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TF: There is a difference between educational level and functional literacy.
True; Think about the older, educated adult who is functionally illerate in terms of health care.
what are the stages of adulthood (3) and age ranges?
- young adult: 18-39 years
- middle adult: 40-64 years
- older adult: 65+ years
What is the significance of Erickson in terms of theories of aging?
Erickson gave us nine stages of psychosocial development
What is the significance of Maslow in terms of theories of aging?
Maslow stresses that there is a hierachy of needs and that the basic ones need to met first then onto self-actualization
What are the subgroups of the older adults aged 65+ and the age ranges?
- young-old: 65-74
- middle-old: 75-84
- old-old: 85-99
- elite-old: 100+
Of the subgroups of the old, which is the most rapid growing of the population?
The old-old: 85-99 years;
What is usually the first sign of infection in the elderly?
confusion; It is usually not temperature
What is meant by saying that the "elderly have a decrease in reserve"?
Usually, one things goes wrong and it is detrimental.
Even though a great portion of the elderly are obese, what is a big issue for them? Name another key issue for elderly
In the elderly, what is the best indicator of future falls?
What is the SPICES framework?
- This framework is part of the project that generated evidence-based practice guidelines for older adult care. It identifies 6 conditions that can lead to longer hospital stays, higher medical costs and even death.
- Sleep disorders
- Problems with eating or feeding
- Evidence of falls
- Skin breakdown
what is most important in doing a cultural assessment?
self-awareness: are you aware of your personal biases and prejudices towards cultures different from yours?
What is primary prevention?
Primary prevention is action taken to avoid or delay occurrence (using sunscreen, proper diet, masectomy if you carry the CA gene)
What is secondary prevention?
Secondary prevention is action taken to lead to early detection (pap smear, colonoscopy, any screening)
What is tertiary prevention?
Tertiary prevention is action taken for rehabilitation to prevent worsening of reoccurences (cardiac rehab)
What is the role of the rapid response team?
Rapid response teams save lives and decrease the risk for patient harm before a respiratory or cardiac arrest occurs. Nurses should look for either slow or sudden change in clinical condition
What are the three ethical principles that nurses should use as a basis for clinical decision making? Define them
- 1. self determination (self management)
- 2. beneficence
- 3. justice
- Self determination means that the pts are treated as autonomous individuals capable of making decisions about their own care. Beneficence is making sure to prevent harm and ensure pt well being. Justice is treating pt fairly and equally.
Describe the level of evidence scale
It is a hierarchy of evidence in research. LOE 1 is the highest with a systematic review of all randomized controlled trials or evidence-based clinical practice guidelines based on system reviews of the trials. The Lowest LOE is 7 whic is opinion of authorities and/or expert committee resports
TF: When delegating responsibilities to UAP (unlicensed assitive personnel) ensure that there is no need for assessment , evaluation or intervention.
TF: When planning education, it is not a priority to find out what the pt knows.
False; this is the first step and also helps determine whether the pt is receptive to teaching
How do you calculate mean arterial pressure (MAP) and what is the minimum number for perfusion.
- 1/3 Systolic + 2/3 Diastolic
- Must be at least 60.
When assessing the effectiveness of hand-off, what information is necessary?
SBAR. situation, background, assessment, recommendation
Define the nurse's role as an advocate.
In the role of advocate, the medical-surgical nurse assists the client and family through caring interventions
TF: Garlic, while it lowers cholesterol, has anticoagulation properties.
Define relocation stress syndrome
Often experienced by older adults when they are moved from comfortable environment.
TF: Depression is rarely a problem among the elderly
False: It is the most common yet most underdiagnosed and undertreated mental health/behavioral health disorder among older adults
Describe how the physiologic changes of aging predispose older adults to toxic effects of medication
- Drugs are absorbed, metabolized, and distributed more slowly
- Drugs are excreted more slowly by the kidneys
Contrast delirium with dementia
Delirium is acute confusion that is short lived and dementia is chronic confusion that progresses slowly and worsens.
