Exam 3 Flashcards
What is epistaxis?
nose bleeding
What are all the nursing interventions for pt. exhibiting epistaxis?
- upright sitting, high Fowler’s position
- keep patient quiet
- Apply ice compress
- apply direct pressure by pinching the entire soft lower portion of the nose for 10-15 mins
- partially insert gauze pads into the bleeding nostril
If epistaxis takes place posteriorly, what is another alternative?
epistaxis balloon used for nasal packing
What is allergic rhinitis?
inflammation of the nasal mucosa in response to a specific allergen
What are some pt. teaching for allergic rhinitis?
- identify the allergen by keeping a diary
* *2. avoidance of environmental triggers** - less exposure to the trigger
- med therapy
What is a thoracentesis?
is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, removal of pleural fluid, or instill medication
What position should the patient be in for a thoracentesis?
the patient should sit on the edge of the bed and leaning forward over a bedside table
What is a bronchoscopy?
visualization and biopsy of the airway
What are the nursing actions after a bronchoscopy?
- keep pt. NPO until gag reflex returns.
2. Monitor for recovery form sedation
If a pt. asks for something to drink or eat after a bronchoscopy, do you give it to your pt?
no, the dr. has to order a gag reflex test
What is TB?
is an infectious disease caused by Mycobacterium tuberculosis
How do you diagnosis for TB?
- PPD
- Quantiferon Gold
- chest x-ray
How do you determine if still has TB in the hospital setting?
3 sputum tests consecutively in the am ac
What are the early SI/SX of TB?
- fatigue
- malaise
- anorexia
- weight-loss
- low-grade fevers
- night-sweat
- chills
- productive cough
- pleuritic pain
- normal or crackles in lungs
What type of isolation should TB patients be in?
airborne isolation
What are some nursing interventions for TB patients in the hospital?
- negative pressure
- close door
- N95 respiratory
- for pt. transferring pt wear a regular mask
- anyone less than 14 years old should not visit
What type of med is usually prescribed to a pt with TB?
Rifampin
What is some pt. teaching for Rifampin?
*1. turns fluids orange (sputum, urine, sweat, and tears)**
What is an acute infection of the lung parenchyma?
pneumonia
List the organisms that can cause pneumonia
- Strep. aureus
- Staph. pneumonia
- Mycoplasma
- Chlaymdia
- Haemophilus influenzae
A pneumonia patient is at risk for what?
- *1. aspiration**
2. atelectasis
3. bacteremia
4. acute respiratory failure
5. sepsis
What are some pt teaching for a pt with pneumonia?
- frequent hand washing
- proper nutrition
- adequate rest
- regular exercise
- coughing or sneezing into the elbow rather than hands
- avoidance of cigarette smoking
- Avoid people with upper respiratory infections
In what position do we place a pt. at risk for aspiration due to pneumonia?
- side-lying, upright. turn and reposition q2h
- elevate HOB at least 30 degrees and have the pt sit up for all meals
- assess for gag reflex
What are some nursing Dxs for those with pneumonia?
- impaired gas exchange related to fluid and exudate accumulation within the alveoli and surrounding lung tissue
- ineffective breathing pattern rt inflammation and chest discomfort
- Acute chest pain rt inflammation and ineffective pain management and/or comfort measures
- Activity intolerance rt chest discomfort, inflammation, SOB and generalized weakness
What is a tracheostomy?
a surgically created stoma in the anterior portion of the trachea
What are the 5 reasons why a pt gets a trache?
- *1. establish a patent airway b/c airway is compromised**
2. bypass an upper airway obstruction
3. facilitate removal of secretions
4. permit long-term mechanical ventilation
5. facilitate wearing from mechanical
After insertion of a trache what is the nurse role?
- keep obturator near bedside in case of decannulation
- suctioning the airway to remove secretions
- cleaning around stoma
- changing ties
- providing inner cannula care
- assess site for infxn
7 educate the pt if A x O= 0
How often should trache care be performed?
qshift (minimum) or PRN
If pt becomes cyanotic during trache suctioning, what is your intervention?
stop and give O2
When you are trache suctioning do you suction on the way out or in?
on the way out
Before taking a pt to get an MRI what should you assess?
- assess for a pacemaker. If yes then notify the physician
- assess for claustrophobia. If yes then notify physician, they may recommend a sedative. If pt is still uncomfortable after the sedative then MRI may not be done.
