Condition Flashcards
AIDS
Bowel programs, stool softeners and laxatives reduce intestinal stasis and bacterial overgrowth
Addison’s
Hyperkalemia
Symtoms: muscle cramps, fatigue and hypotension
Anxiety
Sleeping 7 hours a night and dreams are calm indicates major resolution of anxiety as the sleeping and dreaming both reflect and affect the body, mind, and spirit and are not conscious processes; in anxious states, insomniac symptoms of disturbed sleep pattern, sleep deprivation, fatigue are common; intrusive thoughts, worrying, fear, and/or replaying traumatic events contribute to difficulty falling asleep and/or staying asleep
Apnea
Longer than 15 seconds in a newborn should be reported
Able to leave baby for brief periods of time
Sleep by baby’s crib
Can remove monitor during bath time
Asthma
Wheezing: high pitched musical sounds heard on expiration caused by narrowing of the bronchials
A fib
Sinoatrial node no longer functions, atrial contractions reduced and stasis of blood in atria occurs
Pulse rate greater than 100 bpm, totally irregular rhythm, no definite P waves
Bell’s Palsy
Use artificial tears qid bc paralysis of eyelid allows cornea to dry; drops reduce chance of corneal damage
Bipolar
Manic: hyperactivity, poor concentration, and distractibility; redirect into activity that promotes rest, nourishment; reduce stimuli
Borderline personality disorder
Extremely angry and need help with anger management
Limit setting, including clarity and boundaries is important; they often present in a frantic, unstable, irritable, intense, impulsive manner, with frequent temper displays
Chronic bronchitis
Rhonchi: deep, low pitched rumblings are heard mainly on expiration caused by mucus in the airway
Cushing’s Syndrome
Prone to fluid overload and CHF due to sodium and water retention
Increased susceptibility to infections
Monitor patient’s blood glucose because hypercortisolism causes hyperglycemia
symptoms: fatigue, weakness, osteoporosis, cramps, edema, hypertension, decreased resistance to infection, truncal obesity, buffalo hump, moon face
Cystic fibrosis
Autosomal recessive trait Both parents carry recessive trait 25% chance of passing to offspring Positive Sweat test Increased salt in diet
Bulimia
Hoarse voice that is barely audible needs immediate referral to the physician because patient is at high risk for tracheoesophageal fistula from esophageal tear; laryngitis is danger sign
Buergers disease
Recurring inflammation of arteries and veins in upper and lower extremities, results in thrombus and occlusion
Seen in men 20-35 yo
Smoking is causative factor
Pain at rest and coldness major symptoms
Check fingers and toes every day for ulcer formation and gangrene
Detached retina
Photophobia, loss of a portion of the visual field
Cholecystitis
Symptoms: nausea, frequent belching, right upper abdominal pain
Concerning: jaundice indicates a possible stone in bile duct causing obstruction
Avoid fatty foods and gas forming foods
Compartmental syndrome
Symptoms: pale and cool to touch, complains of pain
Don’t elevate
Cleft lip and palate
Upper airway congestion: position infant on side to facilitate drainage of mucus and will promote adjustment to breathing through nose
Type I diabetes
Polyuria, polydipsia, polyphagia
Weight loss
Quivering feeling in abdomen indicates hypoglycemia
Inspect feet daily for blisters, sores, ingrown nails and cuts
Bathe feet daily in warm water
Cut toenails straight across
Don’t go barefoot
Vomiting for 24 hrs: diabetic ketoacidosis is frequently associated with dehydration so drink liquids as often as possible
At risk for heart disease
Type II diabetes
Recurrent vaginal and UTIs are an early sign in adolescents
Dawn phenomenon
Increase in blood sugar during hours of 2-8 am
Treat: stop high carb snacks before bed, adjust insulin before bed
DVT
