Nursing 308 Exam I

lasting more than 3 months

• prevention of complications
• maitaining ability to function

Arthritis

Diabetes

• balanced nutrition
• immunizations
• cessation of smoking

• screenings
• ex. PAP smears, mammograms, prostate and dental exams

rehabilitation (cardiac, stroke)

• Patient-centered care
• teamwork and collaboration
• evidence based pratice
• quality improvement
• safety
• informatics

Lifestyle changes

To render the patient or members of the family capable of meeting the patient's self care needs.

wholly and partly compensatory care and supporting, educative care

Titrated for the dose

• fear of lawsuits
• lack of support from insurance carriers
• perception of pain "in pt head"
• fears of addition
• suspicion of pt when know schedule/drug

inc in metabolic demands > muscle breakdown> weight loss

tachycardia, inc BP, inc myocardial 02 demand, hypercoagulation

Anorexia, fever, dec GI motility, depression and anxiety

lowest intensity of pain stimulus that is percieved as pain

amount of pain a person is willing or able to tolerate

transient, moderate to severe pain, occurs beyond the pain treated by prescribed analgesics. Has a rapid onset and a breif duration with varying intensity and incidence

from damage to somatic (bone, muscle, skin, connective tissue) or visceral (GI, bladder). Nervous system is functioning properly

from damage to peripheral nerves or CNS and does not serve a useful purpose

tingling, prickling, shooting, electric shock like, jabbing, squeesing, spasm or cold and are cause by trauma, inflammation, metabolic diseases, infections, tumors and toxins

sudden dizziness or faiting that can be triggered by pain, fright, or trauma

• Bradycardia
• treated with atropine and opioid analgesic

• Short duration (<6 months) and has known cause
• usually associated with high levels of pathology or tissue damage
• can evolve into chronic pain

• extends beyond the period of healing from an acute episode
• may have no identifiable pathology to explain
• can be disabling

Migraines, sickle cell anemia, IBD exacerbation

• hypertension
• tachycardia
• anxiety
• dilated pupils
• diaphoresis

• No alterations in VS
• depression
• fatigue
• decreased level of functionoing

• a detailed history of the pain includeing:
• intenisty
• characteristics
• conduct a PE
• Psych eval
• dignostic workup

• onset
• duration
• quality (dull, sharp, aching)
• pattern
• loaction
• intensity
• associated symptoms
• exacerbating or alleviating factors

• a dose of one analgesic that is equal in pain relieving effect compared with another analgesic
• larger doses of oral medications given to give the same effect as IV doses
• Need to be uses with MD consultation by nurse

adjusting the dose or administration interval for safety and effectiveness.

to use the smallest dose possible to provide the desired effective analgesic control and with minimal side effects

oral

extended release morphine

faster-acting narcotic

to manage intermittent pain and breakthrough pain that breaks through the pain relief, provides a baseline analgesia

• continuous pain
• allows pt to sleep through the night

• used for mild pain (1-3 on 10 scale)
• NSAIDS
• acetaminophen
• aspirin

• used for moderate (4-6) to severe (7-10) pain
• Binds to specific opioid receptors

• can be used in any pain state
• added to primary analgesics to further improve pain control

• Step1- mild pain (non-opioid with or without adjuvant)
• Step2- mild to moderate (opioid with or with out non opioid and a adjuvant
• Step3 moderate to severe (same as step 2)

• can cause hepatic toxicity if > 4g/24 hrs;for chronic diseases or > 6g/24 hrs
• hepatic disease or heavy alcohol use inc risk
• minimal anti-inflammatory effect

• prescribed with opioids for mild to moderate pain and moderate to to severe pain in conjuction with narcotics
• anti-pyretic
• infuse over 15 mins

• N&V
• HA
• insomnia
• constipation
• pruritus

• Percocet: 325mg
• Vicodin and Lartab: 500mg
• Vicodin ES: 750mg

• effective step 1
• inc dose beyound a point does not inc pain relief
• inhibit cyclo-oxygenase which converts arachidonic acid into prostaglandins

• Hx of gastric ulcers or bleeding
• bleeding disorders or anticoagulation treatment
• ensure hydration and urine output to dec renal impairment
• risk for CV complications
• use gastric cytoprtection to dec. GI irritation

• controlled drugs, contains natural or synthetic morphine
• mimic endorphins
• most effective analgesic
• alter perception of pain
• no ceiling effect

