FUND Exam 4 Study Guide PDF

Preview

Summary

fundamentals exam 4 study guide on Oxygenation, Sleep/Rest/Mobility, Cognitive/Sensory, Fluid/Electrolyte/Nutrition...

Description

Nursing Fundamentals Exam 4 – Study Guide 4 Competencies (Oxygenation, Sleep/Rest/Mobility, Cognitive/Sensory, Fluid/Electrolyte/Nutrition) 80 Points -Stages of sleep and characteristics within each Circadian rhythm  biological 24-hour cycle influenced by internal and external factors  fluctuations in HR, BP, body temp o hormone secretion, metabolism, mood Phases of sleep NREM (quiet sleep)  50-90 min 4 STAGES  stage 1- only a few minutes long, arouse very easily, somewhat aware of surroundings  stage 2- deeper relaxation, falls into sleep stage, still aroused easily, 50% of sleep time  stage 3- snoring, little movement. Depth of sleep increased, difficult to arouse. 10% of sleep  stage 4- deep sleep, slow brain waves, body functions decrease, sleep walking, bed wetting. 10% of sleep REM (active sleep)  20 minutes average  deepest stage of sleep  most dreaming done  darting eye movements  irregular respirations A single normal sleep cycle 4 stages of NREM, pattern is then reversed, instead of entering NREM stage 1 the person enters REM, reenters NREM stage 2 and so on.  This pattern is repeated 4 or 5 times, 90 min each Developmental sleep considerations Older adults  Recurrent insomnia  Need more time to fall asleep  Wake earlier and wake frequently in the night  Frequently nap during the day Focused assessment: sleep history  Sleep diary  Interview or questionnaires  “sleep study” diagnostic testing I. nocturnal polysomnography  obtaining physiologic data during sleep  sensors attached to head/body to record brain waves, eye movement, muscle tone etc II. multiple sleep latency test  assessment of daytime sleepers

-Interventions to promote sleep non-pharm methods  restful environment  bedtime rituals  appropriate bedtime snacks  relaxation  comfort  respecting normal sleep-wake cycle  schedule nursing care and minimize sleep disturbances pharmacological methods  short term use= benzos  long term= lunesta for chronic insomnia  ordered on a PRN basis sedative hypnotics  barbs  benzos  anti anxieties  -Sleep disorders (Narcolepsy, Hypersomnia, Insomnia, Sleep Apnea, Parasomnias, Nocturnal Myoclonus) Insomnia- difficulty falling asleep Hypersomnia- excessive sleep- still feels sleepy Narcolepsy- sudden onset of daytime sleepiness Sleep apnea- person stops breathing 10sec-2min  Wakes feeling tired  O2 sat drops Restless leg syndrome- nocturnal myoclonus Muscle contractions and jerking = insomnia Parsomnias  Somnambulism-sleep walking  Bruxism- teeth grinding  Enuresis- bed wetting -Proper body mechanics- part of illness prevention and health promotion  develop habit of erect posture (no slouching)  broaden your base of support  use the longest and strongest muscles  activate your “internal girdle” first I. abdominals and glutes  work as close to the object as possible I. center the load over the feet  avoid twisting your body  push rather than pull- use weight of the body  break up heavy loads in smaller loads, I. OSHA limit of 51 lbs  Review safe patient transfers

-Adverse effects of immobility and interventions to prevent/treat factors that affect mobility  mental health  lifestyle  attitude and values  fatigue and stress  external factors  MS/neurological problems Effects of activity and exercise Positive effects  Increase blood flow and oxygen to all body parts  Increase muscle mass, strength, mobility  Increase appetite, intestinal tone, and weight control  Increase rate of metabolism  Increase efficiency in maintaining f/e balance  Improved skin tone, and turgor  Improved appearance and self concept, improved sleep Risks related to exercise  Cardiac event  Orthopedic discomfort/disability  If injury occurs teach RICE 1. Rest 2. Ice 3. Compression 4. elevation Immobility= effects all body systems Respiratory effects  Decrease in depth of respirations  Decrease in RR  Risk for actelectasis I. Actelectasis= decrease in are exchange, you would hear no movement of air  Risk for hypostatic pneumonia I. Inactivity and immobility II. Secretions aren’t removed, bacteria grows III. Interventions= cough and deep breathe Cardiovascular  Orthostatic hypotension  Increased workload of the heart  Blood clot formation Metabolic  Less energy used  Nitrogen balance- more protein is broken down then manufactured  Catabolism- calories not supplied when increase in metabolism, body breaks down own proteins

