, tendon or muscle, slough or eschar, undermining and tunneling. can get osteomylitis
unstageable ulcer full thickness tissue loss w base of ulcer covered by slough or exchar in wound bed
braden scale assesses pt for risk of developing a pressure ulcer. range 6-23. lower score=higher risk for ulcer
removal of nonviable, necrotic tissue debridement
an abnormally firm/hard area on the skin induration-firm swelling
skin is consistently wet, skin softens, turns white and can easily get infected maceration-wet tissue, white skin like been in the tub too long
a narrow, elongated channel in the body that allows the escape of fluid sinus tract
yellow or white stringy substance attached to wound bed slough
a chronic skin ulcer having overhanging margins, caused by bacterial infection undermining
black or brown necrotic tissue that must be removed for healing eschar
upper airway nose, pharynx, adenoids, tonsils, epiglottis, larynx, trachea
Lower airway Bronchi Bronchioles- in the lungs Alveolar ducts Alveoli
Ventilation air moves from area of high concentration to low
Inspiration active): muscles contract = ↑intrathoracic volume
Expiration (passive): air expelled as volume ↓
Elastic recoil ↓chest size & ↑pressure = air movement out of chest
Compliance ease of expansion, diseases can ↑ or ↓
Diffusion O2 & CO2 move across alveoli-capillary membrane, hi to low
surfactant Surface tension of alveoli, ↓ inflation pressure, ↑strength, Secretion triggered by sighing and DB, deficit leads to ATELECTASIS
Control of respiration brainstem response, signals move from medulla thru spinal cord thru phrenic nerve
(acidosis = ↑resp rate and volume
alkalosis ↓resp rate and volume)
Mechanical receptors: carotids, respond to ↓ PaO2 & pH or↑ PaCO2
Clearance mechanisms: Cilia, Cough reflex,
Reflex bronchoconstriction prevents entry of irritants
Alveolar macrophages phagocytize foreign particles, removed by cilia or lymph
Some contaminants can’t be removed coal dust, silica
Alterations in structure due to ageing Decreased elastic recoil & expiratory muscle strength, Stiffening of chest wall, Increased AP diameter, Decreased functioning alveoli, Spinal changes
Reduced defense mechanisms Decreased immunity, cilia function, cough force, alveolar function
Impaired resp control RT reduced response to changes in gases Decreased response to hypoxemia (↓PaO2), hypercapnia (↑Pa CO2)
CALCUALTED IN PACK YEARS One pack/day X 20 yrs = 20 pack years two packs/day X 10 yrs = 20 pack years Half pack/day X 40 yrs = 20 pack years
Classification of respiratory disease RESTRICTIVE Decreased lung expansion, compliance/capacity,
OBSTRUCTIVE (obstruction or narrowing) Increased compliance, airway resistance,
Restrictive airway disease Anatomy affected: lung tissue or thorax Breathing difficulty: Inspiration Pathophysiology: ↓lung or thoracic compliance Lung function: ↓lung volume/capacities
Restrictive pulmonary disease scarring or inflammation limits lung expansion & impairs gas exchange. “Stiff” lungs have lower volumes. (PNEUMONIA, FIBROSIS, SILICOSIS, ASBESTOSIS, TUMORS)
Restrictive pulmonary disease Impaired expansion of chest wall can limit lung expansion as well. (SCOLIOSIS, OBESITY, KYPHOSIS, LORDOSIS)
Pneumonia Entry of organisms: ASPIRATION (often flora from upper airway) INHALATION (microbes present in the air) HEMATOGENOUS SPREAD (primary infection elsewhere)
COMMUNITY-ACQUIRED Pneumonia Onset in the community or first 2 days of hospitalization Most common cause is Streptococcus pneumoniae
HOSPITAL-ACQUIRED pneumonia Onset 48 hrs or longer after hospital admission or other contact with health care system (eg.: clinic, ECF, IV antibiotics
ASPIRATION pneumonia Mechanical obstruction – inert substances into airway (barium) Chemical injury – acidic GI contents Bacterial – most common (aerobic & anaerobic organisms)
OPPORTUNISTIC pneumonia Occur in individuals with altered immune response (HIV, malnourished, chemo, LT steroids) Often more gradual onset
stage 1 of pneumonia Congestion Fluid response in alveoli, microbes multiply & spread to adjacent alveoli. Fluid impairs gas exchange.
stage 2 Red hepatization Capillaries dilate, alveoli fill with organisms, WBCs, RBCs, & fibrin. Lungs look red and granular.
stage 3 Gray hepatization Blood flow decreases & WBCs & fibrin consolidates in affected area. Fibrin deposits & phagocytosis.
stage 4 Resolution Exudate processed by macrophages, healing occurs, and lung tissues restored & gas exchange returns to normal.
