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Adult Health 1 > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

Understand nursing interventions for a patient post-op laparoscopic cholecystectomy

A
  • Relieving Pain
  • Improving Respiratory Status – splinting, deep breaths, IS
  • Maintaining Skin Integrity - pressure ulcers!
  • Promoting Biliary Drainage; might go home with drain
  • Improving Nutritional Status ; difficulty eating fatty foods, low fat high in carbs and protein, fat restriction 4-6 weeks (liver picks up bile job)
  • Monitor/Managing Potential Complications – hemorrhage, peritonitis (hard rigid abdomen, horrible pain pinpointed), monitor surg sites
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2
Q

Know clinical manifestations of cholelithiasis

A
  • May be silent with no symptoms

Symptomatic clients =

  • Pain (r upper q; radiate to right shoulder) and Biliary Colic
  • Jaundice – depends on where obstruction is
  • Changes in Urine and Stool Color
  • Vitamin Deficiency – fat soluble (D E A K)
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3
Q

Understand nursing interventions for acute pancreatitis

A
  • Relieving pain/discomfort – NPO
  • Improving breathing pattern – cough, semi fowlers
  • Improving nutritional status – monitor labs and weight
  • Maintaining skin integrity
  • Monitoring/Managing complications – FLUID AND ELECTROLYTE DISTURBANCES - strict IO, daily weight, IV fluid, frequent labs, HYPOVOLEMIC SHOCK – IV fluids, labs, PANCREATIC NECROSIS
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4
Q

Know patient education regarding bariatric surgery

A 
NPO before, clear liquid 48 hrs, 8 weeks until solid foods
Limit starchy foods
Avoid NSAIDS
Avoid pregnancy for 18 months 
Dumping syndrome is huge comp
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5
Q

Understand dumping syndrome and its clinical manifestations regarding bariatric surgery

A

Food hits stomach too quickly
15 min - 2 hrs after eating
Using bathroom will relieve

CMs - DATED W

  • Dizziness
  • ABD cramping
  • Tachy
  • Epigastric fullness
  • Diaphoresis
  • Weakness
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6
Q

Assessment findings for diverse skin tones

Pallor, cyanosis, erythema, jaundice

A 
Pallor 
- Darker = ashen, grey, dull
- Lighter = white/pale
Cyanosis
- Darker = dull, grey
- Lighter = blue, purple
Erythema
- Darker = purple, grey
- Lighter = bright pink, red 
Jaundice 
- Darker = yellow of eyes
- Lighter = yellow
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7
Q

Complications related to radiation therapy to head and neck

A

Chemo brain - planner and no multitasking
Alopecia - hair might grow back different
- If d/t radiation, hair might not grow back

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8
Q

Client education related to infection risk with cancer treatments

A

Immunocompromised
No crowded places
No sick friends
No flower or fresh fruit/veggies or deli meat

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9
Q

Priority action for diabetes education

A 
Measuring BG
Diet
Insulin administration
S/S of hyper and hypoglycemia
Stress management
Exercise
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10
Q

Managing type 1 diabetes and exercise

A

Eat 15g carb snack

Exercise at the same time of day for the same length of time

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11
Q

Priority nursing actions for a post-operative thyroidectomy patient

A
  • Monitor dressing for bleeding!
  • Monitor for swelling, hematoma, or injury to
    laryngeal nerve (can cause respiratory
    difficulties, keep trach kit next to bed)
  • Semi-fowler position, with head elevated and
    supported by pillows
  • Support the head when moving and turning
  • Avoid neck extension
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12
Q

Patient education related to glucocorticoid therapy

A

Can increase blood sugars
Can cause pituitary & adrenal suppression (Adrenal suppression may last up to 1 year after course of corticosteroids)
Do not stop abruptly! Taper off