What is chronic venous insufficiency and venous leg ulcers?
valves are damaged, pooling of blood in the legs and swelling
If pt can’t get shoes on what should you consider?
chronic venous insufficiency and venous leg ulcers
What is Raynaud’s Phenomenon?
an episodic vasopastic disorder of small cutaneous arteries most often involving finger and toes
Which gender is more common to have Raynaud’s Phenomenon?
females
What is VTE?
Represents pathology from DVT to PE
What are some nursing actions for VTE?
- Early and aggressive mobilization
- pts who are on bed rest should be turned and repositioned q2h
- unless contraindicated, teach pts to flex and extend their feet, knees, and hips q2h or q4h
- pts who can get out of bed need to be in a chair for meals and walk at least 4-6x/day
- SED and compression stockings
- compression devices
- anticoagulants
What are some antiHTNsive meds?
- thizades
- ACE Inhibitors
- beta blockers
- Ca 2+ channel blockers
When administering a beta blocker what should you observe?
HR and BP
When administering a thiazde what should you observe?
increase in glucose level
When administering an ACE inhibitor what should you observe?
hyperkalemia
What is a pt. teaching for a pt. taking hydrochlorothiazde?
to change positions slowly due to orthostatic hypotension
What should you assess in a patient taking benezopril?
- do not apsirin or NSAIDS simultaneously
- addition of enhance effectiveness
- hyperkalemia so K+ levels
- increase Cr
What are some nursing interventions for HTN?
- Lifestyle modifications
- weight reduction
- DASH eating plan
- diet Na+ reduction
- moderation of ETHOL intake
- physical activity
- avoid tobacco products
- management of psychosocial factors (i.e. stress)
What is Coumadin?
Warfarin is an anticoagulant
If pt in room 205 is taking Coumadin what would you educate about him regarding his diet?
- avoid rich K+ foods such as dark greed leafy veggies
- no
- spinach
- avocado
- cabbage
What is the chemical class of Atenolol?
beta blocker
What is the technique to take blood pressure?
- have the pt rest for 20 mins
- use the proper cuff size
- place arm AT heart level
if bp is not read properly on an extremity than switch to the opposing
if bp is high or low than ask the pt if that is normal, if not see if they have an hypertensive PRN med if not notify the physician
What is CAD?
coronary artery disease is a blockage by cholesterol and lipids
What are risk factors for CAD?
1. Atherosclerosis Modifiable - cigarette smoking - HTN - Obesity -Diet/ nutrition ( high cholesterol, glucose, and fat) - sedentary lifestyle - stress Nonmodifiable - Age - Genetics - Ethnicity and Race Gender
What is the chemical class of enoxaparin sodium (Lovenox)? warfarin (Coumadin)?
lovenox is an antithrombotic
coumadin is an antigcoagulant
Can Lovenox and Coumadin be taken simultaneously? How?
Yes. Coumadin is long-term taking a few days for it to take effect. Lovenox works immediately. So by the time Coumadin begins to work lovenox will no longer be in the system
Why would you administer lovenox and coumadin simultaneously?
DVT prevention
What is the normal range for Cr?
0.6-1.3
What is the normal range for BUN?
6-20
What is the normal range for C6H1206?
70-120
What is the normal range for Hct?
female: 0.35-0.47
male: 0.39-0.5
What is the normal range for Hb?
female: 13.2-17.3
male: 11.7-15.5
What is the normal range for Na+?
135-145
What is the normal range for K+?
3.5-5.0
If pt can’t get shoes on and you consider chronic venous insufficiency what are your nursing considerations?
- change jobs if it requires a lot of standing
- buy comfortable shoes
- compression socks
- elevate extremities with pillows
- ambulate
What is Acute Arterial Ischemia?
sudden interruption in the blood supply to tissue organ
What is the cause of Acute Arterial Ischemia Disorder?
embolism, thrombosis or trauma
What are the clinical manifestations of Acute Arterial Ischemia?
- foot drop from nerve damage
- anticoagulant therapy-IV heparin
- 6 P’s
- pain
- pallor
- pressure
- pulselessness
- paralysis
- parathesia - Poikilothermia- adaptation to evntl temp
What are the 2 types of stroke?
