Blue Book Flashcards
In Abruption Placenta, the placenta ___ from the uterine wall ____
separates, prematurely
Abruptio Placenta usually occurs in ___ gravida over the age of ____
Mutligravida, age 35 (d/t: HTN, trauma, cocaine)
How is the bleeding of Abruptio Placenta different from that in Placenta previa?
usually painful; bleeding is more voluminous in placenta previa
if you are the nurse starting an IV on the client with abruptio placenta, what gauge needle should you use?
18 gauge (in preparation to give blood if necessary)
how often should you measure the VS, vaginal bleeding, fetal HR during abruptio placenta?
Q5-15 min (in preparation to give blood if necessary)
how is an infant delivered when aburptio placenta is present?
usually C-section
there is a _____ incidence of fetal death with abruptio placenta compared to placenta previa
Higher
in what trimester does abrutpio placenta most commonly occur?
third
at what age are accidental poisonings most common?
2 y/o
if a child swallows a potentially poisonous substance, what should be done first?
call for medical help
should vomiting be induced after ingestion of gasoline?
NO- not for gas or any other petroleum products
when taking a child to the ER after accidental poisoning has occurred what must accompany the child to the ER?
The suspected poison
an elderly client is at __ risk for accidental poisoning what about a School age child?
High (d/t- poor eyesight), High
what types of chemicals cause burns to oral mucosa when ingested?
Lye, caustic cleaners
children at highest risk for seizure activity after ingestion are those who have swallowed ___ and ___
drugs, insecticides
can impaired skin integrity ever be an appropriate nursing diagnosis when poisoning has occurred?
Yes, when lye or caustic cleaners have been ingested
what is the causative organism of acne?
P. acnes (propionibacterium acnes)
what structures are involved in acne vulgaris?
the sebaceous glands
name 3 drugs given for acne?
vitamin A, antibiotics, retinoids
dietary indiscretions and uncleanliness are causes of acne?
False
what are the 3 causative factors in acne vulgaris?
hereditary, bacterial, hormonal
uncleanliness is a cause of acne?
False
what is the most common retinoid given to people with acne?
Accutane
accutane is an analog of which vitamin?
vitamin A
what is the most common side effect of accutane? and what is most important in health teaching in administration?
inflammation of the lips; causes birth defects
what is the antibiotic most commonly given to clients with acne?
tetracycline
how long will it take for the person to see results when acne is being treated?
4-6 weeks
does stress make acne worse?
yes
how often should the client with acne wash their face each day?
twice a day
what instructions do you give to a client taking tetracycline?
take it on an empty stomach and avoid the sunlight (photosensitivity)
what are comedones?
blackheads and white heads
what virus causes AIDS?
HIV- human immunodeficiency virus
the AIDS virus invades helper
T-lymphocytes (or CD4 cells)
AIDS is transmissible through what four routes?
blood, sexual contact, breastfeeding, across placenta in utero
HIV is present in all body fluids?
Yes, but is not transmitted by all. only blood, semen and breastmilk
name the 5 risk groups for AIDS
homosexual/bisexual men, IV drug users, hemophiliacs, heterosexual partners of infected people, newborn children of infected women
what is the first test for HIV antibodies?
ELISA
what test confirms the ELISA?
western blot
which test is the best indicator of the progress of HIV disease?
CD4 count
a CD4 count of under ___ is associated with the onset of AIDS-related symptoms
500
a CD4 count of under ___ is associated with the onset of opportunistic infections
200
give 6 symptoms of HIV disease
anorexia, fatigue, weakness, diarrhea, night sweats, fever
which 2 classes of drugs are given in combination for HIV zero-positivity?
NRTI’s (nucleoside reverse transcriptase inhibitors) & PI’s (protease inhibitors)
they prevent viral replication
NRTI (nucleoside reverse transcriptease inhibitors)
an antiviral drug used against HIV
is incorporated into the DNA of the virus and stops the building process. results in incomplete DNA that cannot create new virus
often used in combination with other drugs
PI’s (protease inhibitors)
most potent of antiviral meds.
inhibit cell protein synthesis that interferes with viral replication.
does not cure but slows the progression of AIDS. prolongs life
used prophylactically and used in AIDS to decrease viral load and opportunistic infections.
what do NRTI’s and PI’s do?
they prevent viral replication
what does the physician hope to achieve with NRTI’s and PI’s for HIV?
a delayed onset of AIDS for as long as possible
usually can delay onset for 10-15 years
what is the most common NRTI used?
AZT (zidovudine)
what is the most challenging aspect of combination of drug therapy for HIV disease?
the number of pills that must be taken in 24 hours can be overwhelming. the frequency also makes it hard to remember (an alarm wrist watch is used)
clients with AIDS gain or lose weight?
lose weight
the typical pneumonia of AIDS is caused by ___
pneumocystic carinii
what type of oral/esophageal infections do AIDS patients get?
candida
what is the #1 cancer that AIDS patients get?
kaposi’s sarcoma
kaposi’s sarcoma is cancer of the ___
skin
true or false:
AIDS patients get lymphomas?
true
what lab findings are present in AIDS?
decreased RBC’s, WBC’s and platelets
if the AIDS patient has leukopenia they will be on ____
protective (reverse) isolation
define leukopenia
decrease in WBC’s; indicative of viral infection
without leukopenia the AIDS patient will be on ___ precautions
standard precautions or blood and body fluid precautions
when the AIDS patient has a low platelet count, what is indicated?
bleeding precautions; No IM injections, no rectal temps, other bleeding precautions
does AIDS require a single room?
Yes- if WBC count is low
when do you need a gown with AIDS?
if you are going to get contaminated with secretions
when do you need a mask with AIDS?
not usually unless they have an infection caused by an airborne bug
when do you need goggles with AIDS?
suctioning, central line start, arterial procedures
if an AIDS patients blood contaminates a counter top, with what do you clean?
1:10 ratio solution of bleach and water
are all stuff used by AIDS patient double bagged?
No- only those contaminated with secretions
can AIDS patients leave the floor?
yes, unless WBC’s are very low
is dietary protein limited in AGN (acute glomerulonephritis)?
not usually, however if there is severe azotemia then it may be restricted
define azotemia
nitrogenous wastes in the blood (increased creatine, BUN)
what is the best indicator of renal function?
serum creatine
do people recover from AGN (acute glomerulonephritis)?
yes, the vast majority of all clients recover completely from it
how can AGN (acute glomerulonephritis) be prevented?
by having all sore throats cultured for strep and treating any strep infections
what is the most important intervention in treating AGN (acute glomerulonephritis)?
bedrest- they can walk is hematuria, edema and hypertension are gone
what is the most common dietary restriction for AGN (acute glomerulonephritis)?
moderate Na+ (sodium) restriction
fluid restriction is #2 if edema is severe
what are the urinalysis findings on AGN (acute glomerulonephritis)?
hematuria, proteinuria +3 to +4, increased specific gravity
how long after step infection does AGN (acute glomerulonephritis) develop?
2 to 3 weeks after initial infection
how do you assess fluid excess in the child with AGN (acute glomerulonephritis)?
daily weights
what organism causes AGN (acute glomerulonephritis)?
group A beta hemolytic strep
what happens to the kidney in AGN (acute glomerulonephritis)?
it becomes clogged with antigen-antibody complexes which then cause inflammation and loss of function
how often are VS measurements taken in AGN (acute glomerulonephritis)?
Q4 hours with BP
will the client have hypo or hyper tension with AGN (acute glomerulonephritis)? why?
hypertension, because of fluid retention
what are the first signs of AGN (acute glomerulonephritis)?
puffiness of face, dark urine
what are the 3 adult staged of development?
early adulthood, middle adulthood, late adulthood
what is the age range for early adulthood?
19-35
what is the age range for middle adulthood?
35-64
what is the age range for late adulthood?
64-death
what is the developmental task for early adulthood?
intimacy vs. isolation
what is the developmental task for middle adulthood?
generativity vs. stagnation
what is the developmental task for late adulthood?
ego integrity vs. despair
intimacy vs. isolation
erikson’s stage in which individuals form deep personal relationships, marry, begin families
generativity v. stagnation
erikson’s stage of social development in which middle-aged people begin to devote themselves more to fulfilling ones potential and doing public service
ego integrity vs. despair
erikson’s stage of people in late adulthood either achieve a sense of integrity of the self by accepting the lives they have lived or yield to despair that their lives cannot be relived
“time is too short to start another life, though I wish I could” is an example of ___
despair
“if I had to do it over again, I’d live my life just about the same” is an example of ___
ego integrity
the result of the positive resolution of the final life crisis. viewed as the key to harmonious personality development; the individual views their whole life with satisfaction and contentment.
what does “AKA” mean?
above the knee amputation
what does “BKA” mean?
below the knee amputation
if the patient had an AKA they should lie ____ several times per day.
prone (to prevent flexion contracture)
the #1 contracture problem in AKA is ___ of the ___
flexion, hip
what will prevent hip flexion contracture after AKA?
lying prone several times a day
what is the #1 contracture problem after BKA?
flexion of the knee
how do you prevent flexion contracture of the knee after BKA?
remind the patient to straighten their knee constantly while standing
to prevent post-op swelling, the stump should be ___ for 12 t 24 hours
elevated
how long should the stump be elevated to prevent post-op swelling?