Can you delegate assessment to an LPN?
No, but LPN can monitor and administer oral meds
TF: The RN should supervise all care that is delegated to unlicensed personnel such as nursing assistants.
TF: Chemical sedation is not considered a restraint.
How often should restraints be checked?
Every 30-60 minutes
TF: The Joint Commission recommends releasing restraints every 2 hours for client care.
True: toileting, repositioning, turning
TF: Motor vehicle accidents are the most common cause of injury-related death in those between 65 and 74 years of age.
When assessing a patient's sexual orientation, questions should be _____-ended and non-______________
open ended and non judgemental
Define cultural competence
Cultural competence refers to the ability of health care providers and organizations to understand and respond effectively to the cultural and linguistic needs that clients bring to the health care setting.
Define cultural sensitivity
Cultural sensitivity refers to an awareness and appreciation of cultural differences, thus avoiding stereotyping and biased, negative, impolite, and offensive language and actions when interacting with people of diverse cultures
TF: Women who identify as lesbians report experiencing health care provider discrimination and may therefore avoid routine preventive care such as Pap smears and mammograms.
Thiazide diuretics are effective for lowering blood pressure in _________ clients, but not as effective in __________ clients
TF: Alcohol use can increase or decrease the absorption rate of thiazide diuretics
Belief in the evil eye and hand of God is common in ________ and ________ cultures
Hispanic and Arab cultures
TF: Use of clay for healing is common in some parts of the southeastern United States and Appalachia
What is the tonicity of plasma ? (range)
TF: If an isotonic solution is given intravenously to a patient, both the intracellular and extracellular volume increases.
- False; the isotonic solution has the same tonicity as plasma so it doesn't cause a shift in water into the cell. The extracellular volume will increase because of more content going to the extracellular space.
- Note that extracellular includes interstitial and intravascular. Only intravascular increases because that is where the fluid is going and there is no shift to the interstitial (equal leave and goes out)
What type of saline is isotonic?
normal saline of 0.9%NS
TF: D5W is hypertonic solution?
False D5W is an isotonic solution
What must you look for (cautionary) when a pt is receiving an isotonic solution?
Remember that the solution will increase the volume of the intravascular space.
When do we use an isotonic solution to treat patients?
administeration of blood products
during cardiac arrest
Explain why giving a hypotonic solution intravenously causes water to leave the intravascular space.
a hypotonic solution has less solute and more water. when given by IV, the water will move from the intravascular space into the interstitial and intercellular spaces.
when do you give hypotonic solutions?
- when the pt is losing more watr than electrolytes
- cellular dehydration
What are your concerns when giving hypotonic solutions
- water shift from intravascular space quickly
- if there is a risk for increased intracranial pressure, it's not a good idea
requires careful monitoring
What are examples of hypotonic solutions?
- <0.9% normal saline, <5%dextrose in water (D5W) i.e.
- 0.45% sodium chloride
- 0.33% sodium chloride
- 0.2% sodium chloride
- 2.5% dextrose in water
What is the osmolarily of hypotonic solutions?
what is the osmolarity of hypertonic solutions?
Explain why giving a hypertonic solution intravenously causes water to come into the intravascular space.
Hypertonic solutions have more solute and less water so water will flow into the intravascular space from the interstitial and intercellular spaces.
What are examples of hypertonic solutions?
anything greater than normal saline(0.9%), D5W(5% dextrose in water) including TPN
What are the reasons to give hypertonic IV solutions?
- increased intracellular fluid
- increased interstitial fluid
intravascular dehydration (decreased volume)
*only given in critical situations
What should you consider when delivering hypertonic IV solutions
- only in critical situations
- irritating to the vein wall
what is the normal pH of blood
7.35 - 7.45
Can blood pH be altered significantly by dilution?
