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엔클렉스 패스하자 > 우선순위 > Flashcards

우선순위 Flashcards

1
Q

pacemaker malfunction

A

pulse 60 ↓, 100↑, 10-20회 차이, dizziness, syncope, faint

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2
Q

PCV 5회 ↑

A

우선순위.

PVC (Premature ventricullar contraction,심실조기수축)

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3
Q

ALS with pn

A

ALS: amyotrophic lateral sclerosis 근위축 축삭경화증 루게릭병

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4
Q

baby with drroling (swallowing difficulty) no eat when eat

A

-> 식도정맥류 Sx.

예외) cystic fibrosis는 예상 sound

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5
Q

MI보다도 asthma without wheezing 우선. PEFR 50% ↓ 우선. sitting with diaphoresis & dizziness

A

.#PEFR[peak expiratory flow rate. 최대날숨속도]

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6
Q

DM pt 우선순위

A

BST 250↑,60↓/ fatigue after meal(고혈당 Sx)/ diaphoresis, fruit odor, slurred speech, diziness, drowsy, lethargy( ㅈㅓ혈당 Sx)

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7
Q

COPD Pt

A

.

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8
Q

Thyroidectomy Pt인데 우선순위

A

jaw pain(턱관절통증.MI), neck stiff, side-lying(chould be SFP[semi-fowler’s position], stridor/hoarseness, pulling sense(tetany), neck tight, tingling sense(tetany)

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9
Q

lung ca 우선순위

A

목, 얼굴 edema

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10
Q

neck hematoma

A

.

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11
Q

chest tube Pt

A

drainage 200cc/hr ↑ = 우선순위

nml= 800-1000cc/day

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12
Q

WBC 우선순위

A

2000 ↓, 18000↑

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13
Q

BT

A

38.6 ℃ ↑ 우선순위: shievering, chemo Tx 후, haldol 복용, scarlet fever(목통증+고열+전신발진->전염병.. Sx: nausea, headache, 심한인두염, 림프절종창, 딸기혀)

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14
Q

Na

A

125↓ 우선순위 (seizure)

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15
Q

THR pt

A 
#sitting ->(should be extension & abduction),
#pillow ->THR,TKR,PVT aovid
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16
Q

SaO2

A 
91% ↓ = 우선순위 (pulseoximetry X, PaO2=80-100이 정상)
#예외 : COPD, Pn
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17
Q

Tonsilectomy 우선순위

A

편도절제술

tight, hoarseness, swallowing sense,

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18
Q

epigastric compression

A

MI attack sign 우선

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19
Q

huntington’s Pt 우선순위

A

dysphagia 연하곤란(음식물이 입에서부터 위로 통과하는데 장애를 받는 느낌이 있는 증세)

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20
Q

bronchoscopy Pt

A

sore throat

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21
Q

osteomyelitis 우선순위

A

osteomyelitis = 골수염

-> oozing

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22
Q

glaucoma

cataract 우선순위

A

glaucoma- eye pain

cataract- nausea(ICP ↑)

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23
Q

cleft lip&palate

A

baby crying

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24
Q

abd aorta aneurysm/carotid aneurysm Pt

A 
abd pain, back pain, pulseless, 우선 pedal pulse X, radial pulse ↓, headache
#예외: bruit/Thril 
#예상: cramping
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25
Q

long bone Fx/OP후 우선순위

A

pin point rash, chest petechia, hemoptysis, rales, dyspnea, RR ↑

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26
Q

Blunt trauma (흉부압박상)

A

umbilicus echymosis

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27
Q

flail chest

A

연가양 흉부.동요가슴.흉곽동요
호흡시에 역방향으로 운동하는 가슴. 늑골의 다발성 골절이 원인.
paradoxical movement

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28
Q

pneumothorax Pt 우선순위?

A

lung sound ↓

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29
Q

hemovac 우선순위

A

40-50cc/hr
예외) 40-50cc/hr↑ 경우임에도 serosanguineous[장액혈액성,옅은 빨강] color =normal
왜지..?

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30
Q

endocarditis Pt

A

심내막염

38.6℃ ↑, 흡기시 pain, 흡기시 호흡음 소실, WBC 18000↑, dyspnea

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31
Q

COPD Pt

A

체중 ↑, dyspnea, RR28↑, 잘떄SOB, pillow 2개이상, 91% ↓, non productive cough, N/V

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32
Q

BPH Pt TURP 후

A 
#TURP: transurethral resection of prostate 경요도적 전립선 절제
->light red urine, USG ↑
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33
Q

MI pt

A

PVC 5개 이상/min, SaO2 91%↓, 체중 ↑, pillow 2개 이상, epigastric pain, NTG 투여해야 하는 경우(chest pain), jaw pain, BT38.6↑

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34
Q

cardiac tamponade

A 
#cardiac tamponade= 심장눌림증. 심장막액 저류에 의해 급속하게 일어나는 심장 압박증상
->muffled sound들리면 우선순위
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35
Q

pulmonary edema

A

체중증가시 우선순위 (CHF, adenocarcinoma, cancer, COPD Pt)

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36
Q

CABG 후,

A

affected leg pain, pulse(-), pallor

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37
Q

quiet sitting & epigastric pain

A

.

