| what is first line treatment of hypertension | ACE inhibitors |
| What is the mode of action of ACE inhibitors? | Works in the RAAS system - ACE inhibitors works in the lungs by inhibiting the conversion of angiotensin I to angiotensin II which Reduces vasoconstriction and Decreases aldosterone secretion from the adrenal gland = loss of fluid and sodium in the urine |
| Side effects of ACE inhibitors? | GI upset, persistent dry cough, dizziness, anemia,
hyperkalaemia, hyponatraemia, angioedema |
| What is the mode of action of calcium channel blockers? | Inhibit the movement of calcium ions across cell membranes of myocardium and arterial muscle cells (stops action potential- block heart muscle cell contraction, Depresses myocardial contractility, Relaxes and dilates arteries
Decreases BP and venous return |
| Nursing considerations for ACE inhibitors? | *Take 1 hour before or 2 hours after food
*Teratogenic
* Warn patient to avoid dehydration and excessive perspiration as it may lead to a greater fall in BP, increasing the risk of fainting, therefore patient should maintain hydration within prescribed limits
*BP is recorded every 15 minutes for 1 hour after the initial dose and, if a hypotensive response occurs, place the patient in a supine position
*NSAIDS react with medications |
| Side effects of calcium channel blockers? | peripheral oedema, skin flushing, rash, liver damage, heart block |
| Nursing considerations for calcium channel blockers? | *No grapefruit (increases serum levels)
*Good oral hygiene - risk of gingiva hyperplasia
*Swallow whole -dont crush or chew
*Monitor blood pressure and pulse |
| What is the mode of action of thiazide diuretics? | inhibit reabsorption of sodium and chloride at the beginning of the distal convoluted tubule which promotes excretion of water and sodium resulting in increased urinary volume |
| Side effects of thiazide diuretics? | • GI irritation
• Thirst
• Polyuria
• Electrolyte imbalances (hyponatremia and
hypokalaemia).
• Postural hypotension |
| Nursing considerations of diuretics? | *Monitor for dehydration
*Monitor renal function and electrolytes
*take in the morning due to polyuria |
| What is the mode of action for Angiotensin 2 receptor blockers? | Works in RAAS. Selectively binds to ACE 2 receptors sites in vascular smooth muscle and adrenal cortex. Blocks vasoconstriction and release of aldosterone which decreases blood pressure. |
| Side effects of ARBs? | hypotension, dizziness, syncope, dry mouth, resp tract infections |
| Nursing considerations of ARBs? | *Assess blood pressure and pulse routinely
*Monitor potassium levels - hyperkalemia
*Teratogenic - can cross placenta
*Falls risk due to hypotension
*Avoid potassium substitutes |
| What is the mode of action for beta blockers? | Beta 1 adrenergic receptor blocker – blocks receptor sites in the myocardium preventing epinephrine from binding to receptors causing decrease heart rate, contractility and cardiac output and reduce the release of renin |
| What are the side effects of beta blockers? | gi upset, dizziness, bradycardia, cold extremities, CNS effects |
| Nursing considerations for beta blockers? | • Withheld less than 60bpm
• advise to change positions slowly to prevent
orthostatic hypotension
* monitor blood glucose |
| What class is digoxin from? | cardiac glycoside |
| what is digoxin used for? | Heart failure and atrial fiblliration |
| What is the mode of action of digoxin? | Inhibition of the sodium pump increases intracellular sodium and increases the calcium level in the myocardial cells causing an increased contractile force of the heart. indirect effect : Stimulates parasympathetic nz via vagus nerve- leading to sinoatrial (SA) and atrioventricular (AV) node effects that decrease the heart rate |
| Nursing considerations for digoxin? | *Not to be used in pregnancy
*Pulse for 1 min before administering; hold dose if pulse < 60
*Retake pulse in 1 hr. If adult pulse remains < 60 hold drug and notify prescriber
*Educate patient on signs of toxicity and – rehiterate the importance of blood tests
*Avoid meds with meals- delays aborbtion |
| Mode of action of GTN? | provide a source of nitric oxide which mediates relaxation of smooth muscle - widening blood vessels, letting more blood and oxygen reach your heart. This reduces strain on your heart, making it easier for your heart to pump blood. |