Clinical manifestations: pneumonia Fever, chills, SOB, cough with purulent sputum, pleuritic chest pain, confusion or ↓mental function
Diagnosis of pneumonia chest xr, sputum gram stain
inflammation of pleura (painful, teach splinting) Pleurisy
fluid in pleural space Pleural effusion
collapsed, airless alveoli Atelectasis
bacterial infection in blood Bacteremia
Infectious disease caused by Mycobacterium tuberculosis, 2nd most deadly infectious disease worldwide Tuberculosis
Spreads person-to-person via small airborne droplets, The immune response walls off the bacteria, scars, and forms granulomas in the lungs – can be seen on x-ray Tuberculosis
Latent TB infection : bacteria are inhaled but immune response effective & no active disease develops (usually have + skin test) However, it is possible to develop active disease later.
Active TB infection : bacteria multiply and cause clinical disease clinical/X-ray evidence of disease & significant reaction to skin test
Clinical manifestations of tb Fatigue & malaise Anorexia & weight loss Low –grade fever NIGHT SWEATS Cough (can have purulent sputum and progress to hemoptysis in advanced stages)
Diagnosis of TB Mantoux skin tests=Read by 48 – 72 hrs
drug therapy for latent tb isoniazid (INH) once daily for 6 – 9 months, rifampin if resistant to isoniazid
Active TB up to 6 months, isoniazid (INH) rifampin pyrazinamide ethambutol
teaching with tb treatment Side effects: hepatic damage, orange body fluids with rifampin, vision damage with ethambutol
TB precautions Airborne isolation if suspected: neg pressure room, HEPA masks, handwashing
Pulmonary fungal infections no isolation precautions, Amphotericin B is drug of choice for severe illness, IV only
Obstructive airway disease increases resistance. It’s a PRESSURE problem. Anatomy affected: airways Breathing difficulty: expiration Pathophysiology: ↑airway resistance Lung function: ↓airway flow rates, ↑residual volume due to trapped air
Obstructive pulmonary diseases the diameter of the airway is reduced and the air flow becomes more turbulent. (ASTHMA, COPD (Chronic bronchitis & Emphysema), CYSTIC FIBROSIS, BRONCHIECTASIS)
chronic episodes of variable inflammation leading to airway obstruction; usually reversible ASTHMA
progressive limitation of expiratory airflow COPD (chronic obstructive pulmonary disease
Asthma Clinical manifestations: (S/S worse at noc/early am, unpredictable, variable) Wheezing Breathlessness & prolonged expiration Chest tightness Cough
asthma can cause respiratory acidosis
meds for asthma Beta-adrenergic agonists Inhaled anti-cholinergics Corticosteroids – oral or IV
productive cough for 3 months in 2 successive years in pts in whom other causes of cough have been ruled out damage to larger airways Chronic bronchitis
abnormal permanent enlargement of airspaces distal to terminal bronchioles , with wall destruction and without obvious fibrosis damage to alveoli Emphysema
COPD Etiology= impaired EXHALATION CIGARETTE SMOKING and/or occupational chemicals/dust/pollution Infection: recurrent inflammation & colonization Genetics: ɑ-Antitrypsin deficiency Aging
Clinical manifestations copd Gradual onset (classic = 50 + yrs of age and 20 pack yr hx) Cough, sputum, SOB, exposure to risk factors Dyspnea is persistent and progressive Fatigue and limited ADLs
Complications of copd Cor pulmonale: right sided heart failure due to pulmonary HTN, Exacerbations, Acute respiratory failure, Depression & anxiety
Treatment of COPD Smoking cessation, Medications, Surgery (lung volume reduction, Breathing retraining pursed lips, diaphramic breathing, Airway clearance techniques
Goals for oxygen use ↓work of breathing, ↓workload of heart, keep SaO2 >90 % with rest, sleep, & exertion. 2ml for copd
Medications for O2 uptake problems Expectorants Antitussives Mucolytics
anti-inflam durgs for copd Corticosteroids: Inhibit the release and action of inflammatory mediators (-ONES) IV: Solumedrol Oral: prednisone Inhaled (ICS) (use spacer & rinse mouth): Pulmicort, Azmacort, Flovent
Leukotriene modifiers These meds block production or action. Dilate & ↓inflammation. (-kast) Prevention & maintenance; not for acute attacks Meds (oral): montelukast (Singulair), zafirlukast (Accolate)
Antihistamines directly blocks histamine receptor Sedating : diphenhydramine (Benadryl) Nonsedating: DON’T CROSS THE BLOOD/BRAIN BARRIER loratidine (Claritin), cetirizine (Zyrtec)
Beta-adrenergic agonists (beta agonists): Bronchodilators act on receptors in the bronchiole & produce dilation & promote mucociliary clearance (-OL). OVERUSE CAN CAUSE REBOUND BRONCHOSPASM & ↓ EFFECTIVENESS, Short-acting
short acting bronciodilators albuterol, levalbuterol (Xopenex), pirbuterol (Maxair)
long acting bronciodilators salmeterol (Serevent), formoderol (Foradil)
relax bronchial smooth muscle, ↑diaphragm contractility, CNS stimulant Methyxanthine derivatives (theophylline family):
block the parasympathetic NS (-pium) Anticholinergics: Cause dry mouth
Leading cause of cancer-related deaths in the US Pulmonary tumors
a tumor that arises from new, abnormal growth and invades surrounding tissue or metastasizes Cancer
risk factors for cancer Heredity Lifestyle Environment Age related
cancer CAUTION Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge from any body orifice Thickening or a lump in the breast or elsewhere Indigestion or difficulty in swallowing Obvious change ina wart or mole Nagging cough or
May be used to debulk a tumor prior to surgery or to eliminate submicroscopic cancer cells. Chemotherapy
Alkylating agents damages DNA by causing breaks in the double-strand helix.
