333 Review Flashcards
Hyper Ventilation
S/s: rapid respirations, sighing breaths, numbness/tingling of hands feet, light headedness, loss of consciousness
Conditions associated with Atelectasis
-immobility
-obesity
-sleep apnea
-chronic lung conditions
Hypoxia
Apprehension, restless, inability to concentrate. decreased LOC, behavioral changes
Can’t stay still
Fatigued yet agitated
Early rat late bed
Specimen collection sputum
Best to collect early morning
Wait 1-2 hours after patient eats
sterile container and teach patient to not touch inside of container or lid
Tell patient to cough into container and get as much sputum as possible
May require suctioning
How to manage pulmonary secretions
Mobilize
Hydrate
Humidification
Medications
Postural drainage
Opposite side Trendelenburg position
Danger of prolonged inflation of trach
Increase mucosal pressure
Ischemia
Softening
Mucosal erosion
Trach dislodgement
Keep obturator at bedside
Insert into out cannula
Extend neck and open tissue
Remove obturator
Check breath sounds
Secure trach
Nursing problems for patient with trach
-Ineffective airway clearance
-Impaired verbal communication
-Risk for infection
-Body image disturbance
-Anxiety
Hypertensive crisis
Higher than 180 or Higher than 120
Orthostatic Hypotension
Lying down for 5 min take
Standing for 1 min take
Standing for 3 min take
SBP decrease 20mmHg
DBP decrease 1o mmHg
Malnourished person at risk for
Dysrhythmias
Skin breakdown
Sepsis
Increase length of stay
Delayed healing
Infection
BMI Under weight and Obese
Less than 18.5 and greater than 30
Malnutrition Nursing Problems
-Imbalanced diet
-Imbalanced nutrition
-Impaired swallowing
-Risk for aspiration
-D/C/V
Plan of care dysphagia
Sit in high fowlers
Minimize distractions
Allow for time between bites
Check oral pocketing
Don’t feed altered LOC
Leave unattended
Administer sedatives
Use straw
Enteral Nutrition Indications
Prolonged anorexia
Severe protein energy malnutrition
Coma
Impaired swallowing
Critical illnessess
Feeding Tube complications
-Aspiration
-Diarrhea
-constipation
Tube occlusion or displacement
Delayed gastric emptying
Fluid overload
Normal fasting blood glucose
100 or below
Casual blood glucose
<200
Nursing considerations for the hospitalized diabetic patients
-stress and surgery can increase blood glucsoe
Wound healing is impaired in patines with diabetes
High risks for infection
Prevent urinary infection
-Follow hospital protocol
-Assess
-Perineal care
-Void regular intervals
-Maintain fluid intake
Nursing catheter care
Regular peri care
Secure catheter
Empty drainage bag when 1/2 full
Ensure no kinks in catheter tubing or below bladder
Maintain a closed drainage system
Accurate monitoring of output
Post care catheter removal
-Patient should void within 6-8 hours post removal
-If not then assess and preform a bladder scan
-If over the hospital amount then obtain order to in and out cath
Constipation prevention
Fluids
High fiber
Active
Manage stress
Don’t ignore the urge
Create a schedule