| Side effects of GTN? | Headache
Dizziness
Hypotension
nausea/vomitting |
| What are the symptom of right sided hear failure? | Distended, pulsating neck vein (sit patient upright- more noticeable)
Peripheral oedema – weight gain, swollen ankles/feet
Hepatomegaly and splenomegaly(enlarged speen) (enlarged liver – size and weight due to fluid in abdomen
Ascites (abdo fluid)
Anorexia and GI upset
Dyspnoea |
| What are 4 factors that cause cardiac arrest? | *Myocardial infarction
*hypovolemic shock(decreased volume of blood)
* Hypoxia
*Trauma |
| What are signs of cardiac arrest? | *chest pain
*SOB
*fatigue
*anxiety-impending sense of doom |
| how are deteriorating patients managed in hospital? | *MET call
*EWS score
*emergency bells
*Resuss trolley and defib |
| What does CPR stand for? | cardio pulmonary resuscitation |
| What does CPR do for the heart? | Chest compressions increase intrathoracic pressure and apply direct compression of the heart |
| Why do children most likely go into cardiac arrest? | Because they are deprived of oxygen |
| What are the shockable rhythms? | Ventricular fibrillation & ventricular tachycardia |
| What are the non shockable rhythms? | Asystole & pulseless electrical activity |
| How much adrenaline is administered for anaphylaxis? | 0.3-0.5mL 1:1000 - Intramuscular into vastus lateral(side of thigh) |
| What is the goal from post resuscitation treatment? | *assess ABCDE
*treat causes
*12 lead ECG
*re-evaluate oxygenation and ventilation
*temperature control |
| Risk factors associated with anesthesia? | *Type of procedure
*Age
*Diabetes - impaired healing, electrolyte balance
*Cardiac/resp disease
*Cognitive/renal/hepatic function |
| What info is gathered in pre-op assessment to identify risk factors? | *Medical history
*Medications
*Physical disabilities
*Surgical/anesthetic history - PONV |
| What other things are considered in the pre-op assessment? | *Cultural considerations
*Emotional status
*Baseline obs
*Patient education
*Post op support |
| What are the triad of medications used in general anesthetic? | Hypnotic, analgesic and muscle relaxant |
| What are the three phases of GA? | induction, maintenece, emergence |
| What are some physiological changes in surgery due to positioning? | Skin - risk of pressure/sheer injuries or temp
Resp system - Less room for lungs to expand – abdominal area shifts upwards – reduces inspiration and expiration
Cardiovascular system - risk of DVT- anesthesia causes peripheral dilation lowers BP and causes blood to pool in areas |
| why is thermal support important intraoperatively? | risk of hypothermia - agents provide vasodilation causing heat loss |
| identify and explain two medications that are risk factors intraoperatively ? | Anticoagulants - alter normal clotting factors - risk of hemorrhaging. Discontinue at 48 hours before surgery
Antihypertensive - beta-blockers and calcium channel blockers, interact with anesthetic agents to cause bradycardia, hypotension and impaired circulation |
| What is the aim of post op care? | oxygenation
circulation of blood
comfort
nutrition and fluids
elimination
movement and exercise
hygiene
psychological support
protection and safety |
| What the goal of oxygenation in post op care? | Assessment is also made of colour and breathing to observe for the signs of any respiratory tract complications. Mucus secretions can accumulate, leading to pneumonia, bronchitis or atelectasis. |
| What is the goal of circulation of blood in post op care? | risk of DVT and pulmonary embolus. During this period deep breathing, coughing and, if possible, leg exercises and early ambulation are encouraged |
| What is the goal of elimination in post op care? | It is important to observe urinary output on an ongoing basis. If retention of urine or inadequate emptying of the bladder occurs, it may be necessary for the individual to have a urinary catheter inserted |
| What is the goal of comfort in post op care? | assume a semi-upright position. This position promotes adequate lung expansion, and assists urinary or wound drainage by gravity |
| What is the effects of pain in the post-op patient? | • Enhances surgical stress response
