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.
What is the most common sign of fallopian tube ectopic pregnancy?
Unilateral pelvic pain
What is the most dangerous side effect/complication of fallopian ectopic pregnancy?
Rupture of the fallopian tube
If the fallopian tube ruptures due to ectopic pregnancy, nursing care is the same as that for___________.
Shock and peritonitis
The uterus feels _______ after rupture of a fallopian ectopic pregnancy?
Boggy- tender, also
The first sign that a fallopian ectopic pregnancy had ruptured is…
Sharp abdominal pain
Ectopic pregnancy is usually or almost never carried to term?
Almost never
The most common medical- surgical treatment for ectopic pregnancy is___________.
Surgical removal of fetus and some surrounding tissu e
Name the surgery performed for an ectopic pregnancy.
Exploratory laparotomy
What is ECT?
The use of electrical shock current delivered to the brain to induce a seizure that treats depression.
The client is (awake/under local anesthesia/under general anesthesia) during ECT?
Under general anesthesia– must be artificially ventilated
What conditions does ECT treat?
Depression primarily
is an informed consent necessary for ECT?
yes
Name the three most common complications ofECT?
Aspiration of emesis (most common) into the lung Dislocations of joints Fractures due to convulsion– rare today
What class of drugs is given with ECT?
Muscle relaxant – succinylcholine
What intellectual ability is impaired after ECT?
memory
How long will a client’s memory be impaired after ECT?
2 to 3 weeks
Immediately after ECT, how will the client normally act?
Drowsy, Dull, Apathetic
In what position should the client be immediately after ECT?
On their side– to prevent aspiration
What typical pre- operative type of orders will be ordered before ECT?
- NPO after midnight
- Remove dentures
- Client to void before surgery - Side rails up
true or false: The convulsion (seizure) that the electrical current produced is violent.
False, it used to be, but it isn’t any more with the use of muscle relaxants
What does an EEG measure?
Measures electrical activity generated by the brain
When are there activity restrictions after an EEG?
ONLY when sedatives are used, and then it’s only necessary to keep side rails up.
Should the client wash his hair before an EEG?
yes
What would you tell a client who says what if I get shocked during my EEG ?
That is impossible since the test measures electrical activity coming FROM him, never to him.
Does a client have to be NPO before an EEG?
No, they should never be NPO, it could cause hypoglycemia and alter the EEG results.
What instructions are MOST important to give a client during an EEG?
try not to move
What should the client do after an EEG?
wash their hair
Should sedatives be given before an EEG?
Only if ordered as a pre-test medication .
How much sleep should the client get the night before an EEG ?
At least 4 to 5 hours– unless it is a sleep deprivation EEG
Do you need a signed informed consent for an EEG?
no
Should caffeine be limited beforeanEEG?
Yes. It should be eliminated for 24 hours before the test.
What will excessively fatty stool belike?
Large, pale, foul smelling, greasy
What are the large, pale, foul smelling, greasy stools called?
Steatorrhea
Name the three types of parasites abnormally found in stool.
Roundworm, tapeworm, Pinworm
What does occult blood in the feces mean?
Bleeding somewhere in the GI tract
Are fats a normal constituent of feces?
yes but it should be within normal limits
A decrease in urobilin in stool results in stool that is______ ________.
clay-colored
Name two things for which stool specimens are tested.
Occult blood, fat, ova and parasites
Is blood a normal constituent of feces?
no
What is melena?
A black, tarry stool indicating a GI bleed
What position is best for clients with emphysema under normal circumstances?
Semi-fowlers or higher
What flow rates of O2 are appropriate for the client with emphysema?
Low flow – <2.5 L/min; never exceed 2.5L in COPD
If a client with emphysema has a severe dyspneic episode what position is best?
Sitting upright with arms folded on the overbed table
What will you observe on the hands of the client with emphysema?
Clubbing of the fingernail beds
In emphysema, the alveoli are over-_____ and under-______.
Over-enlarged, under- ventilated so that air is trapped in alveoli
The development of emphysema is most associated with a history of ___________.
smoking
In emphysema, the appetite________ the weight ______ and the anterior- post diameter of the chest________.
Decreases, decreases, increases
What is the increase in anterior- posterior diameter of emphysema called?
barrel chest
The person with emphysema have ________, _______lips and (slow/rapid) breathing.
Grunting, pursed, rapid
What dietary prescription is most appropriate for the client with emphysema?
Frequent small meals to prevent tiring
What fluid order should the emphysema client have?
3 liters of fluid per day (this is an increase)
The client with emphysema is ruddy, pale or cyanotic?
cyanotic
Hyperthyroid (High metabolism)
graves disease
High growth hormone in a child
give another name
gigantism
Over secretion of mineralcorticoids only (give another name)
Conn’s disease
Low growth hormone (give another name)
Pituitary dwarfism
High growth hormone in an adult.
acromegaly
Under-secretion of adrenal cortex
Addison’s disease
Hypothyroidism in an adult.
Myxedema
Over secretion of adrenal cortex
Cushing’s syndrome
Over secretion of adrenal medulla
Pheochromocytoma
Hypothyroid in a child
Cretinism
Oversecretion of ACTH
Cushing’s disease
What is endometriosis?
Growth of endometrial tissue outside of uterus
Endometriosis most commonly occurs in women between ages of ______ and ________.
25 to 40
After menopause, endometriosis decreases or increases?
decreases
What is the MOST common side effect of endometriosis?
Dysmenorrhea (painful menstruation)
What is the major complication of endometriosis?
infertility
What diagnostic procedure confirms the diagnosis of endometriosis?
laparoscopy
What class of drugs is used to conservatively treat endometriosis?
androgens
Which androgen drug is most commonly used to treat endometriosis?
Danazol
Women with endometriosis should be counseled to use tampons or pads during menstruation?
pads only
Will client die of endometriosis? What would you say?
Not life-threatening
What advice is best for women with endometriosis who want to have children?
Do not postpone pregnancy, may not be able to have children
What is the #1 danger of epiglottitis?
Airway obstruction
Epiglottitis most commonly occurs in children from age ________ to ______.
1 to 8 years
What organism causes epiglottitis?
Hemophilus influenza B
What level of fever is present in epiglottitis?
Over 102 degrees
What symptoms are classic epiglottitis?
Muffled voice, Drooling, Stridor
Will a child with epiglottitis cough?
No, there will be a lack of spontaneous cough.
How will the child with epiglottitis breathe?
Leaned forward with flaring nostrils
If a child is suspected of having epiglottitis, should you put a tongue depressor in their mouth to look?
No, never put any instrument in the child’s mouth unless you are prepared to do an immediate intubation.
Would you do a throat culture for a child with epiglottitis?
No, never put anything in their mouth.
If epiglottitis is suspected, what should the parents be told?
To take the child to the ER as soon as possible.
What drug is used to fight epiglottitis?
Penicillin, ampicillin
Children with epiglottitis often need a tracheotomy. What behavior would indicate the need for a tracheotomy?
Restlessness, Increased HR, Retractions
What is recommended for the prevention of epiglottitis?
All children two months and over should receive an H. influenza B vaccine.
Autonomy vs Shame and Doubt
toddler
Industry vs Inferiority
school age
18 to 25 years
young adult
what age group says “no”
toddler
encourage creativity and collecting things
school age
give choices
toddler
Centers on having basic
needs met
infancy
18 months to 3 years
toddler
3 to 6 years
pre-schooler
12 to 20 years
adolescent
initiative vs guilt
pre-schooler
6 to 12 years
school age
trust vs mistrust
infancy
peer group important
adolescent
encourage fantasy
pre-schooler
Identity vs Role confusion
adolescent
intimacy vs isolation
young adult
birth to 18 months
infancy
define EGD
Insertion of a fiber optic scope to visualize the esophagus, stomach and duodenum
What can be done during an EGD besides visualization?
Remove polyps, Take specimens, Coagulate bleeding vessels
Can EGD be done on an uncooperative client?
no
Does client need to have side rails up after EGD?
Yes, until sedative effects of valium have worn off
Can an EGD be done on clients with GI
bleeding?
yes
Is the client sedated before EGD?
Yes, with valium (diazepam) or another sedative
What pre-test activities must be performed before the EGD?
Remove dentures and eyeglasses, Sign consent, NPO after midnight
When can an EGD client begin to eat after the test?
When gagg reflex returns (knocked out with xylocaine)
Is an EGD a fasting procedure?
Yes, after midnight
What drug is given to anesthetize the pharynx?
Xylocaine (a local anesthetic)
What are the complications of EGD?
Perforation of gut, Aspiration secondary to emesis, Respiratory arrest (due to valium)
What two discomforts are common during an EGD?
Vomiting, Gagging
What is the most dangerous complication of EGD?
Secondary respiratory arrest (valium)
What is the most common complaint after an EGD?
Sore throat
Carbonic Anhydrase Inhibitors
- Treat glaucoma
- Decreases aqueous humor production
- Diuresis
Diamox is an example
Anticholinergic
- Dilates pupils
- Causes photophobia
- Used preoperatively for cataract removal
- Don’t use in glaucoma
Atropine is an example
Miotic
Constricts pupil; Timoptic
Pilocarpine are examples
Mydriatic
Tachycardia, Photophobia, Dilates pupil
Do not use in glaucoma
Neo-synephrine is an example
What do carbonic anhydrase inhibitors do to the eye?
Decrease production of aqueous humor and thus decrease intraocular pressure.
Name the most common side effect of carbonic anhydrase inhibitors?
diuresis
Which two groups of these drugs cause photophobia?
Mydriatics, Anticholinergics
Which of these classes of drugs causes contact dermatitis?
miotics
What do mydriatics do for the eye?
Dilate the pupil (My “D”riatic “D” for dilate)
What do miotics do for the eye?
Constrict the pupil
Name one mydriatic
Neo synephrine or Atropine
What do anticholinergics do
for the eye?
Dilate the pupil, Cycloplegia, Paralyzes accommodation
What is cycloplegia?
Paralysis of the iris/pupil
Which two of these classes of drugs cause tachycardia?
Mydriatics, Anticholinergics (sympathetic effects)
What is the most common use for anticholinergics in the eye?
To cause cycloplegia, Dilation
Allowing eye exam
How should eye ointments be given?
Placed on the lower inner eye lid, then have client close eyes
Name two anticholinergics used in the eye.
Cyclogel, atropine
Name one carbonic anhydrase inhibitor
Diomox
How should the eye drops be given?
Place drops into the lower conjunctival sac
How is the flow of eye irrigational fluid directed?
From inner canthus to outer canthus
Name two miotics
Pilocarpine, Timpotic (or any drug ending in -lol)
Define nuclear family
A family of parents and their off spring
When does a nuclear family become an extended family?
When aunts or uncles or grandparents live with the family
true or false: In America, the family is the basic unit of society.
true
Give the 2 major roles of the family in society
to protect and socialize
What percentage of North American families are single- parent?
50%
90% of single-parent families are headed by a ___________.
female
In what step of the nursing process does the nurse ask the family about their beliefs on illness?
Assessment phase
What is the first thing a nurse must do to help families in crisis?
Nurse must first examine her own values
Increasing dietary fiber lowers the risk of ___________ of the __________.
cancer, colon
Foods lose some or all of their fiber when they are ___________. ___________,____________ or__________.
Processed, cooked, peeled, refined
Whole grains and grain products are high or low in fiber?
high
fruits are high or low in fiber?
high
veggies are high or low in fiber?
high
milk and milk products are high or low in fiber ?
low
meats are high or low in fiber?
low
nuts, seeds, and legumes are high or low in fiber?
low
Which has highest fiber? Grains, fruits, veggies, nuts.
grains, especially bran
When a person increases fiber in the diet they should do so____________.
slowly
Side effects of a high fiber diet include__________ and malabsorption of ____________.
Gas (flatus), minerals
Of milled bread, enriched bread, fortified bread and whole grain bread; which is highest in fiber?
whole grain
What type of herpes virus causes genital herpes?
Herpes simplex II
Name the two most common ways genial herpes is transmitted?
Sexual intercourse/contact; through birth
How long is the incubation period of genital herpes?
3 to 7 days (about the same for gonorrhea)
What do lesions of herpes look like?
fluid filled vesicles
What are the two most common sites for herpes?
On the genitals and the mouth
What drug is used to treat herpes?
Acyclovir (or Gancyclovir, Famciclovir, Penciclovir, Valacyclovir)
The client should keep the lesions dry or moist?
dry
What precautions should the person with herpes take in regard to sexual intercourse?
No intercourse while vesicles are evident
When is C-section delivery indicated if the mother is infected with herpes?
If the vesicles are present, then C-section is indicated
How long will it take for the vesicles to heal?
2 to 4 weeks
Glaucoma is an eye disorder in which there is ____________ intraocular pressure in the ___________ chamber.
increased, anterior
The increase in pressure is due to an imbalance in the formation and drainage of __________ humor from the anterior chamber.
aqueous
Glaucoma affects one or both eyes?
