406 Midterm 2 Flashcards
Ativan and seizures
ativan is given during the seize; doesn’t help afterwards
Ativan can help induce
amnesia
if someone has increased triglycerides, they’re at risk for what GI problem
pancreatitis
Good BP for a 60 y/o patient
below 150/90
Good drug for diabetics with HTN
ace inhibitor
Besides women, atypical angina pain is common in
older adults
DM
How do you position an MI patient
semi fowlers
Pulmonary edema position
high fowlers
Elevated BNP is a sign of
HF
pt has Ventricular tachy. what do you do
call RR, then start CPR
PaCo2 greater 50 is bad unless you have
COPD
Digitoxin actions
increase contractility
decrease HR
Dig tox signs
see halos
N/V
What do tachy and brady cardia have in common
both decrease EJ
Amiodarone treats
rhythm problems
A fib patients are always given what med
anticoagulant
2 most important questions to ask an asthma patient
are you on steroids
have you ever been intubated
Hallmark sign of PE
sudden chest pain
Impaired physical mobility r/t pain in extremity
DVT
Acute pain r/t vascular inflammation, edema
DVT
ineffective peripheral tissue perfusion r/t deficient knowledge of aggravating factors
DVT
Anxiety r/t threat of death, possible change in role status
MI
Decreased CO r/t ventricular damage, ischemia, dysrhythmia
MI
Ineffective Denial r/t fear, deficient knowledge, about heart disease
MI
Acute pain r/t myocardial tissue damage from inadequate blood supply
MI
Risk for shock
MI
Acute confusion r/t insufficient blood glucose to brain
Hypogly
Ineffective self-health management r/t deficient knowledge regarding disease process, self-care
Hypogly
Imbalanced nutrition: less than body requirements r/t imbalance of glucose and insulin level
Hypogly
risk for unstable blood glucose level
Hypogly
Impaired verbal communication r/t pressure damage, decreased circulation to the brain in speech center
CVA
Chronic confusion r/t neurological changes
CVA
Impaired memory r/t neurological disturbances
CVA
Impaired physical mobility r/t loss of balance and coordination
CVA
Unilateral neglect r/t disturbed perception from neuro damage
CVA
Impaired swallowing r/t limited physical mobility
CVA
Risk for ineffective cerebral tissue perfusion
CVA
Activity intolerance r/t imbalance between O2 supply and demand
Pneumonia
Impaired gas exchange r/t decreased functional lung tissue
Pneumonia
Hyperthermia r/t dehydration, increase metabolic rate, illness
Pneumonia
Ineffective breathing pattern r/t loss of functional lung tissue, depression of respiratory function or hypoventilation because of pain
Atelectasis
Impaired gas exchanged r/t decreased alveolar capillary surface
Atelectasis
Amputation: Disturbed body image r/t
negative effects of amputation, response from others
ineffective peripheral tissue perfusion r/t impaired arterial circulation
amputation
Impaired skin integrity r/t poor healing, prosthesis rubbing
amputation
Angiography allows visualization of peripheral
vasculature and areas of impaired circulation
Doppler laser and ultrasonography studies
Measure speed of blood flow in an extremity
Traumatic Amputation: Apply direct pressure using
gauze, if available, or clean cloth to prevent life-threatening hemorrhage.
Traumatic Amputation: positioning of extremity
Elevate the extremity above the heart to decrease blood loss
Traumatic Amputation: after wrapping in gauze, place in a
sealed plastic bag.
Traumatic Amputation: Wrap the severed extremity in dry sterile gauze (if available) or in a clean cloth, and place in a sealed plastic bag. Then,
Submerge the bag in ice water, and send with the client to the hospital
This is the most common Amputation technique used
Closed amputation
Amputation: Skin flap is sutured over end of residual limb, closing site.
