Adult Health Test 1

Front 1

factors that affect stress response

Back 1

age: very young and old dec coping
health
attitude: glass half full/empty
personality
genetics: socioeconoic status, culture, # of other stressors in life

Front 2

stress requires

Back 2

resilience adaptation

Front 3

stress involves what body systems

Back 3

nervous: how brain perceives stress
endocrine: the hormones released with stress
immune: decreases immune response

Front 4

after the stress response is perceived, what is the pathway it follows

Back 4

hypothalamus --> anterior pit --> CRH--> ACTH--> cortisol and aldosterone --> increased BG, decreased immune and allergic response. posterior pit--> ADH--> incr water retention and Bvol. adrenal cortex --> adrenal medulla--> E & NE--> incr HR, BP, BG and also aldosterone--> incr Na retention and K+ loss

Front 5

E & NE

Back 5

incr BG, HR, RR

Front 6

cortisol/aldosterone/ADH

Back 6

incr BVol--> incr BP & fluid retention.
decr UOP, K+ loss, Na + retention
decr inflamm--> decr red edema, temp
decr immune--> delayed healing, incr infect

Front 7

Objective S/S of stress

Back 7

Incr HR, BP
BG > 110
pedal edema, decr UOP
I>O
poor wound healing

Front 8

Subjective S/S of stress

Back 8

anxiety, irritability, indecisive, can't focus

Front 9

NANDA for stress

Back 9

ineffective coping
compromised family coping

Front 10

Nursing interventions for stress

Back 10

facilitate coping
individualize teaching
relaxation strategies

Front 11

Nursing Assessment in Pre-Op

Back 11

1. ID risks/plan care
2. prioritize data & estab baseline
3. pre-op check list: TCDB, IS, Med ed., report abnorm labs

Front 12

ABCs

Back 12

Airway: make sure it's open
Breathing: RR, quality, 02, restless: ask, is it from pain or lack of 02?
Circulation: HR & rhythmn, BP, skin color, temp

Front 13

After ABC's then check

Back 13

neurologic, GI, Surgical site, Pain

Front 14

Nsg Dx for Respiratory Prob

Back 14

risk for aspiration (thick secretions)
ineffective airway clearance (weak cough)
ineffective breathing pattern (shallow RR, dimini breath sounds, decr RR)
impaired gas exchange (low 02 sat)

Front 15

Nsg interventions for Respiratory prob

Back 15

monitor resp stat. more freq
give low 02
TCDB/IS
Incr HOB & ambulate
encourage fluid/maintain IV rate
splint incision & time activity with meds

Front 16

Nsg Dx for CV Prob

Back 16

decreased cardiac output (dec BP), ineffective tissue perfusion (d/t decr output), excess fluid vol, def fluid vol, activity intolerance

Front 17

Nsg Interventions for CV

Back 17

monitor IV fluid rate
labs: K+, Hgb, Hct
strict I/O
prevent clots and stasis

Front 18

Nsg Dx for Urinary Prob

Back 18

impaired urinary elimination

Front 19

Nsg Interventions for Urinary Prob

Back 19

assess bladder distention (palpate)
ambulate & position approp. for voiding
report UOP <30 ML/Hr
should void 6 hr after D/C foley (in and out cath if not)

Front 20

Nsg Dx for GI prob

Back 20

nausea, altered comfort, risk for def fluid volume (if vom, or NG tube).

Front 21

Nsg Interventions for GI prob

Back 21

NPO
resume diet when bowel sounds are heard
ambulate to stimulate GI
antiemetics
if paralytic ilius, then NG tube

Front 22

Nsg Dx for Incision prob

Back 22

impaired skin integrity, risk for infection

Front 23

Nsg Interventions for Incision Prob

Back 23

asepsis & reinforce dressing
maintain patency of drain

Front 24

Nsg Dx for pain

Back 24

acute pain, anxiety

*don't use acute pain for post op pt, use altered comfort. acute pain is when you can't get rid of it.

