Adult Flashcards
What medications should be held prior to dialysis treatment?
- cardiac
- antihypertensives
- antibiotics
*DON’T hold analgesics or insulin
What could cause weight gain over time in a patient receiving peritoneal dialysis?
high glucose content in dialysate increases the amount of fluid that is removed during dialysis exchange
What action can help to initiate outflow if not enough fluid is returning after peritoneal dialysis ?
shift patient position
monitor for constipation - could be cause for insufficient outflow
What complications should you monitor for after dialysis treatment?
- peritonitis
- disequilibrium syndrome
- risk for infection/clots (AV fistula)
Symptoms of headache, fatigue, nausea after dialysis treatment
disequilibrium syndrome
Client has continuous sensation to urinate after TURP. Is this normal?
Yes
Things to monitor post-TURP
- bleeding
- bladder spasms
- severe hyponatremia from CBI
symptoms of hemolytic blood transfusion reaction
low back pain, N/V, hypotension, fever, tachycardia, hemoglobinuria, flushing, chills
Cause of myasthenia gravis
low acetylcholine and excessive cholinesterase -
causes weakness and fatigue of VOLUNTARY muscles
Symptoms of myasthenia gravis
weakness, fatigue, diplopia, difficulty breathing, dysphagia, respiratory failure
What antihypertensive medication is less effective in African Americans?
beta blockers
Interventions for dumping syndrome
Goal: slow down speed of food and nutrients through system
- avoid empty carbs and fiber
- eat smaller meals frequently
- lie down after eating
- don’t drink fluids with meals
Treatment for psoriasis
sunlight/ UV therapy
procedures that use contrast dye
- pyelogram
- cardiac catheterization
- contrast CT
- myelogram
*Assess for allergies!
Interventions for IV Pyelogram
- bowel prep
- NPO after midnight
- assess for allergies
What is the purpose of IV Pyelogram
X-ray of kidneys, ureters, and bladder that uses contrast dye
Interventions post- cardiac cath
- keep flat for 6-12 hours
- encourage fluid intake
- neurovascular a/s
- pressure dressing to insertion site
- assess for hematoma
- manage pain
- report lightheadedness, chest pain, numbness, tingling
Correct positioning during and after liver biopsy
During: supine and right arm raised and extended behind head
After: Right lateral position w/ small towel under site
how many mL are in 1 cup?
240 mL
What is Systemic Lupus Erythematous ?
chronic, systemic, inflammatory disease that causes vasculitis of the small vessels, leading to necrosis and inflammation
What lab values are elevated in SLE?
- Elevated ESR and CRP
- Monitor BUN and Cr for signs of kidney damage
What is the priority before starting Tracheostomy suctioning?
hyper-oxygenate the patient!
What is proper trach suctioning?
- start suctioning once you’re INSIDE the chest
- intermittent suction while swirling out (10 seconds)
- normal suction pressure: 90-120
What are diabetic sick-day rules?
- check blood glucose every 3-4 hours
- can become hyperglycemic from stress of being sick
- can become hypoglycemic from N/V and lack of food
What are symptoms of autonomic dysreflexia?
- HTN
- bradycardia
- pounding headache
- nasal congestion
- sweating
- restless
Interventions for autonomic dysreflexia
- make sure catheter is draining
- make sure bowel is not impacted
- immediately place in High fowler’s
risk factors for cholelithiasis
4 F’S
- female, fat, forty, fertile
- US southwestern hispanic or Native american is highest risk
- fasting (decreased gallbladder movement)
patient presents with: dyspnea, diaphoresis, anxiety, restless, cough, and chest pain.
What does this indicate and what do you do?
indicates air embolus - central line associated complication
Intervention: position patient on left side to displace air to the right side of the heart
when should compression stockings be placed on a client?
after elevation of the limbs
or when there is minimal dependent edema
the nurse should be most concerned if a patient having an acute asthma attack auscultates _____.
decreasing breath sounds - indicates severe spasm or obstruction
(inspiratory wheezing is also a major concern)
Cushing’s syndrome is caused by _____
chronic exposure to excess corticosteroids
- edema of LE
- at risk for infections because of immune system suppression
- hypokalemic
- hyperglycemia
- weakness
- hypernatremia
- risk for weak bones
- risk for cataracts
- weight gain
What does it indicate when S3 (ventricular gallop) is heard?
