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345 Cards in this Set
- Front
- Back
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What are the 2 inflammatory GI disorders? |
1. Regional enteritis (chrohn's disease) 2. Ulcerative colitis
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who is commonly affected with Chrohn's disease? |
- common in adolescents and 2x as higher in smokers |
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who is affected in ulcerative colitis? |
- patients b/t 30-50 yo and prevalent in Caucasians and jewish persons |
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Chrohn's - what part of the GI tract is commonly affected? |
- any part of the GI tract but common in the distal ileum and ascending colon |
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Ulcerative colitis - what part of the GI tract is affected? |
- mucosal/submucosal layers in the colon and rectum |
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what is an option for treatment for Chrohn's disease? |
- surgery to remove portions of the bowel or to create a stoma (depending on where the diseased portion of the colon is located) - less curability through sx - recurrence is inevitable |
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What is an option for treatment for Uclerative colitis? |
- medications - increased risk of mortality b/c of systemic complications |
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T/F - Persons with Chrohn's are not at an increased risk of developing CA |
F- they are at an increased risk of developing CA |
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T/F - persons with ulcerative colitis have a 25% chance of developing colon CA |
F - they are at an ~5% chance of developing colon CA
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What are 3 barriers to a patients recovery? |
1. age 2. co-morbidities 3. compromised immune system |
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____________ is a big advancing part of our Healthcare system. |
Technology - we have the ability to keep a person alive on machines. As the illness and chronic diseases progress we will need to continue to advance and improve our technologies. |
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what are the 5 fundamental challenges our healthcare/hospital systems faces? |
1. funding/budget cut backs 2. closing beds/bed shortages 3. outbreaks (ineffective infection control) 4. patients wait for ALC (take up precious beds) 5. nursing/physician shortages (funding) |
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T/F - numbers of patients admitted to the hospital are increasing. |
F - numbers of patients being admitted to the hospital overnight are decreasing as they are being encouraged to rapidly recover to previous self care |
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what are the 2 nursing models of care? |
1. Team nursing - one nurse does all the bed baths, one nurse does all the VS, one nurse does all the Meds for all the patients for that shift 2. Primary nursing - one nurse does all aspects of care for their assigned patients for that shift |
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name one pro and one con for Team nursing. |
pro - efficient care con - decreased personal time with patients leading to decreased communication with patients |
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name one pro and one con for Primary nursing |
Pro - efficient care Con - cross contamination between the patients |
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Perioperative means? |
peri - the whole thing
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Pre-operative means? |
pre - from the patients decision to have the surgery to the patient lying on the OR table
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Intra-operative means? |
intra - In OR to lying on a bed in the recovery room in the PACU |
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PACU means? |
Post anesthetic care unit |
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Post operative means? |
Post - from PACU to home |
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list 6 roles and responsibilities of the nurse during the pre-operative phase. |
1. get informed consent 2. do a complete health history of the patient 3. get a baseline for VS 4. discus pain and symptom management after the surgery 5. diet and mobility restrictions/limitations/encouragements 6. respiratory instructions to take deep breaths/coughing |
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list the 5 types of surgeries (hint: elective) |
1. Emergent (no delay) 2. Urgent (appendix or C section) 3. required (THA/TKA) 4. elective (reconstructive) 5. optional (Laser eye Sx)
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List as many factors that will influence a surgical risk/outcome for a patient. |
1. Patients WT (fat tissue does not heal as well) 2. immune status/Age (young and old are immune deficient) 3. respiratory status (underlying co-morbidities - COPD/smoker) 4. nutrition - good wound healing 5. cardio - BP - controlled or uncontrolled HTN 6. Meds (currently taking, incl herbal and OTC) 7. health, medical, sxl hx 8. allergies 9 overall health of organs - liver and kidneys are the organs that help get rid of medications from the system if they are in good shape recovery from surgery is promising |
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What would be considered a physical impact of surgery on a patient? |
physical - scars/body image after surgery |
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List 3 major psychological impacts of a surgery on a patient? |
1. QOL after the surgery 2. fear of 'going under' and the 'unknown' 3. anxiety |
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with regard to spiritual, what does a patient do just before a surgery? |
- may rediscover faith in the sight of impending death (which may be very NB to that patient at that time) |
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Answer: technique where a vein is punctured through the skin by a sharp rigid styled (what is the term) |
Venipuncture |
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why do you not puncture an artery for IV/blood drawing? |
- increased pressure in artery and is not easily accessible (deep to vein) |
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What is the term used to describe both IV therapy and blood specimen procurement (hint: CBS) |
- phlebotomist |
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T/F - nurse is not the key person in caring for IV sites |
F - nurse is the key person in caring for IVs and IV sites to ensure no infection developes |
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R.E.P.T.I.L.E - means? |
R - redness E - edema P - pain T - temperature I - infection L - leakage E - emboli |
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What is the term to describe intellectually disciplined process of actively and skillfully conceptualizing, applying, synthesizing or evaluating information |
Critical thinking |
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T/F - IV therapy was first used in 1830s as a one time treatment for a single condition (EX. cholera) |
T - Cholera can cause profound fluid and electrolyte imbalances |
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VAD means? |
vascular access device - common and used for administration of fluids, meds, blood products |
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what is the common site of an IV |
AC (ante cubital) or dorsal vein |
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5 common purposes for IV insertion |
1. faster bioavailability 2. if patient does not/is not able to take oral medications 3. certain drug irritate GI tracts 4. used for trauma/unresponsive patients 5. replacement of TPN, blood, fluid, electrolytes |
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T/F - a doctors order is needed to begin an IV |
T - IV is considered similar to a med order |
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What 3 pieces of information must a doctor give on an IV order? |
1. Rate/hr 2. Type of solution to infuse 3. Timing (when to d/c) |
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NS, Lactated ringer, dextrose and water are examples of what? |
common IV solutions to help regulate the electrolytes in the body's circulation |
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what are the 5 main cations in the body's circulation? |
- Na - K - Ca - Mg - H |
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what are the 3 types of IV solutions? |
1. isotonic 2. hypotonic 3. hypertonic |
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what are the 4 main anions in the body? |
- Cl - HCO3 - P - sulfate |
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The major electrolytes in the body are controlled by what structure in the brain? |
- hypothalamus |
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This solution is most commonly used, will not cause a fluid shift b/t ECF and ICF and is used for rehydration. |
Isotonic solution |