What is the pH of Dilantin
12 - basic
What is the pH of vancomycin
2.4 - 4.5 acidic
Normally, basic and acidic agents are irritating to the vein, but what are two examples of isotonic agents with normal pH that are irritating?
What are two types of IV nutrition
- glucose solution
- TPN - lipids, protein, vitamins, minerals, glucose
Describe the gauges of peripheral IVs?
- The larger the gage, the smaller the bore.
- Usually 16- 24
- 20 & 22 - most application
- 18 - blood products, viscous meds
16 - major surgery, trauma, ob emergencies
TF: Peripheral IVADs require a heparine flush
False; they are saline locked
Note the difference between infiltration and extravasation
Both are inadvertent administration of a IV substance into surrounding tissue. For infiltration, the substance is not a vesicant. With extravasation, the substance is a vesicant
TF: Post infusion phlebitis can occur 2-4 days after the peripheral catheter is removed
There are three types of phlebitis; bacterial and chemical are two; what's the other?
mechanical i.e. the vein was too small for the catheter, the joint was immobilized, the catheter was not secured
Describe the phlebitis grading scale
0: no symptoms
2: erythema, edema w/ pain
3: erythema, edema, pain, streak, palpable venous cord
4: erythema, edema, pain, streak, palpable venous cord > 1 inch, pus
what are signs of infiltration?
cool, taut skin
no blood backflow
infusion rate slows
how do the signs/symptoms of extravasation differ from infiltration?
the skin will be blistered, have tissue damage, erythema, necrosis
- there will be increased resistance
- the patient will report pain and burning
what should be done in the case of extravasation
stop the IV infusion immediately
aspirate for any remaining infusate and administer antedote (per protocol) before removing the cathether
elevate extremity with warm compresses.
restart IV in another extremity
When are external jugular lines used and what differentiates it from a central line?
they are used in emergent sitatuins when other veins cannot be assessed. A line is only considered central when the tip extends into the vena cava
TF: Cental venous catheters can be inserted into the veins in the arm, neck, chest or groin
When a pt needs a long term central vascular access device, what are the two types?
Describe the insertion and exit sites of a tunneled catheter
The "exit site" is where the catheter is inserted and tunnels through subcutaneous tissue; the "insertion site" is where the catheter enters the vascular system
Where are the implanted ports usually placed and how are they accessed?
chest wall or arm
Since they are completely under the skin, they are accessed with a special needle called a huber needle
TF: A tunneled cathether may have more than one lumen.
False; an implanted port may be single or double
a PICC line may be single, double or triple
What are the advantages of intraosseous access?
The vasculature facilitates rapid transport of drugs to central venous system
How long does it take for medications given via intraosseous access to reach the heart
How long can Intraosseous access stay in place?
maximum of 24 hours
Which vein insertion site has the lowest infection rate?
what are the normal values for sodium in the body
Why are PICCs prone to occlusion?
Because they are long and thin. Care must be taken to flush with adequate but not too much force.
TF: Long term corticosteroid use leads to fragile veins
How often should peripheral IV tubing be changed?
How often should an intact transparent dressing be changed
every 7 days
Why flushing a central line and you are met with resistance, why should you stop flushing immediately and try to aspirate for blood?
Success will indicate that the line is not occluded by a thrombus. Pushing against resistance might push a thrombus into circulation
Differentiate the length of time before removal for PICCs, short peripheral and midline peripherals
short: 3-4 days
midline: 1-4 weeks
For intubated patients, the head of the bead should be kept at what angle
what should you consider regarding preventing infections with indwelling catheters
- only use when necessary
- use smaller cathers
- maintain a closed system
- proper securement
use impregnated catheters for short dwelling catheters
TF: the signs and symptoms of sepsis are subtle
What are the early signs of sepsis?
narrow pulse pressure
- HR > 90 (tachycardia)
- Resp > 20 (tachypnea)
- warm exremities
- bounding pulse
- Changes in level of consciousness
decreased O2 levels
WBC > 12,000
When drawing aerobic and anaerobic blood samples, which should be drawn first?
what are the drugs of choice for treating MRSA infections?
vanomycin - IV
zyvox - PO
When treating infection, what must you keep in mind about antipyretics?