Left-sided heart failure
normal in kids
A finding of ______ in a client with bulimia requires IMMEDIATE notification to the HCP.
hoarse voice that is barely audible (laryngitis)
osteoarthritis is characterized by joint pain that is relieved by ______.
resting
- rheumatoid arthritis pain is relieved by ROM
characteristics of osteoarthritis
- crepitus w/ ROM
- pain worsens with activity
- affects weight-bearing joints
- joint atrophy
- tylenol and NSAIDs
- corticosteroid injections
characteristics of RA
- Joint stiffness in the AM
- joint tenderness
- joint swelling
- decreased ROM
- encourage range of motion
Phalen maneuver
assessing for symptoms of carpal tunnel syndrome
- put back of hands together and bend both wrists at the same time to produce paresthesia
what can cause a falsely HIGH blood pressure reading
- short cuff
- repeating assessments too quickly
- positioning artery BELOW the heart
- deflating the cuff too quickly
cataracts occurs when the lens becomes less ____ and more ____.
less hydrated
and
more dense
clients diagnosed with PUD should avoid:
rich in cream or milk aspirin alcohol meat extracts caffeinated beverages
HPV vaccine is recommended at ages ____ to reduce risk of ______ cancer.
at ages 11-12
to reduce risk of CERVICAL/PENILE cancer
If a client has low back pain, the nurse should ask ___?
how many rest periods the client gets during work hours
- should avoid standing for long periods of time
Diet for patient w/ CKD
- low sodium, potassium, phosphorus
- adequate calcium
- limit protein
*decrease diary intake because even though they are hypocalcemic, dairy products are high in phosphorus
If female client’s dialysate outflow is cloudy, determine if ________.
she is menstruating. blood from uterus can be pulled through into the dialysate
before a skin biopsy, it is most important to assess if the patient is using ______.
antiplatelets
a client with addison’s disease should _____ their sodium intake
INCREASE
symptoms of addison’s disease
- hyponatremia
- hypoglycemia
- hyperkalemia
- hyperpigmentation
- lethargy, weakness, fatigue
patient’s with addison’s disease need lifelong _______.
lifelong steroid replacement
When taking corticosteroids,receiving _____ should be avoided.
vaccinations - because of decreased ability to mount an inflammatory response
interventions for if a ventilator alarm is activated:
- assess breath sounds FIRST
- assess for hypoxia and vital signs
- then check the tubing for excessive fluid
What meds would be given in an anaphylactic reaction?
- epinephrine IM
- diphenhydramine IV
- prednison IV
- albuterol via nebulizer
symptoms of vitamin B 12 deficiency:
- fatigue
- constipation
- diarrhea
- sore tongue
After a seizure, ______ and _____ are common.
postictal confusion and sleepiness
post-lumbar puncture, the client should remain ____ in bed for ____ hours.
remain flat in bed for at least 8 hours
What is the crede maneuver?
often used for patients with SCI
manually apply pressure to bladder to aid in complete emptying - reduces risk for infection
Bell’s Palsy
- can use heat on affected side of face
- don’t bend over b/c of IOP
- do isometric exercises
- use artificial tears
- place eye shield over eye at bedtime
- avoid cold winds b/c of nerve ending sensitivity
The weight of the body when using crutches should be transferred to the _____.
hands and arms
crutches should be placed 8-10 inches in front with each step
How should the patient post-cataract surgery be positioned in the immediate post-op period?
on the unaffected side or on back with the head slightly elevated
Interventions for dumping syndrome
- avoid empty carbs and fiber
- eat lying down or lay down after meals
- avoid drinking fluids with meals
- eat small meals more frequently
What is Guillain-Barre syndrome?