Front 25

Nsg Interventions for Pain

Back 25

use pain scale
give pain meds and monitor RR
teach PCA before activity

Front 26

Nsg Dx for temperature prob

Back 26

hyperthermia

Front 27

Nsg Interventions for temperature prob

Back 27

culture wound, body fluids, tubes
preventative antibiotics
asepsis at IV so you don't introduce bact
antipyretic drugs: tylenol

Front 28

local s/s of inflammation

Back 28

redness, heat, pain, edema

Front 29

systemic s/s of inflammation

Back 29

malaise, incr HR, RR, and fever, incr WBC (if severe inflammation will appear as Bands on CBC, because the need for neutrophils has exceeded what the blood held so the bone marrow shoots out immature ones. Appear as a "shift to the left" on CBC.

Front 30

3 types of wound healing

Back 30

primary secondary and tertiary intention

Front 31

primary intention

Back 31

first clot forms (3-5 days), then granulation tissue forms 3 weeks after, then scar forms (could take up to 3 yrs).

Front 32

secondary intention

Back 32

happens with more traumatic wounds. there's more granulation tissue and a larger scar.

Front 33

tertiary intention

Back 33

delayed primary intention. have to wait for it to heal on it's own first, then clot forms, then granulation tissue, then scar.

Front 34

Nsg Dx of wounds

Back 34

hyperthermia, risk for infection, def fluid volume

Front 35

Nsg Intervention for wounds

Back 35

promote health: nightengale
protect skin: long sleeves, clean/dry, hydrate skin
for open wounds keep moist, check for infect

Front 36

Intervention for abrasions or skin tears

Back 36

replace skin flap: steri-strips, vaseline, non adherent gauze

Front 37

Interventions for Lacerations

Back 37

approximate edges with sutures/staples and use betadine or chlorhexadine

Front 38

interventions for incontinence dermatitis

Back 38

clense skin, powder, moisutre barrier cream

Front 39

interventions for pressure ulcers

Back 39

debridement of "dead" stuff

Front 40

interventions for surgical wounds

Back 40

keep dry if closed. could open esp if obese, post op distension, N/V, coughing, infection

Front 41

wound vacs

Back 41

use negative pressure to remove toxins, germs, edema. also stimulates blood flow and speeds healing by getting rid of bad stuff in wound. used for trauma, pressure and dehisced wounds.

Front 42

potential resp prob

Back 42

atelectasis & pneumonia (collapsed alveoli cause pneumonia)

r/t immobility, shallow RR, smoking, meds

you see: dec RR, breath sounds, shallow poor quality breathing, low 02, restless, pain meds, thick secretions and weak cough.

Front 43

potential CV prob

Back 43

fluid volume imbalance (ADH/Aldosterone, hemorrhage)
electrolyte imbalance (cortisol, NE/E, renal/GI electrolyte loss)
alt tissue perfusion (DVT from venous stasis).

Front 44

assessment for CV prob

Back 44

hypotension
warm, dry, pink = vasodilation with anesthesia/cool, clammy, rapid pulse = shock.
cap refil, pulses, homan, edema, pulse, lab, I/O, admission wt (baseline)

Front 45

potential urinary prob

Back 45

bladder doesn't release urine
decreased blood flow to kid.

*palpate bladder, check UOP and color, clarity, odor. could be r/t stress resp, anesthesia, surg, decr blood flow.

Front 46

potential GI prob

Back 46

N/V & abd distention
paralytic ileus d/t manipulation of bowel, pain meds, anesthesia, slowed peristalsis

Front 47

assessment for GI prob

Back 47

will see N/V, distension, hypoactive bowel sounds, gas pain, no flatus, if NG tube should see greenish watery drainage

Front 48

potential incision prob

Back 48

inadequate healing r/t nutrition, age, disease, wound infection.

drainage should be 1. sanguineous
2 serosanguineous 3. serous. if infected will have pus, pain and odor

Front 49

post op pain

Back 49

r/t tissue trauma, muscle spasm, anxiety, mvmt.

will see incr BP & HR (E & NE), pain scale, nonverbals from pt

Front 50

potential temp prob

Back 50

hyperthermia (temp up to 100.4 in 1st 48 hrs will be seen with inflammation/stress response and atelectasis, dehydration, or infection.) monitor: temp q4h, incr WBC, purulent wound drainage.