12-24 hrs
how often should a stump be washed?
daily
when a stump is wrapped, the bandage should be tightest ___ and loosest ___
distal (far from the center), proximally (nearest to the point)
if after a right BKA, the client complains of pain in their right toe, they are experiencing ____.
phantom limb sensation (which is normal)
when will phantom limb sensation subside?
in a few months
is it acceptable for the patient to push the stump against the wall?
yes, this is one way to toughen a stump so it will not breakdown due to the wear of the prosthetic leg; hitting it with pillows is another good method
an aneurysm is an abnormal ___ of the wall of an artery
widening (it is also weakening)
what artery is widened in a thoracic aneurysm?
the aorta
an aneurysm can result from an ____ and from ____
infection, syphillis
the most common symptom of abdominal aneurysm is:
a pulsating mass above the umbilicus
which aneurysm is most likely to have no symptoms?
abdominal aneurysm is most often “silent”
which vital signs are most important to measure in clients with aneurysm?
the pulse and BP
an aneurysm will most affect which of the following, the BP or the pulse?
the pulse. many times the aneurysm will rupture and much blood will be lost before the blood pressure starts to change.
what activity order is the client with an aneurysm supposed to have?
bedrest. DO NOT get these people up.
if the client with an aneurysm is physically unstable, should you encourage turning, coughing and deep breathing?
NO, BEDREST until the client is stable
what class of drugs is the client with an aneurysm most likely be on?
antihypertensives
what is the BIG danger with aneurysms of any type?
rupture, leads to shock and death
if an aneurysm has ruptured how would you know it?
all signs of shock
decreased LOC (restlessness), tachycardia, hypotension
if an aneurysm ruptures what is the #1 priority?
get them to the operating room ASAP
is there anything that can be done for the client with a ruptured aneurysm before they get to the operating room?
Yes, if available you can get them into ANTISHOCK TROUSERS but not if this causes a delay in getting them to the operating room
the post-op thoracic aneurysm is most likely to have which type of tube?
chest tube, because the chest was opened
the post-op abdominal aneurysm repair client is most likely to have which type of tube?
NG tube for decompression of the bowel
if you care for a client who is post-op for a repair of a femoral popliteal resection what assessment must you make every hour for the first 24 hrs?
check the distal extremity (far from center), color, temperature, pain, pulse, also must document
what causes angina pectoris?
decreased blood supply to myocardium, resulting in ischemia and pain
describe the pain of angina pectoris
crushing substernal chest pain that may radiate
what drug treated angina pectoris?
nitroglycerin
how do you tell if a client has angina or MI?
the pain of the two is similar, the way to tell the difference is if nitro and rest relieve the chest pain.
Angina= nitro and rest relieve the pain
MI= nitro and rest DO NOT relieve the pain
how many nitroglycerin tablets can you take before you call the doctor?
3 tablets
how many minutes should lapse between the nitro pills you take?
5 minutes- take 1 nitro tab every 5 minutes, 3 times, if no relief- call MD
by what route do you take nitro?
sublingual
what is the action of nitro?
dilates coronary arteries to increase blood supply (O2 supply) and reduces preload
what are the top 2 side effects of nitro?
hypotension and headache
what precaution must the nurse take when administering topical nitro?
wear gloves, nurse may get a dose of the med
true or false: everyone with angina needs bypass surgery?
false
anorexics are usually ___ under the age of ___
females, 25
the diagnosis of anorexia nervosa is made when there Is a weight loss of ___% or more of body weight
15 (patient weighs less than 85% of normal body weight)
a major mental/emotional nursing diagnosis seen in anorexia nervosa is ___
altered body image
the pulse rate of anorexics is tachycardia or bradycardia?
bradycardic
list the most common gynecologic symptom of anorexia nervosa?
amenorrhea
what is found over the body of the client with anorexia nervosa?
lanugo (soft downy hair)
what is the top priority in the care of the client with anorexia nervosa?
intake of enough food to keep them alive, have them gain weight
the best goal to evaluate the progress of the client with anorexia nervosa?
an adequate weight gain
what is the APGAR scale?
quick objective way to evaluate the vital functions of the newborn
when is APGAR scoring performed on infants?
at 1 minute and again at 5 minutes after birth
name the 5 criteria that are recorded on an Apgar scale
1. cardiac status 2 respiratory effort 3. muscle tone 4. neuromuscular irritability 5. color
the total Apgar score can range from?
0 to 10
the maximum score an infant can receive on any one of the criteria is…
2
a 10 on the APGAR means the baby is…
in terrific health
a 0 on the APGAR is..
bad, the baby is stillborn
on heart rate or cardiac status, a 2 means that the HR us above ___ bpm
100
on the HR criteria an infant scored a 1 if their HR is ___ than 0 and ___ 100
greater, less than
In order to score a 0 on HR the infant must have a HR of
zero
a high score of 2 is given for respiratory effort if the newborn
cried vigorously
an infant is given a score of 1 if their respirations are ___ or ___
slow or irregular
an infant is given a score of 0 for respiratory effort if___
they are not breathing
in order to get a score of 2 on muscle tone, the infant must
move spontaneously (actively)
to get a score of 1 on the APGAR for muscle tone the newborn must place their extremities in ___
flexion
a newborn receives a score of 0 on muscle tone when there is ___
no movement (limp)
to score the maximum of 2 points on neuromuscular reflex irritability, the infant must __
cry
of the neonate ___, they will score a 1 on neuromuscular irritability
grimaces
to receive a 0 on reflex (neuromuscular) irritability the neonate must exhibit __
no response
to score a maximum score of 2 on color the child must be
totally pink
if the child’s ___ are ___ and the trunk, face, abdomen are __, the child score a 1 on color
extremities are blue (cyanotic), pink
to get a 0 on color the infant is
totally blue, pale
acrocyanosis
temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. may last for a few hours and disappear with warming
appendicitis is an ___ of the appendix due to ___
inflammation, obstruction
appendicitis occurs most in what age group?
15 to 35 y/o
wha tis the most common complication of appendicitis?
peritonitis
peritonitis
inflammation of the peritoneum
what is the first sign of appendicitis?
RUQ pain
what follows the RUQ abdominal pain of appendicitis?
nausea, vomiting
where does the pain of appendicitis finally end up?
RLQ
what is the name of the RLQ abdominal pain where appendicitis pain finally localizes?
McBurney’s point
what is present when rebound tenderness is present?
peritoneal inflammation
what is the highest that the temp will be in appendicitis?
102 degrees F
what blood count is elevated in appendicitis?
WBC
what is the name for an elevated WBC?
leukocytosis
what is the only treatment recommended for appendicitis?
surgery, appendectomy
before the client with suspected appendicitis sees the physician what should be avoided?
pain meds, enemas, laxatives and food! NPO
to lessen the pain, place the client with appendicitis in ____ position
fowlers (also use post-op)
never apply ___ to the area of the appendicitis
heat (it causes rupture)
after an appendectomy, document in the nurses notes the return of ____
Bowel sounds (peristalsis)
name the five/six essential nutrients
carbs, fats, proteins, vitamins, minerals, water
the major source of energy for the body is __
Carbs
carbs provide ___ kcalories per 1 gram
4
sucrose is sugar found in ___ and ___
fruits, veggies
what is glycogen?
it is a stored form of glucose/energy manufactured by the liver
lactose is a sugar found in?
milk
when the body foes not receive enough carbs it burns ____ and ___
protein and fat
the most concentrated source of energy for the body is ___
fats
fats provide ___ kcalories per 1 gram
9
fats carry vitamins __, __, __, __
A, D, E, K
the nutrient needed most for growth and repair of tissue is ____
protein (2nd best is vitamin C)
proteins provide __ kcalories per 1 gram
4
true or false: vitamins and minerals provide energy for the body
false
they are necessary for a body’s chemical reactions
true or false: water is present in all body tissues
true (even bone)
water accounts for ___ to ___% of an adults total weight
50 to 60
name the four basic food groups
milk & cheese, meat & legumes, veggies & fruits, bread & cereal
water accounts for ___ to ___% of an infants total weight
70 to 75
an individual is obese of they weigh ___% above the ideal weight
20
an individual is overweight if they are ___% above the ideal weight
10
what spoliation and material are used to cleanse the eyes of an infant?
plain water, cotton balls, wash cloths
can you use cotton swabs to clean the eyes, nares or ears of an infant?
no, this is dangerous
can you use the same cotton ball/washcloth edge for both eyes?
no, it would cross contaminate
should you cover an unhealed umbilical site with the diaper?
no, fold the diaper down
what temperature is appropriate for the water used ti bathe an infant?