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Who are at risk for overload? |
1. children 2. patients with kidney disease 3. patients with CHF
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this solution gives energy and water, can be used at 1/2 strength, and causes a shift from blood vessels into cells and interstitial spaces |
- hypotonic solution |
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what is the solution used to treatment hypernatremia? |
- hypotonic solution |
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causes fluid to shift into intravascular space from intracellular and interstitial space, not used for dehydration and is a treatment for Hyponatremia |
Hypertonic solution |
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PICC means |
Peripherally inserted central catheter |
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T/F - a PICC can not been inserted into the jugular vein |
F - a PICC can be inserted into the jugular vein |
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T/F - proper placement of a PICC line inserted is checked by the physician |
F - Xray |
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preferred placement for a PICC line is? |
- ACF - antecubital fossa |
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what is the #1 complication of a PICC line? |
- infections |
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what is meant by infiltration? |
fluid enters the surrounding area/tissue rather than the vein |
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what is an IV option that is typically used in Paeds patients? |
Port-A-Cath - LT/stable and discrete (goes underneath the skin) |
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what is meant by the saying "start downstream and move upstream to relocate IV site"? |
- want to move up the arm for placements of IV sites rather than down the arm as it decreases the chance of infection by moving up the arm for locations |
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What is a safe procedure that is becoming more common among Paeds patients if a venous access site is difficult? |
the Intraosseous access - rapid infusion directly into the bone marrow |
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Name 5 common factors that would affect the flow rate of an IV infusion. |
1. Height of the pole/or bag - the higher the quicker b/c of gravity 2. diameter/length of the tubing 3. viscosity of the fluid and solution 4. kinked tubing 5. clamp is still shut |
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what is meant by the term reconstitution? |
mixed at the moment before administration b/c the solution is not stable as liquid (drug is in powder form) and will need to be mixed just before infusion |
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what is meant by the term extravasation? |
irritent that damages tissues (chemo drug) |
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what is meant by the term phlebitis? |
red at site/inflammation at site |
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what is meant by the term hematoma? |
bleeding under the surface |
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what are the 3 major signs of a closed airway? |
1. cyanosis 2. choking/coughing 3. O2 sats are decreasing |
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what is meant by the term hypervolemia? |
inadequate cellular oxygenation with the inability to excrete waste products of metabolism |
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A patient can be confidently discharged from the PACU when they show these 5 signs |
1. VS stable 2. A&O x 3 3. controlled N&V 4. output is good 5. managed pain |
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what is meant by the term circulating overload? |
in HF patient there is an increased BP b/c heart is being overworked b/c of additional fluid and kidney cannot output fluid |
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T/F - there is more chances of infection with the IJ (intrajugular vein) over the PICC |
T - decreased chances of infection with a PICC line |
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T/F - the term Leukocyte reduce means to take out leukocytes from the blood |
T - it means to take out the leukocytes that may have been in contact and carry an existing pathogen |
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What is Pentaspan? |
this is an artificial blood (fake RBCs) |
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If a patient presented with an acute massive blood loss what type of blood would they receive? |
- whole blood |
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if a patient presented with symptomatic anemia what type of blood would they receive? |
PRBCs - packed RBCs |
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if a patient is deficient of clotting factors (hemophiliacs) what type of blood would they receive? |
FFP - fresh frozen plasma |
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DIC means? |
disseminated intravascular coagulation - the body has a problem forming a stable blood clot |
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what type of blood would you give a patient with DIC? |
platelets |
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what are the 4 classifications of blood? |
A, B, AB, O |
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What type of blood is the universal donor? |
type O
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what type of blood is the universal recipient? |
type AB |
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What does it mean by Group and Screen? |
Group - to get blood bag jus to have it ready Screen - check for compatibility |
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for blood IV do you use a small bore needle or Large bore needle |
Large bore - blood is chunky |
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T/F - start a blood transfusion fast |
F - start a blood transfusion slowly as any hemolytic or allergic reaction will happen with in 15min and can be fatal |
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what is the most common transfusion reaction? |
Febrile nonhemolytic - caused by WBC present in the unit of blood - can continue infusion |
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the elderly are at particular risk for this transfusion reaction. S&S include crackles, dyspnea and anxiety. |
Fluid overload, potentially too much infused too quickly - can continue infusion at a slower rate and change patients position |
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What is meant by the term TRALI? |
Transfusion related acute lung injury - potentially fatal - 1 in 5000 cases - WBC form and occlude the microvasculature of the lungs, pulmonary edema - can occur with in 4 hrs **stop transfusion |
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if the patient receiving a blood transfusion shows these signs - hives, itchy, increased breathing, swelling of airway, bronchial constriction - what type of transfusion reaction are they having? |
Allergic - usually mild and can give diphendydrinate (Benadryl) before transwfusion if patient has a hs of reactions - can continue infusion just at a lower rate and monitor patients S&S - if reaction was severe - then stop the transfusion (bronchospasm, laryngeal edema, shock) |
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Which transfusion reaction indicates the patients blood is incompatible to the blood donor? |
Acute hemolytic - human error and is preventable S&S - respiratory distress, dyspnea and chest tightness, febrile, decreased BP, flank pain (kidney) anxiety, hemoglobinuria (hgb is in the urine b/c the RBS were destroyed and kidneys excrete hgb as waste) **stop transfusion and push NS to maintain blood volume and renal fxn |
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injury and disease can lead to this complication as the body's adaptive responses (compensatory response) that balance the demand for Oxygen and nutrients is unable to maintain homeostasis |
shock |
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T/F - without intervention Shock can be fatal |
T - potential for multisystem organ failure |
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what is one early indicator of shock? (hint: BP) |
Narrowing Pulse pressure - the narrowing or decreasing pulse pressure is an early indicator b/c of a drop in the SBP |
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Nurses role in shock development. |
the earlier it is detected the greater the chance of the patients survival |
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Adequate blood flow to the tissue is regulated by these 3 things. |
1. cardiac pump 2. effective vasculature 3. volume (fluid and blood volume) |
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T/F - shock may develop rapidly or slowly |
True |
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name 2 management strategies when dealing with shock. |