Deep vein thrombosis (thrombophlebitis) Decrease inflammatory response in the affected extremity and prevent embolus formation Elevate foot of bed 6 inches Warm moist packs to the affected leg On bed rest 5-7 days -bedpan Positive Homans sign
Surgery induced diabetes insipidus
4000 ml in 24 hrs
Increased urine output with pale colored urine and low specific gravity
Dumping syndrome
Include foods with fat and increase calories
Lie down or sit in recliner for 30-60 min after eating
Wait 1 hr before drinking
Chronic glomerulonephritis
May be treated with peritoneal dialysis if end stage renal disease develops
Acute Glomerulonephritis
Occurs secondary to other infections
Meds: antibiotics, corticosteroids, antihypertensive, immunosuppressive agents; restrict sodium intake, restrict water if oliguric; dialing weights, monitor I and O, bed rest, high calorie, low protein diet
Droplet
Private room, maintain spatial separation of 3 ft between patient and visitors
Pertussis
Wash hands, remove mask and throw trash in container in room
Hip fracture
Abduction wedges
No more than 90 degrees
Don’t cross legs
Hypoglycemia
Tachycardia
Cold and clammy skin
Weakness and pallor
Treat at home: drink 1/2 c fruit juice followed by protein snack
Evisceration
Immediately cover open area with sterile gauze soaked in normal saline and notify physician
Impetigo
Honey colored crusted lesion
Notify parents first
Loosen scab with burrow’s solution compress
Systemic antibiotics, antibacterial soap
Possible complication is peri orbital edema indicative of poststreptococcal glomeruli nephritis
ICP
Normal 7-15;
3 mo old with high pitched cry indicates increased ICP
5 yo with closed head injury- assess orientation to person, place and time every hour to detect early signs of increased ICP
Determine cough reflex and ability to swallow prior to administering PO fluids
Increased systolic pressure and widening pulse pressure indicates increased ICP
Hepatitis A
Communicable for 2-3 weeks before onset of jaundice and about 1 wk after onset of jaundice
Eat small frequent meals
Increase calories to 2000-3000 per day to meet energy needs
No alcohol
Eat protein sources
Spead by oral rectal route
Practice good hand washing
Caution about taking any drugs not approved by doc bc it may become dangerous bc of livers inability to detoxify and excrete them
HHNK (hyperglycemic hyperosmolar nonketotic syndrome)
Seen after 50 yo
Age-related changes in thirst perception result in dehydration and decrease in urine-concentrating abilities of kidney
Hepatic encephalopathy
Early sign: impaired thought process
Late sign: hyperventilation, stupor, decerebrate/decorticate posturing
Hypoparathyroidism
Symptom: tetany
Treatment successful if denies numbness and tingling
Herpes simplex virus abscess
Clean lesions twice daily with diluted solution of povidone-iodine (betadine) and leave open to air
Age related macular degeneration
Causes permanent loss of central vision
Smokers at risk
Hypertension is silent killer
CVAs can be related to long term hypertension
Hyperthyroidism
Exophthalmos-requires ophthalmic drops
Provide calm, restful environment
Frequent high calorie snacks
Systemic lupus erythema
Auto immune
Joint pain, malaise, weight loss
Hypothyroidism
Symptoms: Tired, coarse hair and skin, persistent weight gain
MI
Most common complication following MI is dysrhythmias, ventricular types most serious
Generally related to coronary artery disease
Pneumonia
Crackles: Soft high pitched interrupted sounds heard on inspiration caused by fluid in the alveoli
Hyperparathyroidism
Abdominal discomfort, muscle weakness, diaphoresis
Report hematuria, sign of renal calculi
Opisthotonos
condition in which the body is held in an abnormal position. The person is usually rigid and arches the back, with the head thrown backward. If a person with opisthotonos lies on his or her back, only the back of the head and the heels touch the supporting surface.
