Exam 1 Flashcards
Early signs of Hypoxia
Agitation Anxiety Changes in level of consciousness Disorientation Headache Irritability Restlessness Tachypnea
Late signs of Hypoxia
Bradycardia Cardiac dysrhythmias Cyanosis Decreased respiratory rate (bradypnea) Retractions
When taking the tympanic temp for children under 3
Pull the pinna slightly down and back
When taking the tympanic temp for adults and children over three
Pull the pinna slightly up and back
Adults HR
60–100 bpm
Maslows Hierarchy of needs from bottom to top
Physiological needs, saftey needs, belonging &love needs, self-esteem needs, self actialization/self fufilment
Critical thinking traits
Intellectual humility, intellectual courage, intellectual empathy, intellectual autonomy, intellectual integrety, intellectual perserverence, faith in reason, fair mindedness
Intellectual Humility
Admiting when you don’t know something and looking for more info
Intellectual courage
Willingness to listen to all sides of an argument
Intellectual empathy
Putting yourself in someone else’s shoes to understand how they feel.
Intellectual Autonomy
Being able to think about what you bserve and determining for yourself weather it is safe.
Intellectual Integrety
When someone wants a certain level of proof applied to something before using/practicing it.
Intellectual perserverance
Perservering for the sake of a patient
Faith in reason
believing in your heart that good clinical reasoning will result inthe best clinical judgement and therefore have the best outcomes for your patients.
Fair-Mindedness
thinking is not biased by something that you just want fo yourself.
Interdisciplinary team
Within a discipline…i.e. between nurses
Peripherial Pulses
Temporal, facial, carotid, radial, brachial, apical, femoral, Popliteal, posterior tibial, doral pedis
3+ or bounding pulse
Pulse feels very strong and full and is easily counted; does not obliterate even with moderate pressure.
2+ or strong pulse
Pulse is easily detected, feels strong, and is easily counted; can be obliterated with moderate pressure. This is considered the normal finding.
1+ or weak pulse
If the pulse is so faint and weak that it is difficult to feel it long enough to count the rate, an additional descriptor may be used.
0 or absent pulse
pulse is not detectable
Newborn respirations
30-60
Infant respirations
20-40
Children respirations
20-30
Adolescents Respirations
14-25
Adult Respirations
12-20
normal blood pressure
120/80
When takining blood pressue always make sure
Patient has not smoked in the last 30mins.
Both feet are flat ont he flor
Elbow is slightly flexed with palm facing up and forearm heart level.
FLACC scale is mostly used for
Pedi patients
FLACC stands for
Face, Legs, Activity, Cry, Consolability
When reassessing a patients pain…
Always use the same scale you assesed him/her with.
When using oxygen remeber…
Must have provider order, may apply in an emergency then obtain order
NO SMOKING
No petroleum-based products
Can be piped in from walls, from a stored tank, oxygen concentrator, or liquid oxygen
May have order to humidify, especially if flow rate is high
Nasal Cannula
1-6 L
Delivers oxygen into pt’s nares.
Pt must breath through nose fo rmost benefit.
Nasal prongs must be curved inward when inserted.
Simple face mask
5-10L
Delivers O2 to pt’s nose and mouth.
Flow rate less than 5L can cause CO2 to accumulate in mask.
Can cause pt to be hot and claustraphobic.
Monitor for sores under the mask.
Partial Rebreather
6-15 L
Mask with bag attatched that traps CO2 for rebreathing to lower PH levels. Ports on side of mask allow for air to discharge,
If bag collapses increase flow rate
Nonrebreathing mask
6-15 L
Prevents pt from rebreathing any exhaled air; escapes through a one way valve that does not allow room air to enter.
Only delivery device that can deliver 100%O2
Increase O2 if bag collapses
Venturi mask
24-80 %
Good for COPD patients
Allows for precise mix of room air and O2
Face Tent
8-12 L
Good for claustraphobic pt’s
O2 delivery is not precise so it is important to assess O2
Amoxicillin
Antiulcer agent
Anaphylaxis
Monitor bowel function -> diarrhea, abdominal cramping, fear, bloody stools -> C. Diff
Women can deveople yeast infections
Cross sensitivity exists to cephalosporins and other beta-lactams.
Finish completely
Digioxin
Antiarrhythmic Monitor for ECG changes Apical pulse must be checked for 1 full min before administering; withold if pt is bradycardic or tachycardic until PCP says otherwise Narrow therapeutic range Vision changes Monitor weight
Cipro
Broad spectrum anti-infective GI changes (discuss c-diff) Renal impairment Rash Liver changes Tendon rupture
Lipitor
Lipid lowering agent Any kind of Muscle pain MUST be reporter Educate patient...LOW CHOLESTROL DIET SHOUDL BE FOLLOWED Monitor Cholesterol and liver function Take in the evening NO Grapefruit juice
Flexiril
Muscle relaxer can cause Serotonin syndrome Take with food Fatigue Assess ROM May need stool softeners
Asprin
Anti-inflammatory Watch for changes in skin Fever reducer Anticoagulant Can cause tinnitus Should not be given to children under 18
Benedryl
Generally used as an antihistamine
Can cause hypotension
Risk of central nervous system depression
Do not take four days prior to skin testing for allergies
Avoid giving to children under age 4
Can cause photosensitivity
Calcium Carbonate
GI upset
Can be used as a calcium replacemetn if pt is Hypocalcemic–pt should also be taught to exercise to maintain bone strength
Pt should be on heart monitor if being given by IV
Antacid
If take too closley to certain meds or foods can cause constipation.
Review bowel issues
Plavix
Reduces risk of blood clots
Do not use if history of gastrointestinal (GI) bleed
May increase total cholesterol
300 mg initially, reduce to 75 mg daily
Do not take with omeprazole
Antiplatelet compound can increase bleeding times…Stop 5days before surgery.
Tylenol
Analgesic
Fever reducer
Use cautiously with hepatic dysfunction
Takes at least 30 minutes to start working
Antagonist—mucomyst
Inform diabetics that it can alter Blood glucose readings
Continuity of Care
continuous seamless care. When a pt recieves appropriate care from any healthcare professsional.
Parts of an interview
Opening, body, closing
ISBARR
Introduce yourself Situation Background Assessment Recommendation Readback
Nursing Diagnosis is established by…
the rn
Nursing dx is based off of the
Medical diagnosis
The nursing process?
Assessment DIagnosis Planning Implementation/intervention Evaluation
RN’s can delegate to who?
Other RN’S, LPN’s, and UAP’s
LPN’s can delegate over Other
LPN’S AND UAP’s
Theraputic communication
a way to help patients express their needs and feelings