Antipyretics mask fever and are not always prescribed. A decision is made whether a high temperature is detrimental to the patient.
TF: It is not necessary to implement airborne precautions for an individual with chicken pox
TF: The current CDC recommendation is that a certified infection control practitioner be employed for every 100 occupied acute care beds
Is it necessary to wear a mask and protective eye wear when caring for a CDiff patient?
What is the role in insulin in the body? Produced by? How much daily? What are the two types?
Insulin regulates blood sugar by allowing for the uptake of glucose by the body's cells. It also keeps blood lipid levels in range by promoting triglyceride storage in fat cells.
Insulin is produced by the beta cells in the islets of Langerhorns of the pancreas. About 40-50 are secreted daily into the liver circulation
The two types are basal and prandial. basal is continuous and prandial is released after eating.
What is the role of glucagon in the body? How is it produced?
Glucagon is produced in the alpha cells of the pancreas and released in response to low blood glucose levels. It is counterregulatory and causes glucose to be released from cell storage sites
Without insulin, how does the body handle the glucose?
The body can't utilize glucose for energy since there is limited uptake in tissue cells and more glucose is released by the liver.
Explain how osmotic diuresis occurs with hyperglycemia and what it is
Osmotic diuresis is excessive urine leaving the body that occurs when blood sugar levels are high. a consequence of this occurence is that potassium, sodium and chloride leave too.
This is because of an osmotic gradient. If there is excess sugar in the blood, then that excess gets filtered into the kidney tubules --> so the tubules have greater solute, less water; water is going to flow in and follow => greater urine output.
what are the symptoms of hyperglycemia (3Ps) and why do they occur
Polyphagia - excessive hunger
Polydipisa - excessive thirst
Polyuria - excessive urination
Polyuria occurs as a result of the osmotic diuresis. Polydipsia occurs because of the dehydration caused by polyuria. Polyphagia occurs because the body can't use the glucose for energy and the cells are starved.
What is ketoacidosis and when does it occur?
Ketoacidosis is the when the body produces ketones. Ketones are produced from the breakdown of fats. They are broken down in response to the body needing energy and the glucose in the body not being utilized (hyperglycemia). Fatty acids are released. All of this causes metabolic acidosis
Explain how lactic acid is produced and Kreb's cycle is blocked during hyperglycemia
In hyperglycemia, there is no insulin to assist in the tissue cell's uptake of glucose and dehydration occurs due to polyuria. The cells are hypoxic and because of this are unable to metabolize glucose and the Kreb's cycle is blocked and lactic acid is produced causing overall acidosis
How does the body compensate for acidosis?
The body tries to get rid of CO2 and acid and respirations become more heavy and deep. Acetone is exhaled -> Kussmaul repirations
Explain how ketoacidosis doesn't occure type 2 diabetics.
Type 2 diabetics are producing some insulin, although minimal.
TF:Type 2 diabetes does not have a genetic cause
False; Type 2 DM has both genetic and non genetic causes
What's characteristic of those diagnosed with latent autoimmune diabetes
It often occurs later than type 1 (in adulthood); pt usually has a normal BMI; early insulin therapy can perserve beta cells
What is the relationship between corticosteroids and hyperglycemia?
The use of corticosteroids may cause hyperglycemia
In general, distinguish between type 1 and type 2 DM
Type 1 is an autoimmune that destroys beta cells of the pancreas
Type 2 still has beta cells. The characteristics are that there is (1) decreased sensitivity to insulin, (2) less insulin production & release, and/or (3)increased output of glucose by the liver. It is largely preventable
TF: In studies, giving Metformin to those at risk out performed lifestyle changes in preventing DM.
False; lifestyle changes make a big difference.
