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Exam 2
Delirium
Mechanism
Rapid Onset
Reversible
Assessment
Hallucinations
Decline in Cognition
Short Attention Span
Rapid Speech
Change in Activity Level
Mood Swings
2 mins
Alzheimer's Disease Interventions
Diagnostic Tests
PET Scan and CT
Mini-Mental State Examination
Interventions
Drug Therapy
Safe Environment
Moderate Exercise
Behavioral Modification
Assistance with Functional Independence
Assistance and Support for Caregiver
2 mins
5 A's of Alzheimer's Disease
Agnosia
Anomia
Aphasia
Apraxia
Amnesia
1 min
Alzheimer's Disease Assessment (Early Symptoms)
Risk Factors
Advanced Age
Early Signs and Symptoms
Poor Judgment and Decision-Making
Difficulty Having a Conversation
Inability to Manage a Budget
Losing Track of the Date or Season
Misplacing Things
1 min
Alzheimer's Disease Assessment (Late Symptoms)
Late Signs and Symptoms
Memory Impairment
Wandering Behavior
Confabulation
Perseveration
Lack of Abstract Thinking
Severe Cognitive Decline
1 min
Total Parenteral Nutrition (TPN)
Mechanism
Nutrition Given Outside GI
Side Effects
Hyperglycemia
Hyperlipidemia
Refeeding Syndrome
Nausea and Vomiting
Considerations
Slow IV Infusion
Use Large Central Vein
No Added Meds to TPN Line
2 mins
Braden Scale
Characteristics
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
2 mins
Low Sodium Diet
Decreased Sodium in Diet
2,300 mg of salt
Hypertension
Heart Failure
Chronic Kidney Disease
DASH diet
Increase Water intake
read nutrition labels
exercise
1 min
Therapeutic Diets
Common Therapeutic Diets
High Fiber
Low Residue (Fiber)
Low Sodium
Low Cholesterol
Diabetic
Renal
Dysphagia
Nursing Considerations
Diet Education
2 mins
Immobility
Assessment
Mobility Continuum
Complications
Cardiovascular
Respiratory
Musculoskeletal
Integumentary
Gastrointestinal
Urinary
Considerations
Turn, Cough, Deep Breathe (TCDB)
Range of Motion (ROM)
Skin Care
Fluids
Balanced Diet
2 mins
Skin Anatomy
Characteristics
Epidermis
Keratinocytes
Melanocytes
Dendritic Cells
Merkel Cells
Dermis
Sweat Glands
Hair Follicles
Sebaceous Glands
Hypodermis
3 mins
Skin Functions
Characteristics
Thermoregulation
Protection
Innate Immune Protection
Synthesize Vitamin D
Water and Salt Excretion
Dilated Capillaries are a Blood Reservoir
2 mins
Interventions for Impaired Skin Integrity
Assessment
Signs of Skin Breakdown
Pain
Redness
Decreased Skin Turgor
Bleeding
Bony Prominences
Intervention
Reposition Q2H
Pressure Relief
Maintain Clean and Dry Skin
Adequate Nutrition and Hydration
2 mins
Pressure Ulcers
Risk Factors
Prolonged Immobilization
Neurologic Disease
Decreased Level of Consciousness
Classification
Stage 1: Intact Skin with Non-blanchable Erythema
Stage 2: Partial Thickness Skin Loss
Stage 3: Full-thickness Skin Loss without Fascial Involvement
Stage 4: Full-thickness Skin Loss with Fascial Involvement
Management
Wound Care
Surgery
Considerations
Septicemia
Osteomyelitis
Prevention
3 mins
Types of Wound Healing
Types of Wounds
Acute
Chronic
Healing Process
Primary Intention
Approximated Edges
Secondary Intention
Edges Not Approximated
Tertiary Intention
Delayed Closure due to Infection and Necrosis
2 mins
Wound Drainage Types and Devices
Drainage Types
Serous
Serosanguineous
Sanguineous
Purulent
Drainage Devices
T-tube
Penrose
Jackson-Pratt (JP)
Hemovac
Considerations
Record Drainage Amounts
Check Device Function
2 mins
R.I.C.E. (Treating Soft Tissue Injury)
Rest
Ice
Compression
Elevation
1 min
Mediators of Wound Healing
PDGF secreted by platelets and macrophages
PDGF Induces smooth muscle cell migration
PDGF induces vascular remodeling
Stimulates Fibroblast Growth for Collagen Synth
FGF Stimulates Angiogenesis
EGF Stimulates Cell Growth
TGF-B Mediates angiogenesis
Causes fibrosis
TGF-B transforms fibroblasts into myofibroblasts
Metalloproteases Mediate Tissue Remodeling
VEGF Mediates angiogenesis
Increases capillary permeability
EGF Promotes Granulation Tissue formation
Prevention of Falls
Risk Factors
Physical Aging
Polypharmacy
Environmental
Hospital / Facility Prevention
Call Light within Reach
Assistive Devices Available
Bed Alarms
Home Prevention
Improve Lighting
Remove Home Hazards
Priority Nursing Interventions
Promote Exercise
Fall Risk Assessment
2 mins
Cane
COAL
Sizing a Cane
Quad Cane
Rubber Tips for Safety
1 min
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