- hemorrhagic
2. ischemia- most common
What type of med is given primary to aspirin for a stroke occurrence?
TPA- tissue plasminogen activator
What is the nurse role if a pt. has a stroke?
bedside swallow test
What is the most common cause of hemorrhagic stroke?
HTN
SI/Sx of hemorrhagic stroke
- *1. worst headache of their life**
2. N/V
3. decreased/ Altered LOC
4. HTN
5. Neurologic deficits
Describe a wheeze
continuous high-pitched squeaking or musical sound caused by rapid vibration of bronchial walls
Describe a stridor
continuous musical or crowing sounds of constant pitch `
Describe fine crackles
discontinuous high-pitched sounds heard just before the end of inspiration. sounds similar to that rolling hair between fingers
Describe coarse crackles
discontinuous low-pitched sounds caused by air passing through airway intermittently occluded by mucus. similar to sound blowing through straw under water
What is tactile fremitus?
vibration of the chest wall produced by vocalization
How do you assess for tactile fremitus ?
placing palmar surface of the hands against the pt’s chest with the fingers hyperextended ask the pt to say 99
What is the nursing action for a pt with a respiratory disease?
apply O2
How do you assess lungs?
- inspect
- palpate
- perucssion
- auscultation
How do you screen Tb in immigrants?
Bacille Calmette-Guérin vaccine, not recommended in the US.
Not candidates for PPD may result in a false positive result
What are patient teachings for a pt. with pulmonary edema?
- instruct the patient on effective breathing techniques
- stress taking medications
- the client should measure weight daily at the same time
- teach common adverse effects of medications
- Instruct the patient on a low-sodium and fluid restriction
- Avoid ETHOL
If patient exhibits sharp pain, cough, and fever what is your first consideration?
pneumonia
What is the clinical assessment for pneumonia?
history, physical examination and chest x-ray
1. sputum culture and sensitivity test
If patient complains of pain near the IV site, what is your nursing intervention?
DC the IV
What is included in the PreOP teaching to prevent DVT?
- Demonstrate and teach the importance of ROM and early ambulation for thrombi prevention
- instruct the patient about the purpose of antiembolism stockings and pneumatic compression devices to prevent DVT
What is the normal range for CO2?
35-45
What is the normal range for HCO3-?
22-26
What s the normal range for pH?
7.35- 7.45
What is respiratory acidosis?
pH is low and CO2 is high
What is metabolic acidosis?
both pH and HCO3- are low
What is metabolic alkalosis?
both pH and HCO3- are high
What is respiratory alkalosis?
pH is high and CO2 is low
What are some causes of metabolic alkalosis?
vomiting, NG suctioning, diuretic therapy, and hypokalemia
What are some causes of metabolic acidosis?
renal failure, poisonings, and diarrhea
What are some causes of respiratory alkalosis?
hyperventilation and PE
What are some causes of respiratory acidosis?
hypoventilation, oversedation, cardiac arrect and CHF
What are some interventions if a trace is accidentally dislodged?
- immediately call for help (MD)
- replace tube
- insert the obturator in the replacement trache tube
If the trache cannot be replaces what are some nursing interventions?
- Assess level of respiratory distress
2. cover stoma with dressing and ventilate with bag until the MD or RT arrives
T/F. Try to avoid suctioning through the newly created trache in the first few hours after procedure
T.
What should you have at the bedside of a trache pt?
trache tube of equal or lesser size for emergency reinsertion
Because an inflated cuff exerts pressure on the tracheal mucosa, what is important?
inflate the cuff with minimum volume of air required to obtain an airway seal
What is the result of an excessive cuff pressure?
- compress tracheal capillaries
- limit blood flow
- predispose to tracheal necrosis
A patient has had a hemorrhagic stroke and is taking coumadin with history of A-fib? Are they a priority?
yes, they are number ONE priority
If i assume a patient has influenza what is my nursing action?
place the patient on droplet precaution even before I get labs
Can a pt with active TB leave the hospital?
no if they do call police
If a pt has a stroke and they are alone, can they get TPA?
no because you don’t know how long the stroke lasted
What is a stroke pt at risk for?
aspiration
Is a stroke pt aspirating a priority?
yes number ONE
Can a patient go home with a trache?
yes, they should be taught how to care for their trache using a clean technique