1. fluid replacement - to restore intravascular volume and improve cardiac fxn (electrolytes) 2. nutritional support - to address dramatically increased metabolic requirements |
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List the 3 stages of shock |
1. Compensatory 2. Progressive 3. Irreversible |
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During compensatory shock what certain areas is blood constricted to protect what organs? (hint: 3 of each) |
blood is constricted to the skin, kidneys and GI tract and sent to the brain, heart and lungs to protect them |
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T/F - during compensatory shock skin is cool and clammy |
True |
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What is happening to the BP and RR during compensatory shock? |
BP = normal ( as the body is trying to maintain homeostasis) RR = increased b/c our body is now fighting for oxygen |
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What are 2 NB roles of the nurse during compensatory shock? |
1. monitor VS 2. monitor neurological - early indications of shock is confusion and combativeness |
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during the progressive shock stage how is the heart adapting to this change? |
- there is a loss of compensation and the MAP falls becoming Hypotensive and PP is narrowing - overworked heart becomes dysfxl, lack of oxygen leads to ischemia, biochemical mediators cause myocardial depression |
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Nurse will notice what changes neurologically in progressive shock stage? |
1. delirium 2. anxiety then later lethargy 3. confusion 4. decreased LOC 5. not A+Ox3 6. coma 7. stridor |
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what major dermatologic changes can a nurse see in progressive shock? |
1. delayed capillary refill 2. cold, pale, molted, cyanotic skin 3. diaphoresis and flushing |
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What major hepatic changes would a nurse see in progressive shock? |
1. unable to filter metabolic waste (ammonia, lactic acid), medications not filtered, unable to filter bacteria from blood |
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What renal changes would a nurse see in progressive shock? |
GFR not maintaining filtering therefore resulting in a decrease in urine output. |
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What is a Nurses role in Irreversible shock? |
encourage the family members to talk and touch the patient but also to consider speaking to the family about EOL and organ donation |
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What stage of shock is it when damage has been done to vital organs, weak, thread pulse, and apnea |
irreversible shock |
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What is the most common classification of shock? (hint: massive blood loss) |
Hypervolemic |
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A loss of 750-1300mL of blood, is what type of shock? |
hypervolemic |
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if a person looses 15-25% of their intravascular volume of blood what type of shock is it? |
hypervolemic |
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If a persons is showing these S&S skin is cold, clammy and they are clearly disoriented and restless what type of shock are they experiencing? |
hypervolemic |
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First step in management of Hypervolemic shock? |
establish a large bore IV and restore intravascular volume with fluids |
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If a person is experiencing sepsis (septicemia) what classification of shock is it? |
circulatory |
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A client has an IV and is taking prednisone what type of shock are they at risk for? |
circulatory (developing sepsis) |
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This type of shock is the most common cause of death in non-coronary ICU deaths |
Circulatory |
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list 4 causes of non-coronary deaths |
1. hypoxia 2. hyperglycemia 3. acidosis 4. hypoglycemia |
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T/F a patient with pneumonia could still be at risk for developing sepsis |
T - pneumonia is an acute illness that can spread to sepsis |
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A client has an IV, what is the nurses role in while monitoring the IV over a period of time? |
To question if the IV is still needed to decrease the patients risk of developing an infection that could lead to sepsis |
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describe the 3 identifiers of the first phase of septic shock |
1. increased HR (bounding) 2. hot and flushed skin 3. confusion |
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describe the 3 identifiers of the second phase of septic shock |
1. low cardiac output (BP drops) 2. skin is cool and clammy and pale 3. afebrile |
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T/F anaphylactic shock is preventable |
T - requires previous exposure |
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A patients throat is closing off, they have hives, skin is reddened and itchy, increased anxiety and increased HR, what type of shock could they be experiencing? |
anaphylactic (rapid onset and it is life threatening) |
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What two organs are the bodys buffering system? |
kidneys - regulate bicarbonate level in ECF by either retaining it or excreting it) lungs - control carbonic acid via ventilation by increasing respirations to attempt eliminate carbon dioxide or by decreasing carbon dioxide |
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if the client has a low pH level, what would the patient be experiencing? |
acidosis |
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if the client has a high pH level, what would the patient be experiencing? |
alkalosis |
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the patient has a pH level less than 7.5, increased amount of carbon dioxide as a result of inadequate ventilation - what is the patient experiencing |
respiratory acidosis as a result of OD or too much morphine in the patients system |
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the patient is experiencing respiratory depression, bradypnea, tachycardia, mentally cloudiness, high BP, guillian barre (temp paralysis) what is the patient experiencing? |
respiratory acidosis |
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a patients pH level is elevated above normal caused by hyperventilation and breathing very fast causing a decreased amount of carbon dioxide in their body what is the patient experiencing? |
respiratory alkalosis - breath into a paper bag (closed system) this will correct the carbon dioxide levels |
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the patient is experiencing a low pH, and low bicarbonate and the patient is diabetic and has not eaten for a period of time, what might the patient be experiencing? |
metabolic acidosis - administer bicarbonate to correct DKA (diabetic ketoacidosis |
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the patient has a high pH and a high bicarbonate as a result of vomiting, what might the patient be experiencing? |
Metabolic alkalosis - produced by a loss of acids (gastric suctioning or vomiting), or overuse of antacids, patient might experience tingling of fingers/toes, dizziness, nurse to replace fluids |
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this is a condition when the heart or blood vessels heart the heart do not develop normally before birth (invetro) often including the foramen ovale, what condition is it? |
congenital heart defect - defined as a disease and injury of the CV system, the heart, the blood vessels of the heart and the system of blood vessels (veins/arteries) throughout the body and w/in the brain - idiopathic in most cases but is connected with FAS and certain genetic inherited conditions (downs) and viral infections (rubella) |
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list 5 common S&S of congenital heart defects? |
1. heart murmur 2. blue baby - bluish tinge to lips, skin, fingernails 3. increased respirations/SOB 4. poor feeding, esp in infants b/c they tire easily while nursing/poor WT gain in infants 5. fatigue during exercise or activity in older children |
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Blood and fluids follow the path of least resistance and therefore problems with circulation are common and two common types of holes in the heart are: |
1. septal defect - most septal defects are congenital and are repaired during infancy (low morbidity/low mortality) 2. ventricular defect - more complicated /bc their proximity to the intraventricular conduction system and the valves makes this repair complex |
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list the 4 defects of Tetralogy of fallot that makes the level of oxygen in the body too low |