Front 51

body weight changes

Back 51

good indicator of gains or losses. think* if a pt loses 4.4 lbs in 48 hours, they are losing 2 L of fluid (because one pound is 16 oz so that x 4 = 64 oz, and if there are 32 oz in a lb, they lost 2 L)

Front 52

Na+

Back 52

135-145
controls osmolality of ECF, so Na+ changes in ECF will alter vol of fluid in cells (bc H20 and Na go together).

Front 53

things that could cause hypovolemia

Back 53

hemmhorage vomiting, wound drainage, diabetes (polyuria), ADH deficit, NG suctioning, wound drainage, no fluid intake.

Front 54

S/S of hypovolemia

Back 54

dry mucous membranes, wt loss, thirst, incr HR, incr BP, flat neck veins, decr turgor, incr hct, decr UOP.

Front 55

how do you treat hypovolemia?

Back 55

give fluids IV or PO, or give blood.

Front 56

things that could cause hypervolemia

Back 56

cusings, kidney failure, SIADH, hypertension, incr aldosterone

Front 57

S/S of hypervolemia

Back 57

bounding pulse, incr BP, distended neck veins, decr Hct, lung crackles, edema, wt gain, HA

Front 58

for fluid imbalances you want to make sure to...

Back 58

take daily weights, monitor CV, BP, HR, breath sounds (in excess), give NS for irrigations because it's isotonic!

Front 59

things that could cause hypernatremia

Back 59

loss of thirst sensation, fever, diuresis, diabetes insipidus, diarrhea, vomiting, excess IV w/ NS, hyperaldosterone ***all leads to cellular dehydration (fluid pulled out of cells and into blood).

Front 60

tx for hypernatremia

Back 60

diuretics, Na restrict, give HYPOtonic solution (more H20 will dilute Na)

Front 61

causes of hyponatremia

Back 61

Na+ loss: GI loss, diarrhea, wound drainage, renal loss

H20 Gain: CHF, excess IV/PO fluids, SIADH

Front 62

what is lost with too much Na+? how will you treat it?

Back 62

water

give hypotonic sol to dilute Na+, increase water, decrease Na+

Front 63

what is lost when someone has too little Na+? how will you treat it?

Back 63

Na+ loss or water gain

give NS% and PO Na+

Front 64

what will you see with too little Na+?

Back 64

muscle weakness, cramps, lethargy, HA, behavioral changes, coma

Front 65

what will you see in a person with too much K+?

Back 65

muscle twitching, weakness, diarrhea, weak pulse, EKG changes, dysrhythmias, impaired DEPOLARIZATION.

Front 66

what will you do for a person with too much K+?

Back 66

kayexalate enema, IV insulin, eliminate K+ intake, place on cardiac monitor, VS, HR

Front 67

what causes too much K+?

Back 67

renal failure, ACIDOSIS where K+ shifts out of cell, increased intake of K+

Front 68

what causes too little K+?

Back 68

NG suctioning, vomiting, renal loss with diuretics, K+ shift into cells with ALKALOSIS.

Front 69

what will someone with too little K+ look like?

Back 69

flaccid mucles, decresed reflexes, weakmess, slow GI motility that can lead to illius, EKG changes, impaired DEPOLARIZATION.

Front 70

how will you treat someone who has too little K+?

Back 70

cardiac monitor, VS, HR, give K+ if they have urine, teach about diet sources.

Front 71

what will someone with too much Ca+ look like?

Back 71

lethargic, weak muscles, decr reflexes, LOC changes.

Front 72

how will you treat someone with too much Ca+?

Back 72

promote excretion, increase fluids, prevent kidney stones by making urine acidic (cranberry), encourage activity, decrease dietary Ca+.

Front 73

what can cause too much Ca+?

Back 73

cancer, hyperparathyroidism, immobility

Front 74

what can cause too little Ca+?

Back 74

loss of parathyroid hormone, thyroidectomy

Front 75

what will you see in someone with too little Ca+?

Back 75

check trousseau and chvostek, spasm of muscle tissue (tetany), airway stridor, numbness and tingling.

Front 76

how will you treat someone with too little Ca+?

Back 76

monitor airway!! give tums or Ca+ and Vit D, give phosphate binders, assess these things for anyone who has had a thyroid surgery.

Front 77

hypertonic solution

Back 77

3% NS, D10W, D51/2NS

has more solutes to solution so you give it to someone who is hypotonic so it will give them solutes.