• Causes tachycardia & hypertension
• O2 demand increases
• Respiratory function compromised
• Reduced ability to mobilise |
| Injured tissues release prostaglandins that stimulate the pain pathway to the cerebral cortex where pain is perceived. True or false? | True |
| What is the nursing management of a post op hemorrhage? | *Assess vital signs - cognition
*Check wound dressing
*Check estimated blood loss
*Pain assessment
*Blood tests (FBC + hemoglobin |
| What is the nursing management of hypotention/shock? | *IV fluids, blood products
*position patient flat
*Assess causes |
| What is the nursing management of a post-op CVA? | Assessment of hemiparesis, facial drooping, speech, orientation, LOC |
| What is the nursing management of post-op urinary retention? | Usually normal after surgery - should pass urine within 6 hours
*monitor fluid balance
*encourage fluid intake
*sit upright position for gravity
*monitor weight
*sound of running water
*warm shower
*bladder scan if nor successful
*possible catheter |
| What is the nursing management for post op delirium? | *check underlying causes - medications, dehydration, electrolyte imbalance
*delirium assessment
*close monitoring
*re-orientate patient
*falls risk
*Promote safe environment |
| what is the nursing management of a post op pulmonary embolism? | vital signs
anticoagulant if needed
mobilization
TED stockings - calf pumps |
| what is the nursing management of hypoventilation? | *monitor resp rate, depth and effort
*check medication history
*Sit patient upright
*assess pain - remove restricting dressings
*administer o2 if decreased o2 sats |
| what is the nursing management of post-op constipation? | *Encourage fluids(kiwi crush)
*mobility
*manual evacuation
*laxatives |
| what does hypersensitivity mean? | An excessive or abnormal sensitivity to a substance. A person who is hypersensitive to a certain drug will often suffer a severe allergic reaction |
| what is hypersensitivity type 1? | Also known as allergic reaction - Immediate reaction – IgE mediated response
Occurs within minutes of exposure |
| what is the physiological effects of anaphylaxis? | vasodilation - hypotension
bronchoconstriction - reduced breathing - cyanosis
increased heart rate
fluid shift - reduced blood volume
increased capillary permeability - swelling |
| Signs of anaphylaxis? | *Swelling of the eyes and face
*noisy breathing - wheeze or stridor
*red raised rash
*hypotension
*tachycardia
*stomach pain
*loss of consciousness |
| what is the treatment of anaphylaxis? | Adrenaline,O2, IV access, fluid replacement, antihistamines, hydrocortisone |
| why is adrenaline given in anaphylaxis? | Prevents (or relieves) –laryngeal oedema, circulatory collapse, release of histamine and other mediators
Provides bronchodilation (SYMPATHETIC) |
| how much adrenaline is used in anaphylaxis? | 0.5mLs - 1:1000 |
| what is HIV? | Type of retrovirus that attacks CD4 T helper cells which help the body fight off infections - therefore making a person with HIV more vulnerable to other infections (dendritic cells present virus to T cells) |
| what is a retrovirus? | a type of virus that inserts a copy of its RNA into the DNA of a host cell - hijaks host cell and causes it to die and the retrovirus will move into surrounding cells |
| What are the symptoms of HIV? | Flu like symptoms develop 2-4 weeks after exposure
As the virus replicates patient remains symptom free as the body makes antibodies to try fight the infection
further progression means the CD4 cell count is less than 200 which leads to aids defining conditions |
| what are aids defining conditions? | classified as being directly associated with advanced HIV infection - presence of AIDS |
| what is the mode of action of NNRTIs (non-nucleoside reverse transcriptase inhibitors? | Binds to and blocks HIV reverse transcriptase enzyme to prevent replication |
| what is the mode of action of integrase strand transfer inhibitors (INSTIs)? | Inhibits the strand transfer step of retroviral DNA integration which is essential for HIV replication. |
| what is the mode of action of protease inhibitors? | inhibits the action of protease enzyme preventing replication |