GI  gas retention  stool retention  decreased appetite Urinary system  increased risk for UTI  renal calculi formation, high level of urinary calcium and decreased fluids Integumentary  Pressure ulcers  Friction/shear forces Psychological effects  Self esteem  Body image  Social isolation Nursing diagnoses related to mobility  Impaired bed mobility  Impaired physical mobility  Impaired wheelchair mobility  Activity intolerance Nursing Interventions Safe patient handling and movement  Movement and transfers I. Assistive devices: gait belts, slide sheets, etc II. Turning patient in bed, move bed up III. Transfer bed to stretcher, bed to chair IV. Logrolling patient (spinal or back injury, keep patient in straight alignment)  Positioning patients I. Pillows, mattresses, trapeze bar, etc II. Foot board or boots, hand rolls Nursing measures -Think safety first-

-Interventions for hypoxia Hypoxia= inadequate amount of oxygen available to cells. S/S of hypoxia= dyspnea, elevated blood pressure, small pulse pressure, increased respirations, clubbing of fingers, increased pulse, pallor and cyanosis. CNS s/s of hypoxia= anxiety, restless, confused, drowsy Causes of hypoxia= hypoventilation (decreased rate or depth) Can be chronic= detected in all body systems Nursing interventions to promote comfort: Positioning: should allow free movement of diaphragm and expansion of chest wall.

Dyspnea/orthopnea= most comfortable in high-fowlers position because accessory muscles can easily be used to promote respiration  Pulmonary disease= prone position promotes oxygenation. Posterior sections of lungs can get better ventilation Adequate fluid intake: Humidified air: moisturizes respiratory passages that protect irritation Promote proper breathing  Deep breathing (hypoventilation)  Incentive spirometry, visual reinforcement for deep breathing (actelectasis prevention)  Pursed lip breathing (dyspnea, panic) 

Coughing= cleaning mechanism of the body to keep airways clear of secretions  Voluntary coughing, preoperative and post operative care. More effective with deep breathing  Involuntary coughing, respiratory tract infections and irritations Treatment  Chest physiotherapy: loosens secretions. Ineffective cough and large amount of secretions  Airway suctioning: maintain a patent airway -Oxygenation assessment techniques Physical assessment: Inspect skin color, mucous membranes, appearance of chest, RR, rhythm, and depth Abnormal findings:  pallor of skin and mucous membranes  cyanosis  kyphosis  barrel chest  unsymmetrical chest movement  use of accessory muscles Palpate chest expansion, skin temp and color, pulses and cap refill Abnormal findings:  Edema  Tenderness  Masses  Chest expansion not symmetrical Auscultate to assess airflow. Normal: Vesicular: low, soft sounds (peripheral lungs) Bronchial: loud, hollow, high pitched (trachea) Bronchovesicular: medium, blowing (bronchi) Abnormal findings: Adventitious sounds  Crackles, high pitched popping  Wheezes, continuous musical sounds

-Diagnostics associated with oxygenation  CBC I. look at WBC for infection. H/H (hemoglobin and hematocrit)

  





 

II. Hemoglobin delivers oxygen to tissues III. Hematocrit measures the volume of RBC’s compared to total blood volume Cytologic studies/sputum collection I. examination of sputum. Detects malignant cells Pulmonary function studies I. assess respiratory function to evaluate respiratory disorders. Spiromentry I. measure air exhaled or inhaled. II. Lung function and airway obstruction Peak expiratory flow rate I. highest flow during forced expiration. II. Detects changes in size of pulmonary airways Pulse oximetry I. measures arterial oxyhemoglobin saturation of arterial blood. II. Post op patients, risk of hypoxia, those receiving o2 therapy, etc. III. Normal ranges 95-100, COPD 90-92 Capnography, I. monitors ventilation and blood flow in lungs, detects hypoventilation before pulse ox ThoracentesisI. puncture chest wall and aspirate pleural fluid. Obtains specimen for diagnostic

-Respiratory rate/pattern for infants and adults -Nursing diagnoses associated with oxygenation  ineffective airway clearance  ineffective breathing pattern  ineffective gas exchange  ineffective peripheral tissue perfusion Teach patient health  Lifestyle  Healthy weight  Exercise  Smoking  Nutrition Vaccinations Reducing anxiety Environmental pollutants -Oxygen delivery devices bronchodilators- open narrowed airways mucolytic agents- liquefy or loosen thick secretions corticosteroids- reduce inflammation nebulizers- meds get into deeper parts and absorbed by resp tract. MDI- controlled dose of medication with each compression Mistakes  does not shake canister  holding upside down