1. pulmonary stenosis - narrowing of the pulmonary valve causing an obstruction of blood flow from right ventricle to pulmonary artery 2. VSD - ventricular septal defect 3. overriding aorta - appears to arise from the right and left ventricle VS the left ventricle 4. Right ventricular hypertrophy - ventricle that worked too hard got larger than normal |
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What is the disease known as the silent killer? |
Hypertension - because persons can be asymptomatic for many years and ~90-95% have primary HTN (SBP >140mmHg DBP>90mmHg) |
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What are the two most prevalent type of CVD - one is hardening of the arteries, the other is the abnormal accumulation of fatty substances |
1. arteriosclerosis - caused by the angles and the curves of the coronary arteries contribute to the vessels being susceptible to plaques 2. atherosclerosis - abnormal accumulation of fatty substances/fibrous tissue in the Bessel wall, blocks and narrows blood flow to myocardium |
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This is the result of ischemia of the heart and includes chest pain but is not MI, what is the cause? |
Angina pectoris |
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Woman have more atypical clinical manifestations (nausea, indigestion, back pain), what is the cause? |
myocardial infarction |
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This has a paroxysms of symptoms in the anterior chest brought on by working out, stress, anxiety, what is the cause? |
Angina pectoris |
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this condition is characteristic of fluid overload resulting in the heart working harder. |
CHF (impaired cardiac pumping of the ventricles) causing congestion |
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this distinguishes R sided heart failure from L sided heart failure |
the appearance of the JVD while standing upright |
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what is meant by paroxysmal nocturnal dyspnea? |
decreased oxygen exchange as a result of fluid in the alveoli, patient experiences painful breathing and therefore no sleep while laying flat |
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if there is pink frothy sputum what might that indicate? |
potentially a pulmonary embolus |
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List 3 common blood thinning medications |
1. fragmin 2. heparin 3. dalteparin |
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What is the most common endocrine problems becoming even more common in children |
DM - is a multi-system disease related to abnormal insulin production or impaired insulin utilization |
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T/F - Type I DM - cannot use the insulin produced |
F - Type I DM - the pancreas stops producing insulin |
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T/F - Alpha cells and islets of Langerhans stop responding in Type II DM |
F - Beta cells and islets of Langerhans stop responding |
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What disease is the leading cause of non-traumatic amputation, blindness, ESRD? |
DM - very costly to the Healthcare system to manage DM and the complications associated |
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list 5 risk factors associated with DM |
1. family hx and genetics 2. aboriginal (high risk group) 3. gestational 4. elevated cholesterol levels (from fast food)/WT gain 5 Age (>40) |
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T/F - Type I is seen in ~90% of cases |
F - Type I is seen in 10% of the cases Type II is seen in 90% |
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List one function for each - Kidneys, ureters, bladder, urethra |
1. remove waste from blood to form urine 2. transport urine from kidney to blood 3. reservoir for urine 4. urine leaves the body |
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What organ produces hormones that regulate essential body functions like BP? |
kidney |
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What organ removes excess water from the body or retains it when necessary |
kidney |
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if you see edema in the feet, it may be caused by a malfunction in one of these organs (list 3) |
1. kidney 2. heart 3. liver |
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What organ in the body regulates RBC volume by producing erythropoietin (EPO) |
Kidney |
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What is the function of the hormone renin on our systems? |
to increase blood flow and increase BP, and to decrease urine output |
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the _________________ is the initial site of filtration of the blood and beginning formation of urine |
Glomarulus |
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what is the term for decreased urine production < 400mL (common sign of acute renal failure) |
Oliguria |
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What is the term for <50mL production of urine within a 24hr period |
Anuria |
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What are the 3 categories of ARF? |
1. pre-renal (above the kidneys) 2. intra-renal (reservoir/in the kidneys) 3. post-renal (below the kidneys) |
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Describe pre-renal phase |
hypofusion probably resulting from BP and volume depletion resulting from hemorrhage impaired cardiac efficiency resulting from MI, HF, dysrhythmias, cardiogenic shock, decreased CO - all can lead to Renal failure |
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Describe intra-renal |
parenchymal tissue dmg/actual dmg to the kidneys - trauma, medications that do dmg (nephron toxic agents), infection |
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what is the number one technique for infection prevention? |
hand hygeine |
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What is the pH range our body likes to try to maintain by homeostasis? |
6.8 - 7.8 |
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What test provides a true reflection of gas exchange in the pulmonary system. (hint: can only be done by physicians, trained nurses, lab techs, and RTs) |
ABG - arterial blood gases, used to evaluate a clients ABB and oxygenation, there is a high chance of bleeding a bruising after the blood is drawn, have to keep pressure on it for awhile , extremely painful procedure |
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T/F - when you see 'white' on an Xray that is good |
F - if you see white on an Xray that is bad potentially indicating pulmonary embolism, black on an Xray is good and indicates dead air space |
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LIst 4 modifiable risk factors for CVD |
1. stress 2. exercise (increase physical activity) 3. diet 4. smoking |
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List 3 non modifiable risk factors |
1. family hx 2. genetics 3. age |
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what is the term for a muscle deprived of oxygen and is primarily caused by atherosclerosis |
ischemia |
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what is the term for these characteristic - insufficient blood flow -> decreased oxygen supply -> the needs exceeds the demand of oxygen -> anaerobic -> lactic acid -> pain!! |
Angina pectoris |
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what are the two types of angina |
1. stable - predictable, consistent, typically occurs with exertion and relieved by rest 2. unstable - unpredictable, inconsistent, more frequent and lasts longer and can occur at rest |
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T/F - the appropriate answer for chest pain is 2/10 |
F - there is no acceptable level of chest pain |
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What are the enzymes indicative of MI |
these are present when there is muscle cell death - creatine kinase - myoglobin -troponin (appears first)
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if you suspect cardiac issues what are the 4 primary comfort measures? (hint: MONA) |
M - morphine O - oxygen N - nitrogen A - antigoagulants |
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to be effective what must be administered ASAP after onset of S&S of chest pains |
Thrombolytics - dissolves and lyse the thrombus including all blood clots present (do not give to a patient just out of surgery or experiencing a hemorrhagic stroke) |
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What analgesic reduces pain and anxiety while reducing preload and relaxing bronchioles? |
Morphine |
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SV depends on what 4 things? (hint: PACC) |
1. preload - the amt of myocardial stretch just before systole caused by the vol of blood within the ventricle 2. afterload - how hard the heart has to pump, the workload of the heart muscle having to overcome resistance and eject the blood 3. contractility - force of contraction means how hard the heart is beating, related to the # and health of the myocardial cells 4. compliance - degree of stretch or give, the force of contraction and recoil like an elastic |