TF: When a type 2 diabetic progresses to insulin after oral therapy, it suggests non compliance.
false; at the time of diagnosis, a significant potion of islet cells may have already been lost.
Diabetes causes both micro and macro-vascular changes. Give examples of each.
Which complications(s) of diabetes can be significantly improved by controlled blood sugars?
Of microvascular and macrovascular changes, which is most common among diabetics
Macrovascular i.e. cardiac problems
what is metabolic syndrome?
- syndrome that indicates increased risk for Diabetes and cardiovascular disease
- waist circumference > 35 (f) and > 40 (m)
- elevated fasting blood sugar >100mg/dL
- high bp > 130/85
- low HDL <40
- high LDL > 150
what's the limitation of the urine dip stick test?
Only finds high blood sugars above 200; not good indicator
What is A1C and what are the normal ranges?
A1C is glycoysylated hemoglobin assay that indicates blood glucose control over the last 120 days. Normal ranges should be 4-6%. Goal for diabetics is 7 or less.
What is the serum protein blood test
The serum protein blood test indicates control of blood sugar level over the last 2 weeks.
When testing fasting, random, pre- and post-prandial blood sugars, what are some guidelines?
- The fasting blood sugar can be normal and there still be an issue.
- fasting > 126
- random 200 or greater with symptoms
- preprandial >90-130
- postprandial >180
what's the impact of exercise on diabetes? Precautions?
- improves carbohydrate metabolism
- improves insulin sensitivity
- decreases insulin requirements
- reduces risk of cardiovascular disease
- decreases cholesterol
Pt increases risk for hypoglycemic; know when you have peak insulin times, have quick digestible carb handy; know if there are ketones in your urine, eat carb rich snack prior to exercising
TF: Proteins, fats and carbs have signficant impact on your blood glucose levels.
False; only carbs
15g carbs = 1 insulin level
For type 2 diabetics, increasing fiber ________________ (increases/decreases) insulin sensitivity
What the role of alcohol with diabetes?
- With some oral meds, it may produce disulfrim effects
- leads to an increase in triglycerides
- decreases ability to recognize signs of hypoglycemia
What's important to note when choosing a quick digestible carb to combat hypoglycemia
Fat delays the absorption of the glucose
biguanides (1)drug names, (2)actions, (3) best for, (4) risk for hypoglycemia?, (5) caution use with?, (6) A1C effect?, (7)taken how?
- Metformin, Glucophage
- decreases liver's release of glucose("l")
- increases cell's sensity to insulin ("c")
- *does not stimulate pancreas' insulin release
- best for initial therapy with Type 2 DM
- No insulin release so no hypoglycemic risk
- Use with caution with renal disease
- risk for lactic acidosis (no insulin & glucose not used up) b/c of hypoxic tissues
- lowers HgbA1C by 1-2%
- taken twice daily with meals
Think: big guns locked (lc) up - MG takes these
sulfonylureas: (1) drug names, (2)actions, (3)risk for hypoglycemia? (4) A1C effect?, (5)taken how? (6)overall effect
- -mide drugs (Acetohexamide, Chlorpropamide, Tolazamide, Tolbutamide)
- -ide drugs(2nd generation: Glipizide, Glyburide, Glimepiride)
- stimulates pancreas' insulin release("p")
- increases sensitivity of cell receptors ("c")
- risk for hypoglycemia although second generation have shorter half like -> less risk
- use caution with those susceptible to hypoglycemia
- lowers HgbA1C by 1-2%
- Taken differently depending on which drug;
- overall effect is to reduce fasting blood glucose
Think: suffer if you are politically correct, "I'd....."
alpha glucosidase inhibitors: (1)drugs, (2)actions, (3)best for?(4)risk for hypoglycemia, (5)taken how?