  

inhaling through nose and not mouth stopping when cold is felt in throat failing to hold breath DPI- breath activated. Require less manual dexterity. Actuated by patients inspiration so no need to coordinate delivery of puffs with inhalation Oxygen therapy: Requires a prescription In emergencies, it’s okay to administer without oxygen  Nasal cannula- 1-6 L good for eating and drinking. Low flow or high flow. Down side is dryness, mouth breathing  Simple face mask- 6-8L low flow, check placement  Partial rebreather- low flow, mask should be 2/3 full during inspiration  Nonbreather- low flow, monitor sa02 with pulse ox  Venturi- high flow careful monitoring to verify fi02 Artificial airways- used to preserve a functioning airway, unable to speak. -Communication must be part of the nursing assessmentoropharyngeal- mouth, keeps tongue clear, patients who are unable to maintain patent airway nasopharyngeal- nose, easy nasotracheal suctioning, patients who are unable to maintain patent airway endotracheal tube- nose or mouth into trachea, administer oxygen by ventilator tracheostomy- in trachea, sterile procedure, provide method of mechanical ventilation

-Abnormal findings related to oxygenation Factors affecting cardiopulmonary function and oxygen Level of health: acute/chronic illnesses can affect function. Renal/cardiac disorders = fluid overload, impaired tissue perfusion Anemia- decreased oxygen to tissues. Low hemoglobin = low carbon dioxide exchange (more on PPT) Developmental considerations: Infants: chest small and airways short = increased risk of aspiration -Surfactant produced 34/36 weeks gestation, premies have increased risk of collapsed aveoli = poor respiration and perfusion -belly breathers, fast RR 20-40/min, irregular rate and depth Toddlers: elongated and less angular. -frequent colds/resp infections common -increased risk of asthma -> second hand smoke Older Adultes: tissues of airways lose elasticity -decreased power in muscles, diaphragm -decline in max inspiration/expiration, airways collapse easy Medication considerations: drugs that affect CNS need to be monitored for respirations Lifestyle considerations: sedentary vs exercise

-culture plays role in lifestyle -smoking -role model as a nurse = more effective teachers Environmental considerations: air pollution, occupational exposures, etc Psychological considerations: stress can lead to hyperventilating, anxiety

-IV solutions isotonic: -same concentration of particles as plasma, no net movement of water -Expand volume, fluid resuscitation hypertonic: -greater concentration of particles than plasma, net movement of fluid into cells -NA, volume replacement, monitor for signs of hypervolemia hypotonic: lesser concentration of particles than plasma, net movement of fluid out of cells D5NS -Electrolytes and their functions (Potassium, Magnesium, Calcium, Sodium, Chloride) intracellular fluid=  fluid within cells  2/3 of body water  potassium primary electrolyte extracellular fluid=  fluid outside of body  1/3 of body water  sodium is primary electrolyte  2 major areas- intravascular fluid (plasma), interstitial fluids (lymphatic),  1 minor area- transcelluar fluids (CSF, pleural, peritoneal, and synovial) fluid balance in children and older adults children:  less able to concentrate urine, greater water loss through urine  greater insensible fluid loss  greater risk for fluid balance problems older adults:  less body water  sodium and water regulation less efficient  less thirst perception

-Assessment findings for hypovolemia and hypervolemia -Signs of malnutrition

-Interventions for confused patients -Characteristics of delirium, dementia, Alzheimer’s Disease -Sensory deprivation, perception, overload -Sensory deficits (different types and interventions)

Online recorded review session What happens in the various stages of sleep? Stage 1- light sleep, involuntary muscle jerking, easily aroused muscles Stage 2- relaxation, falling into sleep stage, easily aroused relaxed, into sleep stage Stage 3- snoring, relaxed muscle tone, little movement, snoring, relaxed muscles Stage 4- deep sleep, vitals decrease difficult to awaken deep sleep vitals increase REM- most difficult to awaken, dreaming, eye movement, vitals increase What are some interventions to help with sleep? Keep room dark, eliminate noises, white noise, routine, going to bed and getting up at the same time, small protein or carb snack, get up and move out of bed if unable to fall asleep in 20 min time frame (?) What are some things we do as nurses to interrupt sleep? Hourly rounding at night to get vitals or assessments, environmental factors (beeping, interruptions etc) Define the following Narcolepsy- uncontrollable desire to sleep, can happen anywhere Hypersomnia- excessive sleep, particularly during the day Eneresis- bed wetting during sleep Bruxism- grinding teeth during sleep Nocturnal myoclonus- jerking legs Somnambulism- sleep walking Important teaching tips for infant sleep? Safe sleep environment, always lay them on their back, no blankets, no toys, no crib bedding besides a sheet. Teaching safe sleeping is the most important tip for parents with infants

What are teaching points for a patient with osteoarthritis? Maintain body alignment, make sure they maintain a recommended body weight What are some postural abnormalities? Hip dysplasia- newborns Scoliosis and Lordosis- teens Kyphosis- elderly, person is hunched forward.  Osteoporosis= weakening of bones over time  Demineralization of the bone  About the calcium that moves out  1. causes blood to clot more easily  2. Renal calculi may form – what are these? Another name? (Kidney stones!)