autoimmune attack on the peripheral nerve myelin - can be triggered by a viral infection
affects the PERIPHERAL nervous system
interventions for Buck’s traction
- weights should always hang freely
- keep HOB 15-20 degrees
- keep on strict bedrest
- turn q 2 hours to unaffected side
interventions for rheumatoid arthritis
- heat
- ROM exercises
- weight reduction
immediately report _____ after thyroidectomy
hoarse voice
symptoms of neuroleptic malignant syndrome
fever, tachy, incontinence, muscle rigidity, seizures, sweating, salivation
PPE order
Donning - gown, mask, eye shield, glove
Removing - gloves, goggles, gown, mask
correct pursed lip breathing
- tighten stomach muscles when breathing out
- take 2x as long to breathe out than breathing in
- pretend you’re whistling when you breathe out
Preparing for cardioversion
- administer sedative/hypnotic (midazolam)
- assess heart rhythm
- hold digoxin 48 hours before
- don’t drive for 24 hours after
adventitious breath sounds
rales - crackling or gurgling on inspiration
rhonchi - musical sounds or vibrations on expiration
wheeze - squeaky sounds on inspiration and expiration
pleural friction rub - grating sound during I and E
what to do during a PTSD flashback?
maintain a safe distance and limit stimuli
Walking with a cane
hold cane in unaffected arm
move weak leg first
then strong leg
CANE, WEAK, STRONG
R.A.C.E
rescue/remove
alarm
contain/confine
evacuate
using a hydraulic lift
used to move patient from bed to chair
- suspend patient in the sling above the bed before moving the lift
- leave the sling in place under the patient once seated
- set lift base in widest position
- gently push on knees when lowering the patient
symptoms of VTE
unilateral leg edema extremity pain warm skin erythema heaviness in the chest - PE
time frame for activated charcoal
within one hour of ingestion
septic shock: early and late stage
early:
strong bounding peripheral pulses and hyperventilation, warm dry skin
late:
weak or absent peripheral pulses and decreased respirations, cool clammy and pale
interventions post-myelogram
- encourage oral fluid intake
- lie flat for 12-24 hours to prevent headaches
- monitor V/S and neuro signs
multiple sclerosis
demyelination of neurons
urinary retention
hyperreflexia
numbness or tingling
decreased short-term memory
interventions:
- ambulate as tolerated
- don’t overexert
- don’t force spastic extremities open
- avoid overexposure to heat or cold
- include ROM exercises
- participate in social activities
myasthenia crisis
dyspnea anoxia cyanosis absent cough/swallow reflex increased HR, BP, RR
Interventions for AAA:
bruit over aorta increase fluid intake and fiber don't lift heavy objects don't palpate mass immediately report SOB, chest/back pain, difficulty swallowing
signs of autonomic dysreflexia
HTN bradycardia pounding HA nasal congestion flushing above pale below goosebumps restless sweating
interventions for autonomic dysreflexia
make sure catheter is draining
bowel are NOT impacted
IMMEDIATELY place in High fowler’s
What confirms diagnosis of glomerulonephritis?
positive ASO titer
differentiate from UTI b/c negative for WBC and no bacteria in urine
post thyroidectomy, monitor for which electrolyte imbalance?
hypocalcemia
and monitor for thyroid storm!
keep calcium gluconate for IV administration ready
Thyroid storm
increased temp, BP, HR, RR
agitation
seizures
tremors
Give propranolol - bring down HR and BP
Give D5W - restore glycogen stores
antithyroid meds
signs of bacterial meningitis
headache photophobia nuchal rigidity changes in LOC fever brudzinski and Kernig's
*DROPLET for 24 hours until after ABX start
restrict fluids b/c of ICP
client with meniere’s disease should have a _____ diet.
low sodium to decrease fluid retention
symptoms of mononucleosis
malaise fever severe sore throat headache epistaxis
*monitor for splenomegaly!!
what do positive nitrates in a urinalysis indicate?