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what is the term for having difficulty breathing while lying flat? |
orthopnea |
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what is meant by the term bibasilar crackles |
as heart failure increases, so does pulmonary congestion, decreasing patients oxygen sats. |
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what is meant by right sided HF? |
right side cannot eject/accommodate blood returning from venous circulation, leading to blood backing up into the peripheral and visceral tissues (edema in the legs) |
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what is the term for enlargement of the liver? |
hepatomegaly - RUQ engorgement of the liver |
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what is the term for accumulation of fluid in the peritoneal cavity |
ascites (client appears to gain wt but is just related to retention of fluids) |
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|
what are the effects of diuretics? |
Lasix - increases urine output - but could have a risk of losing electrolytes such as K/Na in the urine Furosemide - increase urinary output at loop of henle |
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what are the effects of digitalis/digoxin? |
similar to beta blockers by slowing the HR and BP by improving the contractility of the heart |
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what is the term for accumulation of fluid in the lungs? |
pulmonary edema - SOB, restlessness, anxious, cyanosis (nailbeds) pink frothy sputum (L sided HF) |
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what is the term for abnormal accumulation around the heart? |
pericardial effusion - resulting from an advanced HF, a feeling of chest fullness, a decrease in BP |
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____________ shock is the hearts inability to pump blood and adequate oxygen to the body affecting all body systems |
cardiogenic |
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describe the respiratory, skin and neuro S&S of a patient with pulmonary edema |
Respiratory - decreased respirations, dyspnea Skin - moist, cool, grey ashen Neuro - confusion, stuperous, difficult to arouse, attunded (decreased LOC) |
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Key to DM is keeping a close eye on ___________ _________ and management with ______________ |
- blood sugar - insulin - insulin moves sugar and controls the level of glucose in the body by regulating the production (pancreas) and storage of glucose in the body or used as a synthetic insulin for patients who cannot produce insulin effectively |
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characterized by elevated levels of glucose in the blood indicates what diagnosis |
hyperglycemia |
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kidney failure leads to what medical intervention? |
hemodialysis - this is an artificial kidney that cleans the blood outside the body - filters out waste, excess fluids, and electrolytes not able to be excreted through the urine |
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DM is the cause of 3 main health complications |
1. heart disease 2. kidney disease 3. peripheral vascular disease |
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first sign of DM is what? |
frequent urination and increased thirst |
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T/F - Type I DM is genetic |
F - you do not inherit Type I DM you inherit a pre-disposition to developing the disease (found in people with HLA - human leukocyte Ag) |
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|
these are malfunctioning and not producing insulin therfore exogenous insulin is administered. |
pancreatic beta cells (autoimmune) |
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glucose derived from food cannot be stored in the liver but instead remains in the blood stream and contributes to the blood sugar increase. this is called? |
hyperglycemia (post prandial glucose increase) |
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what is the term for when the glucose is in the urine? |
glucosuria - glucose in the blood is more than the renal can filter, and the kidneys can not reabsorb all the glucose |
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Type I or Type II DM has an insidious onset? |
Type II - may take years, very slow to progress |
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T/F - may develop DKA as a complication of Type II DM |
F - will not develop DKA as the body does not break down fat for energy as in patients with insulin deficiency, they have stored fat as a source of energy, resulting in production of ketone bodies as the fat is broken down which can lead to DKA - type II is not insulin deficient but does not use the insulin it produces. |
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T/F - 75% of the time DM is found by accident |
T - found incidentally throught routine or incidental testing |
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what is a complication of gestational diabetes |
increased chances of developing Type II DM in ~5 years post delivery |
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What are the 3 major complications associated with DM? |
1. Macrovascular - changes in the medium to large blood vessels, blood vessels walls thicken, harden, and become occluded - leading to peripheral vascular disease, cardiovascular disease, MI, stroke 2. Microvascular - affects retinas and kidneys - leading to renal disease, retinopathy (legal blindness) 3. Neuropathic - stress, self esteem, numbing of feet/toes, decreased healing |
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Of the three complications of DM which one is strictly unique to DM? |
Microvascular - legal blindness - retinopathy |
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What is the technique for assessing neuropathy in DM patients? |
test 10 spots on both feet to see if patient can feel it, if no feeling then the patient is a risk for developing ulcers
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What is the danger of DM patients getting a cut on their foot? |
* The cut may not heal properly or at all. ulcer -> necrotic -> gangrene -> amputation - 15% of people with DM will develop a foot ulcer - 14-24% of those who have a foot ulcer will have a major amp. b/c of lack of healing wounds - 35% of those people who have had an amp. will have another ulcer within a year |
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what is the term for a patient with low BS? |
hypoglycemia - an imbalance b/t glucose and inslulin |
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hyperglycemic hyperosmolar nonketotic syndrome indicates? |
HHNS - more likely to occur in Type II b/c there is a scant amount of glucose circulating in the blood |
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what is the term for when the body uses carbohydrates, and cannot access carbs the body then looks for ketones to use for energy |
DKA - diabetic ketone acidosis - not enough insulin, patient is ill, or initial presentation of DM if undiagnosed or untreated
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what is the misconception when a DM patient is experiencing N&V |
they may think that since they are not eating anything and since they are vomiting they do not need to take their insulin, when in fact this is possibly the opposite as illness may increase BS levels and the patient may need to increase their insulin dosage |
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these are acids that disturb the ABB of the body when they accumulate in excessive amounts and the patients breath smells fruity |
ketones |
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what is the term when the patients breathing is very deep but not labored? |
this is the body's attempt to decrease the acidosis, counteracting the effect of ketone buildup |
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T/F - patients with DM can soak their feet |
False |
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T/F - patients with DM should eat 3 large meals a day |
F - should eat smaller meals but at the same time each day |
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BS levels normal range pre and post - prandial and the critical values are what? |
Pre-prandial 4-7 mmol/L post-prandial 5-10mmol/L critical values <2.8 or >20mmol/L |
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S&S of Severe Hypoglycemia |
- LOC - seizure - disoriented - decreased LOC |
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T/F - for a DM experiencing hypoglycemia they should eat a donut |
F - better choices are carbs, juice, pop, candy - the sue of cookies, cakes, donuts to tx hypo may slow the absorption of the glucose b/c of their increased fat content |
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what are the 3 'polys' of hyperglycemia? (hint: output/thirsty/hungry) |
- polyuria (increased output) - polydipsia (increased thirst) - polyphagia (hungry - the body is not using sugar so you still feel hungry) |