Interventions: •Leg exercises •Range of motion •Physical therapy •Get patient up and ambulating Some effects of immobility? Effects on all body systems, one of the big ones is orthostatic hypotension -Orthostatic hypotension= blood pressure drops Interventions?  When sitting have them dorsi plantar flex their ankles  Change positions slowly  Sit on side of bed and dangle legs -Constipation Interventions?  Increase fluid/fiber -Increased cardiac workload -Contractures in the extremities -Pressure injuries -Blood clots -Pneumonia How do we prevent nurse-related injuries?  Use proper body mechanics (review slide in power point)  Use proper lift equipment  Request assistance when repositioning What are we assessing in our physical assessment of mobility?  General ease of movement  Gate and posture  Endurance  Alignment  Joint structure  Muscle mass, tone, and strength Ways to assess, you can watch:  How are they walking?  How do they move from chair to the table?  In and out of bed What is the optimal position for a patient with difficulty breathing? High fowlers

How do we prioritize patient care? If you have a bunch of patients to see, how will you prioritize? Tools you may utilize?  ABC’s= airway, breathing, circulation  Use maslows

What is a pneumothorax and hemothorax? Pneumothorax= air in the pleural space Hemothorax= blood in the pleural space Pleuracy= inflammation of tissues that line the lung and chest cavity How do we physically assess a clients oxygenation status? Respiratory rate, how does chest rise and fall? Is it symmetrical What does breathing pattern and effort look like? Normal respiratory rate for infants and adults Infants: 30-60 Adults: 12-20 What does an arterial blood gas measure? What does pulse oximetry measure? -here are a couple but do an overview of all of themABG= measures the adequacy of oxygen, ventilation, and perfusion Ventilation= movement of air in and out of lungs Pulse ox= non-invasive way to measure oxy hemoglobin of arterial blood  Book says 95-100 is normal, with patients above 92 is good  COPD normal 88-92%  pulse ox is a late sign of respiratory distress What is hypoxia? What are some nursing diagnoses associated with hypoxia? S/S=  Dyspnea  elevated bp  small pulse pressure  increased resp and pulse rate  pallor and cyanosis  anxiety  restless  confused  drowsy Diagnoses:  anxiety from the fear of not being able to breathe  Ineffective gas exchange (read over those) What is atelectasis? When alveoli collapse, you’ll tend to see dyspnea or difficulty breathing What will you hear when you listen to their lungs? You wont hear anything, sounds will be absent. Make sure you review some of the oxygen devices, what is a normal L/min for the devices Nasal cannula: low flow, up to 6L/min, not good for above. Simple mask: 6-8L/min

What are some interventions to prevent post-op pulmonary complications? Cough and deep breathe, early mobility, incentive spirometer Which direction does fluid move in the following: Isotonic: equal, same particles as plasma, no net movement Hypotonic: moves into cells, out of intravascular space, less particles than plasma Hypertonic: moves out of cells and into intravascular space, more particles than plasma

What makes up the fluid in our blood? Read over the main electrolytes and know their primary function and purpose

What are the functions of the following? Potassium: major cation of ICF regulate cellular enzyme activity, regulates cellular water activity CATION Sodium: helps control water distribution, primary regulator of ECF body fluid, regulated body fluid, maintain water balance CATION Calcium: structure in bones and teeth, most abundant in body, nerve impulses and transmission, blood clotting CATION Magnesium: metabolism, nutrition, carbs proteins CATION Chloride: maintains osmotic pressure in blood, produce hydrochloric acid, ANION What are signs of fluid volume deficit? (dehydration)  Thirst  low BP  less urinary output  tachycardia  orthostatic hypo/low blood pressure

 poor skin turgor  low potassium high BUN  high hematocrit, hmg unchanged  Nursing interventions  Assess for changes in LOC and vital signs  Administer oral fluids  IO  Daily weights  Assess for fluid overload  Skin care  Teach prevention What are signs of fluid volume excess?  Edema  Sob  Weight gain  Crackles in lungs and fluid starts to fill  High blood pressure, bounding pulse Nursing interventions  Decrease fluid in cells, hypertonic  Monitor breath sounds  Monitor electrolytes potassium and sodium  Elevate HOB  Limit fluids and Na  Teach fluid restriction Normal fluid intake per day? 2-2.5 L, 2000-2500 ml Most reliable indicator of a patients fluid balance? Daily weight What is hypovolemia? Low fluid volume, loss of both water salutes in the same proportion from ECF, dehydration if not treated What is biggest risk associated with n/v diarrhea? Dehdryation, fluid and electrolyte imbalance What is sundowning? Habitual agitation, restlessness, confusion that occurs after dark in the older population. Can be with dementia or without. What are some people/patients at risk for sen...