| what is the mode of action of the biologic medication 'infliximab? | Binds to tumor necrosis factor inhibiting the inflammatory cascade which suppresses chronic inflammation and immune response activation. (TNF is high with autoimmune diseases ) |
| How do DMARDs work | work to slowly modify autoimmune diseases by suppressing immune and inflammatory response - inhibit T & B cells |
| Why are injections used to administer medication? | *Faster absorption time
*Patients who are unable to swallow
*Some meds are poorly absorbed in the GI tract
*Patients who have fluid restrictions |
| Length of a needle is dependent on? | IM or S/C
Site
Muscle mass
Subcutaneous fat |
| importance of subcut injections? | *Used for small volumes of medications
*slow absorption time - not as many blood vessels
*risk of lipohypertrophy - |
| importance of intramuscular injections? | In the muscle layer
Suitable for larger volumes than subcutaneous sites
Faster absorption |
| Potential complications of IM injections? | *Pain
*Bleeding
*Injury to nerves or blood vessels
*Abscess |
| Common sites for IM injection? | Deltoid
Vastus lateralis – Side of thigh
Rectus femoris – Not commonly used - front of thigh
Ventrogluteal - side of hip
Dorsogluteal - upper outer glute - not recommended due to sciatic nerve injury |
| skin is pulled while administering IM injection using a Z track technique to prevent medication going into the subcut tissue. True or false? | True |
| What is the pathophysiology of lymphedema? | collection of fluid that collects in the interstitial spaces of the arm or leg due to a blockage in the lymphatic system. |
| What causes lymphedema? | *Removal of lymph nodes
*Damage from cancer treatment
*Trauma
*Genetics |
| Signs and symptoms of lymphedema? | *Swelling in affected limb
*Soreness
*Weakness |
| What are some things to consider post mastectomy with node removal ? | *Physiotherapy - exercise - to help with drainage
*Compression bandage |
| Things to avoid after surgery to reduce risk of lymphedema? | *Injections/blood tests on the affected area - local inflammatory response
*Vigorous lifting
*Sunburn
*Tight clothing on area |
| Education around post surgery to reduce risk of lymphedema? | *Elevate arm when possible
*healthy diet
*prevent trauma
*maintain skin care |
| What is Lymphadenopathy? | Enlarged swollen lymph nodes |
| What causes Lymphadenopathy? | Usually infection - elevated white blood cells |
| Tonsillitis is a cause of Lymphadenopathy, what are symptoms? | *sore throat
*swollen enlarged tonsils
*fever
*difficulty swallowing |
| what is the first line treatment for tonsillitis caused by bacteria(streptococcus)? | Penicillin |
| What is Non-Hodgkin's lymphoma ? | cancer of the lymphocytes in the lymphatic system without the presence of reed Sternberg cells - more common |
| What is Hodgkin's lymphoma? | cancer of the lymphocytes WITH the presence of reed Sternberg cells |
| What is the symptoms of malignant lymphomas? | *Enlarged lymph nodes
*night sweats
*fever
*weight loss
*fatigue |
| Nursing considerations for lymphomas? | *Patient education
*Psychological support
*identify barriers |
| treatment of lymphomas? | dependent on severity
chemotherapy - most common
radiation
immunotherapy
stem cell transplant |
| side effects of lymphoma treatment? | chemo can damage bone marrow
Anaemia (low hemoglobin) can cause shortness of breath, tachycardia, or fatigue
Thrombocytopenia (low platelet count) puts patients at risk of bleeding or bruise
Neutropenia (low white blood cell count) puts the patient at increased risk of infection
Nausea and vomiting |
| What are some factors that hinder wound healing? | Age - impaired venous return + decreased Langerhans cells
genetics
predisposing medical conditions (diabetes, renal disease)
stress - affects immune system
Nutrition- malnutrition will affect wound healing such as a protein deficiency
Smoking- causes vasoconstriction which reduces the amount of oxygen available to the cells |
| What is a chronic wound? | A wound that has remained unhealed for more than 4 - 6 weeks- pressure sore, diabetic wound, post-op wound |
| What mnemonic is used for wound assessment | HEIDI |
| what is involved in the examination part of HEIDI? | Assess the peri-wound - measurement, infection, edema, pulse(circulation) |
| what is the goal of moisture in a wound? | goal is to maintain moisture - not to dry or too wet - dressings correct this |