presence of E. Coli
Controlling odor and gas in colostomy care
cranberry juice, yogurt, buttermilk, deodorant, crackers and toast
don’t skip meals, chew gum, smoke, drink beer
cocaine withdrawal symptoms
cravings
depression
fatigue
hypersomnia
alcohol withdrawal
tremors, increased HR, anxiety, insomnia, hallucinations
- peaks in 24-48 hours
- determine when last drink was
- quiet, well-lit room
- initiate seizure precautions
phlebitis vs infiltration
phlebitis - red and warm around site and up vein
DC IV, warm/moist compress
infiltration - swelling at insertion site
D/C IV and elevate the arm
interventions for paracentesis
measure weight before and after
measure abdominal girth before and after
have BP cuff to monitor for hypotension
why should a client with PAD be encouraged to exercise?
because exercising increases collateral circulation
understanding of aseptic technique dressing changes
wash hands!
use only what HCP ordered
have someone look at wound every dressing change
throw dressing away wrapped in nonsterile glove
when should the nurse irrigate the NG tube?
if they check the tube and it is not patent and not draining
check for patency by aspirating stomach contents first and then by auscultation
what is the most important thing to check for post thyroidectomy surgery?
monitor for signs of respiratory distress every hour from swelling
What should the nurse instruct the patient to do if the client feels faint?
place the client’s head between the knees
exercise for osteoarthritis
warm-up exercises before and after
don’t exercise severely painful joints
swimming is a helpful exercise
Expected findings in burn resolution
pain around periphery
increased edema
elevated hematocrit
*gastric pH less than 5 is UNEXPECTED –> at risk for Curling’s ulcer (develops 24 hours after severe burn)
signs to monitor for post bronchoscopy
signs of respiratory distress
tachycardia
respiratory stridor
retractions
depressed gag reflex, sputum streaked with blood and sore throat - expected findings
characteristics of diabetes insipidus
deficiency of ADH
- increased UO
- dilute urine
- specific gravity < 1.005
what is normal specific gravity?
1.010 - 1.030
What is given for diabetes insipidus?
desmopressin nasally or SQ for life
defibrillator
- don’t touch the bed when using the defibrillator
- check it every 8 hours
- should always be plugged in
- don’t place paddles over electrodes
what does subcutaneous emphysema post chest-tube removal indicate?
pneumothorax!
observe for respiratory distress and contact HCP
Sengstaken-Blakemore tube
triple lumen gastric tube that compresses esophageal varices and also has a NG suction lumen
if client is in respiratory distress:
- cute balloon ports
- remove the tube
what are 2 notable symptoms of type 1 diabetes?
excessive thirst and weight loss
bulge test
confirms presence of fluid in the knee
ask the client to lie down and extend the legs on the bed
chest tube
expected findings:
- 2 cm of water in water seal chamber
- clots of blood observed in collection chamber (hemothorax)
unexpected:
- constant bubbling in water-seal chamber (AIR LEAK)
normal CVP range
3-12 mm Hg
reading of 8 mmHg indicates desired response to fluid replacement
early and late stages of hepatic encephalopathy
early:
- impaired thought processes, insomnia or sleep disturbances, writing changes or hand tremors
late:
- asterixis, lethargy, extended sleep patterns, decerebrate posturing, hyperventilation
expected urinalysis results for UTI
WBCs and RBCs present
for inflammation and bleeding from bladder mucosa irritation
obtaining throat culture
rub cotton swab over both tonsillar areas and posterior pharynx
what should be assessed post pneumonectomy?
position of the trachea in the sternal notch because a tracheal shift could cause and increase in pressure on the operative side and cause pressure against the mediastinal area
interventions for chronic constipation
- increase intake of cereals, fresh fruits and veggies
- plan day to be around usual time of defecation
- establish daily exercise pattern
lumbar puncture
- does NOT use general anesthesia
- fluids NOT restricted
- no compression bandage
- CAN use analgesics after for headaches
what indicates a client undergoing alcohol withdrawal symptoms will go into withdrawal delirium?
increased pulse rate
what is an adverse effect of magnesium sulfate?