• sedation
• mental confusion
• Resp depression
• N&V
• constipation and urinary retention
• pruritis

• Impaired ventilation pt.
• liver and renal failure
• inc. intracranial pressure (except at end of life)

morphine

• not indicatied in long term treatment of pain
• metabo in liver
• excreted through kidneys
• in renal dysfuction normeperidine is not excreted and acculamtes in the blood stream and is toxic to the CNS putting pt at risk for seizures

est. optimal dose through titration

• 90 min after oral and rectal admin (includes feeding tubes)
• 30 mins after SubQ or IM
• 6 mins after IV injection

• Naloxone (Narcan)
• treats opioid-induces respiratory depression

relief of spasms assoc. with muscle pain

• inhibit prostaglandin synthesis and reduce inflammation
• neuropathis and bone pain

• relieves pain by circulating and depleting substacne P involved in pain transmission
• may cause intial pain

• infection
• heat
• radiation
• trauma
• allergens
• alway present with infection

• levels of c-reactive protien (CRP)
• tumor necrosis factor (TNF)
• markers dec. after cessation of smoking
• some markers are assoc. w/ heart disease

local: redness, heat, pain, swelling, loss of function

systemic: fever, leukocytosis with shift to left, malaise, nausea, anorexia, tachy-cardia/pnea

• monitor VS
• monitor and treat fever
• RICE

bacterial infection, vascilitis and inflammatory conditions e.g. RA, Lupus, and vasculitis

serious infection or meds, e.g. chemo

allergies, skin inflammation, parasitic infections or bone marrow disorders

can indicate infection

leukemia, chronic inflammation, food allergies or radiation therapy

viral infection, leukemia, bone marrow cancer or radiation therapy

immune system diseases (lupus, HIV infection)

• infection
• inflammation
• cancer

bone marrow disorders, leukemia

• absence of immature neutrophils
• more mature neutorphils
• indicates viral infections

• more immature neutrophils
• acute bacterial infection

• MRSA methicillin-resistant staphyloccus aureus
• MSSA methicillin-susceptible aureus
• VRE vancomycin resistant enterococci
• PRSP penicillin-resistant streptococcus pneumoniae
• ESB extended spectrum betalactamases
• HBV
• HIV and TB

• poor pt. outcomes
• mortality 42-100%
• 3% nationwide prevalence
• acute and community settings
• 10-40% of e. coli and klebsiella pneumonia produce ESBL enzymes
• PCN & cephalosporins resistant

• UTIs
• resp. infections
• life-threatening infections

tx: carbapenems

• CDC recoommends giving most prophylactic anitbiotics less than 1 hour before the first surgical incision to reduce surigical site infections
• exceptions: vancomycin and fluoroquinolones such as cipro and levaquin (give more than 1 hour before)

• higher depression rates
• more med errors
• fewer daily visits from attending physicians

3 x 3 feet

inflammation of subcutaneous tissues possibly from a primary or secondary infection complication

• S. aureus
• streptococci

• skin break down
• could turn into gangrene is untreated

• A: upper extremties
• peds: upper or lower extremties
• neonates/young infants: scalp

a midline cath or PICC

minimum

as soon as possible within 48 hours

subclavian; jugular or femoral

fistula or graft

reduce infection complications

steel

neutrophils arrive to site within 6-12 hours to phagocytize bacteria, foreign material and damage cells and die within 24-48 hours

monocytes arrive to site within 3-7 days and phagocytize inflammatory debris

lymphocytes arrive later and produced humoral and cell mediated immunity

• zinc
• vit C
• iron
• protien

primary intention wound healing

secondary intention wound healing

tertiary intention wound healing

• exesss granulation tissue that needs to be cauterized or cut off. healing proceeds
• contractures: necessary for healing but may become abnl and is from excessive fibrous tissue formation close to joints and in burn pt.

delays formation of collagen fibers and capillary development

decreases supply of amino acids for tissue repair

impairs epithelization

• impairs phagocytosis by WBCs
• inhibits fibroblast proliferations and function
• depress formation of granualation tissue
• inhibit wound contraction

• purpose of treatment is to protect the wound and gentle cleansing if prescribed.
• Clean wounds that are granulating and re-epitihilzing should be kept slight moist
• transparent film or adhesive semi-permeable dressings
• cover with sterile dressing