Both (it is a bilateral d isease)
The most common visual field defect in glaucoma is loss of _________.
Central vision (loss of peripheral vision–also called tunnel vision)
What are the two types of glaucoma?
Open-angle, closed angle
Which one is the typical type and the one you should know well?
Open angle–90% of all cases
Open-angle glaucoma is seen most commonly in ____________life.
later
Open angle glaucoma is painless or painful?; whereas closed angle is painless or painful?
Open is painless; closed is painful
What drugs (class) are given to treat glaucoma?
Miotics – these constrict the pupil (remember: in glaucoma DO NOT DILATE the pupil)
Name two miotics.
Pilocarpine, Timoptic
any drug ending in - lol
Why is diamox given to glaucoma patients?
It is a diuretic that decreases aqueous humor production thus lowering intraocular pressure.
What type of drugs are contraindicated for glaucoma patients?
ANY drug that DILATES the pupils are BAD (i.e. mydriatics)
Can surgery be done for glaucoma?
yes
What do you do if the patient complaints of severe ocular pain after surgery?
Call the MD– hemorrhage into eye is most likely
true or false: Gonorrhea is the most common venereal disease next to chlamydia.
true
true or false: gonorrhea can infect the eyes
true
true or false: gonorrhea can lead to sterility
true, in women
Gonorrhea occurs most commonly in people ________ to _________ years of age.
19 to 35
The almost exclusive way gonorrhea is transmitted to an infant’s eye is through _____________.
The birth process, from mother to infant eyes
What is the name for the gonorrhea conjunctivitis that neonates get during birth?
Ophthalmia, Neonatorum
In males, what is the most common sign of gonorrheal infection?
Dysuria or purulent discharge
How long is the incubation period of gonorrhea?
2 to 3 weeks
Which sex is most likely to be asymptomatic with gonorrhea?
women
What is the most common symptom of gonorrhea in females?
Greenish-yellow discharge from the vagina
When does the purulent discharge of opthalmia neonatorum begin?
2 to 3 days after birth
What is the most serious complication of opthalmia neonatorum?
blindness
Gonnorrhea is caused by a gram (negative/positive) organism?
negative
The drug of choice for gonorrhea is __________.
Penicillin - If resistant organism, Ciprofloxacin
Why is probenecid given before administration of penicillin?
To prevent the excretion of penicillin and thereby prolong its action
How is the penicillin given (what route)?
IM
What is pelvic inflammatory disease?
Infection of the reproductive tract in the female, usually but not always an advanced stage of gonorrheal
in fection .
How is pelvic inflammatory disease treated?
By IV penicillin
In what position should a patient with pelvic inflammatory disease be positioned?
Semi- to high- fowlers to keep the infection in the pelvis
What drug is given to neonate to prevent gonorrheal conjunctivitis?
Erythromycin or tetracycline drops in eyes
true or false: The sequence of growth and development is predictable.
true
true or false: The rate of growth and development is even.
False, it goes in spurts and is often very uneven.
true or false: Growth and development is a pediatric concern only.
false
true or false: Heredity determines most development.
true
true or false: Environment determines most development.
true
true or false: The rate a person grows and develops is predictable.
False, the sequence is more predictable than rate.
true or false: Heredity has no influence on development.
False, it is a secondary influence (it is not the primary influence– environment is)
The heart is a fast or slow growing organ?
slow
Which component of growth and development is predictable: time of onset, length or stage, effect of stage and sequence of stage?
sequence
What is meant by the phrase– growth and development is cephalocaudal?
Growth and development starts with the head and moves to the extremities.
Growth and development occurs first in __________ body parts and progresses to _________ body parts.
Proximal, distal
In which phrase is rate and growth most rapid–infancy or adolescence?
Infancy
The proportion of the body that is water rises or falls with age?
Falls, in infants is 70% water and adult is 58%.
An infant’s stomach is more or less acid than adults?
less
true or false: Lymphoid tissue mass grows steadily throughout life.
False, it decreases in mass after adolescence
An adult’s height begins to decline after the average age of__________.
30
true or false: The brain is fully mature in size at birth
False, but by end of the first year of life you will have all the brain cells you will ever have
By what age do most children have all their deciduous teeth?
End of the 2nd year of life.
What is the #1 finding with Guillian-Barre?
Progressive ascending paralysis
What causes the paralysis of GBS?
Demyelination of peripheral nerves (unknown cause)
What kind of infection precedes Guillian-Barre?
viral
true or false: The patient completely recovers from Guillian-Barre.
False, there are usually residual effects but they do recover most of what was lost.
Recovery usually occurs within ______ to _____ months for patients with Guillian Barre.
4 to 6
What is the first symptom of Guillian-Barre?
Clumsiness in ambulation (function in legs and feet is lost first. )
What is the biggest danger of Guillian-Barre?
Respiratory arrest secondary to diaphragmatic paralysis
In the acute phase of Guillian-Barre, it is very important to assess _______ _________ every 2 hours.
Motor function of all muscles (especially the diaphragm)
Before feeding in a patient with Guillian-Barre you must_________.
Check the gag reflex
What is the most aggressive medical therapy for GBS?
Plasma phoresis– to remove antibodies from the blood.
What information does the measurement of skin fold thickness yield?
The amount of body fat
true or false: In general, males have a higher risk of heart disease than females.
true
true or false: Post-menopausal females have a lower risk of heart disease than males aged 25-40.
False. They have a higher risk.
true or false: Family history of diabetes increases the risk fo heart disease.
true
true or false: Family history of liver disease increases the risk of heart disease.
false
true or false: Cigarette smoking increases the risk of heart disease.
true
true or false: Oral contraceptives decrease the risk of heart disease.
False, use increases the risk
true or false: Routine exercise decreases the risk of heart disease.
true
What is done in a graft for hemodialysis?
A blood vessel is sutured between an artery and a vein.
What is done in an AV fistual?
A surgical anastomosis is made between the artery and a vein.
Does anything exit the skin in an
AV fistula?
no
How long can an AV fistula be used?
Indefinitely
Who is the most likely to receive a graft for dialysis?
People with diabetes mellitus.
How often do clients with renal failure undergo dialysis?
3 times per week
Is hemodialysis short term or long term?
Both- but most short term dialysis is achieved by
hemodialysis
How long does the average dialysis last?
4 to 6 hours
What are 3 ways to gain access to the circulation in hemodialysis?
AV shunt, AV fistula, AV graft
What is the most common site for an AV shunt?
Radial artery to radial vein
What should be avoided in the arm of the client with an AV shunt?
No venipuncture or blood pressure allowed in the arm with a shunt, graft or fistula
What syndrome results when too much fluid is exchanged during hemodialysis too quickly?
Disequilibrium syndrome
What are the symptoms of disequilibrium syndrome?
Change in LOC, N/V, Headache, Twitching
Does anything exit the skin in an AV shunt?
Yes, the plastic tube that connects the artery and vein outside the arm
How long can AV shunt be used?
Just for a few weeks
Hemophilia is a ___________ disorder.
bleeding
Hemophilia A is a deficiency of Factor # __________.
VIII
During an acute bleeding episode, you should apply________ for 15 minutes and apply________.
pressure, ice
The inheritance patterns for hemophilia is:
Sex linked recessive
In hemophilia, the PTT is up or down?, the coagulation or clotting time is up or down? and the platelet count is up or down?
- Up (increased or longer)
- Up (increased or longer)
- Neither (hemophilia does not affect platelets)
What does hemarthrosis mean?
Bleeding into the joints
During bleeding into the joints you should mobilize or immobilize the extremity??
Immobilize to prevent dislodging the clots that do form.
To treat hemarthrosis you should _______ the extremity above the __________.
Elevate, heart
What is the name of frozen factor VIII given to hemophiliacs?
Cryoprecipitate
Once you have stopped the bleeding into the joint, how long should the hemarthrosis patient wait before bearing weight or doing range of motion?
48 hours
What drug can you apply topically to stop bleeding?
Epinephrine, or topical fibrin foam
Whichofthese symptoms are NOT seen in hemophilia? Prolonged bleeding, petechiae, ecchymosis or hematoma?
petechiae
Hepatitis is an _____, ______ disease of the _______.
Acute, inflammatory, liver
Hepatitis A,B,C and D are all bacterial or viral
diseases?
viral
An early sign of hepatitis A is ________.
Anorexia or fatigue
Early stage hepatitis often looks like the _______.
flu
In later stages of hepatitis, the ______ turns dark.
urine
What does pre-icteric mean?
The stage BEFORE the patient exhibits jaundice
What is the icteric stage?
When the patient exhibits jaundice.
What skin symptoms do
you see in hepatitis? (Give2)
Pruritis (itching), Jaundice (Both are due to bilirubin accumulation)
Which disease has more severe symptoms–
Hepatitis A or B?
Hepatitis B
Patients with hepatitis have an aversion to _________.
Cigarettes
In hepatitis the ________ are light colored.
Stools: remember the urine is dark and stools are light. (Bilirubin ends up in the skin and urine instead of the stool where it should have gone.)
What is the common name for Herpes Zoster?
Shingles
What type of rash occurs with shingles?
A vesicular rash over the pathway of a sensory nerve
How long does it take for shingles to heal?
30 days
What is the most common subjective symptoms of shingles?
Pain, pain, Pain
What three drugs are given for shingles?
Acyclovir (anti-infective), Tegretol (anticonvulsant–given to stabilize nerve cell membranes) Steroids (anti-inflammatory)
What other disease is related to shingles?
chickenpox
What organism causes shingles?
Varicella–herpes zoster
What is the #1 nursing diagnosis with shingles?
Alteration in comfort: pain, #2 Impaired skin integrity
Hepatitis A
- Enteric precautions
- Fecal/oral route of transmission Incubates 3 to 5 weeks
- Vaccine available (Can give immune globulin after exposure)
- HAsAg (this is what the blood test show)
- Hepatitis A surface Antigen
Hepatitis B
- Watch those needles
- HBsAg (this is what blood tests show)
- Hepatitis B surface antigen
- HBIG - vaccine
- Vaccination available, can give immune globulin after exposure
- Transmitted by blood and body fluids
- Incubates 5 to 35 weks
Hepatitis C
- Watch those needles
- Incubates 2 to 23 weeks
- Transmitted by blood only
- No vaccine, immune globulin doesn’t work
Which types of client should have their
toenails trimmed only by an MD?
Diabetics, peripheral vascular disease, very thick nails
Two purposes of bed bath are…
Cleanses the skin Provides comfort
The typical hospital client should or should not wear their dentures?
should
What type of movement should be used for
cleansing eyes?
Inner to outer canthus
Before applying elastic hose the nurse should…
Elevate the clients legs for 3 to 5 minutes to decrease venous stasis
Clients on what class of drugs should use an elastic razor?
Anticoagulants (heparin/coumadin/lovenox)
When a client is unable to hold his dentures firmly in his mouth, the nurse should…
Leave them out
How often should mouth care be performed for those clients on oxygen?
Every 2 hours
Should lemon and glycerine swabs be used to cleanse the mouth?
No, they are not cleansing agents. They are used AFTER cleansing as a moistening agent
How should a client’s toenails be trimmed?
Straight across
Are nurses permitted to give perineal care to clients of the opposite sex?
Yes, nurses are permitted to give perineal care to clients of the opposite sex.
Clients on what type of therapy must use a safety blade razor (non electric)?
Oxygen therapy, since an electric razor could cause sparks
How should a nurse carry soiled linen?
In a neat bundle held away from the body
When giving a bed bath, on which body party should the nurse begin to work?
the eyes
Give three reasons for giving a back rub.
Comfort, Stimulate circulation and muscles, Relaxation
The greatest danger in placing water in the mouth of the unconscious patient during oral hygiene is…
Aspiration
When shaving a client, water used should be more hot or cold than bath water?
hot
What does evening or hour of sleep (HS) care consist of?
Oral hygiene, Washing face/hands, Back rub, Tightening linens
What is dentifrice?
Agents which promote adherence of dentures to gums, ie, Polygrip
What is sordes?
Crusts on the tongue and gums due to improper oral hygiene
What action will facilitate the trimming of brittle toenails?
Soaking in warm water
Should the client roll the elastic stocking down to wash legs? Why or why not?
No, it can cause a constricting band around the ankle/foot.
true or false: Elastic stockings should be removed for the bath.
true
When should a patient put on TED hose?
Before getting out of bed (before the swelling occurs).
Hyperemesis Gravidarum is ______ and ________ vomiting that persists into the _____ trimester.
Severe and prolonged; 2nd trimester (normal vomiting should be gone before 2nd trimester)
Give three possible causes of hyperemesis gravidarum.
Pancreatitis, Multiple pregnancies, Hydatidiform mole
Has hyperemesis gravidarum ever been associated with mixed feelings about pregnancy?
Yes, increased incidence of it in women who are ambivalent about pregnancy
What are the two most common complications of hyperemesis gravidarum?
