Assessment
A Nurse is caring for Patient John who has an admission diagnosis of ischemic stroke. The nursing assessment for a patient with ischemic stroke should include what 3 assessments:
Neurological assessment:
Vital signs:
Cardiovascular assessment:
Respiratory assessment:
Swallowing ability:
Pain assessment
Skin assessment:
Mobility and balance:
Cognitive function:
Emotional status:
History:
Laboratory values:
Regular reassessments are crucial to monitor for changes in John's condition and to evaluate the effectiveness of interventions.
The Nurse is caring for Patient Betty who is admitted for chest pain. What 3 NANDA-approved nursing diagnoses may the Nurse consider to guide his care.
Acute Pain
Anxiety
Decreased Cardiac Output
Ineffective Breathing Pattern
Activity Intolerance
What are 2 appropriate nursing goals for a patient with Addison Disease?
Two appropriate nursing goals for a patient with Addison Disease are:
Maintain fluid and electrolyte balance
Prevent Addisonian crisis
These goals focus on managing the primary physiological challenges of Addison Disease and preventing life-threatening complications.
The Nurse sees these findings:
True or False? The Nurse should assess this to indicate respiratory alkalosis.
True.
For respiratory alkalosis, the key lab values to look for are:
Additional findings:
Remember, in chronic respiratory alkalosis, the compensatory decrease in bicarbonate brings the pH closer to normal, despite the persistently low PaCO2.
True.
The main characteristics of pancreatitis include:
In acute cases, symptoms often develop suddenly and can be life-threatening. Chronic pancreatitis may lead to long-term digestive issues and increased risk of pancreatic cancer. Both forms can significantly impact a patient's quality of life and require careful management.
True or False? Two appropriate NANDA approved nursing diagnosis for atrial dysrhythmia is: activity intolerance related to reduced cardiac efficiency as evidenced by exertional dyspnea; and, increased cardiac output related to irregular heart rhythm as evidenced by ECG changes, palpitations, and fatigue.
False. Must be decreased cardiac output.
Decreased Cardiac Output
Activity Intolerance
Anxiety
Risk for Impaired Gas Exchange
Risk for Thromboembolism
Ineffective Health Management
To address ineffective communication between the Nurse and Patient due to language differences, what are at least 5 appropriate nurse planning steps?
Appropriate nurse planning for ineffective communication due to language differences includes:
Arrange for a professional medical interpreter
Use visual aids and translated written materials
Implement teach-back method
Learn key phrases in the patient's language
Utilize language assistance services
Employ nonverbal communication techniques
Allow extra time for appointments
Document language preferences
Provide culturally competent care
Use plain language
5 lab values and/or diagnostic imaging for respiratory failure.
Key lab values for respiratory failure include:
Arterial Blood Gases (ABGs):
Pulse oximetry:
Additional relevant lab values:
Diagnostic imaging:
Monitoring:
These values help assess oxygenation, ventilation, and acid-base status, guiding treatment decisions in respiratory failure.
Patient presents with: Severe abdominal pain, particularly in the right lower quadrant, elevated white blood cell count (>10,000 cells/mm³) with increased neutrophils, and elevated C-reactive protein. Upon assessment, the nurse notices rebound tenderness. What condition should the nurse consider is happening with this patient?
Appendicitis with complications.
The main characteristics of appendicitis with complications include:
Diagnostic imaging such as abdominal ultrasound, CT scans, or MRI (especially for pregnant women and children) may be used to confirm the diagnosis and rule out other conditions. Treatment typically involves antibiotics and appendectomy, with more intensive care required for complicated cases.
5 NANDA approved nursing diagnoses for myasthenia gravis including related to and as evidenced by parts?
Impaired Physical Mobility
Ineffective Breathing Pattern
Risk for Aspiration
Impaired Verbal Communication
Anxiety
Name at least 2 differences between acute and chronic pancreatitis.
Acute Pancreatitis:
Chronic Pancreatitis:
Key differences include the duration of the condition, the pattern of enzyme elevation, and the presence of long-term pancreatic insufficiency in chronic cases.
State 3 implementation steps for respiratory alkalosis.
Implementation for respiratory alkalosis includes:
Identify and treat the underlying cause
Assist with breathing techniques
Monitor arterial blood gases
Provide oxygen therapy as needed
Administer medications as prescribed
Implement relaxation techniques
Avoid rebreathing techniques
Educate the patient
Monitor for compensatory mechanisms
Provide emotional support
What are the uncompensated respiratory acidosis lab values and nursing interventions?
Uncompensated respiratory acidosis lab values:
What are the characteristics for uncompensated respiratory acidosis? what is the pathophysiology?
Sherpath AIanswered:
Characteristics of uncompensated respiratory acidosis:
Pathophysiology:
This acute condition results from an inability of the lungs to adequately expel CO2, causing a rapid build-up of carbonic acid in the blood and a subsequent decrease in pH. The body's compensatory mechanisms, particularly renal compensation, have not had sufficient time to correct the imbalance, leading to an uncompensated state.