Meningitis
Rheumatoid arthritis
Contributes to mitral valve disease
Plan of care: Heat, range of motion exercises, weight reduction, firm mattress
Symptoms: symmetrical joint swelling, rheumatoid nodules
Orthostatic hypotension
Teaching: Arise slowly from bed and avoid standing still for long periods
Lower limb compression devices aid in prevention
Schizophrenia
Inappropriate affect, expressions of feelings bizarre for situation
Ex: client laughs while talking about being raped
Intermittent claudication
Pain in calf during exercise that disappears at rest
Ankle-brachial index
Respiratory acidosis
Treat: high fowlers, encourage coughing and deep breathing, evaluate airway patency
Pericardial friction rub
Harsh grating sounds heard best during inspiration
Shock
Low BP, high pulse, low resp
Cool, clammy skin, and tachypnea
Weak thready pulse
Cyanotic, short of breath, complaining of pain
Lower head of bed and place patient on left side -air will rise to right atrium, minimizes chance of air bubbles entering cerebral circulation
MS
Visual disturbances, weakness in extremities, muscle tremors
Risk for Falls, skin breakdown, fatigue
Avoid overexposure to heat (sauna, hot tubs, sunbathing) or cold
Ambulated as tolerated
ROM, stretching and strengthening
Avoid alcohol
Avoid crowded places (May cause infection)
Osteomalacia: adults
Rickets: peds
Poor vitamin D and calcium
Bones become soft and weak
Respiratory alkalosis
Administer anti anxiety agent, assist patient with rebreathing device to increase O2 levels
Spina bifida
Spinal nerves destroyed by myelomeningocele can’t be corrected
MVA don’t leave pt alone if
Disorientation and irregular vital signs
Chronic renal failure
Increase intake of carbs to help maintain energy requirements
Rupture of membranes (ROM)
Assess for prolapsed cord
If so, position patient supine with foot of bed elevated. Nurse would place 2 gloved fingers to push on presenting part to take pressure off cord. Prepare for csection.
Third trimester
Epigastric pain most concerning because indicative of an impending convulsion
Shortness of breath expected
Increased rectal pressure expected
Diabetic: check blood sugar before meals, 2 hrs after meals and bedtime CONCERN if client taking less insulin than 2 mo ago bc would indicate placenta not functioning
Scoliosis
Brace ordered
Hold on rail down stairs to prevent falls
Thermal injury (burns)
Most concerning: Increased respiratory rate and decreased BP bc may indicate burn wound sepsis
Muscle weakness and lethargy are signs of hypokalemia, which can occur on the third day after a burn; hypokalemia is caused by diuresis
Report to doc if gastric pH is less than 5 bc client at risk for Curling’s ulcer. May develop 24 hrs after severe burn injury (gastric pH 1-5)
Positive pregnancy
Fetal HR detected by Doppler 10-12 wks
Active fetal movements palpable by examiner
Outline of fetus by radiography or ultrasonography
SIADH
Low sodium
Weight increase
Shingles
Herpes zoster
Can care for non high risk clients, cover lesions, can’t care for immunosuppressed clients until lesions have crusted
Disseminated: airborne and contact precautions
Thumb sucking
Peaks at 18-20 mo, normal behavior, usually subsides after 24 mo
Malocclusion occurs if thumb sucking persists past 4 yo or when permanent teeth erupt
Transition phase of labor
Pant with pursed lips to allow patient to control pain and urge to push and promotes oxygenation of fetus
Cervix is 8-19 cm dilated with complete effacement; increased pressure in pelvis causes intense desire to urinate
Somogyi effect
Blood sugar goes down at 3 am and then high in am
Treat: bedtime snack with insulin
Wilm’s tumor
Blood in urine, pain, fever
Childhood (5yo) kidney cancer
Don’t palpate it or massage bc it may cause dissemination of cancer cells
Pyloric stenosis
Infant fussy and seems hungry all the time
Lethargic, dehydrated and malnourished
Infant with reflux
Head of bed at 30 degrees
Small volume, frequent feedings
Presumptive Pregnancy
Amenorrhea N/V Increased breast size and fullness Pronounced nipples Urinary frequency Quickening Fatigue Discoloration of vaginal discharge
Peripheral vascular disease (PVD)
Decreased blood flow
Low tolerance for exercise
Increased venous pressure