100 to 105
what is the #1 reason for a tepid sponge bath?
lower body temperature during a fever
how should the temperature of the water be tested if no thermometer is available?
dropping water on the inside surface of your forearm
with which body part do you begin when bathing an infant?
eyes always
when cleansing an infants eye, cleanse from ____
inner to outer canthus
should you retract the foreskin of a 5 week old male, uncircumcised infant to cleanse the area?
no, not until foreskin retracts naturally and without resistance- then it should be retracted, cleansed and replaced
when sponge bathing with tepid water the correct temp is ?
98.6 degrees F
how long does it take for the umbilical stump to fall off?
7 to 14 days
true or false: the primary reason why an infant is draped during the bath is to provide privacy
false, the primary purpose of draping is to prevent chilling
true or false: you may use friction to remove vernix caseosa from an infants skin
false, it causes damage/bruising
what solution is commonly used for care of the umbilical cord?
70% alcohol to promote drying (trend is toward soap and water)
what cranial nerve is affected in bell’s palsy?
7, facial nerve
what is the #1 symptom of Bell’s palsy?
one sided (unilateral) facial paralysis
complete recovery from the paralysis of Bell’s palsy should occur in ___ to ___ months
4 to 6
in addition to the facial paralysis, the sense of ___ is also affected in bell’s palsy
taste
will the patient with bell’s palsy be able tp close their eye on the affected side?
no
give three interventions for the client with bell’s palsy
dark glasses, artificial tears, cover eye at night
as the prostate enlarges it compresses the ___ and causes urinary ___
urethra, retention
at what age does BPH occur?
men over 50 years of age
what does BPH stand for?
benign prostatic hypertrophy
in BPH, the man has ___ frequency of urination
increased
in BPH, the force of the urinary stream is ___
decreased
the man with BPH has a ___ stream of urine
forked
the man with BPH has hesitancy, what does this mean?
difficulty starting to void
will the man with BPH have enuresis, nocturia or hematuria?
nocturia and maybe hematuria, not enuresis
enuresis
inability to control the flow of urine and involuntary urination
what is the best way to screen men for BPH?
digital rectal exam
should fluids be forced or restricted in BPH?
forced
what does TURP stand for?
transurethral resection of the prostate
the most radical prostate surgery is the ___ prostatectomy
perineal
what type of diet is used for BPH?
acid ash
acid ash diet
decrease pH (makes urine acid)
eggs, meat, fish, oysters, poultry, bread, cereal, whole grains, pastries, cranberries, prunes, plums, tomatoes, peas, corn, legumes
what is the purpose of a 3 way continuous bladder irrigation (CBI) after TURP?
to keep the catheter clear of clots and to drain urine
what solution is used for continuous bladder irrigation?
normal saline (0.9% NaCl)
how fast do you run the CBI?
at whatever rate it takes ti keep the urine flowing and free of clots
what drug is used to treat bladder spasm?
B&O suppositories
should you take a rectal temp after a prostatectomy? give stool softeners?
no rectal temps after a prostatectomy, yes stool softeners
you should call the MD after TURP when you see ___ thick ___, ___ clots and ___ urine
bright thick blood, persistent clots, persistent urine on dressing (don’t call MD for transitory clots and urine on dressing)
if you see increase in blood content of urine coming out of the catheter, you would first ___
increase the flow rate
what exercises should the post prostatectomy patient do upon discharge and why?
perineal exercises, start and stop stream of urine, because dribbling is a common but temporary problem post-op
if you see clots in the tubing you would first ___
increase the flow rate
will the post prostatectomy patient be impotent?
if TURP, no impotence, if perineal prostatectomy, yes impotence
how often should the drainage bag be emptied with a prostatectomy?
every 8 hours
what is the most common organism to cause a UTI with catheterization?
E. coli
what is the most common problem due to catheterization?
UTI
what is the most common route for organisms to enter the bladder when a catheterization is used?
up through the inside of the catheter in the days following catheterization
name the foods that make acid urine
cranberry juice, apple juice (avoid citrus juices- they make alkaline urine)
what is important about the level of the urinary drainage bag?
never have the bag at higher level than the bladder
how is the catheter taped in a male client ?
to the lateral thigh or abdomen
how is the catheter tapes in a female client ?
to the upper thigh
what urinary pH prevents UTI?
acidity, low pH
should the drainage bag ever touch the floor?
no
is it okay to routinely irrigate indwelling catheters?
no
what agents are best for catheter care?
soap and water
what is the most effective way to decrease UTI with catheters?
keep the drainage system closed, do not disconnect junction of tubing
give some signs of infection in a foley catheter
cloudy urine, foul smelling urine, hematuria
is urinary incontinence an indication for catheterization?
no
give three appropriate indications for bladder catheterization
urinary retention, to check for residual, to monitor hourly output
what are the top 2 diagnoses for a client with a catheter? which is #1?
1- potential for infection, potential impairment of urethral tissue integrity
what is systole?
the maximal force of blood on the artery walls
what is diastole?
the lowest force of blood on the artery walls
accurate clots pressure is obtained by using a cuff the has a width of ___ of the arm
two-thirds
which artery is most commonly used to measure BP?
brachial
can the thigh ever be used to obtain a BP?
yes, but it is rare
when pressure is auscultated the first sound heard is the ____ measurement
systolic
when taking manual BP, the change in the character of the sounds is known as the ___
first diastolic sound
the cessation of sounds is knows as the ___
second diastolic sound
when 2 values are given in a BP, the first is the ___ measurement
systolic
when 2 values are given in a BP, the bottom number stands for the change in sounds or cessation of sounds?
cessation of sounds
what is the normal adult blood pressure?
120/80
abnormally high blood pressure is called _____
hypertension
what is the pulse pressure?
the difference between the systolic and the diastolic blood pressure
if you deflate a cuff too slowly, the reading will be too high or too low? why?
high, venous congestion makes the arterial pressure higher (increases resistance)
if you use too narrow of a cuff the reading will be too high or too low?
high
vasoconstriction will ___ blood pressure
increase
vasodilation will ____ blood pressure
decrease
shock will ____ blood pressure
decrease
increased intracranial pressure will ___ the pulse pressure
increase or widen
if my blood pressure us 190/110, what is my pulse pressure?
80 mmHg
what blood test must be done before a transfusion?
type and cross match
what does a type and cross match indicate?
whether the clients blood and donor blood are compatible
what should the nurse measure before starting a transfusion?
vital signs
with what solution should blood be transfused?
0.9% normal saline
how many nurses are required ti check the blood?
2 nurses
what happens when blood is administered with dextrose IV?
the cells clump together and don’t flow well
if a transfusion reaction occurs what should the nurse do first?
stop the blood flow and start running the saline
how long can a unit of blood be on the unit/floor before it must be started?
less than 1/2 hour
what should the nurse do with the IV line if a transfusion reaction is suspected?
keep it open with saline
if a transfusion reaction is suspected, what two samples are collected and sent to the lab?
urine and blood
if a unit of blood is infused through a central line it must be ___
warmed
what are signs of transfusion reaction?
low back pain, wheezing, fever, hives
what are three type of transfusion reactions that can occur?
hemolytic, febrile, allergic
what would you do first if you suspected a transfusion reaction?
stop the blood and start the saline
what are the signs and symptoms of a hemolytic transfusion reaction?
shivering, headache, low back pain, increased pulse and respirations, decreasing BP, oliguria, hematuria
what are the sings and symptoms of a febrile transfusion reaction?
low back pain, shaking, HA, increasing temperature, confusion, hemoptysis
what are the signs and symptoms of an allergic reaction to a transfusion?
hives- urticaria, wheezing, pruritus, joint pain (arthralgia)
give three reasons for a blood transfusion
restore blood volume secondary to hemorrhage, maintain hemoglobin in anemia, replace specific blood components
what does blood-typing mean?
check for surface antigen on the red blood cell
when does typing and cross matching need to be done?
whenever a client is to get a blood product. it is only good for 24 hours
what does blood cross matching mean?
mixing a little of the clients blood with the donor blood and looking for agglutination
when are hemolytic reactions likely to occur?
in the first 10 to 15 minutes
when is a febrile reaction likely to occur?
within 30 minutes of beginning the transfusion
what test identifies Rh factor?