| what is the E part in TIME assessment? | Edges - make sure not undermining and rolling |
| what is the investigations part of HEIDI? | Investigations - do we need more investigations? checking pulses and sensations(monofilament pen), wound swap, tissue biopsy, xray |
| What are 4 responsibilities of the RN in the assessment and management of wounds? | undertake appropriate monitoring
select appropriate dressings
complete and update wound care plans
wound swabbing if directed |
| stages of pressure injuries? | Stage 1 - non blanchable erythema
stage 2 - partial thickness skin loss
stage 3 - full thickness skin loss
stage 4 - full thickness tissue loss with exsposed bone or muscle |
| what is SSKIN to manage and prevent pressure injuries? | S: Surface - Make sure patients are on supportive surfaces
S: Skin assessment – early inspection = early detection
K: Keep moving – encourage mobilisation where appropriate
I: Incontinence – individualised continence management plan.
N: Nutrition: refer where necessary |
| What is a primary dressing? | Come in contact with the wound. They can either:
- Maintain adequate moisture
- Absorb excess moisture
- Add moisture |
| what are some general principals of wound care? | The Patient! Pain, comfort and psychological considerations
Manage exudate and fill cavities
Dry wounds need moisture |
| what is the first line treatment for heart failure? | Diuretics |
| What is the symptoms of SVT? | Palpitations
Pounding in the neck or head
Chest discomfort (chest pain is unusual)
Dyspnoea |
| what does a mental state exam involve? | Behaviour and Appearance
Affect and Mood (feelings)
Thought process, content and perception (includes thoughts of harm to self or others)
Orientation and cognition
Motivation
Insight and judgement |
| what are the factors that help with recovery of mental health? (CHIME) | connectedness
hope
identity
meaning
empowerment |
| what are the barriers to gaining informed consent? | Health literacy
Communication problems
Medical jargon
Unfamiliar words
English as an Additional Language (EAL)
Hearing loss
Time constraints
Cognitive impairment |
| When assessing competence what should the doctor take into consideration? | the seriousness of the patient’s medical condition
the implications of treatment and non-treatment
the patient’s current mental state and cognitive ability
complexity of the information being given |
| when is WRITTEN consent required? | the consumer is to participate in any research
the procedure is experimental
the consumer will be under general anesthetic
there is significant risk of adverse effects to the consumer. |
| A child under the age of 16, is capable of providing consent to medical treatment “If the child has sufficient understanding and intelligence to enable him or her to understand fully what is proposed. True or false? | True |
| the emphasis in mental health care has moved to a recovery and social wellbeing model of health, with more emphasis on human rights. True or false? | True |
| The MHA promotes supported decision-making, aligns with the recovery and wellbeing model of mental health, and provides measures to minimise compulsory or coercive treatment, true or false? | true |
| What are the key aims to define the circumstances in which compulsory assessment and treatment may occur? | Ensure that individuals and the public are protected from harm
Ensure that Patients Rights are protected
Ensure that assessment and treatment occur in the least restrictive manner consistent with safety |
| Under the mental health act what is the definition of mental disorder to meet the criteria? | *abnormal state of mind
*abnormal state of mind must be of such a degree that it poses a serious danger to the health or safety of that person or others or it seriously diminishes the capacity of that person to take care of themselves. |
| under what sections of the mental health act can compulsory assessments begin for someone believed to be mentally disordered? | section 8-15 |
| under what section of the act can a judge make a compulsory treatment order? | section 28-34 |
| under what section a nurse has the power to detain a person for no more than 6 hours until a medical practitioner examines them if they believe a person may be mentally disordered? | section 111 |
