April 6_Cardiac & Fund 40 qns Flashcards
Carone Dsilva, RN
Cardiac Tamponade
decreased cardiac output, hypotension, muffled heart sound
Nurse will auscultate for pulses paradoxes with changes in SBP during expiration (10 mmHg higer)
than inspiration
Variant Angina
*Occurs at rest,
*Vasospasm of the coronary artery
*Changes in electrocardiogram seen.
*Variant angina pain occurs at the same time everyday.
Braden Scale parameter
Nutrition
Sensory Perception
Moisture
Activity
Mobility
Friction and Shear
Breast examination
Examine both breasts simultaneously.
Bone-marrow biposy pre procedure
Painful pulling sensation
Death and Dying
*Judaism stay with the body until burial
**Islamic faith body is washed, wrapped and buried as soon as possible.
**Buddhism male members prepare the body for burial.
**Hindus don’t bury the body, instead creminate. Do place the head north facing.
Bowel retraining for older adult - bowel retraining.
*minimum 1,500 mL of fluid every day to avoid constipation
sit 30 mins on toilet seat following defecation. As food entering the stomach causes peristalsis.
CPR (cardiopulmonary resuscitation)
first chest compressions, then open airway.
Repurfusion indication following thrombolytic therapy for MI
Ventricular Dysrhythmias
Use your brain for HF patient don’t use salt sparingly
Note
Blood transfusion for sickle cell anemia complication
Iron toxicity
Crutches
Keep the rubber tips securely in place, Inspect the tips regularly, and replace them
Right foot is affected - clinet should put his weight on the crutches, place his left food on the 1st setp, transfer his weight to the left foot, move the crutches to the step, and then bring up his right foot.
The basic crutch stance should have the crutches 15 cm (6 in) in front and 15 cm (6 inc) to the side of the client’s feet, formin a tripod or triangular position.
The client should have his arms bear the weight of his body. Pressure on the axillae can damage the radial nerve and cause weakness and partial paralysis below his elbows.
Use gait belt to get up after the client is in bed for 3 days.
dangle legs for 60 secs.
nurse should walk beside the client to provide support.
Palpation to detect the client’s skin moisture levels
Medication compliance
motivation to change, positive personal outcomes should perceive steps to change