Coombs test detects antibodies to Rh
what is the difference between whole blood and packed cells?
packed cells don’t have nearly as much plasma or volume as whole blood does
what would you do if the client had an increasing temperature and was to get blood?
call the MD because blood is often held with an elevated temperature
how long should it take for one unit of blood to infuse?
from 1 to 3 hours
how long should you stay with the patient after beginning the transfusion?
at least 15 to 30 minutes
what blood type is the universal recipient ?
AB
what blood type is the universal donor?
O+
what is the routine for vital sing measurements with a transfusion?
- once before administration
- Q15 minutes X 2 after administration is begun
- Q1 hr X 1 after transfusion has stopped
what IV solution is hung with a blood transfusion?
0.9% normal saline (no glucose)
what gauge needle is used with a blood transfusion?
large gauge, 18 gauge
what other things are appropriate after a blood transfusion reaction?
call MD, get a blood sample, get urine sample, monitor VS, send blood to lab
can blood be given immediately after removal from refrigeration?
no, it has to be warmed first for only about 20 to 30 minutes
with what solution and when should a breast feeding mother cleanse the areola?
plain water, before and after each feeding
for a woman who doesn’t have retracted nipples, is towel drying or air drying better?
air drying of the nipples is best
the goal is for the infant to breast feed for ___ minutes per side
20
how does the mother break the suction of the breast feeding infant?
she inserts her little finger into the side of the infant’s mouth
when should the breast feeding infant be burped?
after feeding from each breast
assuming no mastitis, on which side should the breastfeeding begin?
begin feeding on the side the baby finished on the last feeding
how ling can breast milk be frozen?
6 months
how long can breastmilk be refrigerated?
24 hours
in what type of container should breast milk be stored?
sealed plastic bags
can you microwave frozen bread milk in order to warm/thaw it?
never
which two nutrients is breast milk lower in ?
fluoride and iron
what should you tell a breast feeding mother about her milk supply when she goes home from the hospital?
milk should come in post partum day 3. breast feed every 2-3 hours to establish good milk supply
can a woman on oral contraceptives breastfeed?
no, should not use oral contraceptives during the first 6 weeks after birth because the hormones may decrease milk supply
estrogen is not recommended. non-hormonal methods are recommended.
remember breastfeeding is an unreliable contraceptive
what is another name for buerger’s disease?
thromboangiitis obliterans
which extremities are affected by buerger’s disease ?
lower extremities only
which sex does buerger’s disease affect most often?
males
the group with the highest incidence of buerger’s disease is ____
smokers
upon walking, the patient with buerger’s experiences ____
intermitten claudication
what is intermittent claudication?
pain in calf upon walking
what color is a first degree burn?
red
true or false: a first degree burn has vesicles
false
what color is a second degree burn?
red
a second degree burn is dull or shiny?
shiny
true or false: a second degree burn has vesicles
true
a second degree burn is wet or dry?
wet
what color is a third degree burn?
white
a third degree burn is wet or dry?
dry
a third degree burn is hard or soft?
hard
of first, second and third degree burns which has less pain? why?
third degree burns have less pain because nerve damage has occurred
for what purpose do you use the rule of nines?
to estimate the percentage of body surface burned; it is not used for children
in the rule on nines, the head and the neck receive ___: each arm receives ___
9%, 9%
in the rule of nines, the front truck gets___, the posterior trunk gets ___, each leg gets ___, and the genitalia gets ___
18%, 18%, 18%, 1%
what is the only IM given to a burn patient
- tetanus toxoid- if they had a previous immunization
- tetanus antitoxin- if they have never been immunized before (or immune globulin)
in the emergent phase do you cover burns? (in the field)
yes, with anything clean and dry
should you remove adhered clothing on a burn patient
no
name the 3 phases of burn
shock, diuretic, recovery
fluid moves from the ___ in the shock phase
bloodstream, interstitial space
the shock phase lasts for the first ___ to ___ hours
24 to 48 hours
during the shock phase of burn management, is potassium increased or decreased? why?
increased, because of all the cells damaged- the K+ is released from the damaged cells
what acid-base disorder is seen in the shock phase of a burn?
metabolic acidosis
what is the #1 therapy in the shock phase of a burn?
fluid replacement/resuscitation
what is the simple formula for calculating fluid replacement needs in the first 24 hours ?
3cc X kg X % burned per day
if the MD orders 2,800 cc of fluid in the first 24 hours after a burn, one- ___ of it must be infused in the first 8 hours
half (or 1,400cc)
what blood value will dictate IV flow rate?
hematocrit
how will you know the patient has entered the fluid mobilization or diuretic phase ?
the urine output will increase
how long does the fluid mobilization or diuretic phase of a burn last?
2 to 5 days
in the diuretic phase, K+ levels fall or rise?
fall, remember diuresis always causes hypokalemia
if the nurse accidentally runs the IVs at the shock phase rate during the diuretic phase the patient will experience?
pulmonary edema
the burn patient will be on ___ urine output and daily ___
hourly, weight
sulfamyon cream ____
burns
silver nitrate cream ____ the ____
stains, skin
pain medications should be administered ____ before ____ care
30 minutes, wound care
when using silver nitrate, the dressings must be kept ____
wet
what is curlings ulcer? why is it a problem in burn patients? what drug prevents it?
- it is a stress GI ulcer, you get these with any severe physical stress.
- Tagamet, Zantac, Pepcid (any H2 receptor antagonist/blocker), Protonix Prilosec
true or false: neoplasm refers to benign and malignant tumors
true
which type of tumor is more malignant? differentiated or undifferentiated?
undifferentiated, is worst to have (highly differentiated is better to have)
when cancer spreads to a distant site it is called?
metastasis
true or false: the cause of cancer is known
false
a person should have yearly workup exa, for cancer detection over the age of ___
40
in general, cancer drugs have side effects on which three body systems?
GI, hematologic (blood), integumentary
what are the 3 most common chemotherapeutic GI side effects?
N/V, diarrhea, stomatitis (oral sores)
true or false: clients receiving chemotherapy must be NPO
false
true or false: is to permissible to give lidocaine viscous ac (before meals) if the patient has chemotherapeutic stomatosis
true
with what solution should the client with chemotherapeutic stomatitis rinse pc (after meals)?
H2O2- hydrogen peroxide
what lubricant can safely be applied to the cracked lips of chemotherapy stomatitis?
K-Y jelly
name the 3 hematologic side effects of chemotherapy
thrombocytopenia, leukopenia, anemia
which cells are low in thrombocytopenia?
platelets
what drug should not be give to the patient with chemotherapeutic thrombocytopenia?
ASA (aspirin)
when should the nurse withhold IM injections in the client on chemotherapy?
only when their platelet count is down
what are the 3 objective symptoms/signs of thrombocytopenia?
petechiae, epistaxis, ecchymosis (P.E.E)
what is epistaxis?
nose bleeds
what is ecchymosis ?
bruising
what is petechiae?
small pin point dots, they are hemorrhages on the skin
what blood cell is low in leukopenia?
white blood cells
when the absolute neutrophil count (ANC) is below ____ the person on chemotherapy will be placed on reverse isolation
500
what is the #1 integumentary side effect of chemotherapy?
alopecia
what is alopecia?
hair loss
true or false: the hair loss due to chemotherapy is usually temporary
true
can scalp tourniquets prevent chemotherapy alopecia?
in some cases, yes
can ice packs to the scalp prevent chemotherapy alopecia?
in some cases, yes
CD (celiac disease) ____ among the leading cause of maternal death
fourth
what is the #1 cause of CD (celiac disease) of pregnancy?
rheumatic heart disease
pregnancy requires a ____ increase in the cardiac output
30%-50%
what is the #1 cause of maternal death in CD (celiac disease) of pregnancy ?
decompensation
what is the #1 cause of maternal death in CD (celiac disease) of pregnancy?
failure of the heart to maintain adequate circulation
what will you see when you observe the neck of a client with CD of pregnancy
distended neck veins- JVD
what will you hear when you auscultate the heart of the client with CD (celiac disease) of pregnancy?
heart murmurs
what will you heat when you auscultate the lungs of the client with CD (celiac disease) of pregnancy?
crackles-rales
if the client with CD of pregnancy experiences sudden heart failure what is the most common thing you will see?