CNS depressant –> decreases blood flow to the kidneys
watch for decreased UO
Jackson-Pratt drain should always be attached to ____.
the patient’s gown or pajamas only
positioning post-mastectomy
semi-fowler’s position with affected arm elevated
facilitates removal of fluid from venous pathways and lymphatic system - enhances circulation and prevents edema
what is treatment for head lice?
gamma hexachloride shampoo - apply to dry hair and work into lather for 4-5 minutes
correct precautions for Measles (rubella)?
droplet precautions
care of open Kaposi’s sarcoma lesions
clean with soap and warm water every day and cover with sterile dressings to prevent secondary infection
care of herpes simplex virus abscesses
clean 2x a day with diluted solution of povidone-iodine and leave open to air
causes of autonomic dysreflexia
full bladder
impaction
pressure on skin
cold draft
what do you administer in autonomic dysreflexia if BP does not go down after relieving bladder or impaction?
hydralazine hydrochloride IV
principles for radiation therapy
time
distance
shielding
*lead apron should be used when the nurse has to spend any length of time at a close distance
signs and symptoms of opioid (heroine) withdrawal
what is the antidote?
N/V, abdominal cramping, restlessness
Nalaxone - response will be N/V, HTN, tachycardia
what info about medications should be included in change of shift report?
new medication orders
recent PRN administrations
symptoms unrelieved by administered meds
what should be monitored after administered naloxone?
monitor rate of respirations
symptoms of acute GN
fever chills hematuria dyspnea weight gain, edema HTN headache decreased LOC confusion abdominal/flank pain
how often should pedal pulses be checked post- cardiac cath?
immediately after procedure and q 15 minutes for several hours after
patients with SLE should avoid _____
all direct exposure to sun or UV light
don’t work/dig in a garden for risk for injury
Continuous ambulatory ECG
- no electric razor or hairdryer
- keep a log of all activities
- no bathing/showering
when going upstairs with a cane, you should step up firs with your _____ leg.
strong
symptoms:
respiratory failure
flaccid paralysis
urinary retention
_____?
guillain-barre syndrome
treatment for itching in hepatitis A
calamine lotion and antihistamines
report ______with hyperparathyroidism (sign of urinary calculi)
hematuria
frontal lobe of brain controls:
personality changes voluntary activity concentration motivation ability to plan problem solving
precautions for DISSEMINATED herpes zoster
airborne and contact
why should the client diagnosed with chronic adrenal insufficiency avoid exposure to infection?
exposure to infection, cold, or excessive fatigue can cause circulatory collapse
enteral feedings via NGT
- aspirate and measure amount of gastric aspiration
- measure pH of aspirate
- clamp feeding tube at the end
- HOB 30 degrees
- warm formula to room temp
- intermittent feedings - 30 minutes minimum
verifying placement and checking pH must be done by RN only
polyarteritis nodosa
inflammation of the small arteries causing diminished blood
treatment w/ cortisone is increased survival rate
where are signs of jaundice best observed in asian americans?
posterior hard palate
symptoms of early-stage Alzheimer’s
recent memory loss and changes in motor activity - pacing, wandering, agitation
post concussion syndrome
- persistent headache for 2 weeks or more
- notify continuous vomiting
- don’t resume contact sports
- trouble remembering small details
- no recollection of evens about the incident
why does a client with TB need vit B6 supplementation?
to prevent the side effects of isoniazid - peripheral neuropathy, dizziness, and ataxia
what vitamin supplementation does a client with chronic alcoholism need?
all B vitamins but especially vitamin B1 (Thiamine) - thiamine deficiency is the primary cause of alcohol-related changes
what is a common cause of chronic gastritis?
H. Pylori
positioning after intracapsular cataract extraction
semi-fowler’s or non operative side
fluorescein angiography
measures circulation in the retina
- avoid sunlight directly after
- temporary yellow skin staining
- increase fluids to excrete dye
what should the nurse be concerned about after a TURP?
elevated temperature
bladder spasms
leaking fluid around catheter
hemorrhage
*urge to void is normal
what should you do if a depressed client does not eat meals?
ask the client to identify her favorite foods
autologous blood donation
- can give up to 5 wks before surgery
- can give 2-4 units of blood
- no blood draws within 3 days of surgery
- take iron supplements
signs of heat stroke
hypotension, tachypnea, tachycardia, elevated temp, hot and dry skin
Gtube with frequent loose stools - caused by ____
if liquid medication that has sorbitol is given through the tube.