• needs absorption dressing that absorbes exudate and cleanse the wound surface
• wash with sterile saline or water
• hyrocolloid dressing- designed to be in place for up to 7 days or until leakage occurs around the dressing

debridment of nonviable, eschar tissue

• causing constriction of the blood vessels w/o creat hypoxia
• allows oxygen to diffuse into the serum allowing it to move past narrowed arteries and capillaries where RBCs cannot go
• Kills anaerobic bacteria and inc killing power of WBC
• excelerates granulation tissue formation and speeds up would healing
• stiumlates formation of new blood vessels (angiogenesis)

nonblanchable redness

partial-thickness loss of dermis

full-thickness tissue loss; subQ fat may be visible

Full-thickness tissue loss with exposed bone, tendon, and muscle

• Infants: 70-80%
• Adults: 60%
• Elderly: 45-50%

• 2.2 lbs (1 kg)
• 500 cc

1.015-1.025

• hypothalamic-pituitary (ADH, aldosterone)
• renal (RAAS)
• caridac (BNP)
• GI
• insensible water loss

Hypothalamic > pit to release ADH > regulate waters in kidneys by allowing dital tubules and collecting duct to become more permeable> water reabsored from tubular filtrate

• H: CRF
• A: ACTH (glucocorticoids- coritsol and mineralcorticoids-aldosterone)
• P: ADH (vasopressin)

dec renal blood flow> renin + angiotensiogen> angiotension I + angiotensin converting enzyme (ACE)> Angiotensin II> 1.) adrenal cortex> aldosterone> Na and H₂0 retention 2.) brain> thirst or vasopressin> Na and H20 3.) blood vessels> vasoconstriction

restoration of blood pressure is the end result

• respond to ^ blood volume that stretches heart wall (CHF, pulm edema)
• act on renal tubules to excrete Na and water ^ urine output
• antagonist to RAAS
• nL BNP 0-100 picograms and an indicator for HF

• loss of normal body fluids- diarrhea, vomiting, hemorrhage
• decreased intake or sig fever
• inadequate intake due to impaired thirst, nausea, dec LOC

• decrease intravascular volume
• lytes level "higher"
• hypovolemic shock if left untreated

• HCT > 55%
• NA> 145 mEq/L
• urine specific gravity> 1.025
• BUN> 25 mg/dl
• Plasma osmolarity> 295 mOsm/Kg

• hypertonic IV fluids
• Isotoinc IV fluids in HHNK
• D5W or LR
• plasma expanders (albumin, dextran)
• rapid replacement can stimulate diuresis, hypernatremia, and HF
• may need oxygen therapy

• over hydration
• fluid overload
• FVE may result from escessive intake of fluid or abnormal fluid retnetion (edema)

• intravacular space
• hemodiluted and lytes appear to be "low"
• FVE refers to inc. fluid in interstitial space (edema) e.g. HF

• 1st space: fluid in intravascular space
• 2nd space: edema in interstitial space
• 3rd space: fluid accumulation in areas in which exchange with the rest of ECF cannot easily occur: pleural, pericardial, peritoneal spaces

• Plasma osmolarity < 275 mOsm/kg
• Na < 135 mEq/L
• BUN < 8 mg/dl
• HCT < 45%
• urine specific gravity < 1.010
• plasma protein alnumin may be low

• fluid and Na restricitions
• diuretucs
• mointor NA K and Mg levels
• may need 02 for pulm congestion

• hypercalcemia
• hyponatremia
• hypokalemia
• hypophosphatemia
• hypomagnesemia

• Hypovolemia from ascites, dec. oncotic pressure, and edema
• Hypokalemia from inc intravascular volume
• hypernatremia

• hypovolemia from severe vomiting
• hyopcalcemia: Ca⁺⁺ trapped in necrotic tissue around pancreas
• hypomagnesemia: Mg trapped in necrotic tissue

SIADH: inc ADH secretion causes hypervolemia, dilutional hyponatremia

DI: dec ADH secretion causing polyuria and dehydration. Hypernatremia and hemoconcentration

• FVO
• hyperkalemia
• hyperphosphatemia
• hypocalcemia
• metabolic acidosis
• hyponatremia from hemodilution

• ECF expanded: JVD, liver congestion, pulm crackles
• dec output> vasoconstrict> Fluid and Na retention
• stretching of cardiac wall > BNP

• Diabetes Insipidus (DI)
• primary hyperaldosteronism
• Cushings
• uncontrolled DM

intense thirst, lethargy, agitation, seizures, and coma