- Precose, Glyset
- slows digestion and absorption of CHO to prevent postmeal blood glucose spike
- best for the elderly
- risk for hypoglycemia if given with insulin or sulfonylureas
- taken three times days with the bite of first meal
Think: alphas #3 preset, slow
Thiazolidinediones: (1)drugs, (2)actions, (3)risks
- -zone drugs (Pioglitazone, Rosiglitazone)
- improves tissue sensitivity ("c")
- reduces liver glucose production ("l")
- lipid lowering
- high potential for liver damage
- risk for contraception failure
- weight gain
think; don't like (lc) this zone
meglitinide analogues: (1)drugs, (2)actions, (3)hypoglycemic risk?, (4)overall action, (5) taken how?
- -glinide drugs (Repaglinide, Nateglinide)
- increases insulin secretion ("p")
- hypoglycemic risk b/c of insulin secretion
- short acting to counter postmeal glucose elevation
- take 15 mins before meal
Byetta: (1)class, (2)action, (3)method, (4)good for, (5)cons
- Incretin agent
- increased beta cell response
- decreases liver glucagon production
- delays stomach emptying (decreases appetite)
- weight loss
Januvia: (1)class, (2)action, (3)method, (4)not intended for,(5)good for (6)cons
- incretin agent
- increases and prolongs the activity of incretins
- those with renal disease
- good in combination
Insulin injection in the _________ is absorbed fastest
What happens if you accidentally inject insulin in muscle?
There will be a more rapid absorption
If you are about to give a short acting insulin (regular), what determines whether the patient's food should be there?
If the pt's blood sugar is high, it doesn't matter if the tray is there or not. If the pt's blood sugar is normal, the food needs to be available.
what insulin should never be mixed with anything else?
lantus & levemir b/c of pH and precipitate
Why do we tell patients to rotate sites within the same anatomical area?
There is variability of absorption between the abdomen and the arm. If the patient always gives in one anatomical part, you do the same. However, within that anatomical part, you should rotate to prevent loss of SubQ fat and build up of scar tissue (absorption issues)
When are insulin pens not useful?
when one is using different insulins
The insulin pump is programmed for the _________ rate.
basal; the pt dials in coverage prior to eating
what is the drawback of the glucowatch
it does not do will with hypoglycemia
explain islet cell transplantation
islet cells are taken from cadaver donors, purified and then given through a portal vein. they nest in the liver and work well for a time and then begin to lose function
what are the causes of hypoglycemia?
- inabilit to adapt insulin release to changing blood glucose levels
- decreased ability of the pancrease to release glucagon (alpha cells)
- decreased epinephrine release in response to falling blood glucose levels
TF: Glucagon can be given SubQ or IM in response to severe hypoglycemia
what are some examples of quick acting carbs?
- hard candy
- fruit juice
what are the causes of foot ulcers
- sensory neuropathy
- motor neuropathy
what's important to note with structural damage to the foot?
now, there are pressure points where there were none before.
give examples of both peripheral and autonomic neuropathies.
- peripheral: arms, legs, feet, temperature, etc.
- autonomic: affects organs i.e. cardiac, urinary, gi
TF: neuropathy progresses with symptoms moving from positive sensory (feeling pain) to negative sensory (no perception).
List the medications that are used to treat neuropathy?
- tricyclic antidepressants
distinguish between proliferative vs non proliferative retinopathy
proliferative - in response to hypoxia, overgrowth of fragile blood vessels that bleed
non-proliferative - increase in vascular permeability
TF: HTN leads to leaky blood vessels in the kidney
What is the earliest sign of an issue with renal disease?
microalbuminuria - ANY amount of protein in the urine
What's a good med to slow kidney disease and lower blood pressure?
Describe micro-and macro- drop set for IV tubing. Describe what the drop factor is.
- Macro drops give a huge drop so you get less drops per ml. Macro drop tubing comes in drop factors of 10, 15, 20 gtts/ml.
- Micro drops give a smaller drop so you can get more drops per ml. Micro drop tubing comes in drop factors of 60 gtts/ml.
Be sure to look at "Learning Insulins" file on laptop