Electrolyte imbalance (dehydration) Starvation
What is the initial diet order for clients with hyperemesis gravidarum?
NPO
Why are doctors cautious in using antiemetics to treat hyperemesis gravidarum?
They don’t want to harm the fetus
What are the instructions given to clients recovering from hyperemesis gravidarum in relation to mealtime?
Remain seated upright for 45 minutes after each meal
What is the biggest challenge in nursing care of the client with hyperemesis gravidarum?
Getting them to eat
Hypertension is an ________ or sustained elevation in the systolic or diastolic __________?
Intermittent, diastolic blood pressure
true or false: Hypertension is often fatal if untreated.
true
Hypertension is more common in blacks or whites?
blacks
true or false: Aging decreases the risk of hypertension.
False, it increases the risk
true or false: Obesity increases the risk of hypertension.
true
Oral contraceptives increase, decrease or do not effect the blood pressure?
increase
What four organs does hypertension affect the most?
Brain (stroke), Eyes (blindness), Heart (MI), Kidney (renal failure)
How many measurements must be made before you can say a person has hypertension?
at least three
What blood pressure is considered to be
hypertension?
Anything greater than 140/90 mm Hg
Which pressure is most damaging, an increased systolic or diastolic?
an increased diastolic
When a doctor takes three different blood pressure readings at different times, how far apart must the measurements be made?
At least one week
Can hypertension be cured?
No, just treated
What class of drugs is used to first treat hypertension?
Diuretics
Name the two most common dietary prescriptions used to treat hypertension?
Calorie reduction for weight loss, Sodium restriction
What two non-dietary lifestyle changes are used commonly to treat hypertension?
Decreases stress, Increase activity
When you take the blood pressure of the client with hypertension you would measure _____- _______, with the client _____, _______ and _______.
Both arms; lying, sitting and standing
What do caffeine and smoking do to blood pressure?
increase it
What is the #1 side effect of antihypertensives?
Orthostatic hypotension (means you feel weak whenyourisetoa standing position because your blood pressure falls)
Would vasodilators or vasoconstrictors treat hypertension?
Vasodilators (decreases resistance)
Would sympathetic stimulators or sympathetic blockers treat hypertension?
Sympathetic blockers (decrease cardiac output and decrease resistance)
In hypovolemic shock there is a ________ in the circulating __________ volume – this _______ tissue perfusion with ________.
Decrease; blood; decreases; oxygen
What gauge catheter would you use to start an IV in hypovolemic shock?
16 or larger
What is the #1 cause of hypovolemic shock?
Acute blood loss
What happens to the blood pressure in hypovolemic shock?
It decreases
What happens to the pulse pressure in hypovolemic shock?
It narrows (becomes a smaller number)
How do you calculate the pulse pressure?
You subtract the diastolic from systolic
If J. Doe’s blood pressure is 100/60, what is his pulse pressure?
40 (100-minus 60 equals 40)
What is the normal pulse pressure?
40 (+ or -10)
In hypovolemic shock the level of consciousness (LOC) is (increased/decreased).
decreased
Which heart rate is associated with hypovolemic shock, bradycardia or tachycardia?
tachycardia
In hypovolemic shock the output of urine will be less than _______cc per hour.
25 to 30cc
The client’s skin will be _____, ______, and ________.
Cool, pale, clammy (due to arterial constriction to shunt blood from skin to vital organs)
Which acid-base disorder is MOST commonly associated with hypovolemic shock?
Metabolic acidosis (due to lactic acid accumulation- no oxygen = anaerobic metabolism)
Of all the following, which one(s) increase in hypovolemic shock? Blood pressure, output, heart rate, pH, LOC, pulse pressure, respiratory rate
Only the heart rate and respiratory rate
What are the first two sings of hypovolemic shock?
Change in LOC and tachycardia
What is the #1 medical treatment of hypovolemic shock
Replace blood and fluids
What are mast trousers?
Pneumatic device placed around the legs and lower body that is inflated to force blood centrally
Do clients in hypovolemic shock have to have a Foley inserted?
Yes, to measure urine output (when output is >30 cc per hour the shock has resolved)
In what position would you place a client in suspected hypovolemic shock?
On back with arms and legs elevated
How often are vital signs measured in hypovolemic shock?
Every 15 minutes
If the blood pressure (systolic) falls below 80 mmHg, what would you do first in hypovolemic shock?
Increase the oxygen flow rate
What is a hysterectomy?
It is surgical removal of the uterus
How long must a woman
wait before having intercourse after hysterectomy?
4 to 6weeks
Is the woman likely to have a foley catheter in after a hysterectomy?
yes
Are enemas common before a hysterectomy?
yes
What would you do if the client complains of flank pain (back pain) after hysterectomy?
Call the MD, probably had a ureter tied off accidentally in surgery
What are 2 common psychological reactions to hysterectomy?
Grief, depression
What causes thrombophlebitis after hysterectomy?
Venous stasis in the abdomen (the woman was in the vaginal lithotomy position for hours)
What sign would indicate the presence of
thrombophlebitis?
A hard, red swelling in the posterior calf
Should you assess for Homan’s sign?
No. Homan’s sign is no longer recommended as a test for thrombophlebitis because it can cause a clot to embolize
How long does the woman have to be off oral contraceptives before hysterectomy?
Oral contraceptives should be discontinued 3 to 4 weeks preoperatively.
How long should a woman wait before lifting heavy objects after a hysterectomy?
2 months
How long does a lady have to wait before driving after a hysterectomy?
3 to 4 weeks
If the client complains of abdominal gas after a hysterectomy, the best intervention is…..
ambulation
What are two major complications of a
hysterectomy besides hemorrhage?
Thrombus and pulmonary embolus Urinary retention
What body position should be avoided
after hysterectomy? Why?
Knee flexion (because it increases the chance of thrombophlebitis)
When will bowel sounds return after a hysterectomy?
After 24 hours but before 72 hours
What is the speculated cause of ITP?
autoimmune
What two things do the clients with ITP complain of before clinical diagnosis?
Bleeding gums and epistaxis (nose bleed)
What two observable skin signs are common with ITP?
Ecchymosis (bruises), Petechia (small dot-like hemorrhages)
What is papilledema and how is it related to increased ICP?
It is edema of the optic disc, it is present when increased ICP pushes brain tissue through the optic foramen. (You see it with an ophthalmoscope)
What environmental changes are necessary when there is increased ICP?
Dark, calm, quiet environment
When there is increased ICP the nurse should first
_______ the ______ of the bed to _________ degrees.
Position; head; 10-30 degrees
After positioning the HOB the nurse should then…
Call the doctor
What activities/action MUST be avoided in the client with increased ICP?
Sneezing, coughing (non- productive), straining at stool or doing anything which requires the valsalva maneuver
When a patient has increased ICP the nurse should (hyper/hypo) ventilate the patient?
Hyperventilate
The most common osmotic diuretic used to decrease ICP is…
Mannitol
The most common loop diuretic given to decrease ICP is…
Lasix
The most common anti- inflammatory drug given to decrease ICP is…
Decadron
If analgesia is necessary for the patient with increased ICP the doctor should order__________.
Codeine
Why is codeine alone used for analgesia in increased ICP?
Because it does not depress respiration or LOC as much as other narcotics, and it suppresses cough
What body system is attacked by
mononucleosis?
Lymphatic
What blood count will be elevated in
mononucleosis?
Lymphocytes increase, monocytes increase, granulocytes decrease
How long is the average recovery from
mononucleosis?
Three weeks
What two medications are given to clients with mononucleosis?
ASA– steroids if a bad case
What organism causes mononucleosis?
Epstein-barr herpes virus
Give four symptoms of mononucleosis.
Sore throat, malaise, stiff neck (nuchal rigidity) and nausea
Give three nursing measures for care of clients with mononucleosis.
Rest, ASA, fluids
What age group most commonly gets
mononucleosis?
15 to 35
What organ should not be palpated in the client with mononucleosis?
The spleen, it could rupture which may lead to shock and death
How is mononucleosis transmitted?
Respiratory droplets
Upon physical exam of a client with
mononucleosis, you find…
Increased temperature, Enlarged lymph nodes, Splenomegaly
Nametwo complications of
mononucleosis.
Hepatitis, ruptured spleen, meningoencephalitis
Should you shampoo the scalp and hair of the patient before cranial surgery?
yes
What should you do with the hair shaved from the scalp pre- operatively?
Save it for the patient
If surgery was supratentorial (cerebral, pituitary) position the patient _______ post- operatively.
On back or non-operative side, with HOB up 15 to 45 degrees.
If the surgery was infratentorial
(cerebellum/brainstem) position the patient…
Keep HOB flat
Should the client turn, cough, deep breathe after a craniotomy?
Turn every 2 hours, deep breathe every hour, no cough (could cause increased ICP)
Should the client with cranial surgery have fluids forced or restricted?
Restricted to 1500 cc
What are three common complications of
craniotomy?
Diabetes Insipidus (frontal craniotomy), increased ICP, meningitis
If the post-operative craniotomy patient has a high temperature in the first 48 hours post- operatively, it is probably due to ________.
- Increased ICP, especially hypothalamus
- (remember surgical wound infections don’t occur until day 3 or 4)
- post operative inflammatory temperatures are not usually over 100.8
What drug will be used for post-oeprative analgesia?
codeine
Why is the patient taking dilantin post-craniotomy?
prevent seizures
Describe two ways to determine if drainage post- craniotomy is CSF.
Test for glucose (if positive then CSF), watch for halo effect on gauze (if present then CSF)
What painful procedure must occur as part of an IVP?
IV puncture
Does the client need to empty his bladder before an IVP?
yes
Is the client NPO for an IVP?
Yes, after midnight
What subjective experience
will the client have at the beginning of an IVP?
Hot flush, salty taste in mouth (these are transitory and will pass quickly)
Does the client need to have a catheter inserted for an IVP?
no
Is a dye always used during an IVP?
yes
What structures are visualized during an IVP?
Kidneys, renal pelvis, ureters, bladder
true or false: If the client is allergic to iodine dye an IVP cannot be done.
False, they will just give Benadryl or steroids for a few days pre-test
What question should be asked to assess a client’s risk of allergic reaction to IVP dye?
If the client is allergic to iodine or shellfish
What is required the evening before an IVP?
An active bowel prep with laxatives (optional in infants and children)
What are important post- test measures after an IVP (intravenous pyelogram)?
Encourage fluids, ambulate with assistance
Performance of an IVP on what group of clients is most dangerous?
Dehydrated elderly (can get renal failure)
Intussusception is a condition in which the bowel __________ into itself.
telescopes
intussusception is more common in boys or girls?
boys
Name two ways to correct intussusception.
Barium enema (the barium pushes the bowel straight), or surgical repair
Themajor complication of
intussusception is ______ of the bowel.
necrosis
Intussusception occurs most
commonly at age ______ months.
6
Intussusception is commonly seen in
children who have_____ _______.
cystic fibrosis
Describe the cry of the infant with
intussusception.
piercing cry
In addition to experiencing severe abdominal pain tell what position the infant will assume.
Pull legs up to chest/abdomen
Describe the stool of a child with intussusception.
Current-jelly stool, bloody mucous. If surgery is scheduled and the infant has a normal bowel movement, surgery may be canceled. Call MD
Describe the vomitus of a child with
intussusception.
Bile stained
What organ is most frequently removed in ITP (idiopathic thrombocytopenia purpura)?
the spleen
Why is this organ removed in ITP?
The spleen destroys old platelets so if you removed the organ that destroys platelets, you increase your platelet count
What lab value is most decreased in ITP?
platelet count
Because these clients withITPareon
steroids they have an increased risk of…
Infection (fungal and viral primarily)
Transfusions with what product are
common in ITP?
platelets
What is the most-life threatening
complications of ITP?
hemorrhage
Name the class of drugs most commonly given to clients with ITP?
Steroids (decadron, prednisone, hexadrolsolucortef); Immunosuppresive agents (immuran)
Untreated increased intracranial pressure (ICP) can lead to brain ________ and _________.
herniation, death
ICP increases whenever anything unusual occupies ______ in the cranium.
space
The earliest sign of increased ICP is…
Change in LOC (Level of Consciousness)
The pulse pressure _______ when ICP is increased.
widens
Whenever there is increased ICP the ________ blood pressure rises.
systolic
When there is increased ICP the _______ blood pressure remains the same.
diastolic
Which pulse rate is most commonly associated with increased ICP?
bradycardia
In increased ICP the temperature rise or falls?
Rises
Describe the respiratory pattern seen in increased ICP.
First, central hyperventilation (very early on) and at the end, Cheyne-Stokes
When ICP is increased, the pupils FIRST show…
Unilateral dilation with sluggish reaction
Eventually in increased ICP the pupils become ________ and ______.
fixed and dilated
Will the client with increased ICP have a headache?
yes
What type of vomiting is present in increased ICP?
projectile
Why does hyperventilation “treat” increased ICP?
It reduces CO2, resulting in vasoconstriction. CO2 is a vasodilator in the brain, vasodilation would occupy more space and thus increase ICP more.
When ICP increases the patient is more likely to have fluids encouraged or restricted?
Restricted to decrease edema in the brain
What is the primary dietary prescription for calcium nephrolithiasis?
low calcium diet
For the client with calcium nephrolithiasis the diet should be _________ash.
acid
If the kidney stone is calcium phosphate the diet must be low in _____ too.
phosphorous
The primary diet treatment for uric acid
nephrolithiasis is _________ - ________.
low purine
The client with uric acid nephrolithiasis should have a diet low in ___________.
methionine
What is methionine?
The precursor of the amino acid cystine (precursor = material out of which something is made)
Name two foods high in methionine.
milk, eggs
Clients with cystine nephrolithiasis should have a (n) _________ ash diet.
alkaline
true or false: Increasing fluids to over 3000 cc per day is more effective in treating renal calculi ( kidney stones) than any dietary modification.
True. It’s more important to flush the urinary tract than worry about what you’re eating.
RBC
4.0 to 6.0 mil/ul
WBC
5,000 to 11,000
Platelets
150,000 to 400,000
Creatine
0.6 to 1.2 mg/dl
Na+
135 to 145
HCO3
22 to 26
Hematocrit
36 to 54
pCO2
35 to 45
K+
3.5 to 5.3
pO2
3.5 to 5.3
BUN
8 to 25
Hemoglobin
12 to 16 female, 14 to 18 male
pH
7.25 to 7.45
O2 sat
93 up to 100
What is the common
name for LTB?
croup
What is the typical temperature elevation in croup?
Low grade, usually below 102 degrees, but can go up to 104 degrees
Are antibiotics helpful for croup? For epiglottitis?
For croup, no. For epiglottitis, yes.
Is croup viral or bacterial?
viral
With which condition is croup most often
confused?
epiglottitis
Can croup be managed at home? Can epiglottitis be managed at home?
Yes. No, epiglottitis is a medical emergency
Are sedatives used for children with croup?
No, because this would mask the signs of respiratory
distress.
What causes epiglottitis? A virus or bacteria?
H. influenza bacteria
What is the best treatment for croup?
cool moist air
What should never be done to a child with epiglottitis?
Never put anything in the child’s mouth, ie, a tongue blade can lead to obstruction
What are the typical signs and symptoms of croup?
Barking cough, inspiratory stridor, labored respiratory pattern
What three signs tell you that the child has epiglottis instead of croup?
Muffled voice, Drooling, Increased fever
Wheniscroupbaed enough to be evaluated by a doctor?
When retractions, and high pitched stridor are present
What lead level needs intervention?
50 to 60 micrograms/dl
With which class of drugs will a child with lead poisoning be treated?
Chelating agents
What do chelating agents do?
They increase the excretion of heavy metals
The most frequent cause of lead
poisoning is…
Ingestion of lead-based paint chips
Name three common chelating agents for lead poisoning.
EDTA, desferal, BAL in oil
List specific symptoms of lead poisoning
Drowsiness, clumsiness, ataxia, seizures, coma, respiratory arrest
Symptoms of lead poisoning show up in the __________ system.
neurological
Leukemia is cancer of the _________-forming tissues.
blood
The type of cell that is most common and problematic in leukemia is____________________.
immature WBC
In leukemia the RBC count is high or low?
Low, because the bone marrow is going “wild” producing all those immature WBCs–no energy or nutrients left over to make RBCs
In leukemia, the platelet count is high or low?
Low, because the bone marrow is going “wild” producing all those immature WBCs– no energy or nutrients to make platelets.
Because of the immature WBCs, the patient is at risk for_______.
infection
Because of low platelets, the patient is at risk for _________, ______, and __________.
Bruising, ecchymosis, bleeding petechiae
What causes lymph gland enlargement in leukemia?
All those small immature WBCs clog the lymphatic system
Should you take a rectal temperature on a child with leukemia?
no
Should you take an oral temperature on a child with leukemia?
Yes, as long as they are over four years old, in remission, and have no sores in their mouth
Should the child with active leukemia use straws, forks, cups?
No straws, No forks, Yes they can have cups
The nurse’s priority in treating a child with newly diagnosed leukemia is…
Decreasing risk of infection
When the leukemia child’s platelets and WBCsarelow,his activities should be…
limited
When the platelet and WBCs are low
the nurse should not insert a…
suppository
Are IM injections and IV sticks
permitted on a child with leukemia?
When the platelets and WBCs are low, IMs are to be avoided; IV sticks are to be limited, and only done when absolutely necessary (ie, to give chemotherapy or measure blood counts)
Why are children on chemotherapy also on zyloprim (allopurinol)?
To prevent uric acid kidney stones (remember when chemotherapy kills cancer cells, purines and uric acid buidl up and could cause kidney stones).
Whydosome children with
leukemia have joint pain?
The immature WBCs infiltrate the joint and cause inflammation.
Why is a child with leukemia at risk for neurological symptoms due to increased intracranial pressure?
The immature WBCs infiltrate the brain and cause inflammation
If the platelet count islowwhatdrug
should the child not take?
aspirin
Is the alopecia of chemotherapy
permanent?
NO, it will grow back (remember, the alopecia of radiation therapy is permanent because the follicle is destroyed too)
WhatdoesANC stand for?
Absolute Neutrophil Count
What is the ANC usedforin leukemia?
If the ANC is below 500, then the patient will be on protective isolation
Whichisusedmore commonly to
decided if the patient should be on isolation: the WBCs ortheANC?
The ANC is more reliable and valid.
By the end of the first six months of life an infant’s birth- weight should ______.
double
By the end of the first year of life an infant’s birthweigth should_______.
triple
The ideal food for infants is_________.
breast milk
true or false: Breast milk contains substances that increase immunities.
true
true or false: Bottle-fed infants do not bond well with their mothers.
false
The one nutrient that commercial formulas are typically low in is __________.
iron
true or false: Breast milk does not contain iron.
False, however, it does not contain enough iron - so they should be fed iron fortified cereal starting at 6 months.
At what age should the infant be fed cows/goats milk?
Not before 12 months
What is the major problem with feeding an infant skim milk?
They dont get enough calories and don’t grow. Dehydration from excessive solute load and inability to concentrate urine.
When should the infant be introduced to textured solid food? (What age?)
4 to 6 months
What is the first food that an infant should be introduced to?
Iron fortified rice cereal
When forced to eat, the preschool child will….
rebel
Parents of preschooled children should be taught that as long as the child eats ______ good nutritious meal per day, they should not make eating food an issue.
one
true or false: Refusal to eat is common in preschoolers
True, but still offer a variety
Youngsters develop food preferences by…
Observing significant people in their environment
true or false: School-aged children grow at a slower rate than infants, toddlers or adolescences.
true
What dietary strategy is most appropriate for the industrious school-age child?
Wholesome snacks, because they are often too busytoeat
true or false: Girls in adolescence need more calories than
adolescent boys.
False, boys need more calories.
true or false: Adolescents should take vitamin supplements.
true
Mastitis and breast engorgement are more likely to occur in primipara or multipara?
primipara
Where does the organism that causes mastitis come from?
The infant’s nose or mouth
Which organism most commonly causes mastitis?
staph
Prolonged intervals between breast-feeding decrease or increase the incidence of mastitis?
increase
Can too tight bras lead to mastitis?
Yes, preventing emptying of ducts
Mastitis usually occurs at least _______days after delivery.
10
When mastitis is present the breasts are ________, _________, and __________.
Hard, swollen, warm
Mastitis is accompanied by a fever over _________.
102 degrees
If mastitis is caused by an organism, what causes breast engorgement?
Temporary increase in vascular and lymph supply to the breast in preparation for milk production
If mastitis occurs 1+ weeks after delivery, when does breast engorgement occur?
2 to 5 days after delivery
Does breast engorgement interfere with nursing?
Yes, the infant has a difficult time latching on (getting nipple in its mouth)
What class of drugs is used to treat mastitis?
antibiotics
true or false: Antibiotics are used to treat breast engorgement?
false
Application of (warm H2O compress/ice packs) is the preferred treatment for breast engorgement.
Ice packs to decrease swelling
true or false: The mother with mastitis should stop breast feeding.
False, the mother must keep breast feeding. (Offer unaffected breast first)
true or false: If the mother has an open abscess on her breast, must not breast-feed.
true
true or false: For breast engorgement, the non- breastfeeding mother should be told to express breast milk.
No, that would increase milk production and would make the problem worse (warm compresses or warm shower to let milk “leak” is okay- Ice is best)
What is the best treatment for breast engorgement?
Breast-feeding - it will balance supply and demand
What is mastoiditis?
Inflammation/infection of the mastoid process
What is themost
common cause of mastoiditis?
Chronic otitis media
What are 4 signs and symptoms of
mastoiditis?
Drainage from ear, high fever, headache and ear pain, tenderness over mastoid process
What unusual post- operative
complication can result from mastoidectomy?
Facial nerve paralysis due to accidental damage during surgery (law suit time!)
What should you do to assess for facial nerve paralysis post- mastoidectomy?
Have the patient smile and wrinkle forehead.
What is the medical treatment for
mastoiditis?
systemic antibiotics
What is the surgery for mastoiditis called?
Simple or radical mastoidectomy
Will a simple mastoidectomy
worsen hearing?
No, a radical mastoidectomy may
Should the nurse change the post-
mastoidectomy dressing?
No, reinforce it. Physician changes first post op dressing
What is a common side effect of
mastoidectomy?
Dizziness (vertigo)
What is a major nursing diagnosis post- mastoidectomy?
safety
In the chain of infection, hand washing breaks the mode of ____________.
transmission
true or false: The best way to decrease nosocomial infection is sterile technique.
False, hand washing is the best way.
true or false: Sterile gloved hands must always be kept above the waist.
true
true or false: When putting on the second of a set of sterile gloves, you should grasp the cuff.
False, reach under the cuff with the tip of the gloved fingers.
true or false: When putting on the first glove of a set of sterile gloves, you should grasp the cuff.
true
true or false: When putting on the second glove of a set of sterile gloves, you must not use the thumb of the first hand.
true
Airborne microorganisms travel on ________ or ______particles.
dust or water
Another name for medical asepsis is…
clean technique
Sensitivity (susceptibility) means…
The susceptibility of an organism to the bacterial action of a particular agent
When unwrapping a sterile pack how should you unfold the top point?
away from you
Virulence means….
Ability of an organism to produce disease
Another name for surgical asepsis
is…
Sterile technique
What is the best location in a client’s room to set up a sterile field?
on the over-bed table
true or false: Medical aseptic technique are aimed at reducing the number of organisms
True, doesn’t eliminate all of it just decreases the number
What does bacteriostatic mean?
Having the capability to stop growth of the bacteria
What does bacteriocidal mean?
Having the capability to kill bacteria.
What does nosocomial infection mean?
Infection acquired through contact with contamination in the hospital
When pouring liquid onto a sterile field you should pour from a height of _____ to _____ inches above sterile field.
6 to 8
true or false: When you plan to use gloves for a procedure you do not need to wash hands before it.
False, always wash even if you plan to use gloves
Culture means….
Growing colony of organisms, usually for the purpose of identifying them
true or false: Surgical aseptic
techniques render and keep articles free from all organisms.
true
true or false: You must never turn your back to a sterile field.
true
What must you do if you reach across a sterile field?
Consider the area contaminated and not use the articles in the area
Micro-organisms grow best in a _______, _______, _______place.
warm, dark, moist
true or false: It is common practice to regard the edges of any sterile field as contaminated.
True, the outer 1 inch is considered contaminated. You must not touch it with your sterile gloves.
Immediately after opening a bottle of sterile water, can you pour it directly into a sterile basin?
No, you must pour a few cc’s out of the bottle into a waste container before you pour into the sterile basin. (This is called “lipping” the bottle)
Which is the best method for identifying clients accurately?
By ID name-band
An emulsion is a mixture of ______ and ______.
oil and H2O
Syrups and elixirs are of particular concern to diabetic clients because….
they contain sugar
Oral medications have a faster or slower onset of action that IM drugs?
slower
Oral medications have a shorter or longer duration of action than IM medications?
longer
How should drugs that stain teeth be administered?
by a straw
true or false: A drug given by a parenteral route acts outside the GI tract.
true
Name the four most common parenteral routes of administrations.
SQ, IM, IV, ID (intradermal)
When blood is administered by IV, the needle/catheter should be ________gauge.
18 gauge
You can administer up to ____ cc of a drug per site by IM injection in adults.
3 cc
Children should receive no more than _______ cc per site by IM injection.
2 cc
The preferred IM injection site for children under 3 is the _________ ___________.
vastus lateralis
Why is the dorsogluteal site not recommended for IM injection the children less than 3 years of age?
Because the muscle is not well developed yet.
Can 3 cc of fluid be administered per IM into the deltoid of an adult?
No, maximum of 1 cc
The #1 danger when using the dorsogluteal site for IM injection is___________.
Damage to the sciatic nerve
The preferred angle of injection to to be used for IM administration is___________.
90 degrees
The preferred length of needle to administer an IM injection is…
1 to 2 inch
The preferred gauge of needle for IM injection is…
21 to 22 gauge
Which type of medications are given by Z-track injection?
Irritating, staining
How long is the needle kept inserted during Z-track injection?
10 seconds
What must be done to the equipment before injecting by Z- track method?
change the needle
When giving a Z-track injection, the overlying skin is pulled up, down, medially or laterally?
laterally
true or false: Subcutaneous injection must be given at 45 degrees.
True (for boards), false- whatever angle gets it SQ without going IM
The preferred gauge of needle for injection for SQ
injection___________.
25 guage
The preferred length of needle for SQ injection is_________.
5/8 inch
The intradermal route is primarily used for ________ _________.
skin testing
Name the two sites used for intradermal injection.
Inner forearm, Upper back
true or false: In general, the nurse should wear gloves when applying skin preparations such as lotions.
true
After using nose drops, the client should remain ______ for _______ minutes.
supine, 5
true or false: Strict aseptic techniques is required when administering a vaginal medication.
False– only “clean” technique or medical asepsis is necessary
Before administering vaginal medications the client is more comfortable if you ask them to _________ .
void
After administration of a vaginal durg the client should remain _____ for______ minutes.
supine, 10
true or false: Rectal suppositories with an oil base should be kept refrigerated.
true
true or false: Strict sterile technique is required when administering a drug per rectum.
False, clean or medical asepsis
The best way to ensure effectiveness of a rectal suppository is to…
Push the suppository against the wall of the rectum
A rectal suppository is inserted ______ inches in an adult and ________ inches in a child.
4, 2
true or false: The client should remain supine for 5 minutes after having received a rectal suppository.
False– they should be lying on their side for 5 minutes, not supine
true or false: A suppository given rectally must be lubricated with a water soluble lubricant.
True, lubricant fingers also
true or false: Eye medications can be given directly over the cornea.
False, into the conjunctival sac, never the cornea; hold the dropper 1/2 inch above the sac
Eye drops should be placed directly into the _______ _______.
Conjunctival sac
To prevent eye medications from getting into the systemic circulation you apply pressure to the _______ for ______ seconds.
Nasolacrimal sac, 10 (press between the inner canthus and the bridge of the nose)
true or false: The eye should be irrigated so that the solution flows from outer to inner canthus.
False, it must flow from inner canthus to outer (alphabetical: I to O)
If ear medications are not given at room temperature the client may experience…
dizziness, nausea
To straighten the ear canal in the ADULT, the nurse should pull the pinna______ and ________.
up and back
To straighten the ear canal in the young CHILD under 3 the pinna should be pulled _______ and ________.
down and back
After receiving ear drops the client should remain in ________position for ________minutes.
side lying, 5
How far above the ear canal should you hold the dropper while administering ear drops?
1/2 inch
Liquid doses of medications should be prepared at _______level.
eye
Liquid drugs should be poured out of the side opposite of or the same as the label?
opposite
true or false: It is safe practice to administer drugs prepared by another nurse.
false
true or false: In order to leave drugs at the bedside you must have a physician’s order.
true
Young infants accept medication best when given with a _______.
dropper
true or false: It is safe practice to recap needles after injection.
False, Never re-cap
What do you doifyouget blood in the
syringe upon aspiration?
Remove the syringe immediately and apply pressure; you must discard the syringe and redraw medication in a new syringe
Tagamet
Give with meals, remember Zantac does not have to be given with meals
Capoten
Give on empty stomach, one hour before meals (antihypertensive)
Apresoline
Given with meals (antihypertensive)
Iron with nausea
give with meals
Sulfonamides
Take with LOTS OF WATER regardless of whether you give it at mealtime or not – Bactrim, Septra, Gantricin, ie, used to treat UTI
Codeine
Take with lots of water rergardless of meals – to prevent constipation
Antacids
Give on empty stomach 1 hour ac and hs
Ipecac
Give with 200-300 cc water– not related to mealtime – this is an emetic (to make you vomit after ingestion of poisons – don’t give if the poisons were caustic, or petroleum based)
Rifampin
Give on empty stomach (anti-tuberculosis) remember Rifampin causes red urine
Non-steroidal
anti- inflammatory drugs
Give with food (for arthrosis)
Aldactone
Give with meals (K–sparing diuretic)
Iron (without
nausea)
Give on empty stomach with orange juice to increase absorption
Penicillin
give on empty stomach
Erythromycin
Give on empty stomach (antibiotics)
Stool Softeners
Take with lots of water regardless of mealtime
Griseofulvin
Give with meals– especially high fat meals (anti-fungal)
Tetracycline
Do not give with milk products, do not give to pregnant women or children before age 8 or damage to tooth enamel occurs
Theophylline derivative
Give with meals, ie, Aminophylline, Theodur (anti-asthmatic bronchodilator)
Steroids
Give with meals– remember taper the patient off these drugs slowly
Pancreas pancreatin
isozyme
Give with meals-these are oral enzymes used with children with cystic fibrosis to increase the absorption of the food they eat
Para-amino salicylate
sodium (PAS)
Give with meals/food– anti tuberculosis
Colchicine
Give with meals – anti gout, remember if diarrhea develops, stop the drug
Thorazine
Take with LOTS OF WATER regardless of meals to prevent constipation.
All drugs that end in “-zine” are major tranquilizers that also cause Psuedo Parkinson’s or extra-pyramidal effects.
Carafate and sulcrafate
Give on empty stomach 1 hour before meals and at bedtime – remember these coat the GI tract and interfere with the absorption of other medications (give them by themselves)
Allopurinol
- Give with meals
- give with lots of water
- it is an anti uric acid— used to treat gout and the purine build up seen in chemotherapy for cancer
Define Meniere’s
Disease
An increase in endolymph in the inner ear, causing severe vertigo.
Whatisthe famous triad of symptoms in Meniere’s?
Paroxysmal whirling vertigo – sensorineural hearing loss–tinnitus (ringing in the ears)
Does Meniere’s
occur more in men or women?
women
What should the client do if they get an
attack?
bed rest
What safety measures should be followed with Meniere’s?
Side rails up x 4, ambulate only with assistance
What age group in
Meniere’s highest in?
40 to 60
What can PREVENT the attacks of Meniere’s?
Avoid sudden mov emen ts
What electrolyte is given to people with Meniere’s?
Ammonium chloride
What is the surgery done for Meniere’s?
Labyrinthectomy
What disease often follows labyrinthectomy?
Bell’s palsy– facial paralysis, will go away in a few months
What is the activity order after labyrinthectomy?
bed rest
When surgery is performed for Meniere’s, what are the consequences?
Hearing is totally lost in the surgical ear
What should the client avoid after labyrinectomy?
Sudden movements and increased Na food
What type of diet is the client with Meniere’s on?
low salt
What two classes of drugs are given in Meniere’s?
Antihistamines and diuretics (Diamox)
Meningitis is an inflammation of the _______ of the _______ and spinal ___________.
Linings, brain, cord
Meningitis can be caused by _______, _____, and _____.
Viruses, bacteria, chemicals
The four most common organisms that cause meningitis are…
Pneumococcus, Meningococcus, Streptococcus, H. influenza
The child with meningitis is most likely to be lethargic or irritable at first?
irritable
What visual symptom will the patient with meningitis have?
Photophobia (over-sensitivity to light)
What is the most common musculo-skeletal symptom of meningitis?
Stiff neck- nuchal rigidity
Will the patient with meningitis have a headache?
yes
Kernig’s sign is positive when there is pain in the _____ when attempting to straighten the leg with ____ flexed.
knee; hip
What type of vomiting is present in meningitis?
projectile
What is the definitive diagnostic test for
meningitis?
Lumbar puncture with culture of CSF (cerebro- spinal fluid)
If the patient has meningitis, the CSF shows _______ pressure, _____ WBC, ______ protein, ______ glucose.
Increased, increased, increased, decreased
On what type of isolation will the patient with meningitis be?
Contact and respiratory precautions
How long will the patient with meningitis be on these precautions?
Until they have been on an antibiotic for 48 hours
The room of a patient with meningitis should be _______ and ______.
dark and quiet
The client with meningitis can develop________.
seizures
What is opisthotonos?
Arching of back (entire body) from hyperextension of the neck and ankles, due to severe meningeal irritation.
If a patient has opisthotonos, in what position would you place them?
side-lying
Average duration of menstrual flow is _____. The normal range is _____ to ______ days.
5 days, 3 to 6
Average blood loss during menstruation is _____cc.
50 to 60 cc
Name the two phases of ovarian cycle.
Follicular phase (first 14 days), Luteal phase (second 14 days)
In the menstrual cycle, day 1 is the day on which…
Menstrual discharge begins
How long does an ovarian cycle last?
average of 28 days
How many days after ovulation does
menstruation begin?
14 days
What hormones are active during follicular phase?
FSH and Estrogen
During the luteal phase of the ovarian cycle, which of the following hormones increase: estrogen, progesterone or LH?
Progesterone and LH
What is the major function of the luteal phase of the ovarian cycle?
To develop and maintain the corpus luteum which produces progesterone to maintain pregnancy until placenta is established.
If an ovum is fertilized during the luteal phase what hormone will be secreted?
HCG (human chorionic gonadotropin)
During menstruation, the average daily loss of iron is _____ mg.
0.5 to 1.0 mg
What occurs during the follicular phase of the ovarian cycle?
It accomplishes maturation of the graafian follicle which results in ovulation
Whattypeof environmental
modification is best for a migraine?
Dark and quiet environment
The long term treatment of migraine focuses upon…
Assessing things that bring on stress and then planning to avoid them.
What type of pain is typical of migraines?
throbbing
Are migraines more or less common in men?
less
Besides pain, people with migraines complain of what other symptoms?
Nausea, vomiting and visual disturbances
What are the processes occurring in migraines?
Reflex constriction then dilation of cerebral arteries.
Where is the pain of migraine most likely located?
Temporal, supraorbital
Name a drug given to treat migraine?
Sansert (methsergide), Cafergot
Prophylaxis: Imipramine
Are migraine headaches usually unilateral or bilateral?
unilateral
When Inderal is given in migraine headache, it is used to prevent or treat an attack?
To prevent. It DOES NOT treat.
MS is a progressive _____ disease of the CNS.
Demyelinating
Myelin promotes _____, _____ _____ of nerve impulses.
Fast, smooth conduction
true or false: MS affects men more than women
false
What age group usually gets MS?
20 to 40
MS usually occurs in (hot/cool)
climates .
cool
What is the first sign of MS?
blurred or double vision
true or false: MS can lead to urinary incontinence.
true
true or false: MS can lead to impotence in males.
true
Patients with MS should be taught to walk with a ____-____ gait.
wide based
Why are Adrenocorticotropic Hormone (ACTH) and prednisone given during acute MS?
To decrease edema in the demyelination process
For acute exacerbations of MS _______ per IV is often used.
ACTH (Corticotropin)
What drug can be given to treat urinary retention in MS?
Urecholine, Bethanocol
Will the muscles of MS clients be spastic or flaccid?
spastic
What three drugs can be given for muscle spasms?
Valium, Baclofen (Lioresal), Dantrium
Baclofen causes constipation or diarrhea?
constipation
Dantrium causes constipation or diarrhea?
Diarrhea (hint: D’s go together, Dantrium and Diarrhea)
Patient’s with MS should have increased or restricted fluids?
Increased to dilute urine and reduce incidence of UTI.
The diet of a patient with MS should be ____–ash.
acid
What major sense is affected most in MS (besides vision)?
Tactile (touch)– they burn themselves easily
Which will bring on a MS exacerbation: over-heating or chilling?
Both will; but they tend to do better in cool weather (summer will always be a bad time for MS patients)
In Myasthenia Gravis (MG) there is a disturbance in transmission of impulses at the _____ _____.
Neuromuscular junction
The #1 sign of MG is ______ ______ _____.
Severe muscle weakness
What is the unique adjective given to describe the early signs of MG?
The early signs (difficulty swallowing, visual problems) are referred to a BULBAR signs.
true or false: MG affects men more than women.
False, affects women more than men
When women get MG they are usually old or young?
young
When men get MG (myasthenia gravis) they are usually old or young?
old
What neurotransmitter is problematic in MG?
Acetylcholine
What class of drugs is used to treat MG?
Anticholinesterases
What ending do anticholinesterases have?
-stigmine
Are anticholinesterases sympathetic or
parasympathetic?
Parasympathetic
Anticholestinesterases will have
sympathetic or cholinergic side effects?
Cholinergic (they will mimic the parasympathetic nervous system)
What surgery CAN be done forMG?
Thymectomy (removal of thymus)
true or false: The severe muscle weakness of MG gets better with exercise.
False, it is worse with activity
What will the facial appearance of a patient with MG look like?
Mast-like with a snarling smile (called a myasthenic smile)
If a patient has MG, what will be the results of the Tensilon Test?
The patient will show a dramatic sudden increase in muscle strength
Besides the Tensilon Test, what other diagnostic tests confirm a diagnosis of MG?
Electromylogram (EMG)
Whatisthemost important thing to remember about giving Mestinon and other anticholestinerases?
They must be given EXACTLY ON TIME; at home, they might need to set their alarm
Do you give anticholestinerases with or without food?
With food, about 1/2 hour ac; giving ac helps strengthen muscles of swallowing
What type of diet should the patient with MG be on?
soft
What equipment should be at the bedside of an MG patient?
Suction apparatus (for meals), tracheostomy/endotube (for ventilation)
Name the two types of crises that a MG patient can have.
Cholinergic (too much Mestinon ), Myasthenic (not enough Mestinon )
The #1 danger in both Myasthenic and
Cholinergic crisis is _____ ______.
Respiratory arrest
What words will the client use to describe the pain of an MI?
Crushing, heavy, squeezing, radiating to left arm, neck , jaw, shoulder
What is an MI?
Either a clot, spasm or plaque that blocks the coronary arteries causing loss of blood supply to the heart and myocardial cell death
What is the #1 symptom of an MI?
Severe chest pain unrelieved by rest and nitroglycerine
true or false: Males are more likely to get an MI than females.
true
Due to MI occurs within _____ of symptom onset in 50% of all patients.
one hour
What pain medication is given for the pain of a MI (Give three).
Morphine, Demerol, Nitroglycerine
What is the reason for giving post MI patients ASA?
To prevent platelets from forming clots in the coronary arteries
Name a new drug with anti-platelet activity.
plavix
The three most common complications after MI are ____ _____,_____, and _______.
Cardiogenic shock, arrhythmia, CHF
Give another name for an MI.
heart attack
What will the activity order
be for the post-MI client?
Bed rest with bedside commode
What is the most common arrhythmia after a MI?
Premature ventricular contractions (PVCs)
What cardiac enzymes indicate an MI?
Elevated CPK, LDH, SGOT
What serum protein rises soonest after myocardial cell injury?
troponin
Do people without cell damage have troponin in their blood?
No it is only present when myocardial cells are damaged.
How soon after cell damage does troponin increase?
As soon as 3 hours (can remain elevated for 7 days)
When will the client with an MI be allowed to engage in sexual intercourse after an MI?
6 weeks after discharge
Will fluid resuscitation (administering large amounts of IV fluid) treat cardiogenic shock?
No, you must use cardiac drugs (giving IVs and blood will not help this kind of shock)
Will the client with a MI be nauseated?…diaphoretic?
yes, yes
What will the extremities of the client with a MI feel like?
cold, clammy
What is the permanent EKG change seen post MI?
ST wave changes
Of CPK and LDH which rises earliest?
CPK
What drug will be used to treat PVCs of MI?
Lidocaine
Will the client with a MI need 100% O2 for their entire stay in the hospital?
No, just moderate flow (42% or 3 to 6 liters for first 48hours)
Clear liquid diet (UC or Crohn’s)
Ulcerative colitis diet
Bed rest (UC or Crohn’s)
Ulcerative colitis
Women mostly (UC or Crohn's)
Ulcerative colitis
One-layer ulceration’s with edema of bowel (UC or Crohn’s)
Ulcerative colitis
Steroids (UC or Crohn’s)
Either
I&O (UC or Crohn’s)
Either
Rectum & Sigmoid colon (UC or Crohn’s)
Ulcerative colitis
Bloody diarrhea (UC or Crohn’s)
Ulcerative colitis
Young adults (UC or Crohn’s)
Ulcerative colitis
Surgery with ileostomy (UC or Crohn’s)
Either
Ileostomy (UC or Crohn’s)
Either
Jewish clients (UC or Crohn’s)
Either
Lesion through all layers of the bowel (UC or Crohn’s)
Crohn’s
Terminal-distal-small intestine (UC or Crohn’s)
Crohn’s
Regional enteritis (UC or Crohn’s)
Crohn’s
Adults, up to 40 (UC or Crohn’s)
Crohn’s
Lesions form patches (UC or Crohn’s)
Crohn’s
Sulfa drugs (UC or Crohn’s)
Crohn’s
Granulomas (UC or Crohn’s)
Crohn’s—hint: “gran”ny Crohn
“String sign” on barium enema (UC or Crohn’s)
Crohn’s
Diarrhea (UC or Crohn’s)
Crohn’s
Pain & cramping (UC or Crohn’s)
Crohn’s
Steroids (Prednisone) (UC or Crohn’s)
either
The purpose of an upper GI is to detect ___________.
ulcerations
What 3 structures does an upper GI series visualize?
Esophagus, stomach, duodenum
Does barium come in different flavors?
yes
What is the most uncomfortable aspect of an upper GI series?
Lying & turning on a hard, flat X-ray table
Is fasting required before an upper GI series?
Yes, usually NPO after midnight.
How much barium is swallowed?
8 oz
Barium is ___________ in
consistency.
Chalky-bitter taste
If an ulceration does not reduce by 50% on upper GI in 3
weeks of medication treatment then _________ is suspected.
Malignancy
What are the 3 classic vital signs?
Temperature, pulse, respiration
true or false: Measurement of vitals requires a doctors orders.
false
The temperature of the extremities and skin is higher or lower than the core?
lower
List the 5 most common sites in which to measure the temperature.
Oral, axillary, rectal, tympanic, temporal
The normal adult temperature via the oral route is…
98.6
The normal rectal temperature is..
99.6
The normal axillary temperature is..
97.6
Body temperature is increased or decreased with activity?
increased
With any oral temperature device, the meter must be
______ the ________, and the ______ must be _________.
under, tongue, mouth , closed
If your client is 4 years old or younger, should you take an oral temperature?
no
Can you measure an oral temperature on an unconscious patient?
no
Can you measure an oral temperature on someone with an
NG tube in place?
no
If the client is found smoking, eating or drinking when you
are about to take a temperature you should wait ______ (at least).
15 minutes
Should you use the oral route for measuring temperature when a client has oxygen per nasal cannulae?
yes
People on seizure precaution should have their temperature measured by which route?
Rectal or axillary, tympanic or temporal
People with facial trauma should have their temperature measured by which route?
Rectal or axillary or tympanic
Clients with rectal surgery, should have their temperatures measured by which route?
Oral, axillary, tympanic or temporal
People with heart blocks or conduction problems should not have their temperatures taken per _____. Why?
Rectum-vagal stimu lation causes more heart block.
When using a glass thermometer it should remain in the
mouth for _______ minutes.
3-10
When using a glass thermometer it should remain in the rectum for _______ minutes.
2-3
When using a glass thermometer it should remain in the axilla for _______ minutes.
8-11
In the normal adult, which is longer, inspiration or expiration?
expiration
What is the normal respiratory for an adult?
12-20
What is bradypnea?
Any respiratory rate below 10 per minute.
What is tachynpea?
Any respiratory rate about 24 per minute.
true or false: Is it acceptable practice to count the number or respiration in 15 seconds and multiply by 4 to get the rate.
Yes, if the respirations are regular.
What is the pulse?
The surge of blood ejected from the left ventricle.
What is the average pulse rate
for an adult?
72 per minute (60 to 100)
What rate classifies as tachy in an adult?
A rate above 100 per minute
What rate classifies as brady in an adult?
A rate below 60 per minute
Will pain alone increase the pulse rate?
Yes, pain alone can increase the pulse rate?
Which finger should never be used to determine a pulse?
the thumb
What does it mean to measure an apical pulse?
To auscultate with a stethoscope over the chest to hear the heart rate.
If a pulse is irregular how would you determine the rate?
Count one full minute.
If an apical/radial pulse is regular how would you determine
the rate?
Count for 30 seconds and multiply by 2.
What is an apical-radial pulse?
When 2 nurses measure the apical rate simultaneously with the radial rate for
comparison .
How long must an apical-radial pulse be measured?
Always for 1 full minute.
How many nurses are needed to measure an apical-radial pulse?
Always two (it is never acceptable for one nurse to measure the apical pulse for a minute then measure the radial or a minute.)
What is a voiding cystogram?
It is a series of X-rays taken as the person with a full bladder is asked to void. The X-rays show any reflux of urine back up the ureters (a dye if injected prior to this)
Does the client need to have a catheter
inserted for a voiding cystogram?
yes
Is the client sedated for the voiding
cystogram?
no
Is the client NPO for the voiding
cystogram?
No, just clear liquid breakfast
What problems does a voiding cystogram diagnose best?
Bladder filling problems, vesicoureteral reflux
What precautions are necessary for
males during a voiding cystogram?
Shielding the testicles from the X- rays
Is there a bowel evacuation prep for a voiding cystogram?
no
For what reason are Montgomery straps used?
Permit you to remove & replace dressings without using tape (protects the skin)
Sutures in general are removed by the ___ day.
7th
Leaving a would open to air decease infection by eliminating what 3 environmental conditions?
Dark, warm, moist
To remove tape always pull
toward or away from the wound?
Toward (this way you don’t put pressure/pull on the suture line.)
Define contusion.
Bruise (internal)
Define debridement.
Removal of necrotic tissue from a wound.
What is the purpose of a wound drain?
Remove secretions from the area so healing occurs.
To prevent germs from getting into or out of a wound you should use what type of dressing?
An occlusive dressing
What solution is put onto the skin to protect it from the irritating effects of the tape?
Tincture of benzoin
Withwhatisa round closed in first intention?
Sutures or steri-strips, staples
Whatisanother name of second
intention?
granulation
When swabbing an incision you would start at the incision or 1 Inch away from the incision?
Start at the incision and move outward.
After you remove soiled dressings and before you put on the sterile dressing you must….
Wash your hands and put on sterile gloves
What is meant be the phrase “advance the drain 1 inch”?
You pull the drain out 1 inch.
After advancing a Penrose drain you
should or should not cut off the excess drain?
should
true or false: When a dressing is saturated, germs
can enter the wound from the outside.
True, by a process called capillary action .
When is a bad time to change
dressings?
mealtime
define laceration
cut
Whatisthe#1 difference between sealed & unsealed radiation?
Both are internal forms of radiotherapy however, in sealed, a solid object is placed in a body cavity; in unsealed a radioactive substance is injected in liquid form into a vein
What are the 3 principles the
nurse uses to protect
self when caring for a client with a sealed radioactive implant?
Time, distance, shielding
Whatisanother name for external
radiation therapy?
beam or x-rays
Whatisthe difference
between external radiation treatment and internal radiation treatment?
In external the tumor is bombarded with x-rays & nothing is placed in the body; in internal there is some radioactive substance introduced into the body
Of sealed internal, unsealed internal,
and external radiation treatment, which is MOST dangerous for the nurse?
Sealed internal, unsealed internal and external radiation treatment is of no danger to the nurse unless the nurse is in the radiation treatment room during the treatment.
Should pregnant nurses care for
patient receiving sealed internal radiotherapy?
Never. (Lawsuit time!)
Should pregnant nurses care for a
patient receiving unsealed internal radiotherapy?
Maybe, as long as they don’t contact body secretions.
What skin products should
the patient receiving external radiotherapy AVOID?
No ointments with metals like zinc oxide, no talcum powder
Describe the hygiene measures
the you teach the patient receiving external radiotherapy?
Use plain water only, no soaps, pat dry, can use cornstarch for itch
What are the major side effects of radiotherapy?
Pruritis, erythema, burning, sloughing of skin, anorexia, nausea & vomiting, diarrhea, bone marrow depression
When the patient is receiving radioactive iodine what precautions is/are most important?
Wear gloves while in possible contact with urine, special precautions taken to dispose of the urine.
true or false: Rape is a crime of passion.
False, it is a violent act
true or false: Most rapes occur involving two
people of different races.
False, usually the same race
When must psychological care of the rape victim begin?
In the emergency room
…
Disorganization phase, re- organziation phase
true or false: Immediately after rape, a woman who is calm and composed is adjusting well.
False, calmness & a composed attitude are SIGNS of Rape Trauma syndrome, (calm person is just as disorganized as the crying and upset lady)
…
GI irritability, itching or burning on urination, skeletal muscle tension* don’t forget PAIN
Scoliosis is a ______
curvature of the ______.
Lateral, spine
Scoliosis is MOST common in the
_______ and
______ sections of the spinal column.
Thoracic and lumbar
Scoliosis in the thoracic spine is
usually convex to the
left or right?
right
Scoliosis in the lumbar spine is
usually convex to the left or right?
Left (*Hint: curve Left in Lumbar)
With which other two spine
deformities is scoliosis associated?
Kyphosis (humpback), Lordosis (swayback)
What is Kyphosis?
Humpback in the thoracic area
What is lordosis?
Swayback in the lumbar region (Lumbar, Lordosis)
What is the difference between structural and functional scoliosis?
Structural-you are born with; Functional-you get from bad posture
What age group should be routinely screened for scoliosis?
young teens
What are the 3 subjective complaints of clients with scoliosis?
Back pain, dyspnea, fatigue
What test/exam CONFIRMS the diagnosis of scoliosis?
X-rays of the spine
What type of brace is most commonly used for scoliosis?
Milwaukee
Name 4 exercises used to treat mild scoliosis.
Heel lifts; sit-ups; hyperextension of the spine; breathing exercises
What kind of treatment is done for severe
scoliosis?
Surgical fusion with rod insertion
What type of cast is used post-operatively for scoliosis?
Risser cast
What kind of rod is used to “fix” curvature?
Harrington Rod
Scoliosis MOST commonly affects _____ _____
type of clients
Teenage females
How many hours a day should the client wear a Milkwaukee brace?
23
What solution should be used on the skin where the
brace rubs?
Tincture of benzoin or alcohol,no lotions of ointments- you want to toughen the skin not soften it
true or false: Clients with a Milwaukee brace should avoid vigorous
exercise.
true
After corrective SURGERY how is the client turned?
Log rolled (in a body cast)
How often should the neurovascular status of the extremities of a client in a Risser cast be measured? Fresh post- operatively?
Every 2 hours
What is a common complication of a
client in a body cast (like a Risser cast)?
cast syndrome
Whatiscast syndrome?
Nausea, vomiting and abdominal distention that can result in intestinal obstruction
What group of people get cast syndrome?
ANYONE in a body cast
Whatisthe treatment of for cast syndrome?
Removal of the cast, NG tube to decompress, NPO
How would you, the nurse, assess for
developing cast syndrome?
Ask the client if they are experiencing any abdominal symptoms-keep track of bowel movements & passing flatus (if not having BMs or passing flatus, cast syndrome is suspected)
What causes cast syndrome,
specifically in a Risser cast?
Hyperextension of the spine by a body cast: the hyperextension interrupts the nerve & blood supply to the gut
The inheritance pattern of sickle-cell anemia is _____
_____.
Autosomal recessive
What does heterozygous mean?
It means you only have 1 defective gene from 1 parent.
People who are hetero or homo have sickle cell trait?
Heterozygous
What does homozygous mean?
It means you have the defective gene from both parents.
Peoplewhoare hetero or homo-zygous have sickle cell disease?
Homozygous
true or false: People with sickle cell TRAIT only carry the disease, they DO NOT have symptoms.
True-usually it has occurred that in times of SEVERE stress, the TRAIT does cause some symptoms but not usually.
What are the #1 and #2 causes of sickle
cell crisis?
Hypoxia, dehydration
The most common type of crisis that
occurs is a ______-______ crisis.
Vaso-occlusive
In vaso-occlusive crisis the vessels become
occluded with ______ ______.
Abnormal RBC’s
The abnormal hemoglobin produced by people with sickle cell anemia is called Hgb ______.
Hgb S – it “sickles”
What shape does Hgb S make the RBC’s?
Crescent-shaped
Why do the crescent-shaped RBCs cause occlusion
of the vessels?
They clump together and create a sludge.
What are the top 3 priorities in care of the client with sickle-cell crisis?
Oxygenation, Hydration, PAIN control
What activity order will the client with sickle cell CRISIS have?
bed rest
Of Tylenol, Morphine, Demoral, Aspirin which is
NEVER given to a sickle-cell patient?
Aspirin-it can cause acidosis which makes the crisis and sickling worse
At what age is death most likely in sickle cell anemia?
Young adulthood
Sickle-cell anemia symptoms do not appear before
the age of ____ months due to the presence of _____ ______.
6; fetal hemoglobin
Sickle cell anemia is most commonly seen in
blacks or whites?
blacks
Should a child in sickle-cell crisis wear tight clothes?
No, it can occlude vessels even more.
true or false: Spinal cord injuries are more common in males.
true
In what age range is spinal cord injury most common?
15 to 25
The #1 goal in emergency treatment of spinal cord injury is…
Immobilization of the spine
When halo traction is being used to immobilize the spinal cord the client is allowed to _______.
ambulate
When the patient with spinal cord injury is in tongs or
on a stryker frame or on a circoelectric bed they are on……
Absolute bed rest
The 2 most common surgeries used to treat a spinal cord injury are ____ and _____ _____.
Laminectomy and spinal fusion
Whatisspinal shock?
It is a common occurrence in spinal cord injury in which the spinal cord swells above and below the level in injury
When does spinal shock
occur?
Immediately or within 2 hours of injury
How long does spinal shock
last?
5 days to 3 months
When the spinal cord injury is at
level of _____ to _____ the patient will be a quadriplegic.
C1 to C8
When the spinal cord injury is between _____
and
_____, there is permanent respiratory paralysis.
C1 and C4
Can the patient with spinal cord injury at C7 level
have respiratory arrest?
Yes, because even thought his injury was below C4, spinal shock can lead to loss function above the level, however the will not be permanently ventilator dependent-he will breath on when once spinal shock goes away.
Spinal cord injury in the
thoracic/lumbar regions result
in ___plegia.
Paraplegia
Ifairway obstruction
occurs at the accident site and you suspect spinal cord injury, what maneuver is used to open the airway?
Modified jaw thrust
In spinal cord injury never
______ the neck.
Move, hyperextend
How should you change the position of the spinal cord injury patient after he has an order to be up? Why?
Slowly, because of severe orthostatic hypotension (they use a tilt table)
For the patient with neurogenic bladder you should straight catheterize every ____ hours.
Every6hours
The patient with spinal cord injury will have flaccid or spastic muscles?
spastic
Name 3 drugs used to treat spasms.
Valium, Baclofen, Dantrium
What is automatic dysflexia or hyperreflexia?
A common complication of quadriplegics in response to a full bladder or bowel.
What are the vital sign changes seen in autonomic dysreflexia?
Sweating, Headache, Nausea & vomiting, Gooseflesh, Severe HYPERtension
What do you do first for the client experiencing autonomic dysreflexia?
Raise HOB
What do you do second for the client experiencing autonomic dysreflexia?
Check the bladder, check the bowel
Do you need to call the doctor for autonomic dysreflexia?
No, only call the doctor if draining the bladder & removing impaction does not work
What is the #1 treatment for autonomic dysreflexia?
Drain the bladder, empty the bowel
What is the purpose of restricting activity after spinal tap?
To prevent headache due to CSF loss
Should the client drink after a spinal tap?
Yes, encourage fluids to replace CSF
Do you need an informed consent for a spinal tap?
yes
Should CSF contain blood?
no
Does the client have to be
NPO before a spinal tap?
no
What is the normal color of cerebrospinal fluid?
Clear, colorless
Into what space is the needle
inserted during a spinal
tap?
Subarachnoid space
Can the client turn side-to-side after a
spinal tap?
yes
In what position should the client
be during a spinal tap?
Lateral decubitus (on their side) position and knees to chest
Identify the activity restriction
necessary after lumbar puncture?
Lie flat for 6 to 12 hours
What are the 2 purposes of a spinal tap?
To measure or relieve pressure and obtain a CSF sample
Does the client have to be sedated before a spinal tap?
no
Antibiotic (Define)
A drug that destroys or inhibits growth of micro-organisms
Asepsis (Define)
Absence of organisms causing disease
Antiseptic (Define)
A substance used to destroy or inhibit the growth of pathogens but not necessarily their spores (in general SAFE TO USE ON PEOPLE)
Disinfectant (Define)
A substance used to destroy pathogens but not necessarily their spores (in general not intended for use on persons)
Bactericide (Define)
Substance capable of destroying micro-organisms but not necessarily their spores
Bacteriostatic (Define)
Substance that prevents or inhibits the growth of micro-organisms
Anaerobe (Define)
Micro-organisms that do not require free oxygen to live
Aerobe (Define)
Micro-organisms requiring free oxygen to live
Pathogen (Define)
Micro-organism that causes disease
Clean technique
Define
Practices that help reduce the number & spread of micro-organisms (synonym for medical asepsis)
Sterile (Define)
An item on which all micro-organism have been destroyed
Coagulate (Define)
Process that thickens or congeals a substance
Host (Define)
An animal or a person upon which or in which micro- organisms live.
Portal of entry (Define)
Part of the body where organisms enter
Contaminate (Define)
To make something unclean or unsterile
Surgical asepsis (Define)
Practices that render & keep objects & areas free from all micro-organisms (synonym for sterile techniques)
Medical asepsis (Define)
Practices that help reduce the number & spread of micro- organisms (synonym for clean techniques).
Spore (Define)
A cell produced by a micro- organism which develops into active micro-organisms under proper conditions.
Which hand should hold the suction catheter? Which
should hold the connecting tube?
The dominant, the non- dominant
The nurse should use (medical/surgical)
asepsis during airway suction?
Surgical asepsis (sterile technique)
What kind of lubricant should be used on the suction catheter?
Sterile water-soluble
Should the suction be continuous or
intermittent?
Intermittent to prevent mucosal damage
For how long should suction be applied
during any one entry of the catheter?
10 seconds
How often should the nurse clear the tubing during suctioning?
After each pass/entry/removal
Which way would you turn the client’s head to suction
the right mainstem bronchus? The left mainstem bronchus?
To the left, to the right
The best client position during airway suctioning is _______.
Semi-fowlers
The suction should be delivered while inserting or removing the catheter?
While removing the catheter
What outcomes would indicate that suctioning was effective?
Clear even lung sounds, normal vital signs
How often should the client’s airway be suctioned?
When it needs to be, for example moist lung sounds, tachycardia, restlessness (hypoxia), ineffective cough
The unconscious client should assume what position
during suctioning?
Side-lying, facing nurse
If not contraindicated, what action by the nurse, before suctioning, would most likely reduce hypoxia during suctioning?
Administer a few breaths at 100% oxygen before beginning.
What solution should be used to clear the tubing
during suctioning?
Sterile saline
With what size catheter should an adult’s airway be suctioned?
12 to 16 French
How much suction should be used for an infant?
Less than 80 mm Hg
How much suction should be used for a child?
80to100mmHg
How much suction should be used for an adult?
120 to 150 mmHg
Doyouassessfor suicide potential
whenever a
patient makes any statement about wanting to die or kill self?
Yes, in fact whenever a patient makes a statement about wishing or wanting to die or kill self you must ALWAYS AND FIRST assess for suicide potential*-stop everything and assess for suicide patient (except CPR, or course)
Children are at _____ risk for suicide.
low
Adolescents are (low or high) risk for suicide?
high
Young adults are (low or high) risk for
suicide?
High to moderate
People between 25 and 50 years are (low, moderate
or high) risk for suicide?
Low to moderate
People over 50 year are (low or high) risk
for suicide?
high
The patient who has a definite plan is
(low or high) risk for suicide?
Moderate to high, depends upon feasibility and ease of plan
The use of pills makes the patient
(low, moderate or high) risk for suicide?
moderate
The patient who has NO definite plan is
(low or high) risk for suicide?
low
The use of _____, _______, and ______ to kill self,
make high risk suicide.
Guns, ropes, knives
Who is at higher risk for suicide, a man or a woman?
man
Of: married, divorced, and
separated, which marital status is highest risk for suicide? Lowest risk of suicide?
Highest-separated then divorced Lowest-married
The goal of action while the suicidal
patient is still off the phone is to get _______ person _______ the ______.
Another person on the scene (it then immediately decreases risk) Remember: people who are alone are always high risk
What are the four classic suicide
precautions?
Search personal belongings for drugs & alcohol, remove any sharp objects, remove any device for hanging or strangling; must be on constant one-to-one observation (NEVER out of sight)
Once the patient is admitted for
attempted suicide should you ever discuss the attempt with them?
No, you should not focus on the attempt, focus on the present and future.
-pathy
Disease, suffering
-penia
Lack, deficiency of
-sect
To cut
-plast
Plastic surgery on a specified part
-sclerosis
Hardening of a tissue by: inflammation, deposition of mineral salt; an infiltration of connective tissue fibers
-centesis
A perforation or puncture
-genic
Produce, originate, become
-emia
Blood
-otomy
Butting
-pexy
Fixation of something
-atresia
Condition of occlusion
-desis
Binding, fusing
-cele
Combining form meaning a tumor or swelling of a cavity
-cis
Cut, kill
-rhapy; -rrhapy
Joining in a seam, suturation
-scope; -scopy
Instrument for observation
-osis
Indicates condition, process
-oma
Tu mor
-ostomy
Surgical opening
-stasis
Stoppage
-itis
I n flammation
-ology
Study of; knowledge, science
-lysis
Breaking down
-ectomy
Surgical removal of
-tripsy
Crushing of something by a surgical instrument
-ase
Used in naming enzymes
-gram; -graphy
Write; record
true or false: Syphilis is sexually
transmiteed.
True
Syphilis first infects the _____ ______.
Mucous membranes
What are the stages of syphilis?
Primary, secondary, latent, late
true or false: Syphilis is a fatal disease if untreated.
true
What organism causes syphilis?
Treponema palladium
What is the lesion like in primary syphilis?
The chancre (pronounced shanker)
The chancres of syphilis are
(painful or painless)?
painless
true or false: Chancres disappear without treatment.
true
Late syphilis attacks which 3 body organs?
Liver, heart, brain
What test CONFIRMS the presence of
syphilis?
Dark-field illumination of the treponema palladium
What is the treatment of choice for syphilis?
Penicillin
Why is penicillin administered with
Procaine?
With Probenecid?
Procaine makes the shot less painful; Probenecid blocks the excretion of penicillin
What is the most common sign of
neurosyphillis?
Ataxia (gait problems)
What does TENS stand for?
Transcutaneous electrical nerve stimulator
Is it an invasive procedure?
No, the skin in never broken
Can TENS be used for acute or chronic pain?
Both
TENS use is based upon the _______ _______ of pain relief.
Gate control
TENS electrodes stimulate (Large or small) diameter fibers?
Large-this is the basis of gate control theory.
TENS electrodes are placed into the …..
Skin
Can TENS units be placed over an incision to
decrease incisional pain?
never
Patient with what other mechanic device in use cannot use
TENS?
Cardiac pacemaker
How often should the patient be taught to change the TENS electrodes?
Every day
How is a dorsal-column stimulator different than a TENS unit?
Dorsal column stimulation electrodes are surgically implanted by the spinal cord; the patient has to undergo a laminectomy to place the DCS electrodes.
In what group of clients is thoracentesis
contraindicated?
Uncooperative, bleeding disorders
What instruction is most important to give the client undergoing thoracentesis?
Don’t move or cough
What is thoracentesis?
The pleural space is entered by puncture & fluid is drained by gravity into bottles-allows the lungs rto re-expand
If a client has a cough, what should be done before thoracentesis?
Give him a cough suppressant.
Does thoracentesis require a signed
informed consent?
Yes, it invades a body cavity.
Describe the position the client should assume during a thoracentesis?
Upright with arms & shoulders elevated, slighting leaning forward.
What is exopthalmos?
Bulging outward eyes
To care for a patient with
exopthalmos the patient should wear _____ _____ and use _________ ________.
Dark sunglasses, artificial tears
Radioactive iodine is given to hyperthyroid patients because it _______ ______ plus decreases production of ________ _______.
Destroys tissue, thyroid hormone
The #1 problem with using Propylthiouracil is ____.
Agranulocytosis
What do you teach to all patients on drugs which have granulocytosis as a side effect?
Report any sore throat immed iately
Lugols solution decreases the _________ of the thyroid gland.
Vascularity
Lugols solution should be given _____a ______ to prevent staining of the teeth.
Through a straw
SSKI should be given with _____ ______ to decrease the
_________ ________.
Fruit juices; bitter taste (SSKI-super saturated sollution of potassium iodide)
(T/F): patients with either hypo or hyper thyroid can go into thyroid storm.
true
Give another name for thyroid storm.
Thyrotoxicosis, thyroid crisis
In thyrotoxicosis, the temperature ______; the heart rate ______ and the patient becomes __________.
Increases (106);
increases; delirious/comatose
What is the first thing a nurse does when thyroid storm occurs?
Give oxygen
What is the 2nd thing a nurse does when thyroid crisis occurs?
Call MD, can pack in ice or use hypothermia blanket
What are the side effects of thyroid replacement drugs?
Tachycardia, palpitations and other signs seen in hyperthyroidism
Why is Lugols solution given pre- operatively thyroidectomy?
To decrease the vascularity of the gland & minimize blood loss
After thyroidectomy you check for wound hemorrhage by…
Slipping your hand under the neck and shoulders.
The #1 complication of thyroidectomy in the first 8 to 12 hours is __________.
Hemorrhage-or maybe airway
When moving the fresh post- operative thyroidectomy patient you must take care to never _____ _____ _____.
Move the neck
Post-operatively thyroidectomy patients will have sand bags on either side of the ______.
Neck
Why do you assess the post-operative
thyroidectomy patient’s voice for hoarseness periodically?
Because during surgery the surgeon may have nicked the recurrent laryngeal nerve. (This nerve is tested on the state boards!)
Will the post-operative thyroidectomy patient be allowed to talk?
He is on the voice rest unless you are assessing his voice
What positions should the post-operative
thyroidectomy patient be?
Semi-fowlers with neck supported in midline
What3piecesof equipment must be in the room with thyroid storm?
Suction, tracheotomy set, oxygen
What calcium imbalance is common in the post-op thyroidectomy patient?
Hypocalcemia-due to accidental removal of the parathyroids.
When is hypocalcemia most likely to occur after thyroidectomy? Why?
The 2nd and 3rd post operative day-because it takes awhile for the level to drop.
Hypocalcemia will cause (tetany or severe muscle weakness)?
Tetany
What drug is used to treat decreased
calcium?
Calcium gluconate
What is Chvostek’s sign?
A sign of hypocalcemia, it is when you tap the cheek, the patient puffs out the cheeks. (CHvostek and CHeeks)
What is Trousseau’s sign?
It is a sign or hypocalcemia-it is when you get a carpopedal spasm of the hand when you apply a blood pressure cuff to the lower arm.
What is the earliest sign of hypocalcemia?
Tremors/tingling
Should you palpate the thyroid of the
hyperthyroid patient after ectomy?
No, it the could send them into thyroid storm.
Can dental work send a hyperthyroid client into thyroid storm?
Yes, any stress can.
Give another name for TPN.
Hyperalimentation
Hyperalimentation contains
hypertonic ___, ____ acids, ______, ______, and _____.
Glucose, amino acids, water, minerals, vitamins
(T/F): TPN can be safely given via a central
line.
Yes, this is the preferred route.
(T/F): TPN can be safely infused via a peripheral IV line.
It can, but only for a very short period (48 to 72 hours maximum).
(T/F): If a TPN solution is running too slow
and is 2 hours behind
can you increase the rate 20%.
No, never ever speed up the rate.
If a TPN infusion runsintoofastit
creates a ____ osmolar imbalance.
Hyperosmolar-because of all the solu tes
(T/F): with TPN It is okay however to slow the rate
down if the client leaves the unit.
False, never slow the rate down-it could cause hypoglycemia.
What tests must the nurse perform
every 6 hours when a patient is on TPN?
1 accu check, #2 urine glucose/acetone
(T/F): IV lipid emulsions can be given central or peripheral.
true
(T/F): Be certain to shake a lipid emulsion
before admininstration.
False, never shake it, shaking damages the molecules.
Into which port of a peripheral IV line can a lipid infusion be piggybacked?
The port closest to the insertion catheter site. More recently, lipids are included in the hyperalimentation bag & there is no separate administration of the lipids.
What is meant by tracheo-
esophageal malformation?
These are a group of congenital birth defects in which the esophagus and trachea are malformed.
How many types of tracheo- esophageal malformation are there?
Four
What are the 3 most common tracheo-esophageal malformations?
1) Esophageal atresia-EA, 2) tracheo-esophageal fistula-TEF
3) tracheo- esophageal fistula with esophageal astresia- TEF w/EA
What is the defect called esophageal fistula?
An opening between the esophagus & trachea but the esophagus is connected to the stomach & trachea is connected to the lungs.
What is the defect called tracheo-esophageal atresia with fistula?
The esophagus ends in a blind pouch and there is no connection to the stomach and there is a fistula between the esophagus and trachea.
Of: tracheo-esophageal fistula, esophageal atresia, and tracheo-esopheal astresia with fistula, which is the most common?
Tracheo-esophageal fistula with esophageal astresia
Name-a blind end esophagus: the trachea is connected to the lungs.
Simple esophageal atresia
Name-the trachea is connected to the lungs, the esophagus is connected to the stomach, but there is a hole connecting the trachea and the esophagus.
Tracheo-esophageal fistu la
Name-a blind end esophagus, the trachea is connected to the lungs, and the trachea and esophagus are joined.
Tracheo-esophageal fistula with esophageal astresia
If an infant has tracheo- esophageal fistula with esophageal
atresia, what 3 signs will show up at first feeding?
Three C’s-coughing, choking, cyanosis
In an infant chokes, coughs, or gets cyanotic during the first feeding what should the nurse do to ASSESS for tracheo-esophageal fistula with espophageal atresia?
Attempt to gently pass a catheter into the esophagus if you meet resistance STOP, there most probably is esophageal atresia.
How is the diagnosis of tracheo-esophageal fistula with esophageal atresia confirmed?
X-ray with barium
Prior to surgery for repair of tracheo-esophageal fistula with esophageal atresia, how is the infant fed?
They are NPO but fed by G-tube (gastronomy)
Does a tracheo-esophageal fistula with esophageal atresia have to be repaired immediately?
No-can be maintained with G-tube feedings and suctioning until are old enough & stable enough to tolerate surgery.
The #1 problem for infants with un-repaired tracheo- esophageal fistula with esophageal atresia is…
Aspiration, secondary problem in malnutrition.
How do you meet the oral sucking needs of an infant with with un-repaired tracheo-esophageal fistula with esophageal atresia?
Use pacifiers, even though they don’t take anything orally, they should still be encouraged to suck.
How should an infant with tracheo-esophageal fistula with esophageal atresia be positioned?
HOB up 30 degrees.
Should you suction the blind esophageal pouch of esophageal atresia?
Yes, PRN, otherwise they may aspirate mucous
What is the common cleaning solution used during tracheostomy care?
Hydrogen peroxide
Cut the old trach ties (before or after) you have secured the new ties in place?
after
Is it acceptable to scrub the inside of the tracheostomy cannula with a brush during tracheostomy care?
Yes, it is desirable
What are the 2 major reasons for performing tracheostomy care?
To keep the airway patent, to keep the stoma site clean (decrease infection)
Tie the ends of the trach ties in a (bow knot or double knot)?
Only a double knot
Trach care is performed by (clean or sterile) technique?
sterile
What must you do before performing trach care (besides wash your hands)?
Suction the airway
A properly snug set of trach ties allows _______ finger(s) to be placed between the neck and ties.
one
(T/F): Both hands must be kept sterile throughout the entire trach care procedure.
False, only the dominant hand remains sterile
(T/F): When trach suctioning and care is performed by the client at home, sterile technique must be followed.
False, clean technique is adequate
What is another name for trigeminial neuralgia?
Tic douloureux
Which cranial nerve is affected by trigeminial neuralgia?
Cranial nerve 5
What is the #1 symptom of trigeminial neuralgia?
Episodic, severe one- sided facial pain
What drug treats trigeminial neuralgia?
Tegretol
What triggers attacks of trigeminal neuralgia?
Breezes, cold or hot food s/flu id s, tooth brushing, chewing, touching the face, talking
Is surgery done for trigeminal neuralgia?
Yes, nerve avulsion (destroying the nerve)
What environmental modifications are necessary in care of the patient with trigeminial neuralgia?
Prevent drafts or temperature extreme.
What dietary modifications are necessary in the care of a patient with trigeminal neuralgia?
Lukewarm, small frequent semi-solid food s
After surgery for trigeminial neuralgia, the patient’s affected eye will be ______ and the patient should chew food on the _________ side.
Protected; unaffected
What organism causes pulmonary TB?
Mycobacterium tuberculosis
The mode of transmission of the mycobacterium
tubercuolsis organism is by _____ _____.
Droplet nuclei
What living conditions predispose you to TB?
Crowded, poorly ventilated
The incubation period of tuberculosis is…
4 to 8weeks
What is the typical lung lesion in TB called?
A tubercle
In TB, the appetite is ____; the client _______ weight and the temperature ________ in the _________.
Decreased, loses, elevates, afternoon
What is a Mantoux test?
An intradermal skin test to screen for TB-called PPD
When should a Mantoux test be read?
48 to 72 hours after test injection
What qualifies as a positive Mantoux?
More than 10 mm induration (hardness), remember redness has nothing to do with the test being positive
Name three drugs given to treat TB.
Isoniazid, Rifampin, Ethambutol
How often and when during the day should Isoniazid,
Rifampin, and Ethambutol be given?
Every day, all together
What is the #1 side effect of Isoniazid?
Peripheral neuritis-take B6 to prevent
with TB, after how many weeks of drug therapy is the client considered NO LONGER contagious?
2 to 4weeks
What isolation techniques are required for TB?
Masks
What test is most diagnostic for TB?
Sputum for acid-fact bacilla
What does the sputum look like in TB?
Purulent (pus) or hemoptysis (blood)
When should you obtain a sputum specimen for acid fast bacilli TB?
Early AM