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13
Q

Patient education related to age related changes in the cardiovascular system

A
  • Hypertrophy: less volume due to less space, reduced exercise tolerance, fatigue. can lead to HF
  • Thickening/rigidity of AV valves - Causes backflow of blood, causing murmurs
  • Conduction system - Replace conductive tissues with connective tissues. Bradycardia, heart block, ecg changes
  • Vasculature - Stiffens, less elastic. increased ventricular hypertrophy. increased systolic bp and widening pulse pressure/difference between diastolic and systolic. predictors of poor vascular outcomes
  • Increase in left atrium, decrease to stimulation, cant respond to increased demand
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14
Q

Preventing complications related to the treatment of deep vein thrombosis (DVT)

A

DVT can cause PE

Anticoags – heparin – titrate to labs
Bed rest – until anticoagulation
Don’t put SCD on DVT leg

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15
Q

Priority nursing interventions for patients undergoing endovascular procedures (caths)

A

Observe cath site for bleeding, hematoma
Peripheral Neurovascular assessment
Evaluate temp, color, and cap refill of affected extremity
Screen for dysrhythmias
Maintain bed rest 2 to 6 hours
Instruct patient to report chest pain, bleeding
Monitor for contrast-induced nephropathy

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16
Q

Patient assessment related to angina pectoris

A

Cardiac biomarkers
ECG/EKG
CV assessment

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17
Q

Patient education related to coronary artery disease (CAD)

A 
Eat more plants
Manage stress
Go for walks
Check BS and control
HTN controlled
Cholesterol meds
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18
Q

Clinical manifestations of end-organ damage (target organ damage) related to essential
hypertension

A

Eyes

  • Microaneurysms in eye
  • cotton wool spots
  • Inc. intraocular pressure (damages vessels)

Kidneys

  • Renal damage
  • Affected by increase in pressure
  • Protein in urine
  • Increased BUN/creatinine

Heart

  • Angina/palpitations
  • Peripheral pulse=bounding
  • Dyspnea

Neuro

  • Neuro deficits
  • HA
  • Falls
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19
Q

Clinical manifestations of MI

A 
Chest pain
Indigestion
Choking/heavy sensation
Feeling of impending doom
Radiating pain to shoulder
Pallor
N/V/lightheaded
Difference= biomarkers
- Troponin - >0.35 ng/mL
- CPK - 50-325 mU/mL
- CKMB 0-5 ng/mL
- Myoglobin - 0 mcg/mL
Cool, pale moist skin
Elevated HR and RR
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20
Q

Nursing and medical management of lymphedema

A

Exercise, ted hose, manual lymphatic drainage, diuretic, or surgery

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21
Q

Know what is involved in a neurovascular assessment

A

6 Ps

Pain 
Paresthesia 
Pulse
Pallor 
Pressure
Paralysis
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22
Q

Understand treatment/medical management for osteoarthritis

A 
Weight loss
Incorporate exercise
NSAIDS, corticosteroids, Tylenol 
PT
Assistive devices
Surgery arthroplasty – if none of above work
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23
Q

Understand nursing interventions regarding total joint arthroplasty

A

Preventing DVT – ortho surgery #1 cause of DVT
Preventing Infection
Managing Pain
Promoting Ambulation
Monitoring Wound Drainage
Preventing Dislocation (THA)
- Clinical Manifestations of Joint Dislocation – adduction, external rotation, shorter extremity, pain, loss of ROM, unable to bear weight

24
Q

Know total hip precautions

A

CANNOT bend over at 90 angle, cross legs (adduction pillow)
When sitting, hips cannot be lower than knees
Turn on nonoperated side
No internal or external rotation – 6-8 weeks after surg

25
Q

Know foods high in calcium and vitamin D

A 
milk
dairy
egg yolk
steamed broccoli
fortified orange juice
yogurt
26
Q

Understand nursing interventions for osteoporosis

A

Promoting Understanding of Osteoporosis and Treatment Regimen
Relieving Pain
Preventing Injury – risk for fractures; fall precautions
Improving Bowel Elimination (r/t immobility and medication) – fiber, increase fluids, movement