| Process of compulsory assessment? | Section 8 – application
Section 8b – health practioner examines the patient (accompanies application form)
Section 9 – DAO receives application and arranges psychiatrist assessment
Section 10- preliminary assessment – psychiatrist record findings |
| What is the purpose if IV therapy? | Restore and maintain fluid and electrolyte balance
Administer IV medications
Administer Blood and Blood Products
Provide Parenteral nutrition |
| what are the most common veins a peripheral iv catheter is placed? | cephalic vein
Basilic vein
Median cubital vein |
| what is the use of NON tunneled central venous catheters? | pt’s requiring IV therapy for less than 5 days or up to a max of 10 days - short term use |
| what is the use of tunneled central venous catheters? | for permanent IV access, for pt’s requiring IV therapy > 6 weeks with no max |
| why is a small canula best to deliver medication? | Greater blood flow and haemodilation reducing damage from irritating solutions
Reduced mechanical irritation and insertion trauma (not irritating sides of vessels) |
| What are the principals of Aseptic non-touch technique? (ANTT) | Always cleanse hands effectively
Non touch technique is used at all times (to protect key parts)
Touch non-key parts with confidence
Take appropriate infection prevention precautions |
| What are the factors that some medications put people at risk of iv fluids? | *other medications in system
*obesity
*age
*respiratory conditions |
| what are some things we need to be aware of before giving iv fluids/medications? | *fluid restrictions
*sodium restrictions
*sugar(dextrose) restriction |
| what are the complications of peripheral IV therapy? | Hematoma
infection
phlebitis
infiltration
EXTRAVASATION |
| What is iniltration and causes ? | Partial or complete puncturing of the vessel due to: poor stabilisation of the limb.
-poor location of the cannula
- poor cannulation technique
-fragility of patients veins |
| What causes infection at a IV site? | Self seeding from a distant infection
Introduction of skin organisms
Poor aseptic technique
Contaminated infusate/equipment
General poor health of patient |
| What can cause phlebitis at IV site? | Mechanical such as poor cannulation technique
Chemical such as drug not diluted correctly |
| What is a hematoma and what causes it? | The localised collection of blood in a tissue due to a break in the wall of a blood vessel
Patient susceptibility
Poor cannulation technique
Trauma to IV site post insertion |
| what are considered high risk medications? | opioids
insulin
anticoagulant
potassium |
| What antibiotics are within the beta lactam class? | penicillin's
cephalosporins
carbapenams
monobactums |
| what is the mode of action of beta lactam antibiotics? | They are bactericidal (kill bacteria) kills gram + and - and broad spectrum. Contains beta lactam ring which inhibits the synthesis of the peptidoglycan layer on the cell wall |
| What drugs are under the antibiotic class glycopeptides? | vancomycin |
| What is the mode of action for vancomycin? | only effective against gram-positive bacteria - bactericidal. inhibits the synthesis of the peptidoglycan layer on the cell wall |
| Nursing considerations for beta lactam antibiotics? | Not be given to patients with a history of hypersensitivity to beta-lactam antibiotics >risk anaphylaxis
May reduce the efficacy of oral contraceptives
avoid alcohol
need to adhere to full course |
| side effects of penicillin group? | black hairy tounge
hypersensitivity reaction
GI upset
Renal, hepatic dysfunction
Rash, urticaria
oral candidiasis |
| what is the mode of action of tetracyclines? | inhibits bacterial protein synthesis - bacteriostatic |
| what is the mode of action of glycopeptides and what is an example? | vancomycin. inhibits cell wall synthesis causing cell lysis - bactericidal |
| what is the mode of action of aminoglycosides and what is an example? | gentamycin. inhibits bacterial protein synthesis - bactericidal |
| what is the mode of action of fluoroquinolones and what is an example? | norfloxacin. inhibits DNA synthesis - bactericidal |
| what is the mode of action of tetracyclines and what is an example? | doxycycline. inhibits bacterial protein synthesis - bacteriostatic |