sudden onset of SOB (dyspnea)
what is the #1 treatment of CD during pregnancy?
rest
what are the three most common drugs given to women with CD (celiac disease) in pregnancy?
diuretics, heparin, digitalis
why are diuretics given to women with CD (celiac disease) of pregnancy?
to promote diuresis which will:
- lower circulating blood volume
- decrease preload
- decrease the amount of blood the heart pumps
why are anticoagulants (heparin only) given to women with CD of pregnancy?
to prevent thrombophlebitis due to venous congestion, usually in legs
why is digitalis given to women with CD of pregnancy?
to increase the strength of the heart and to decrease the rate, rest the heart while making it more efficient
can women with CD of pregnancy be given analgesic during labor?
yes, in fact they should be given analgesics, may get too anxious which is bad for the patient
can morphine be given to a woman with CD during labor?
yes, even though it negatively affects the fetus, remember morphine decreases preload and pain which rests the heart
what is the most common dietary modification for the woman with CD who shows signs of decompensation?
decreased sodium, decreased water (restriction)
is a c-section mandatory for delivery of a woman with CD of pregnancy?
no
second to rest, what is very important treatment for CD of pregnancy?
weight control
how ling must the woman with CD of pregnancy be on bed rest after delivery?
at least one week
what nutrients should be supplied in the diet of the pregnant woman with CD?
iron, folic acid
prevent anemia (anemia always makes the heart work more)
what are the two most common subjective complaints of the woman who is decompensating during labor?
SOB, palpitations
in addition to the things you assess for in every woman during labor, what additional assessment must you make for a woman with CD?
you must assess lung sounds frequently
how often must you assess the lung sounds during the first stage of labor? during active labor? during transition labor?
every 10 to 30 minutes
in which position should a woman with CD in labor be?
semi recumbent, HOB up
the nurse should limit the clients efforts to ___ ___ during labor when CD in labor is present
bear down
what is the big danger to staff when caring for a client with cesium implant?
radiation, hazard
what are the three principles to protect yourself from radiation hazard?
distance, shielding, time
will the woman with a cesium implant have a foley?
yes
from where should the nurse provide care to the client with a cesium implant?
the head of the bed
how can the woman with cesium implant move in bed?
only from side to side
what four symptoms in a patient with a cesium implant should be reported to the physician?
profuse vaginal discharge, elevated temp, N/V
these indicate infection and perforation
should pregnant staff care for a client with a cesium implant?
no
can a woman with a cesium implant have the HOB elevated?
yes, only 45 degrees maximum
from where should the nurse talk tot he client?
the entrance to the room
is bed rest necessary when a woman has a cesium implant?
yes, absolute bed rest
what type of diet is a woman with an cesium implant on?
low residue (decrease bowel motility)
no nurse should attend the client with cesium implant more than ___ per day
1/2 hour
what would you do go the cesium implant came out?
pick it up with forceps only- never touch with hand even if you are wearing gloves
should the nurse provide perineal care for the client with a cesium implant?
no, risk of radiation hazard
what part of you hand do you use to handle a wet cast?
the palm
upon what do you support a cast while it dries?
pillows (no plastic covers)
how long does it take a cast to dry?
24 hours
should you cover a wet cast?
no
should you use a heat lamp or hair dryer or fan to help dry a cast?
no heat lamp and hair dryer, yes fan
what signs or symptoms would you report if they were present after cast application ?
numbness, tingling, burning, pallor, unequal or absent pulses, unequal coolness
of there is inflammation under a cast, it will be evident in a ___ spot
hot
to prevent irritation of the skin near the edges of a cast the edges should be ____
petaled
what type of cast causes cast syndrome?
a body cast
what causes cast syndrome?
anxiety and stress leading to sympathoadrenal shut down of the bowel
what is the #1 symptom of cast syndrome?
N/V due to bowel obstruction
what is the #1 treatment of cast syndrome?
NPO and NG tube for decompression
a dry cast is gray or white?
white
a dry cast is dull or shiny?
shiny
a dry cast is dull or resonant to percussion?
resonant
traction is used to ___ and ___ a fracture, relieve ___ and prevent ___
reduce and immobilize, muscle spasm, deformities
can skin traction be removes for skin care?
yes
can the client be removed from skeletal traction?
no
name 3 types of skeletal traction
cranial tongs, Thomas splints with peason attachments, 90 degrees to 90 degrees
name 3 type on skin traction
buck’s, Bryants, pelvic
what type of traction is most commonly used for hip fractures in children?
Bryants
what type of traction is most commonly used for hip fractures in adults?
bucks
in what position should the bed be if the patient is in pelvic traction?
semi-fowlers with knee gatched
to insure that Bryants traction is working the child’s hip/sacrum should be ____
off the bed enough to slip a hand between the sacrum and the bed
what is the advantage of balanced counteraction?
you can easily move the patient around in bed
patients in Russell’s traction are particularly prone to ____
thrombophlebitis
when a patient is in a buck’s traction they may turn to the ___ side
unaffected
define cataract
opacity of the crystalline lens
is surgery done immediately upon diagnosis of a cataract?
no, they usually wait until it interferes with ADLs
What three most common visual defects occur with cataracts?
Cloudiness, diplopia (double vision), photophobia (sensitivity to light)
What are the two common treatments of cataracts?
Laser, surgical removal. Surgery called intraocular or extraocular lens extraction
What does the eye look like when a client has cataracts?
Cloudy, milky- white pupil
what will the client be wearing after cataract surgery?
a protective patch/shield on the operative eye for 24 hours, then a metal shield (at night only) for 3 weeks
when the client asks about the use of glasses to contact after cataract surgery what would you say?
if an intraocular lens in implanted they will not need glasses. if no lens is implanted, then contact will be fitted for 3 months post-op, temporary thick glasses given immediately but will get a different prescription in 2 to 3 months
what will be a high priority nursing diagnosis for a client post cataract surgery?
safety
should the client ambulate independently after cataract surgery?
no the portent should not ambulate independently, depth perception is altered
what posiitions are to be avoided after cataract surgery?
lying face down. also, do not lie on operative side for a month
what are the post-operative signs of hemorrhage into he eye?
severe pain, restlessness
what movements are to be avoided after cataract surgery?
coughing, sneezing, bending at the waist, straining at stool (bearing down), rubbing or touching eyes, rapid head movements
what positions are okay after cataract surgery?
do not lie on operative side; do not lie on back
should you use talcum powder with a post-operative cataract client?
no, it may cause sneezing; also should avoid pepper
what are the three signs of increased intraocular pressure?
pain (moderate to severe), restlessness, increased pulse rate
what is the major objective in caring for a client after surgical cataract removal?
to prevent pressure in or on the eyes
When the lens is to be extracted for cataracts, what drugs are given preoperatively ?
Mydriatics, dilators, antibiotic drugs (gtts)
What three drugs are given post operatively for surgical cataract removal?
Stool softeners, antiemetics, analgesics (mild to moderate)
Give 5 causes of cataracts
Injury, congenital, exposure to heat, heredity, age
Celiac’s disease is a ___ disease
Malabsorption
The client with Celiac’s cannot tolerate ____
Gluten
Gluten is a ____
Protein
What does gluten do to the intestines of the client with celiacs disease ?
It destroys the lining of the intestine
The stools of a client with celiacs disease are ____, ____ and ____
Large, greasy, foul smelling
Clients with celiacs disease do not absorb what mineral?
Iron
Clients with celiacs disease don’t absorb fats; therefore they don’t absorb ____ ____ ____
Fat soluble vitamins
What are the 4 fat soluble vitamins ?
A,D,E,K
Malabsorption of which vitamin leads to bleeding disorder?
Vitamin k, remember do not mix up potassium with vitamin k
What will the abdomen of clients with celiacs disease look like?
Distended with flatus
What is the #1 treatment of celiacs disease?
Gluten free diet
Veggies are allowed or not allowed in a diet of a client with celiacs disease ?
Allowed
Fruits are allowed or not allowed in a diet of a patient with celiacs disease?
Allowed
True or false: grains of all kinds are prohibited
False
What grains are allowed in a gluten free diet?
Rice and corn
What grains are not allowed in a gluten free diet?
Wheat, oats, rye, alfalfa, barley
Are foods made with wheat, oat, rye flour allowed?
No
Is milk allowed in a gluten free diet?
Yes
Are meats allowed in a gluten free diet?