Mottled skin, coolness, loss of hair, dry skin
Slow, steady walking to stimulate development of collateral circulation
Walk until experiences pain, rest, resume walking
Placenta previa
Cannot deliver vaginally
Myelomeningocele
After repair: Head circumference measurement is important because of risk of hydrocephalus following surgery
At risk to develop infection (meningitis) because of myelomeningocele sac; monitor for elevated temperature, irritability and lethargy
Ostomy
Change bag at least 1x/wk
Urinary catheter
If urine appears cloudy and foul-smelling, encourage client to increase fluid intake
Newborn cord
Clean it several times a day and expose it to air frequently
Should be dry with no redness
Meningitis
Isolation can be stopped 24 hrs after start of antibiotic therapy
Probable pregnancy
Uterine enlargement Hagar sign: softening of the uterine Goodells sign: softening of the cervix Chadwick's sign: blue cervix Ballotment: rebound of fetus Braxton hicks Positive test
Myasthenia gravis
Sudden inability to swallow or maintain patent airway
Muscle weakness
Precipitating factors: infection, stress
Ectopic pregnancy
Needs to be evaluated if 4 wks gestation reporting unilateral, dull abdominal pain
If ruptured, fluid most important
Radical mastectomy
Position client in semi-fowler with the arm of the affected side elevated bc it facilitates removal of fluid from venous pathways and lymphatic system through gravity; arm elevated to enhance circulation and prevent edema
Pregnancy
2-5 lb first trimester .66-1.1 lb/wk in second and third trimester Heart beat 3 wks Organs, circulatory 8 wks Formed 12 wks
Kaposi sarcoma lesions
Large, painful, purplish-brown open areas: Clean carefully with soap and water every day and cover with sterile dressing
Withdrawal
Pulse rate is good indicator of client’s progress through withdrawal
Increasingly elevated pulse signals impending alcohol withdrawal delirium, requiring more sedation
Parkinson’s
Tremors, shuffling gait, rigidity
Stage IV: client is immobile-ROM exercise to all extremities 4x/day
Osteoarthritis
Warm up exercises should be done prior to exercising
Phantom pain
“Staying active will help decrease the episodes”
Activity helps reduce frequency and degree of phantom pain
Majority of clients feel pain for several months
Korsakoffs psychosis
Symptom: confabulation (in order to fill memory gaps, client invents elaborate, improbable happenings
Wernickes syndrome
Form of dementia that results from thiamine deficiency
symptoms: diplopia, nystagmus
Hantavirus pulmonary syndrome (HPS)
Caused by rodents
symptoms: fever, aching, and nausea, may cause severe cardiopulmonary disease
observe for hematuria, hematemesis, bleeding gums and melana
Supra ventricular tachycardia (SVT)
If child experiences another episode of sudden chest pain and dizziness, child should stick thumb in the mouth, close the mouth around it and then blow on the thumb as if it were a trumpet. This is a form of a vagal or Valsalva maneuver. Another possible vagal maneuver would include ice to the face, holding the breath and then bearing down, massaging the carotid artery on only one side of the Neck.
Acute epiglottis
Three-year-old leaning forward with mouth open, tongue protruding and drooling indicates acute epiglottitis. Sitting upright to breathe better, tongue protrusion increases pharyngeal movement; drooling caused by difficulty swallowing because of pain and excessive secretions.
Open angle glaucoma
Glaucoma is abnormal increase in intraocular pressure, leading to visual disability and blindness; obstruction of outflow of aqueous humor
Symptoms: cloudy, blurry vision, or loss of vision, artificial lights appear to have rainbows are halos around them, decreased peripheral vision, pain, headache, nausea, vomiting
Periodic to nonmotor readings 1 to 2 times a year; normal IOP is 10 to 21mm Hg
Mydriatic eyedrops contra indicated
Emphysema
Perform pursed lip breathing
Dissociative identity disorde
At least two or more distinct alternative or subpersonalities; each of these has its own name and patterns of thinking, feeling, and behaving; patient spontaneously turning when name is called indicates that subpersonalities are not in control