Front 78

hypotonic solution

Back 78

1/2 NS, D51/4NS

*give to someone who has hypertonic blood, so hypotonic will draw out solutions.

Front 79

isotonic

Back 79

NS, RI (ringers lactate), D5W

**give if you don't want to mess with someones balance.

Front 80

when do you perform a BSE?

Back 80

1 week after period, because estrogen levels are at their lowest and breasts are small.

Front 81

risk factors for breast cancer

Back 81

female, incr age over 60, family hx esp with 1st degree relative, BRCA 1 + 2 genes, hx of breast, colon, or gyn CA, late periods or no pregnancies, early menarche or late menopause. Also, radiation exposure or wt gain in P menopausal women.

Front 82

noninvasive/noninfiltrating tumors

Back 82

stay in their structure

Front 83

invasive or infiltrating tumors

Back 83

are outside of their structure.

Front 84

ALND

Back 84

axillary lymph node disection. powerful prognositc factor that indicates metastasis and risk of recurrence. if it's in the lymph node, it may have traveled. if it's in 4 or more it may reoccur.

Front 85

SLND

Back 85

sentinel lymph node dissection. done for small primary tumors.
removes sentinel node and if its' clean that other nodes probably aren't involved.

Front 86

HER 2 gene

Back 86

if over expression on cell it increases CA growth. have drugs specially treated for this though.

Front 87

HR

Back 87

ER+ means it grown in high estrogen env, and responds better to anti estrogen meds.
ER- means its not affected by estrogen. poorer prognosis.

Front 88

the larger the tumor

Back 88

the poorer the prognosis

Front 89

negative tumor margins

Back 89

means the tumor is inside the margins

Front 90

how does a nurse treat a breast CA pt?

Back 90

lots of preop training. you're the teacher. TCDB, wound care, PCA, pain control, finger wrist ex. *tell them to look for color and amt in drain (<30ml 1-2 wk post), wash with mild soap/H20, altered sensation and numbness is expected (d/t nerve damage).

Front 91

what would you teach someone to do to prevent lymphedema?

Back 91

measure circumference, protect from injury, wear compression sleeve, avoid heavy lifting, no BP, IV, sunburn skin breaks or tight jewelry. wear gloves if injury to hands is possibility.

Front 92

what are the exercises you would teach someone who had Breast CA surgery?

Back 92

Adduct arm in 1st 24 hrs, semi fowlers with arm elevated above heart, gentle finger, wrist exercises, progress to arm/shoulder ROM, prevent contractures by taking warm showers.

Front 93

risk factors for cervical CA?

Back 93

HPV, early sexual activity, smoking

Front 94

S/S of cervical CA?

Back 94

no early symptoms, but late symptoms are bleeding and pain

Front 95

how do you treat cervical ca?

Back 95

hysterectomy, external radiation to pelvis, internal radiation for 2 days then removed.

Front 96

what is someone who just had hysterectomy at risk for?

Back 96

urinary retention. want to palpate bladder, monitor UOP, accidental cutting of ureter which causes urine to leak into pelvic cavity (see in JP drain).

Front 97

what else is someone who just had hysterectomy at risk for?

Back 97

risk for deficient fluid volume. monitor their VS changes, monitor bleeding (expect moderate serosang drainage on pad and if saturated think hemorrhage).

Front 98

what else is someone who just had hysterectomy at risk for?

Back 98

acute pain with delayed peristalsis and abd distention. monitor bowel sounds for gas, ambulate them, encourage mvmt.

Front 99

what else is someone who just had hysterectomy at risk for?

Back 99

risk for impaired peripheral tissue perfusion from venous stasis. SCD, change position, pelvic sx increases risk of DVT, avoid behind knee pressure.

Front 100

side effects of external beam radiation on hysterectomy

Back 100

red tender skin, diarrhea, bladder irritation that can lead to cystitis type symptoms, loss of vaginal lubrication.

Front 101

side effects of internal radiation implants

Back 101

time (minimize time in room), distance (stand by door), shielding (stand behind lead shield). wear dosemetery badge. if seed dislodges place forceps in lead container. use logrolling to prevent dislodgement. low fiber diet to prevent straining.