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38
Q

chest petechia

A

가슴에 점상출혈
예외) ITP는 우선순위 아님
#ITP= 특발성저혈소판자색반병. [idiopathic thrombocytopenic purpura] 혈소판에 대한 자가항체(autoantibody)가 생산된 결과 혈소판이 감소해서 출혈경향을 일으키는 원인 불명의 자가면역질환

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39
Q

coumadine 복용 Pt

A

green leaf vegetable 자주 먹는 경우.

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40
Q

Biopsy Pt

A

수술 전 hemoptysis 있는 경우

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41
Q

COPD Pt, Heart dis

A

confusion, disorientation

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42
Q

chest tube

A

200cc/hr ↑, site swelling & red water seal 계속 bubble, fluctuation X, low base sound 감소

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43
Q

Ventilation

A

low pressure alarm

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44
Q

internal radiation Pt

A

생화, 생과일, 생주스

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45
Q

pulse 60 ↓

A

디곡신, b-blocker

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46
Q

RR 12 ↓

A

opioid

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47
Q

Bp

A

90/60 ↓

48
Q

AIDS Pt

A

chilling, western blot assay(+), diaphoresis(저혈당), diarrhea
#Western Blot = Protein detection
-단백질을 크기 별로 분리하는 기술

49
Q

Chemo Tx Pt

A

BT 38.6℃ ↑, burning sensation urine, severe nausea, WBC 2000 ↓, itching, rash(shock)

50
Q

정신과약 Pt

A

BT 38.6℃ ↑( -zine, haldol etc)

51
Q

orthostatic hypotension

A

기립성저혈압

BP 130->110mmHg

52
Q

CAPD

A

[지속적외래복막투석. continuous ambulatory peritoneal dialysis]

redness, abd tenderness, claudy drainage

53
Q

Hyperthyroidism (Graves)

A

BT↑, restlessness

54
Q

Headache with neck stiffness

A

.

55
Q

allergy with latex

A

.

56
Q

GCS ↓ 12->10점, 14->12점 , 8점 ↓

A

.

57
Q

Head injury (=concussion뇌진탕)

A

headache, vomiting, rinorrhea, epistaxis(bleeding), passive ROM( ICP ↑), mental ↓, weakness, slurred speech, agitation[불안,동요].

58
Q 
#hypophysectomy
#craniotomy
A 
#hypophysectomy[뇌하수체절제술]: oliguria, USG ↓, U/O ↑, CSF leakage
#craniotomy[개두술]: supine (should be head up 30º)
59
Q

DI Pt

A 
#[diabetes insipidus,요붕증] 항이뇨호르몬(antidiuretic hormone, ADH)의 분비이상으로 몸의 수분 균형이 무너져 다뇨(polyuria)가 나타나는 질환
USG↓
60
Q

spinal OP

A

headache, diaphoresis, bowel movemene(-), lumbar puncture, constipation

61
Q

pain scale

A

10점 ↑

예외) burn

62
Q

Lumbar puncture, spinal anesthesia 이후

A

fluid intake teaching

63
Q

isolation 우선 Pt

A

HiV with “ productive coughing”
기침, 가래 with “PPD[정제투베르쿨린], AFB(+)[[acid-fast bacillus,항산균,결핵균&비결핵성항상균] , neck stiffness”
chest red rash & white pressed lession(chicken pox)
eyelid swelling & yellow discharge
pediculosis(이감염증), vesicle & crust on face
brudzinski(+)[supine-> 목을 앞으로 굽히면 엉덩관절, 무릎관절이 자동적으로 구부려진다.], kernig[supine-> 엉덩관절을 구부려 종아리를 수동적으로 들어올리고, 무릎을 펴려고 하면 무릎이 구부러지고 저항이 있으며 통증이 동반(수막자극-> 무릎의 굽힘근이 연축).] with “photophobia, bull’s eye, leg tightly(Lime dis)
라임병, 진드기가 옮기는 세균성 감염증

64
Q

vaccine 우선순위

A

rebella with preg

65
Q

foley remove 후

A 
#6-8hr 후 소변 안나오는 경우(보통 3-4hr기다림)
#Urine 30cc/hr ↓, OP 또는 CRF Pt->U/O X
#urine stream  ↓, burning sensation urine.
66
Q

ESRD Pt

A

U/O↓, K↑, BUN ↑, Cr ↑, severe nausea, antacid 복용(신독성)

67
Q

ileostomy Pt

A

750 /d↑, K ↓, diarrhea

68
Q

5% body weight loss

A

탈수를 의미

69
Q

dehydration

A

IV유지, SCA[sickle cell anemia] Pt IV, transfusion Pt, BP ↓, 설사, abd cramping ↑, mottling반점, NG tube distension(pain) N&V, NG tube& PEG feeding 주입 X, nausea, Hct↑,Hb↑

70
Q

Bowl movement 4일동안 X, bowl sound X

A

.