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what is the life span for an RBC? |
~120 days
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this RBC and glucose complex is permanent and lasts the life of the RBC, what is the name of this item? |
glycosolated hemoglobin - a test is done to show the average blood glucose levels over a period of time which test the amount of BS presenting on an RBC |
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List the 3 main characteristics of the insulin types that a nurse looks for when doing their checks |
- time/course of action - species - manuacturer * RAPID - onset 10-15min * FAST ACTING - onset 1/2 hour to 1hr * LONG ACTING - 3-4hrs * EXTENDED - 90min |
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when administering insulin what needs to be done? |
double check the type of insulin to make sure you are administering the correct type |
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Describe post-renal |
- obstruction of blood/urine causing a urinary tract obstruction (distal to the kidneys) |
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list the S&S of mild hypoglycemia |
- tired/fatigued - confusion - tachycardia - diaphoresis - tremor - palpitations - nervousness - hunger |
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list some S&S for moderate hypoglycemia |
- irrational/combative behavior - numbness of the lips/tongue - harder to concentrate - overall 'not feeling well' - slurred speech - dbl vision |
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pre/intra/post- renal - a patient sustained increased blood loss during surgery |
pre-renal (volume depletion resulting from hemorrhage) |
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pre/intra/post renal - a patient experiencing complication from tattoo/piercing |
intra-renal (infection) |
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pre/intra/post renal - developing prostatic hyperplasia |
post-renal (obstruction to the urinary tract) |
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pre/intra/post renal - accidently took too much altace |
intra-renal (nephrotoxic - medications that do dmg) |
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pre/intra/post renal - hemolytic transfusion prescritpion |
intra-renal (nephrotoxic - medications that do dmg) |
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pre/intra/post renal - trying to loose weight for wrestling |
pre-renal (impaired cardiac efficiency resulting from MI, HF, dysrhythmias) |
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pre/intra/post renal - tobramycin and ACE inhibitors |
intra-renal (nephrotoxic agents - medications that do dmg) |
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pre/intra/post renal - has neurogenic bladder |
post-renal (obstruction of blood/urine) |
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decrease of this electrolyte can lead to dysrhythmias an cardiac arrest (Hint: tx with Kayexalate) |
potassium |
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D50 helps move what electrolyte into the cells to stop excess from circulating |
potassium |
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|
what is the leading cause of CRF and ESRD |
diabetEs = Epidemic = ESRD (with ESRD there is no chance the kidney can recover) |
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T/F - there is a recovery period for ARF |
T - can take up to a year for function to return |
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Uremia is ? |
retention of urea - can lead to uremic frost, a white frost like appearance on the skin |
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Azotemia is? |
retention of other nitrogenous wastes and creatinine |
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|
describe brittle bone disease |
Osteodystrophy - a condition of Calcium and phosphorus imbalance - b/c of decreased glomerular functioning, phosphorus increases so body will try and decrease calcium, then the body will try and increase calcium by leeching it from the bones, patient will need to take phosphate and calcium supplements
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T/F - there is a cure for CKD |
F - there is no cure - you just want to slow down the process by controlling DM and HTN thereby bettering the patients QOL, management is accomplished primarily by meds and diet therapy and dialysis may be needed to decrease level of uremic waste products in the blood. |
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5 important care considerations for the dialysis access site |
1. auscultate for bruit - over the fistula to hear the 'woosh' sound 2. palpate for thrill - feels like a bee 3. do not take BP on that arm 4. monitor site for infection (REPTILE) 5. steel syndrome - circulation problems (cool hand) - this is an emergent situation and needs tx right away |
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|
thyroid produces what 3 hormones |
1. T3 - triiodothryonine 2. T4 - thyroxin 3. calcitonin |
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primary function of the thyroid gland |
to control cellular metabolism |
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T/F - disorders of the thyroid gland are treatable and correctable |
True |
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|
this condition is common in 2/100 persons |
hypothyroidism |
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this complication of hypothyroidism is seem mainly in patients over >50yo |
Myxedema - severe swelling that can lead to coma or death if not treated |
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|
S&S of myxedema |
- decreased mental awareness - apathetic - speech is slowed - tongue enlarged - increased size in hands and feet
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this condition related to hypothyroidism is more common in women than men characterized by a goiter |
Hashimoto's disease |
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T/F - you give hormone replacement to Hyperthryroidism |
F - you give hormone replacement to Hypothyroidism - anginas and dysrhythmias may occur when thyroid replacement is initiated b/c thyroid hormones enhance the cardiovascular effects of catecholamines (hormones made by the adrenal glands s/a epinephrine, dopamine, and norepninephrine) |
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these S&S are characteristic of what condition - decreased energy, brittle nails, dry skin, numbness in fingers, hair loss, change in bowel pattern, constipation, gender bias in women |
Hypothyroidism |
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What is the 2nd most common endocrine disorder after DM? |
Hyperthyroidism |
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these S&S are characteristic of what condition - amenorrhea, decreased WT, hyperexcitable, agitation, moist skin, startled face expression, photophobia, hair is fine and soft |
Hyperthyroidism |
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|
Stress, infection and shock could potentially lead to this in patients |
Graves disease - abnormal stimulation of thyroid gland that causes hyperthryoidism |
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|
tapping over a facial nerve is a sign of what? |
Hypocalcemia - called Chvostek |
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|
when you start taking a BP and the bends at the wrist what is this reflex called |
trousseau |
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|
what particular areas of the spine are usually involved in SCI? |
C 5,6,7 T 12 L 1 |
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list 6 common causes of SCI |
1. physiological (congenital/MS) 2. falls (how/where you fall, the distance you fall and what you hit on impact of fall) 3. Trips (work place accidents) 4. Diving accidents 5. At risk behaviors (GSW) 6. sports injuries (compression #s) 7. MVA (T-bone type of accidents) |
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what is a major concern and complication from a bed ridden patient? |
bed ulcers (can be fatal) - Christopher Reeves died of an unhealed infected bed sore |
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dmg to the SC from direct injury is referred to as? |
primary injury -direct injury to the SC itself (Ex. transection) - initial insult or trauma, usually permanent - SC injuries produce a state of shock, characterized by flaccid paralysis, and complete loss of skin sensation at the time of injury, the most and sensory losses that prevail a few wks after injury are usually permanent |
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dmg to the bones, soft tissue, or blood vessels surrounding the cord is referred to as? |
secondary injury (indirect injury) - once the initial injury resolves ex. swelling goes down, there can be regaining of function, thought to be reversible after about 4-6 wks |
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|
Name 3 impacts on a person surviving a SCI |
- economic (loss in terms of work disruption) - psychological (potential loss of hope) - emotional (role changes in family/depression) |
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|