Yes, but eat h got breaded meats and hot dogs/lunch meats- may have grain in them and are not allowed
Are eggs allowed in a gluten free diet
Yes
is commercial ice cream allowed on in a gluten free diet?
no, even though it is milk product, commercial ice cream has grain in it
are puddings allowed in a gluten free diet?
no, for the same reason ice cream isn’t because there is grain in it
which soups are not allowed on a gluten free diet?
creamed soups- these often have flour
the #1 problem with central lines ____
infection
how often should central line dressings be changed?
QOD- every other day
what type of dressing is applied to a central line insertion site?
sterile occlusive
can drugs be piggybacked into a central line— TPN?
no, use other lumen
when changing a central line tubing, the patient should be told to ____
turn his head away from the site, hold breath and perform the valsalva maneuver
if a central line is found accidentally open, the patient should be positioned on his ____ ____
left side
a CVA is a ____ of the brain cells due to decreased ____ ____ and ____
destruction, blood flow and oxygen
women have a higher or lower incidence of stroke than men?
lower
name the 3 types of CVA
embolus, thrombus, hemorrhage
true of false: use of oral contraceptives increases the risk of CVA
true
true or false: chronic abuse of alcohol increase risk of CVA
false
true or false: obesity increases risk of CVA
true
true or false: smoking increases the risk pf CVA
true
true or false: atrial fibrillation increases the risk of CVA
true, emboli particularly
what is TIA?
transient ischemic attack, warning sign of impending CVA (transient neurologic deficits of any kind can last 30 seconds to 24 hours)
do patients experiencing a CVA have a headache?
yes
the first sign of CVA is usually a ____
change in LOC
the activity order in early management of CVA is ____
absolute bed rest
the patient with a recent CVA is most likely to have fluids restricted or forced?
restricted
how far should the HOB be up after CVA?
30 degrees
can the stroke victim be turned side to side?
yes
how often should the CVA patient be turned or repositioned?
every 2 hours
true or false: the CVA patient should be turned onto his paralyzed side no longer than 2 hours
false, the patient should not be turned on their paralyzed side for more than 20 minutes
true of false: ROM exercises should occur every 2 hours in CVA patients
false– every 4 hours or 3 times a day is enough
true or false: to prevent urinary incontinence, the CVA patient should be catheterized
false– remember incontinence will never be allowed as a reason for catheterization
Which type of paralysis is typical of CVA?
Hemiplegia
What anatomical fact account for the left side of the body being controlled by the right brain?
The motor- pyramidal tracts cross over to the other side (de usage in the medulla)
If the patient has right hemiplegia, he cannot move his ____ ____ and ____ ____ and the stroke was on the ______ side of the brain
Right arm and right leg, left
What he hemianopsia?
Not being able to see one half of the field of vision
They client with hemianopsia should be taught to _____
Scan
What is scanning ?
Moving the head from side to side to see the whole field of vision
If the client has right homonymous hemianopsia, the food on the ____ side of the tray may be ignored
Right
After meals, the nurse must always check ____ if the CVA patient for ____
Mouth (cheek), food
Should a CVA patient have all four side rails up at all times? Should they be restrained?
Side rails yes. Restraints no, unless they are a danger to themselves or others
When a patient does not understand incoming language he is said to have ____ aphasia
Receptive
When the CVA patient understands your question but can’t respond very correctly, he is said to have ____ aphasia
Expressive
Whats is global aphasia?
Both receptive and expressive
Aphasia is most common if the stroke occurred in the ____ hemisphere of the brain
Dominant
How do you tell which side of the persons brain is dominant?
It is the side that controls their dominant hand, ie; a left handed person has a dominant right hemisphere and conversely a right hand person had a dominant left hemisphere
For which type of aphasia are slow, short, simple directions most useful?
Receptive
For which type of aphasia is careful listening and needs anticipation most useful
Expressive
The loss of the ability to perform purposeful, skilled acts, ie; brushing teeth is called ____
Apraxia
Cytoxan cyclophosphamide
Hemorrhagic cystitis
Cisplatin
Peripheral neuropathy, constipaciones, ototoxicity
Bleomycin
Pulmonary fibrosis
Adriamycin
Cardiotoxicity
Vincristine
Peripheral neuropathy (foot drop, numbness, jaw pain), constipation (adynamic ileus due to neurotoxicity)
DTIC-dome
Flu-like symptoms
Chemotherapeutic agent toxicities
Methotrexate
Toxic to just about every organ except the heart, toxicity made worse with aspirin
The infant fears ____ most when hospitalized
Separation from love object
the preschooler fears separation as well as ____ when hospitalized
mutilation- remember preschoolers have vivid imaginations- fantasy
the toddler and preschooler will think that illness is caused by ____
something they did wrong
the school aged hospitalized child is afraid of separation from _____
age group
The school-aged child perceives the cause of illness to to be external or internal?
External, they know that illness is not a result of bad behavior.
the toddler fears ____ most when hospitalized
separation from family
The adolescent who is hospitalized fears separation from _________ and loss of ___________.
peers, Independence
true or false: Preschoolers may require physical restraint during painful procedures.
true
Which age group engages in stalling tactics before painful procedures most?
school age
Which age groups are most likely to physically resist the nurse during procedures?
school age, adolescents
true or false: Toddlers may require physical restraint for painful procedures.
true
The meats that are highest in cholesterol are _________ meats.
Organ meats
liver, heart, brains, kidneys
The meats that are second highest in cholesterol are the ___________
Shell seafood- shrimp, crab, lobster
Egg white is high or low in cholesterol?
low
egg yolk is high or low in cholesterol?
high
The three meats lowest in cholesterol are _________, _________ and __________.
chicken, pork, mutton
milk is high or low in cholesterol?
low
is cheese high in cholesterol?
only moderate, not really that high
which oils are high in cholesterol?
animal oils
is cholesterol a triglyceride?
no
do plant food contain any cholesterol?
no, not many
what is otitis media?
chronic infectious/inflammatory disease of the middle ear
is otitis a disease of the adult or child?
usually the child
What part of the ear is involved in otitis media?
middle ear
What are the 2 common subjective signs of otitis media?
hearing loss, feeling fullness in the ear
What are the 2 common objective signs of otitis media?
hyperpyrexia (fever), drainage from ear
What commonly happens secondary to otitis media?
perforation of the ear drum
Do all the children with otitis media need tubes in their ears?
no
What are the two most common medical treatments for otitis media?
systemic antibiotics, antibiotic ear drops
What is the most severe complication of otitis media?
meningitis or mastoiditis
what is cholesteatoma?
An epidemial cyst in the ear highly associated with otitis media.
What are the restrictions to be followed when tubes are in a child’s ear?
No swimming, no showering, no diving
what is cleft lip?
the lip is open to the nares
what is cleft palate?
the roof of the mouth is open to the nasopharynx
Is it possible to have only one: cleft lip or cleft palate?
Yes, you can have one or or the other or both
when will the cleft lip be repaired?
between 10 feels and 6 months
when will the cleft palate be repaired?
between 1 and 5 years of age
why is cleft lip repaired early?
Feeding is easier after repair and appearance after repair is more acceptable to parents.
Describe the nipples onbottlesusedto feed babies with cleft lip?
large-holed, soft nipples
The infant with cleft lip/palate needs more frequent ___________.
bubbling, burping
Children with cleft lip/palate should be fed in what position?
an almost upright position
Whatisthe#1 complication of cleft lip/palate?
aspiration
Children with cleft lip and cleft palate have long-term problems _____, _____ and _____.
hearing, speech, teeth
In how many surgeries is cleft palate
repaired?
Two surgeries
one at 12 to 18 months the last 4 to 5 years
Why is final repair of the palate delayed until 4 to 5 years?
Earlier surgery would interfere with tooth development.
How are cleft lip and cleft palate primarily treated?
surgical repair
is the infant restrained before repair?
np, just after repair
Should children with cleft palate BEFORE surgery be allowed to cry? To breast-feed?
Yes, they can cry; may breast feed with simple cleft lip however palate interferes with feeding
after repair of cleft lip is infant allowed to cry? To breast feed?
No, the infant should be held to prevent crying; the infant is not allowed to breast-feed because sucking is not good after lip repair.
After clep lip repair, what device will the baby wear?
a Logan bow
what is the purpose of a Logan bow?
to prevent stress on the suture line
With what device will the infant be
restrained?
elbow restraints
How do you care for an infant with a Logan Bow?
Remove the gauze before feeding and cleanse after feeding with peroxide and saline.
Can cleft lip /palate babies sleep on their backs?
yes
What position is contraindicated after cleft lip repair?
never lay on their abdomen
What will be used to feed the infant after cleft lip repair?
A dropper/syringe with rubber tip to discourage sucking
What must the mother do after feeding the baby who has had cleft lip/palate repair?