if the client is allergic - can cause diarrhea
normal IOP
10-21 mm Hg
moist-to-dry dressing
remove gauze dressing
observe wound
clean wound
apply moist gauze
sexual activity post MI
tolerate 1 city block or 2 flights of stairs without SOB or chest pain
stay supine
not after heavy meal
stroke risk factors
male african american substance abuse (cocaine) smoking alcohol diabetes obesity heart murmur oral contraceptive use sedentary lifestyle history of MI high cholesterol
treatment for DVT
bedrest w/ leg elevated
anticoagulants
warm, moist soaks
halo vest traction
report IMMEDIATELY if client has pain while chewing
pain w/ jaw movement 24-48 hours after indicates skull pins slipped into temporal plate
chronic venous insufficiency
thick, dark skin
pain in dependent positions
crater-like lesions
toxic shock syndrome
no superabsorbent tampons
no vaginal products with deodorants
contact HCP if vomiting/diarrhea
change tampons q 4 hours
risk factors for colorectal cancer
age over 50 african american first degree relative high protein, fat, low fiber diet hx of IBD
Breast self-examination
use pads of first 3 fingers in gentle rotating motion
precautions for influenza
droplet for 7 days or until 24 hours after symptom resolution
signs of dehydration
dry skin
tachycardia
cold extremities
increased thirst
airborne precautions
TB
measles
varicella - disseminated
interventions:
door closed
N95 mask
mask during transport
droplet precautions
influenza meningococcal meningitis diphtheria pertussis mumps group A strep pneumonia
interventions:
door open
keep 3 feet
face mask during transport
what to do if tracheostomy tube is dislodged
replace the tube!
OR
extend neck to maintain patent airway call for help place supine check breath sounds use hemostat to open airway
sexual activity after vasectomy
wear a condom for 6 weeks after surgery because some sperm may remain in the vas deferens for up to 6 weeks
anterior wall MI has a high risk for ______.
heart failure
auscultate lung fields!
what do you do if muscle spasms increase in a client placed in balanced suspension traction?
assess the traction weight
patient in balanced suspension traction is allowed to move _____ but not _______
up and down
but NOT side to side
self-catheterization
keep catheter in plastic bag
catheterize q 6-8 hours
wash with soap and water prior
don’t need sterile gloves
diet for crohn’s disease
low fat high protein low residue high calories non irritating
priority of the nurse when a client is contaminated with unidentified hazardous material?
determine what decontamination occurred in the field
turning a patient post lumbar laminectomy
place pillow between client’s legs and turn the client
what class of antibiotics have cross allergies with penicillins?
cephalosporins
what should tracheostomy cuff pressure be?
< 20 mm Hg
wall suction can be
symptoms of Lyme disease
rash intermittent fever headache fatigue muscle pain stiff neck
expected breath sounds in chronic bronchitis
sonorous wheezes or rhonchi
from excessive mucous production
what is important to monitor in a client after a stroke?
auscultate lung q4 hours because decreased O2 levels increases ICP - also puts patient at risk for aspiration
what electrolyte imbalance is possible after thyroidectomy ?
hypocalcemia
injured parathryoid gland causes decreased hormone levels
monitor for tingling of fingers, toes, lips
clients at risk for metabolic acidosis
type 1 diabetes
salicylate toxicity - med is acidic
acute kidney failure
severe diarrhea
kosher diet
no dairy and meat at the same time
no shellfish or scavenger fish- must have scales
no pork products
no gelatin foods
midstream urine for C/S
clean urinary meatus with antiseptic solution
void into sterile container
container must NOT touch penis
order for physical assessment
inspection
palpation
percussion
auscultation
myasthenia gravis interventions
avoid alcohol, heat, stress, OTC meds
thicker liquids better
spread out activities
avoid stress and infection
enema
hold irrigation set 12-18 inches above rectum
insert irrigation tube 3-4 inches into rectum
position client in sim’s position
warm water slightly higher than body temp
interventions for hyperemesis gravidarum
start IV for hydration intake and output q 4 hours NPO to rest GI weight check q AM all meds IV to rest GI bed rest to conserve energy
