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