Rinse the infant’s/child’s mouth with water
what is a colostomy?
A surgically created opening of the colon out onto the abdomen wall.
Name the 3 most common
reasons for a colostomy.
Cancer, Diverticulitis, Ulcerative Colitis
What is meant by the term “temporary colostomy”?
A colostomy that is not intended to be permanent– the bowel will be reconnected at a later date and the client will defecate normally
What is meant by the term “double barrel” colostomy?
A procedure where the colon is cut and both ends are brought out onto the abdomen.
Colostomies performed for cancer tend to be temporary or permanent?
permanent
Colostomies performed for a gunshot are usually temporary or permanent?
temporary
In a double-barrel colostomy, from which stoma (barrel) will the stool come out?
proximal
A fresh new stoma is _________, __________ and __________.
red, large, noisy
When a client voices embarrassment over the noises that their colostomy makes on the first post-op day, what would you say?
The noise will go away in a few days to a week.
What behavior on the part of the client is the BEST indicator that they have accepted their stoma?
When they do their own stoma care
By what day post-op should the client begin to take care of their own stoma?
By the 3rd to 4th day, they should be looking at it and asking questions by day 2.
The MORE colon is removed the more _________ the stool.
liquid
What technique is used to remove feces and flatus from the bowel through a colostomy?
colostomy irrigation
How many times per day will the client irrigate his colostomy?
once
Which solution is used to irrigate a colostomy?
tap water
How warm should the irrigation solution be?
warmer than body temperature, ie; 99-100 degrees F
In what position should the client be when they irrigate their colostomy?
sitting
ileostomy
liquid stool, odor mild, stool very damaging to the skin, continuous drainage, high risk for
fluid/electrolyte, imbalances, incontinent, never irrigate
transverse colostomy
soft stool, typical stool odor, stool damages the skin, empties several times per day, may or may not be at risk for fluid/electrolyte imbalances, may irrigate
descending colostomy
formed stool, typical stool odor, stool doesn’t irrigate unless diarrhea, predictable 2 to 3 times per day, emptying, lowest risk for fluid/electrolyte imbalances, continent
do irrigate
true or false: CHF can be right-sided, left sided or both-sided.
true- left sided usually comes first
What does right sided CHF mean?
Right ventricle has decompensated
- Dependent Edema (legs and sacrum)
- Jugular venous distention
- Abdominal distention
- Hepatomegaly
- Splenomegaly
- Anorexia and nausea
- Weight gain
- Nocturnal diuresis
- Swelling of the fingers and hands
- Increased BP
What does left sided CHF mean?
left ventricle has decompensated
true or false: CHF can result from MI
true
When cardiac output fails, name three ways the heart will try to compensate.
Ventricle hypertrophy, Dilate and heart rate will increase
What is meant by “cardiac
decompensation”?
It means that the compensatory mechanisms - hypertrophy, dilation, tachycardia are not working and the heart has failed.
Name the three groups of drugs used to treat CHF?
diuretics, vasodilators, digitalis
What is the activity order for clients with CHF?
bed rest
What special item do clients with CHF have to wear to decrease venous stasis in the legs?
TED hose
How often should anti- embolism hose (TED) be removed?
daily
When during the day should TED hose be applied?
before the client gets out of bed
Is it okay to use powder with TED hose?
yes
Should you massage the calves of the client with CHF?
never
Before you give digitalis, what action must you take?
measure the apical pulse
If the adult client’s apical pulse is below 60, what should you do?
-Do not give
digitalis
- For a child don’t give for a pulse under 70
- For an infant don’t give for a pulse under 90
What daily measurement best indicates the amount of fluid the client is retaining?
daily weight
Should clients with CHF have a Foley catheter?
Yes, on diuretics and fluid balance is important
What complication is common in CHF?
pulmonary edema
When the client is taking diuretics, what mineral is the CHF client most likely to lose?
potassium– K+
You should tell the client with CHF to immediately report to his/her doctor if he/she gains _____pounds in one week.
three
Name the four most common toxic effects of digitalis.
Anorexia, N/V– very common, yellow vision, Arrhythmia
Should hearing aids be removed before going for surgery?
yes, but just before surgery
Hearing aids are more useful in sensory or conductive hearing loss?
conductive
true or false: Some women experience discomfort when wearing contact lenses during pregnancy or menstrual periods.
true
Should a client sleep with the hearing aide in place?
No, a client should not sleep with a hearing aide in place.
What the two most common causes of whistling and squealing of a hearing aid?
loose ear mold, low battery
What solution should be used to clean a hearing aid?
soap and water
What solution is best to use if you intend to remove a client’s contact lenses?
sterile saline
true or false: hearing aids make sounds more distinct and clear
False, they only amplify–make it louder, they do not clarify
Can you use alcohol on the earmold of a hearing aid?
no, it dries and cracks it
The connecting tube of a hearing aid can be cleansed with__________.
a pipe cleaner
What is the most common complication of malpositioned lenses in the comatose or confused patient?
corneal ulceration
1kg
1000 cc
1 inch
2.5 cm
1 mL
1 cc
1 tsp
4 to 5 cc
1g
1000 mg
1L
1000 cc
1 oz
30 cc
1kg
2.2 lbs
1 tbs
15 cc
1 gm
15 gr
1 gr
60 mg
1 tbs
3 tsp
Cushings syndrome is __________ secretion of _______, _______ and _______ _______ by the _______ _______.
Over secretion;
glucocorticoids, mineralocorticoids, androgenic hormones; adrenal gland
In Cushings the blood sugar is increased or decreased?
increased
In Cushings the sodium level is increased or decreased?
increased
In Cushings syndrome, the client develops __________ face.
moon
In Cushings syndrome, the trunk is ________ and the extremities are _________.
obese, thin
What is seen on the abdomen of the patient with Cushings?
Striae– purple horizontal lines
Men with Cushings develop______________.
gynecomastia
what is gynecomastia?
female-type breasts (man boobs)
Women with Cushings
develop?
hirsutism, amenorrhea
what is hirsutism?
hair where you don’t want it for females
The Cushings syndrome patient will have a _________ on their upper back.
buffalo hump
The patient with Cushings Syndrome will have increased or decreased blood pressure?.
Increased, remember retaining water and sodium
The Cushings syndrome patient will have ________ natremia, _________kalemia and _______glycemia.
hyper, hypo, hyper
Cushings clients will have increased or decreased resistance to infection?
decreased
Chronic _____________therapy imitates Cushings.
steroid
Cushing’s man aka Cush man
- moon face with infection
- buffalo hump on back
- big trunk
- thin extremities
- loses potassium
- keeps glucose and salt
- has striations on abdomen and breasts
is CF (cystic fibrosis) hereditary?
yes
what glands are affected in CF (cystic fibrosis)?
exocrine glands
What is the appearance of the stool in a client with CF (cystic fibrosis)?
- remember the 4 Fs
Fat, Frothy, Foul-smelling, Floating Steatorrhea
What are the top 2 nursing diagnoses for a client with CF (cystic fibrosis)?
- Decreased airway clearance
2. Alteration in nutrition/absorption
what is the classic test for CF (cystic fibrosis)?
lontophoresis- sweat test
In which two systems/organs are
the most problems in CF?
lungs, pancreas
How does the client evaluate the activity of their pancreas if a cystic fibrosis patient?
observe stool for steatorrhea
what is the typical diet for a CF (cystic fibrosis) client?
high calorie, high protein, modified fat
the major problem in CF (cystic fibrosis) is ____
Increased viscosity of the secretions of exocrine glands lead to obstruction.
The most common intervention for the CF client with a diagnosis of decreased airway clearance is _________________.
postural drainage
What vitamins need to be replaced in CF?
Fat soluble in water soluble form – A,D,E,K
What do CF clients need to do (ingest) in hot weather?
take NaCl tablets
The child with the diagnosis of CF probably had a history of _________ ________ at birth.
Meconium ileus– bowel obstruction due to the thickness of the stool.
Why is the child with CF receiving
pancreas/viokase/pancreatin?
They are enzymes which aid absorption of nutrients.
When should the child with CFtakehis
pancreatin/viokase/pancreas?
With meals, so it is in the gut while the food is present, the whole purpose is to increase absorption of ingested food .
define cystoscopy
Direct visualization of the urethra and bladder through a cystoscope.
What would you do if the
client had any one of the following after cystoscopy: bladder spasm, burning, frequency?
Record it but no need to call the MD
What would you do if the client’s urine was pink-tinged after cystoscopy?
Record it in the notes, no need to call the MD.
Is the client NPO before cystoscopy?
No, not unless a child with a general anesthetic– in fact with adults you should encourage fluids.