| what is antibiotic resistance? | when bacteria mutates or changes their structure and has the ability to resist certain antibiotics |
| what is the definition of pain? | An unpleasant sensory and/or emotional experience |
| Things that can happen to the body as a result of unmanaged pain? | • Mental distress
• Burden to the family
• Affect adls
• Cardiovascular problems – tachycardia, hypertension, adrenaline |
| What are the two components of pain? | The physical and psychological response |
| what is acute pain? | normally a protective mechanism - usually come on suddenly - response to internal and external stimuli |
| what is chronic pain? | Usually last longer than 6 months - increasing numbers of pain impulses |
| what is somatic pain? | nociceptors of the skin, muscles and soft tissue are activated - well localized |
| what is visceral pain? | nociceptors of the organs are activated - poorly localized |
| what is neuropathic pain? | injury or disease to the nerves themselves |
| what are some types of neuropathic pain? | diabetic neuropathy
carpel tunnel
phantom pain |
| what are the three systems involved with the perception of pain? | Limbic system - emotion response to pain
Reticular system - autonomic motor response - move hand away suddenly
somatosensory - interpretation of pain |
| what are the inhibitory neurotransmitters involved with the modulation of pain? | enkephalins (bodys natural opioids)
endorphins
serotonin |
| When completing a pain assessment, what should you ask? | P – Provocation/palliation – what makes it better or worse
Q – Quality/Quantity – burning, shooting, sharp, dull, nagging
R – Region/radiation –
S – severity
T – timing –
U – affecting you |
| What is the goals of pain management? | Must use a holistic approach to pain management
Every patient deserves adequate pain relief
comfort function goals
Important to use medication and non medication methods
Always evaluate effectiveness |
| if a pain assessment is required in someone who is unable to self report pain (sedated, dementia) what should the nurse do? | Attempts to obtain self report
Search for potential causes of pain
Observe patient behaviors
ask family members |
| How should a nurse complete a pain assessment on a young child? | Self report - what the child says ( the gold standard)
Behavioural –how the child behaves
Physiological –clinical observations
use FLACC assessment if child unable to communicate |
| what is increased intracranial pressure? | increase of pressure inside the skull caused by the CFS, tissue or blood that can result in brain injury |
| what causes increased intracranial pressure? | infections - meningitis
brain injuries
brain tumor
aneurysm |
| symptoms of increased intracranial pressure? | • Headache
• Blurred vision
• confusion
• Vomiting |
| What causes abscesses and empyema's in the brain? | Infection from an area of the body - The infection will cause your brain to swell from the collection of pus and dead cells that forms that cause ICP |
| treatment for abscesses and empyema's? | Antibiotic therapy
Surgery to drain the infected site-this allows immediate relief of pressure on the brain or spinal cord
Sample is taken for bacterial identification-drug therapy can be altered to a more specific antibiotic
surgery is too dangerous |
| what is multiple sclerosis? | a disease of the central nervous system that affects movement, sensation and body functions - body attacks myelin on neurons |
| symptoms of MS? | fatigue
numbness
lack of coordination
weakness |
| what is the diagnostics for MS? | MRI - number of lesions found |
| what medications can help manage MS? | Disease modifying medications: Immunomodulators
interferon beta 1- Decreases inflammation and prevent nerve damage that may cause symptoms of MS
steroids for acute flare ups |
| what is gillian barr syndrome ? | autoimmune disease - acute inflammatory demyelinating polyneuropathy of the peripheral nervous system characterized by neuropathy and weakness starting at the feet moving towards the head. monitoring of respiratory and cardiovascular status due to paralysis |
| what is epilepsy? | Neurological disorder in which nerve cell activity in the brain is disturbed, causing seizures.