Antibiotics modifies function of DNA and interferes with transcription of RNA
Antimetabolites interferes with synthesis of DNA by mimicking certain essential cellular metabolites that cell incorporates into synthesis of DNA
Hormonal agents alters hormonal status in tumors or inhibits enzyme responsible for activating estrogen.
Mitotic inhibitors interrupt/interfere with mitosis.
Nitrosources similar to alkylating agents and also blocks specific enzymes needed for the synthesis of purine.
Corticosteroids Disrupts the cell membrane, inhibits mitosis and synthesis of protein
Interferons Naturally occurring complex proteins 3 types Inhibits DNA and protein synthesis in tumor cells. Modulates the immune response. Cannot be taken orally and one type cannot be interchanged with another type Side effects : flulike symptoms
Interleukins Family of biological agents that perform many functions related to the immune system e.g. activation of the immune system and alteration in the functional capacity of cancer cells Not given orally Major toxic reaction called capillary leak syndrome (int
Monoclonal Antibodies Antibodies or immunoglobulines produced by B lymphocytes that are capable of binding to specific target tumor cells. Administered by infusion method Anaphylactic reaction can occur – medical emergency.
Treatment of low neutrophils neupogen
Treatment of low RBC epogen
Treatment of low platelets neumega
Nursing Interventions Flulike symptoms – tylenol before treatment and every 4 hours Severe chills – IV Demerol Assist with activities of daily living Perform nursing activities to allow for periods of rest Assess vital signs and general assessment for side effects/therapeu
Autologous marrow transplant patient’s own bone marrow that was harvested and stored before chemotherapy began. The bone marrow is then infused into the patient when needed after intensive chemotherapy or radiation therapy
Allogeneic marrow transplants infused bone marrow is acquired from a donor who has been determined to be human leukocyte antigen matched to the recipient in terms of tissue typing.
Syngeneic marrow transplant obtaining stem cells from an identical twin and infusing them into another.
CHRONIC PYELONEPHRITIS THINK INFECTION.  Bacteria- renal pelvis-inflammatory response-edema, tissue swelling-fibrosis, scars.(usually extension of infection elsewhere - ex: cystitis)With repeated inflammation, scarring, renal tissue permanently damaged.Often due to freq. cyst
Chronic GLOMERULONEPHRITIS THINK IMMUNE REACTION.ANTIGEN-ANTIBODY REACTION with glomerular tissue;swelling & death to capillary cells,enzymes released & attack glomerluar basement membrane. Gradual destruction of glomeruli kidneys atrophy to ESRD in 10-30 yrs Intermittent bouts of
PREVENTION OF CHRONIC RENAL FAILURE Preventative Measures: Limit catheter use; Sterile technique with caths, Aggressively treat DM, HTN, Acute GN, UTI’s Watch for low UO & BP; report promptly, (Prevent ACUTE RENAL FAILURE), Monitor Nephrotoxic meds carefully
tx for esrd dialysis,Fluid Restrictions (Plan Amts. each shift) Monitoring: I&O, Daily Wt, VS, lab values Dietary Restrictions (Na & K) Meds
HEMODIALYSIS- Blood circulates through Artificial Kidney by dializer to  Remove waste products & excess fluid Restore electrolyte and acid base balance
OSMOSIS Glucose in dialysate is hypertonic so pulls fluid from blood
DIFFUSION Particles move from Greater to Lesser concentration
ULTRAFILTRATION Fluid moves due to pressure gradient between blood and dialysate & is removed
NURSING CARE DURING HEMODIALYSIS hold most meds (BP, H2O soluable),
risk for bladder cancer Smoking, chemicals, hi fat, lo fiber diet, sedentary lifestyle
s/s bladder cancer Intermittent painless hematuria, Freq cystitis, Anemia, Suprapubic pain
post op care after bladder cancer surgery Increase Fluids to internally irrigate /prevent clots Catheter to Prevent stress on sutures (cath care) - may also have supra-pubic cath Small capacity (60cc) initially Call Dr for UO < 30cc / hr
Created by: vstein