Are enemas required before cystoscopy?
no, but may be ordered
should you encourage fluids after a cystoscopy?
yes
Is a signed informed consent required for cystoscopy?
yes
What vital sign changes are most ominous after cystoscopy?
A fall in the blood pressure and increase in the pulse– increasing hemorrhage
Is the client sedated for a cystoscopy?
It is done under LOCAL anesthesia. General anesthesia may be used for a child.
. What drugs are most commonly given before cystoscopy?
valium or demerol
first trimester
Developmental Task: Accepting fact of pregnancy (I am pregnant)
- ↑ leukorrhea (normal with vaginal secretions)
- nasal stuffiness
- urinary frequency begins
- fatigue
- epistaxis (nose bleeds)
- N/V
- breast changes (tenderness– pain,tingling,fullness)
- ptyalism (perceived ↑ in salivation)
- gingivitis
second trimester
Developmental Task: Accepting growign fetus as distinct from self and as a person to nurture (I am going to have a baby)
- heartburn
- striae gravidarum
- linea nigra
- urinary frequency lessens
- pruritis
- joint pain and joint mobility
- pelvic pressure
- pigmentation deepens (areola, vulva)
- palmar erythema
- chloasma “mask of pregnancy” (begins after week 16 and ↑ until delivery)
- supine hypotension
- hemorrhoids
- backache
- varicose veins appear
- round ligament pain
- carpal tunnel syndrome
- oily skin and acne
- constipation
- palpitations
- headaches
- faintness
- food cravings
- pica (craving no-food items such as starch, dirt, clay)
third trimester
- Developmental Task: preparing realistically for birth and parenting (I am going to be a mother.)
- Pregnant women fear possible defects in the baby
Pregnant women fears labor and delivery - possible mutilation, pain, loss of control - SOB and dyspnea
urinary frequency returns insomnia - Braxton-Hicks contractions ankle edema (non-pitting) leg cramps
perineal pressure
Other Discomforts and Dangers in Pregnancy
Mood swings - common throughout pregnancy Ambivalence (mixed feelings regarding pregnancy, labor and delivery, parenting, etc.)
Spider nevi appear on neck, thorax, face,arms - 2nd or 3rd trimester
danger signs (pregnancy)
- Severe headaches
- Urinary tract infection (may lead to infection of fetal membranes and premature labor)
- Epigastric pain (signals impeding convulsion [pre-eclamptic])
- Severe abdominal pain
- Seizures
- Decreased fetal movements or absent fetal movements (movements first felt around 16 to 20, any change of pattern or abrupt cessation of fetal movement is ominous)
- Blurry vision (sign of preeclampsia)
- Vaginal bleeding
- Persistent, severe vomiting (can lead to dehydration and electrolyte imbalance)
- Edema of face or fingers (possible hypertension, pre-eclampsia)
The goal of nursing intervention in the care of the violent client is to prevent loss of __________ or to restore _________.
control, control
Use of alcohol and/or drugs decreases or increases risk of violent behavior.
increases
true or false: Pacing can be a warning sign of potential violence.
True, as in any other form of increased motor activity
If the client is not yet out of control, what is the #1 strategy to treat beginning violence?
decrease environmental stimuli
true or false: When a client is becoming violent you should move in close to them to provide a sense of security.
False, allow them space or else they can get worse
When approaching a violent client the first thing you say is….
My name is ___________ and I am a nurse.
After identifying yourself what do you say to the client next?
What you are going to do and ask if these are any questions.
true or false: When the client is having an overt violent outburst you should NEVER be alone with them.
true
When you seek assistance to deal with the violent client, you should obtain_________ personnel.
trained
Should you ever ask the family or other patients to help you physically overcome a violent client?
never
true or false: When a client is overtly and actively violent, they are given a chance to calm down themselves before being subdued.
True, once enough trained personnel are present the client is told that if they don’t control themselves they will be controlled by us
To promote efficient and safe accomplishment of physically-controlling a violent client it is extremely important that…
Only one person talk during the procedure
When a client is losing control it is very frightening to them if the nurse shows________.
fear
The best staff approach to control impulsive outbreaks of violence is….
Setting limits and doing it consistently
Purpose of defense mechanism is to reduce __________.
anxiety
When a person is consciously choosing to disbelieve the truth, they are using _________.
denial
true or false: Defense mechanisms are always unhealthy.
False, in fact defense mechanisms are often and most always healthy because they reduce anxiety.
When a patient hates someone but then expresses the opposite emotion, it is called_____________.
Reaction formation – you form the opposite reaction, ie, you love a person and that makes you anxious so you form the opposite reaction and you ignore them
When an angry patient says “I am not mad, he is…”; they are using________.
projection
Whenapersonis unconsciously choosing to disbelieve the truth, they are using___________.
repression
When the patient makes an excuse about something bad that happened, they are_______.
rationalizing
When a patient becomes demanding and self- centered and attention- seeking, the defense mechanism used is _________.
regression
true or false: Defense mechanisms are ways to lie to yourself.
True, they all involve self- deception .
When a patient tells all kinds of details about very upsetting events but acts very cool and calm, they are using ___________.
intellectualization
When a patient expresses their emotions toward another object they are using_________.
displacement
The defense mechanism most suspected of causing psychosomatic illness is ___________.
repression
What is the most important thing to do immediately when retinal detachment is suspected?
bedrest
Define detached retina
Separation of the retina from the back of the eye– the choroid
What is the most common
complication of retinal reattachment?
hemorrhage
What group of drugs are given to people with retinal detachment?
tranquilizers
What is the most common visual defect with retinal detachment?
A veil or curtain in the line of sight
Give three common causes of retinal detachment?
trauma, aging, cataract surgery
Does the client always need surgery for retinal detachment?
No, lasers can be used, as can freezing probes
Will the clients eyes be bandaged after retinal surgery?
Both will be, also before surgery as well
Can the client return to work after retinal surgery?
Not for 3 weeks– and may not be able to go back active jobs 6 to 8 weeks after that
What environmental change is most appropriate for clients after retinal reattachment?
dimmed light
What are the two non-surgical treatments done for retinal detachment?
Laser surgery (photo coagulation), Cryosurgery (freezing)
Give two odd visual sensations that these clients with retinal detachment have.
flashes of light, floaters
Name a surgical procedure done for retinal detachment.
scleral buckling
When does anterior fontanel close?
18 to 24 months
Infant’s birth-weight should ________ in 6 months.
double
Infants birthweight should ________ in one year.
triple
Infant’s respiratory rate is _________ to __________ breaths per minute.
30 to 60
Infant’s HR is _________ to __________ per minute
110-160
Which are the first teeth to erupt?
lower central incisors
When does infant’s teeth first
erupt?
4 to 6 months
What age can infant follow an object with its head?
2 months
What age are children first afraid of strangers?
6 to 7 months
What age does an infant walk alone?
14 to 15 months
What age does an infant have a pincer grasp?
12 to 13 months
What age can an infant roll over?
4 to 5 months
What age can an infant sit up
unassisted?
6 to 8 months
What age does an infant stand alone?
12 to 13 months
What age does an infant crawl?
8 to 9 months
What age does an infant walk
holding onto furniture?
10 to 11 months
What visual experiences will patients with digitalis toxicity have?
Yellow/green halos around lights
The signs of lithium toxicity are _______ (muscle symptom),______ _______ (abdominal symptom) and thirst.
Tremors, nausea and vomiting
Lithium carbonate is given for __________ disorder.
Bipolar (manic- depressive)
When a patient is on lithium you must watch for a decrease in _____________.
sodium
Theophylline is a broncho-_________ used to treat _________.
dilator, asthma
Digitalis toxicity exists when blood levels exceeds __________.
2.0 ng/dl
The earliest sign of digitalis toxicity is…..
Nausea and vomiting with headache
Is theophylline toxicity life- threatening?
yes
Lithium toxicity occurs when blood levels are higher than _______ mEq/L.
2.0
The signs of theophylline toxicity are _________ (GI), ________ (heart), and ________ (muscle).
Nausea and vomiting (coffee ground emesis), tachycardia, tremors
What is the therapeutic blood level of theophylline?
10 to 20
Digitalis is a cardiac ________, used to _________ the contraction of cardiac muscle.
glycoside, increase
Theophylline toxicity exists when the blood level is above________.
20
Ectopic pregnancy is implantation of a fertilized ovum ________ the _________.
outside, uterus
The most common site for ectopic pregnancy is in the _________ __________.
Fallopian tube - 90%
Have intrauterine devices to prevent pregnancy ever been linked to ectopic pregnancy?
Yes and so have pelvic infections.