occurs basically due to excessive abnormal firing of the neurons and fast spread of these impulses over the brain - thought to be an imbalance of GABA and glutamate |
| what is a seizure? | burst of electrical activity between excitatory and inhibitory neurotransmitters causing temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness |
| what is the mode of action for sodium valporate(anticonsulvant/anti-epileptic)? | blockade of voltage-dependent sodium channels and enhancing brain concentrations of GABA, an inhibitory neurotransmitter. This suppresses repetitive neuronal discharges that generate seizures in epilepsy |
| how is epilepsy diagnosed? | Electroencephalogram (EEG) - check electrical activity in brain
seizure diary |
| what are general seizures? | involving the whole brain - tonic clonic, absence, atonic |
| nursing considerations for seizures? | Stay calm – talk to person reassure
Make the person safe
Cushion the head
Time the seizure
Do not hold down
Do not put anything in the mouth
When the seizure ends place the person in the recovery position
Stay with the person until they have fully recovered |
| what is Alzheimer's disease? | progressive neurodegenerative disorder -amyloid plaques clump together outside the neuron leading to loss of synapses and neurofibrillary tangles occur in the neuron leading to death of the neuron, which results in neuron death and atrophy of the affected areas of the brain - loss of acetycholine (processing memory and learning) |
| Symptoms of Alzheimer's? | Memory loss
Confusion about the location of familiar places
Taking longer to accomplish normal, daily tasks
Trouble handling money and paying bills
Compromised judgment, often leading to bad decisions |
| what medications can help alzheimers? | there is no cure. cholinesterase inhibitors because acetylcholine is decreased in alzheimers |
| What is the mode of action of donzepil (cholinesterase inhibitor? | block the action of the enzyme cholinesterase, which is responsible for breaking down acetylcholine. This increases levels of acetylcholine in the synaptic cleft |
| nursing considerations for neurodegenerative conditions? | Catheterisation
Bowel management
Pain Management |
| what are the subtypes of dementia? | alzheimers
lewy body disease
frontotemporal dementia
vascular dementia |
| hippocampus and memory formation are affected very early on
in alzheimers. true or false? | true |
| what is tempofrontal dementia? | Two key proteins are TDP-43 and tau, which abnormally accumulate in neural cells causing neurons to die and the brain to shrink- Stops the myelin forming stopping the action potentials firing |
| what is lewy body dementia? | Protein deposits, called Lewy bodies, develop in nerve cells in the brain regions involved in thinking, memory and movement (motor control). cause death of neurons and shrinkage of brain. hallucinations, sleep disturbance and fluctuating cognitive changes, as well as physical or motor features of Parkinson's disease (e.g. tremors). |
| what is vascular dementia? | Vascular dementia is associated with accumulated damage to blood vessels in the brain - starved of oxygen |
| risk factors for developing dementia? | genetics
old age
diabetes
obesity |
| what do nurses need to think about when someone has early stages of dementia? | (1) keeping the mind active;
(2) keeping the body active; (benefit from physical activity)
(3) accessing appropriate support; (
(4) managing health conditions and nutrition. (diaetes etc |
| Non pharmalogical interventions for dementia? | Music Therapy
Reminiscence Therapy
Aroma Therapy
Massage |
| what is the pathophysiology of delirium? | reduced production of acetylcholine or decreased acetylcholine transmission and inflammatory cytokines can cross the blood-brain barrier and affect brain function and neurotransmission |
| assessment tool for delirium? | confusion assessment method(CAM) assess when patient is first admissioned and assess regualry after |
| what is delirium ? | an acute disturbance in cognitive abilities resulting in confusion and functional decline that flucuates - can be hyperactive or hypoactive |
| how does the vomiting reflex happen? | The oesophagus relaxes
The diaphragm and abdominal muscles contract
- increasing intra-abdominal pressure
Epiglottis closes to stop regurgitated food travelling to the lungs
Autonomic nervous system changes -Tachycardia, Increased salivation and peristalsis
Expulsion of food |
| where is the vomitting centre located in the brain? | medulla and contains muscarinic receptors |
| what things can break down the blood brain barrier? | hypertension
chemicals
radiation
trauma |
| what is the function of the chemoreceptor trigger zone? | CVO organ - contains serotonin & dopamine receptors - stimulated by chemicals and cytoxic agents which then stimulates muscarinic receptors in the vomitting centre to induce vomitting reflex |