Closed amputation
This Amputation technique is used when an active infection is present
Open amputation
Amputation: Skin flap is not sutured over end of residual limb allowing for drainage of infection. Skin flap is closed at a later date
Open amputation
Amputation: Compare pulse most proximal to incision with
pulse in other extremity
Phantom limb pain is a frequent complication in clients who experienced
chronic limb pain before the amputation
Phantom limb pain occurs less frequently following
traumatic amputation
Administering ___ ___ to relieve the continual dull, burning sensation associated with the Phantom limb pain
beta blockers
Administering _____ meds may relieve sharp, stabbing, and burning phantom limb pain.
anti seizure
Amputation: Teach the client how to push the residual limb
down toward the bed while supported on a soft pillow
Teach the client how to push the residual limb down toward the bed while supported on a soft pillow; it helps to reduce
phantom limb pain and prepare the limb for a prosthesis.
Amputation: Position the affected extremity in
dependent position to promote blood flow/oxygenation
Amputation: Residual limb must be ___ and ____ in preparation for prosthetic training.
shaped and shrunk
Shrinkage interventions: Wrapping the stump, using ____ bandages (figure-eight wrap) to prevent restriction of blood flow and decrease edema
elastic
Shrinkage interventions: Using an ___ splint (plastic inflatable device)
air splint
Amputation: A ____ ____ will train client in the application and care of prosthesis and mobility aids
physical therapist
Flexion contractures are more likely with the ___ or ___ joint following amputation due to improper positioning
hip or knee
Prevention of Flexion contractures includes range-of-motion (ROM) exercises and proper positioning
immediately after surgery
after the first 24 hr following amputation surgery avoid
elevating the stump on a pillow
following amputation surgery: Have the client lie ___ for 20 to 30 min several times a day.
prone
following amputation surgery: Discourage prolonged
sitting in a chair
Atelectasis: chest x ray shows
density
Stroke: occur secondary to a ruptured artery or aneurysm
Hemorrhagic
Stroke: These occur secondary to the development of a blood clot on an atherosclerotic plaque in a cerebral artery that gradually shuts off the artery and causes ischemia distal to the occlusion
Thrombotic
Stroke: These occur secondary to an embolus traveling from another part of the body to a cerebral artery
Embolic
Symptoms of a thrombotic stroke evolve over a period of
several hours to days.
Embolic stroke: Blood to the brain distal to the occlusion is immediately shut off causing neurologic deficits or a
loss of consciousness to instantly occur
An embolic stroke may be reversed with a thrombolytic enzyme, such as
recombinant tissue plasminogen activator (rtPA [Retavase])
An embolic stroke may be reversed with a thrombolytic enzyme, such as recombinant tissue plasminogen activator (rtPA [Retavase]), if given within
4.5 hours of the initial symptoms.
Dysrhythmia associated with stroke
Atrial fibrillation
street Drug associated with stroke
coke
_____ medication and/or surgical removal of atherosclerotic plaques in the carotid artery can prevent the subsequent occurrence of a stroke.
Antithrombotic
Stroke: A ___ ___ is used to assess for the presence of blood in the cerebrospinal fluid (CSF)
lumbar puncture
Stroke: Teach the client how to use the unaffected side to
exercise the affected side of the body.
Stroke: ROM
passive ROM for affected side
active ROM for unaffected side
Stroke: Teach the client to massage the affected hand by stroking it in a
distal to proximal manner, encouraging fluid in the hand to move back into the wrist and arm.
Stroke: Instruct the client to dress the affected side
first and sit in a supportive chair that aids in balance
Shoulder subluxation can occur if the affected arm is not
supported
Stroke: Use of ____ is controversial and not recommended due to the high risk of
intracerebral bleeding
anticoagulants
Stroke: thrombolytic therapy is contraindicated for treatment of a __ stroke
hemorrhagic
Possibility of a hemorrhagic stroke is ruled out with an ___ prior to the initiation of thrombolytic therapy
MRI
After stroke: If the gag reflex is present, give the client a
small sip of water to determine if choking occurs
After stroke: f the client exhibits some difficulty managing food or fluids, a swallowing evaluation should be done by a
speech therapist
After stroke: Initial feedings should be done by the ____, so appropriate interventions can be taken if choking occurs.
nurse
After stroke: teach the patient how to swalloe
Instruct the client to flex his head forward when swallowing to decrease the risk of choking.