Nursing interventions:
Monitor respiratory status closely:
Position patient to maximize ventilation (e.g., semi-Fowler's position)
Administer oxygen as prescribed
Assist with prescribed respiratory treatments (e.g., nebulizers, incentive spirometry)
Monitor arterial blood gases (ABGs) as ordered
Assess for signs of hypoxemia and hypercapnia (e.g., confusion, drowsiness, headache)
Provide airway clearance techniques as needed (e.g., suctioning, chest physiotherapy)
Administer medications as prescribed (e.g., bronchodilators, corticosteroids)
Prepare for possible mechanical ventilation if condition worsens
Educate patient on deep breathing and coughing exercises
Address underlying cause (e.g., COPD management, treating pneumonia)
Monitor for signs of compensation or improvement in acid-base balance
Provide emotional support and education to patient and family
Nurse Samantha was told her patient is now diagnosed with Cushing Syndrome. The diagnoses should not include any of these problems as a part of the nursing diagnoses for her care plan: Imbalanced Nutrition: More than Body Requirements; Risk for Impaired Skin Integrity, and Fatigue.
False.
The pathophysiology of Cushing syndrome centers on chronic exposure to excess cortisol:
Causes:
ACTH-dependent (80% of cases):
Pituitary corticotroph adenoma (Cushing disease)
Ectopic ACTH-secreting tumors (e.g., small cell lung carcinoma)
ACTH-independent:
Adrenal tumors (benign or malignant)
Iatrogenic: Long-term glucocorticoid administration
Effects of hypercortisolism:
Metabolic:
Increased gluconeogenesis leading to hyperglycemia
Insulin resistance
Protein catabolism causing muscle wasting
Cardiovascular:
Hypertension due to increased vascular sensitivity
Skeletal:
Osteoporosis from loss of bone protein matrix
Integumentary:
Thinning of skin and loss of collagen
Easy bruising and poor wound healing
Endocrine:
Suppression of hypothalamic-pituitary-adrenal axis
Menstrual irregularities and reduced fertility
Clinical manifestations:
Redistribution of body fat (central obesity, "moon face", "buffalo hump")
Muscle weakness
Thin, fragile skin with purplish striae
Hirsutism and acne (due to androgen excess)
Mood changes and cognitive impairment
Complications:
Diabetes mellitus
Increased susceptibility to infections
Pathologic fractures
Cardiovascular disease
The excess cortisol affects multiple body systems, leading to the diverse and complex clinical presentation of Cushing syndrome.
NANDA approved nursing diagnoses for Cushing syndrome:
Imbalanced Nutrition: More Than Body Requirements
Risk for Impaired Skin Integrity
Disturbed Body Image
Risk for Infection
Ineffective Health Management
Fatigue
Anxiety
For a patient with ventricular fibrillation, the nurse should plan to do all of the following except:
5. The nurse should prepare for the administration of antiarrhythmic drugs as ordered (e.g., amiodarone)
The nurse should plan to:
The primary goal is to restore a normal heart rhythm as quickly as possible to prevent sudden cardiac death.
What is the highest and lowest priority nursing intervention for fracture?
Highest priority nursing interventions for fracture:
Neurovascular assessment of the affected extremity
Pain management
Monitor vital signs
Lowest priority nursing interventions for fracture:
Long-term patient education
Discharge planning
Psychosocial support
Remember, priorities may shift based on the patient's condition and any acute changes in their status. Ongoing assessment is crucial to ensure appropriate care.
What are the key differences in nursing interventions between respiratory acidosis and metabolic acidosis and what are their lab values?
Key differences in nursing interventions for respiratory acidosis and metabolic acidosis:
Respiratory Acidosis:
Airway management:
Ventilation support:
Medication management:
Underlying cause treatment:
Monitoring:
Metabolic Acidosis:
Fluid and electrolyte management:
Medication administration:
Underlying cause treatment:
Nutrition support:
Monitoring:
Both conditions require:
The primary focus in respiratory acidosis is on improving ventilation and oxygenation, while in metabolic acidosis, it's on addressing the underlying metabolic disturbance and supporting the body's compensatory mechanisms.
To confirm respiratory or metabolic acidosis in a clinical setting, the following diagnostic tests should be prioritized:
Arterial Blood Gas (ABG) analysis
Serum electrolytes
Serum bicarbonate (HCO3-) level
Anion gap calculation
Lactate levels
Blood glucose
Kidney function tests
Urinalysis
Chest X-ray
Pulse oximetry
These tests, particularly ABG analysis, provide crucial information for accurate diagnosis and appropriate treatment of acid-base disorders.
What are the definition, causes, and signs and symptoms of respiratory acidosis and metabolic acidosis?
Respiratory acidosis and metabolic acidosis are two distinct acid-base imbalances:
Respiratory Acidosis
Signs and Symptoms:
Metabolic Acidosis
Signs and Symptoms:
Both conditions can lead to serious complications if left untreated, including organ dysfunction and death in extreme cases.
What is the pathophysiology and highest priority nursing interventions versus lowest priority nursing interventions for myasthenia gravis? State two of each.
Pathophysiology of Myasthenia Gravis:
Highest Priority Nursing Interventions:
Lowest Priority Nursing Interventions:
Acetylcholine receptors are specialized proteins located on the surface of certain cells that bind to the neurotransmitter acetylcholine. There are two main types:
Nicotinic receptors:
Muscarinic receptors:
These receptors play crucial roles in the parasympathetic nervous system, mediating various physiological responses when activated by acetylcholine. Their stimulation can affect heart rate, smooth muscle contraction, glandular secretions, and other autonomic functions.
What is the pathophysiology and highest priority nursing interventions versus lowest priority nursing interventions for acute and chronic renal failure? State two of each
Acute Renal Failure (AKI):
Chronic Renal Failure (CKD):
Highest Priority Nursing Interventions:
Acute Renal Failure:
Chronic Renal Failure:
Lowest Priority Nursing Interventions:
Acute Renal Failure:
Chronic Renal Failure: