COMP B STUDY GUIDE Flashcards
Stoma care:
- Should appear pink and moist
- Ischemia/purple/black is serious finding
- Apply skin barrier and creams (adhesive paste) to stoma skin and allow to air dry before applying
- Empty bag when it’s 1/3 to 1/2 full of drainage
Fiberglass leg cast:
- Are light, stronger, and water resistant.
- Dries very quickly (30 min) and are most commonly used
- Inspect the cast every 8-12 hours
- Elevate during the first 24-48 hours to prevent edema
- Room for one finger between skin and cast
- Report areas under the cast that are painful, have a hot spot, increased drainage, warmth, odor (infection)
- Report change in mobility and complications (sob, skin breakdown, constipation)
Diet for renal calculi:
- Kidney stones are made of CALCIUM OXALATE
- Contributing factors: inadequate fluid intake, elevated urine pH, excess excretion through the kidneys of oxalate, calcium, and uric acid (lean meats, organ meats, whole grains, legumes)
- A patient who has a ileostomy has an increased risk of kidney stones
- Avoid excess protein, sodium, calcium oxalates (rhubarb, spinach, beets, nuts, chocolate, tea, wheat bran, strawberries)
- Daily UP 2L/day
- INCREASE potassium
- Avoid mega doses of vitamin C
Lithium:
- Mood stabilizer for bipolar, manic episodes
- Therapeutic range 0.8-1.2
- Monitor weekly blood draws until steady and then every 3 MONTHS. Monitor LITHIUM and SODIUM.
- May take 1-3 weeks for full effect
- Teratogenic
- Monitor for LITHIUM
Leukocytosis, Increased Urination, Thirsty/tremors, Hypothyroidism, Interaction with many meds, Upset stomach, Must get levels checked - If we have low sodium in the body, the body will use lithium to take place of salt = toxicity
Amitriptiline:
- TCA antidepressant
- Blocks reuptake of norepinephrine and serotonin in the synaptic space, thereby intensifying the effects of neurotransmitters
- Can take 10-14 days or longer before it begins to work
- Monitor for ORTHOSTATIC HYPOTENSION, ANTICHOLINERGIC EFFECTS. (Dry mouth, blurry vision, photophobia, urinary retention, constipation, tachycardia, sedation, excessive sweating.
- Toxicity: dysrhythmias, mental confusion, agitation, seizures, coma, death
- Contraindications: seizures, MI
- Have an increased risk for suicide should received 1 week supply of med due to lethality of toxic doses
Thermoregulation newborn:
- Provides a neutral thermal environment that helps a
newborn maintain a normal core temp with minimal
oxygen consumption and caloric expenditure - The newborn keeps warm by metabolizing brown fat,
which is unique to newborns, but only within a very
narrow temperature range. Becoming chilled (cold
stress) can increase the newborn’s oxygen demands
and rapidly use up brown fat reserves. - Monitor for hypothermia in the newborn.
-Axillary temperature of less than 36.5° C (97.7°F)
-Cyanosis
-Increased respiratory rate
-Core temperature varies within newborns, but it
should be kept at approximately 36.5 to 37° C (97.7
to 98.6° F - Interventions: Conduction: Loss of body heat resulting from direct
contact with a cooler surface. Preheat a radiant
warmer, warm a stethoscope and other instruments,
and pad a scale before weighing the newborn. The
newborn should be placed directly on the parent’s
chest and covered with a warm blanket, and a cap
should be placed on the newborn’s head. Convection: Flow of heat from the body surface to cooler environmental air. Place the bassinet out of the direct line of a fan or air conditioning vent, swaddle the newborn in a blanket, and keep the head covered. Any procedure done with the newborn uncovered should be performed under a radiant heat source. Keep ambient temperature of the nursery or
client’s room at 22 to 26° C (72 to 78° F). Evaporation: Loss of heat as surface liquid is converted to vapor. Gently rub the newborn dry with a warm sterile blanket (adhering to standard precautions) immediately after birth. If
thermoregulation is unstable, postpone the initial
bath until the newborn’s skin temperature is 36.5° C
(97.7° F). When bathing, expose only one body part at
a time, washing and drying thoroughly. Radiation: Loss of heat from the body surface to a
cooler solid surface that is close, but not in direct
contact. Keep the newborn and examining tables
away from windows and air conditioners.
Temperature stabilizes at 37° C (98.6° F) within 12
hr after birth if chilling is prevented.
The best method for promoting and maintaining the
newborn’s temperature is early skin-to-skin contact
with the parent.
Pneumonia:
- S/S: anxiety, fatigue, weakness, chest discomfort d/t coughing, confusion from hypoxia, fever, chills, flushed face, diaphoresis, SOB, tachypnea, sharp pleuritic chest pain, yellow tinged sputum, crackles, wheezes, purulent or blood tinged or rust sputum
Pressure injuries:
- Provide adequate hydration, protein, and calorie needs. Fluid intake of at least 2500 ml/day, protein (meat, fish, poultry, eggs, dairy products, beans, nuts, whole grains)
- If blood ALBUMIN is low (< 3.5) because a lack of protein increases the the risk for a DELAY IN WOUND HEALING and infection.
- Wound cleansing and irrigation from the least contaminated (incision) toward the most contaminated (surrounding skin). Never use the same gauge to cleanse across an incision or wound more than once. DON’T use cotton balls or products that shed fibers.
- If irrigating, use a piston syringe or a sterile straight catheter for deep wounds with small openings. Apply 5-8 psi pressure, 30-60 ml surging with a 19 gauge needle provides approx 8psi.
Hepatitis characteristics:
- History of exposure to infected blood, stool, bodily fluids.
- S/S: fatigue, decreased appetite with nausea, abdominal pain, joint pain, fever, vomiting, dark colored urine, CLAY colored stool, JAUNDICE
Increased ICP care:
Elevate head at least 30° to reduce ICP and to
promote venous drainage.
Avoid extreme flexion, extension, or rotation of the
head, and maintain the body in a midline neutral
position.
Maintain a patent airway. Provide mechanical
ventilation as indicated.
Administer oxygen as indicated to maintain PaO2
greater than 60 mm Hg.
The client should receive stool softeners and avoid
the Valsalva maneuver with increased ICP.
Provide a calm, restful environment. (Limit visitors.
Minimize noise.)
Brief periods of hyperventilation for the intubated
client can be used after the first 24 hr following
injury to help lower ICP. During the first 24 hr,
hyperventilation can cause cerebral
vasoconstriction, which can cause ischemia
Sickle cell crisis interventions:
Promote rest to decrease oxygen consumption.
Administer oxygen as prescribed if hypoxia is present.
Provide intense hydration therapy while maintaining
fluid and electrolyte balance.
Monitor I&O.
Give oral fluids.
Administer IV fluids with electrolyte replacement.
Use caution with potassium replacement
dminister blood products, usually packed RBCs, and
exchange transfusions per facility protocol. Observe for
manifestations of hypervolemia and transfusion reaction.
Treat and prevent infection.
Administer antibiotics.
Perform frequent hand hygiene.
Give oral prophylactic penicillin.
Administer pneumococcal conjugate vaccine,
meningococcal vaccine, and Haemophilus influenzae type
B vaccine.
Monitor and report laboratory results.
Use an interprofessional approach.
Treat mild to moderate pain with
acetaminophen or ibuprofen. Manage severe pain
with opioid analgesics.
Apply comfort measures (warm packs to painful
joints).
Schedule administration of analgesics to
prevent pain.
Mechanical soft diet:
Ground meat, canned fruits, softly cooked veggies
Meditation:
Focuses attention to a single unchanging stimulus to become more mindful of self
Cane instructions:
- Level with greater trochanter
- Move cane first, then move weaker leg
- Hold cane on STRONG side, always keep 2 points on the floor for support at all times
- Going UP: up with the GOOD (strong leg, cane, weak leg)
- Going DOWN: down with the bed (cane, weak leg, strong leg)
Sterile field:
- Keep surfaces dry
- Discard any packages that’s torn, punctured, wet
- Hold items 6 inches above sterile field
Pulse deficit:
The difference between apical and radial pulse
Hypoxia manifestations:
- Early: Think that the body is still trying to compensate -> tachypnea, tachycardia, HTN, anxiety, confusion, pale skin, pale mucous membranes, use of accessory muscles, nasal flaring, adventitious breath sounds.
- Late: think that the body has used up all it’s energy so now it’s slowing down -> stupor, cyanotic, bradypnea, bradycardia, hypotension, cardiac dysrythmias
Skin lesions:
- Macule: freckles, petechiae
- Papule: elevated nevus (mole)
- Nodule: wart (palpable, 1-2 cm)
- Vesicle: pus filled (blisters, herpes, varicella)
- Wheal: insect bite
Transfer documentation:
Med diagnosis and care providers, demographic info, overview of health status/plan of care/recent progress, alterations that can precipitate immediate concern, notification of assessments or care essential within the next few hours
Bowlegged/knock knee:
Is a common finding for a toddler/newborn. Feet should face forward while walking.
Pulse ox locations:
Fingertips, toes, bridge of nose, earlobe, forehead with a clip or band
Indications of stress for a patient hospitalized:
Dilated pupils, speech dysfunctions, severe shakiness, severe withdrawal, inability to sleep, delusions, hallucinations (PANIC LEVEL ANXIETY)
Parkinson’s difficulty chewing and swallowing s/s:
Drooling, dysarthria, progressive difficulty with ADLS, mood swings, cognitive impairment (Dementia)
Medication abbreviations:
- Always write the full name of medication
- Don’t use trailing zeros (1.0 mg)
- Don’t use decimal points without leading zero (. 5 mg)