concussion? |
dmg to the brain caused by a violent jarring or shaking with temporary loss of neurologic function with no apparent structural damage - dmg will not show up on tests, have to rely on witness accounts of what happened as well as the S&S of the patient - never ignore a blow to the head, take time to recover, your brain needs time to heal (cannot read, zero activity)
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contusion |
injury that does not disrupt the integrity of the skin, caused by a blow to the body and characterized by swelling, discoloration and pain |
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laceration |
tearing, torn, jagged wound of the skin |
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complete transsection |
spinal cord is severed/cut in half completely |
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compression |
pinching of the spinal cord |
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why is SCI a medical emergency? List 5 things the medical team should do/consider on the patients arrival to the ED |
- presume it is a SCI until r/o - keep head and neck in a stable/neutral position (neck collar) - immobilization - stays on back board - diagnostics (Xray, CT, MRI) |
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incomplete injury indicates? |
the ability of the SC to convey messages to or from the brain is not completely lost/severed - depending on the location of the injury some sensation and motor may be felt below the injury |
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|
complete injury indicates |
total lack of sensory and motor function below the level of injury - the absence of motor and sensory function below the injury site down not necessarily mean that there are no remaining intact axons or nerves crossing the injury site, just that they do not function appropriately following the injury |
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what is the term for putting limbs, bones, group of muscles under tension by means of weights and pulleys to align or immobilize the part to reduce muscle spasm or to relieve pressure on it? |
Immobilization |
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What is the term for when a bone is put in the right direction to promote healing? |
reduction of fractures |
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what is the term for the orthopeadic device used to help immobilize the neck and head |
halo vest |
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muscles lose sensation, paralysis and flaccidity, reflexes are absent, bladder and bowel affected, insert an NG tube, what is this indicating? |
spinal shock - sudden depression of reflex activity in the spinal cord below the injury |
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bleeding from wounds, bleeding from gums, bleeding from nose - can be a complication of what? |
the patient taking blood thinners (heparin) |
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exaggerated autonomic response, severe pounding headache, paroxymal hypertension, what are these S&S for? |
Autonomic Dysreflexia - it is the body's response to something that is annoying it (hyper-sensation) - considered emergent - can increase BP (MI) and decrease HR, could cause a stroke/seizure - remove causes of irritation p bladder emptied via in/out cath, rectum examined for fecal mass, skin examined for any breakdown or redness, check for any object s on skin, cold draft |
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what is common in a bladder of a patient with paralysis? |
over-distension as there is no sensation in the bladder - intermittent cath/self cath is encouraged to empty bladder regularly (be on a schedule) |
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|
disuse syndrome refers to what? |
contractures from muscle atrophy - hard to reverse contractures |
|
|
heterotrophic ossification |
bone grows where it ought not to grow |
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|
what are the stages of grief (hint: DABDA/R) |
denial anger barganing depression acceptance/resolution
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|
list some high risk areas for pressure ulcers |
occipital ear scapula elbow sacrum/coccyx greater trochanter medial condyla of tibia ankle - lateral/medial heel |
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|
what is the range for the score on the braden pressure ulcer risk assessment scale |
6-23 - the lower the score the higher the risk of pressure ulcer development |
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|
AIP is? |
acute intracranial pressure - includes diseases and disorders that can increase intracranial pressure - this is uniquely challenging to a nurse as these disorders are complex and life threatening and most are irreversible and can devastatingly change a personal QOL |
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|
list some disorders that can lead to ICP increases? |
hydrocephalus CVA stroke brain aneurysms seizures tumors injuries (TBI - teens/young adults are at increased risk due to their risk taking behaviors) |
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|
ALOC is? |
altered level of consciousness - confused drowsy, difficult to arouse, not responding appropriately, verbal response altered, not responding to commands |
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|
List 3 reasons for development of ALOC |
1. Neurologic - stroke, ABI, trauma, psychiatric, seizure 2. toxicologic - OD 3. metabolic - insulin levels, ketoacidosis, electrolytes (hyperkalemia), infection, uremia |
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T/F - even seemingly minor injuries can cause significant brain dmg |
T - hockey game - girl was struck in head with a puck, walked out of game seemingly ok, then later died with in 72hrs |
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|
brain cannot store ___________ and _____________ which allows for cellular dmg to coccur in minutes |
- oxygen -glucose |
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|
T/F - ABI are more common in women than men |
F - more common in men as they take more risks, esp with drugs and alcohol present |
|
|
typical S&S of brain injury include: |
- stiff neck nasal discharge LOC scalp wound fracture swelling, bruising |
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|
T/F minor variations in CSF pressure is normal |
T - coughing, sneezing, straining, valsalva maneuver all alter the CSF pressure w/in the brain slightly |
|
|
typical S&S of ICP |
constant headache (increasing pain) progresses to stupor (partially aware of surroundings) abtunded (unable to follow commands) fixed/dilated pupils |
|
|
cushings response |
occurs when cerebral blood flow decreases significantly, requires immediate intervention, recovery is possible |
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|
Cushings triad |
Bradycardia, HTN, Bradypnea - decreased respiration is a grave sign - herniation - ICP is increased so much it is causing a herniation which his an occlusion of blood flow |
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|
typical S&S of seizures include: |
laughing eyes rolling back in the head shaking convulsing stiff or jerky |
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|
this condition is caused by a sudden discharge from cerebral neurons that may be genetic, a tumor, trauma related, infection, increase in T, or idiopathic, what condition is this? |
seizure |
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this describes what type of seizure - intense rigidity followed by muscle relaxation and contraction |
tonic clonic seizure |
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|
rigid limbs - what type of seizure |
tonic |
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|
relaxed and constricted jerky movements - what type of seizure |
clonic |
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|
dmg to cerebral cortex, plantar flex, arms straight/fists pronates - what type of seizure |
decordicate seizure |
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|
dmg to brain stem - internally rotated, arms flexed - what type of seizure |
decerebrate seizure |
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|
status elipticus |
will not regain consciousness |
|
|
postictal refers to? |
-after the seizure - the patient will be ha, fatigued, have a headache, sore muscles, depressed |
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|
nurses role during a seizure |
1. record the type 2. the duration 3. behaviors |
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|
nurses role after a seizure |
- document the events leading to and occurring during the seizure |
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|
this occurs when there is ischemia (inadequate blood flow) to a part of the brain or a hemorrhage into the brain that results in death of brain cells - what is the term for this event |
CVA - cerebral vascular accident or a stroke - 80% of strokes are caused by ischemia/20% are caused by hemorrhagic |
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|