71
Q

Cholecystectomy

A

담낭절제술
-> T-tube
정상( 450-400cc/d ) 보다 ↑ OR ↓
abd dull pain

72
Q

Pyrolic stenosis Pt

A

유문협착증.

vomiting

73
Q

hernia Pt

A

N&V, coughing(avoid 해야함)

74
Q

PLT 10만 ↓

A

정상= 15-40만

75
Q

청소년 여아

A 
#anorexia nervosa, 
#amenorrhea(무월경)/ lanugo(솜털)/ sternous exercise
76
Q

Baby

A

Fontane(삼첨판 폐쇄증으로 인하여 장애가 생긴 순환 기능을 회복시키는 수술. 오른심방과 폐동맥 사이에 우회로를 만든다.)/ sucken & mottling반점, jittering초조한

77
Q

myasthenia gravis Pt

A

중증근무력증.

salivation(타액분비), swallowing, difficulty, osteomyelitis 악화, nose bleeding, N/V Diaphoresis,secretion ↑

78
Q

multiple sclerosis

A

다발성경화증.

constipation, blurred vision, hopeless

79
Q

산모->분만후 40kg..? 모유수유시 abd pain

A

.

80
Q

Portal HTN Pt

A

nausea (zofran투여가 우선)

81
Q

esophageal varix Pt

A

식도정맥류

N/V, encouraging coughing ( should be avoided)

82
Q

Liver Failure

A

astexis(손떨림)

83
Q

Morphine 투여 후 몸을 긁는다.

A

노폐물 ↑, pruritis

84
Q

Bleeding 우선순위

A 
#hemophilia pt with chest ecchymosis
#OP후, bright red bleeding ( 예외]rectal bleeding)
#Hematuria, occult blood, gum bleeding,
#ERCP 후, abd pain, umbilicus ecchymosis
#TURP 후 dark red urine, 
#hysterectomy(자궁절제술) with PAD#/d ↑?, zantac(라니티딘 계열 제산제) 투여 후 수술
85
Q

Heparin (PTT:30-40초, INR:60-80초) Pt.

A

PLT 15만 ↓ 시 우선순위

86
Q

Coumadin (PT:11-12.5초, INR:25-30초) Pt.

A

occult blood, nose bleeding, gum bleeding 우선순위

green salad 먹는 경우 효과 ↓

87
Q

BKA

A

below knee amputation

BP ↓, loose한 E/B, P↑

88
Q

Renal Bx후

A

flank pai & shoulder pain (bleeding sign)

89
Q

Digoxin

A 
# 복용 전: PGO wave ↓(램수면시 나오는 전기신호)
#복용후: vomit, anorexia(독성 ↑)
*ponto-geniculo-occipital
90
Q

epinephrine 투여 우선순위

A

.

91
Q

ACE inhibitor 복용후

A 
*ACE inhibitor= 고혈압치료약제: 안지오텐신 전환효소 억제제
#dizziness, dry cough
92
Q

PTU 복용

A

[propylthiouracil] 갑상선항진증 치료제

sore throat

93
Q

임산부 - 콜레스테롤 약 복용-> 우선순위

A

.

94
Q

synthyroid 복용

A

pulse ↑(100이상), palpitation

95
Q

aminophyllin 주입 중

A

*이뇨제·혈관 확장제

irritable/ irreguar breathing

96
Q

Cefa anti 투약후

A

inching, coughing, diarrhea

97
Q

anti 우선 투여

A

예외) 수술 전 투여는 우선순위 아님

98
Q

Cast Pt

A

pulse(-), pain↑, tingling sensation, funny feeling?

99
Q

Kidney transplantation

A

U/O 100cc/hr ↓

rejection sign 이므로 반드시 noti

100
Q

Marfan syndrom

A

back pain (aortic aneurysm)

101
Q

After delivery

A 
epigastric pain (eclampsia Sx)
*eclampsia[자간]: 단백뇨와 고혈압을 일으키는 전자간증(임신중독증) 산모에서 임신 기간이나 분만 전후에 전신의 경련 발작이나 의식불명을 일으키는 질환
102
Q

Opioid와 antihistamine X

A

.

103
Q

아기->drooling

A

.

104
Q

CVA->drooling

A

.

105
Q

asthma

A

wheezing X

106
Q

상기도 injury OR OP

A

.

107
Q

shock->stridor

A

.

108
Q

LTB->stridor(croup 증후군)

A

*LTB: [laryngotracheal bronchitis] 후두기관성기관지염.

바이러스감염에 의한 크루프(croup)증후군의 병형 중 하나

109
Q

Neck edema OR neck fulling sense

A

.

110
Q

Thyroidectomy

A

갑상선절제술.

tingling, jaw pain

111
Q

THR

A

sitting, hemoptysis

112
Q

Hyperthyroidism

A

BT 38.6℃↑, PR 148 ↑

113
Q

tonsilectomy

A

편도절제술.

hoarseness

114
Q

asthma

A

dizziness, diaphoresis, restless, PEFR50 ↓, dyspnea

115
Q

Hip Op

A

fever, irritable

116
Q

Epiglottis

A

Croup

117
Q

stoma

A

oozing, crust[딱딱]

엔클렉스 패스하자 (10 decks)

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