what tests are done to determine if a stroke is hemorrhagic or ischemic? |
- CT scan - MRI |
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|
the pipes have burst - refers to what type of stroke? |
hemorrhagic- resulting in deaths of the cells surrounding the burst vessel |
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|
the pipes are blocked - refers to what type of stroke? |
ischemic - blocked to part of the brain - cell death to anything directly after this vessel |
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|
also referred to as a mini stroke |
TIA - transient ischemic attack - lasts from seconds -> min -> hours - you can recover from this as this does not last longer than 24 hours, this is a very big warning sign that there is a risk factor for another more potentially serious stroke |
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|
the deficits seen with a stroke - name 5
|
- facial drop - slurred speech/or aphasia - confusion - bladder loss - cannot obey commands
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|
|
F.A.S.T stands for |
Face - ask the person to smile Arms - look for pronator drift Speech - repeat a simple phrase Time - any signs don't waste time call 9-1-1 |
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|
what is meant by global aphasia |
overall loss of speech |
|
|
what is meant by expressive aphasia |
cannot get the words out but understands what you are asking |
|
|
what is meant by receptive aphasia |
cannot understand what you are asking and does not respond appropriately |
|
|
what is meant by apraxia |
inability to perform previously learned tasks |
|
|
what is meant by dysarthria |
difficulty speaking |
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|
why would a stroke patient admitted to 7th floor at UH - neuro, be placed on NPO? |
potential for dysphagia - the patient that is a new admit, will need to have an assessment by a SLP, preferably to have an assessment w/in 24hours, otherwise there will need to be an NG tube inserted, until the assessment can be completed |
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|
severe headache, pain and rigidity in the back of the neck are S&S of what? |
hemorrhagic stroke - can go unnoticed and undiagnosed until symptoms arise |
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|
recommendation for a patient that has just had a hemorrhagic stroke |
Bed rest with sedation to give the brain a chance to recover - no moving around at all, no reading no tv |
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|
characterized by fluctuations cognition,, mood, attention, arousal and self awareness, onset is typically sudden and my be accompanied by hallucinations, disturbed sleep-wake cycle, and may be caused by an infection, dehydration, or medications. what condition is it? |
delirium |
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|
what is the most common complication of hospitalization of older adults? |
delirium |
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T/F delirium is associated with increased morbidity and mortality |
T - should be considered a medical emergency as it can be life threatening |
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|
T/F - delirium can be seen in children with high fevers |
T- as well as in patients who are terminally ill but most frequently in older adults |
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|
T/F - 45% of the time delirium is diagnosed incorrectly |
F - 75% of the time it is under recognized by nurses and doctors
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|
T/F older adults lose their STM, repeat themselves, and show impaired judgments |
F - not normal in the elderly for them to lose their STM, have repetition, and impaired judgements these are typical S&S of delirium |
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|
These are characteristic of what disorder - change in memory, change in thinking and intellect, change in problem solving and judgement |
delirium - these are not seen in depression or dementia |
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|
This condition develops rapidly, usually within hours to days and fluctuates during the course of the day, what is the condition? |
delirium |
|
|
what condition is typically caused by physiological consequences of a patients medical condition? |
delirium - underlying etiology is based on the patients medical condition, fever, an infection, an addiction, a medication, and is reversible if caught quickly |
|
|
what is the hallmark to delirium |
a change in consciousness [this sets it apart from depression and dementia] - not A&O, disoriented to time (lose first), place, then person (unusual for a person to not know their own identity) - the individual is generally aware that something is very wrong - response is often one of fear and anxiety |
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|
UTI and pneumonia are common causes of what condition? |
delirium |
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|
when you are confronted by an elderly person who appears confused what should you ask yourself? |
is this dementia? delirium? or depression? |
|
|
if a patient is confused on admission what should you do first? |
determine if it is confusion and if it is new or different than their cognitive baseline by asking the family members if this is in fact odd behavior for this particular patient |
|
|
a patient should be assumed to be ______________ until proven otherwise (hint: confused) |
delirium is a medical emergency, must identify predisposing and precipitating factors promptly |
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|
T/F - the elderly may not develop typical S&S in response to an infection |
T - they may also be too confused to report the S&S, or the S&S are misdiagnosed as they are mild, obscured or nonexistent. EX - acute MI presents with chest pains but perhaps in the elderly this may present as only mild pain or acute fatigue |
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T/F - some delirium patients may require psychotherapy(PTSD) to resolve any residual effects of their hallucinations |
T - the delirium/hallucinations/illusions are very real to the patient, the patient experienced/felt/witnessed/lived them and it will never leave the patient |
|
|
diminished interest/pleasure in activities most of the day, nearly everyday for 2 wks |
depression - not just sadness, you can get over being sad, you cannot just get over being depressed |
|
|
hyperinsomnia is characteristic of what? |
depression - sleep changes either sleeping all the time or none of the time (insomnia) |
|
|
poor concentration, indecisiveness, feeling of worthlessness are characteristics of what disorder? |
depression |
|
|
progressive deterioration of thinking ability and memory is characteristic of what disorder? |
dementia - the brain becomes damaged with no change in conscousness |
|
|
loss of memory, judgment and reasoning, changes in mood, changes in personality and behavior are characteristic of what condition? |
dementia |
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|
T/F Alzheimers disease is the most common type of delirium |
F - AD Is the most common type of demetia in older adults and is a devastating disease that affects the patient and the patients family - progressive degenerative neuro-cognitive disorder with loss of memory, impaired memory, and thinking skills |
|
|
what is the second most common type of dementia |
vascular dementia - multiple infarct dementia, is an insidious onset and progresses slowly, causing an interruption of blood supply to the areas of the brain by thromboembolism, hemorrhage, or ischemia
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|
inability to set goals, failure to make plans, does not think things through, failure to initiate, failure to discontinue actions and unaware of limitations, does not recognize and correct errors in grooming, dressing, eating is characteristics of what conditon |
Vascular dementia |
|
|
medications prevent the break down of the neurotransmitters (Ach) which slows the process of degeneration. what condition is this? |
AD - breaks down the NT stopping the messages from sending/recieving |
|
|
stage one of AD |
no impairment to minimal impairment/normal forgetfulness - frequent recent memory loss, particularly of recent conversations and events - repeated questions - some problems expressing and understanding language - mild coordination problems - mood swings - need ADL cuing |
|
|
stage two of AD |
- can no longer cover up the problems - memory loss, including forgetfulness - inability to recognize friends -lost in familiar settings - slowness, rigidity, tremors - need reminders and assistance with ADLs |
|
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Stage three of AD |
- confused about past and present - loss of ability to remember, communicate, process information - severe to total loss of verbal skills - unable to care for self - falls and immobility likely - incontinence - problems with swallowing - extreme mood swings, behaviors and hallucinations, delirium, sz - person needs round the clock support |