27
Q

Know preparation/assessment for MRI

A

No metal
Loud, small space for long time
May use dye

28
Q

Know ways to prevent atelectasis

A

Frequent turning
Early mobilization
Managing secretions
Use of incentive spirometry

29
Q

Know aspiration precautions

A 
HOB 30 - 45°, 90° when eating
Stay upright (45°) for 1 hr after eating
Use sedatives sparingly
SUCTION @ bedside
Small bites
Alt solid food and liquids
30
Q

Know measures to prevent influenza

A

Vaccine
Hand hygiene
MOA – discuss

31
Q

Understand patient education regarding oxygen use

A

NO smoking or the use of fire around oxygen
Post “No Smoking – Oxygen in use” sign
Fall risk education in regards to tubing
Avoid petroleum gel products, like Vaseline
Store extra oxygen cylinders upright and out of direct sunlight - keep away from fire/ heat (5 ft)
Home safety check – working fire detectors and extinguishers

32
Q

Know risk factors for COPD

A 
Smoking* (accounts for 80-90%)
Second-hand smoke
Increased age
Occupational exposure (dust, chemicals)
Pollution
Genetic abnormalities
33
Q

Understand how to read a TB skin test

A 
Read 48-72 hrs
Measure = diam. of INDURATION (hardness)
NEG = 0-10mm
POS = > 10 mm
 > 5mm (HIV/AIDS)
34
Q

Patient education related to the management of fibromyalgia

A
  • Balance WORK and REST → pts have extreme FATIGUE
  • Diet, exercise, & non-pharmacologic management
  • Anti-inflammatory diet: No nightshades, No high fat meat, No red wine, No coffee, tea, soda
  • High omega 3 fatty acid foods: whole grains, dark leafy greens, nuts, soy, turmeric, & fish
  • Low impact exercise
  • Alternative treatment: massage, biofeedback, acupuncture/pressure
35
Q

Priority nursing actions in caring for a patient experiencing type 1 hypersensitivity
reactions

A

Administer EPINEPHRINE
O2 prn
Manage airway

36
Q

Patient education related to management of iron deficiency anemia

A

Iron supps w vitamin C
Iron rich foods🡪 organ meats, beans, leafy greens, fortified cereals,
Stool may be darker
Iron supplements may lead to constipation-increase fluids and fiber

37
Q

Nursing interventions when caring for a client with sickle cell anemia

A 
Pain management (#1 priority) 
Oxygen
IV fluids
Possible blood transfusion
No extreme temps
38
Q

Know ways to measure/assess level of consciousness

A

GCS

39
Q

Understand the Glasgow Coma Scale (GCS)

A 
High = good/with it
Low = bad/unresponsive
40
Q

Know seizure precautions

A 
Pad side rails
Bed in lowest position
Pads on floor
Loose clothing
Oxygen & suction equipment available
Initiate fall risk precautions
41
Q

Know priority nursing interventions for a client during and after seizure activity

A

During - keep them safe

  • Lower them to the floor
  • Protect head/move stuff away
  • Remove anything restrictive

After
- Airway - turn them on their side

42
Q

Understand nursing interventions for Parkinson’s Disease

A
  • Improving Mobility (daily exercise routine, better gait, physical therapy)
  • Enhancing Self-Care Activities (let them be independent/encourage independence, use adaptive/assistive devices, OT consult)
  • Improving Bowel Elimination (est. regular bowel routine, increase fluid/fiber to help with constipation)
  • Enhancing Swallowing (upright when eating, thicken liquids, monitor weight, supplemental feedings, dietician consult)
  • Improving Communication (speech therapy consult, develop methods of communication)
  • Supporting Coping Abilities (supporting family/patient, set achievable goals, encourage independence)
43
Q

Know patient education for post-operative cataract surgery

A
  • Protective eye patch for first 24 hours post op, then eyeglasses/eye shield at night 1 week
  • Eye medications used post-op
  • Wear sunglasses outside
  • Expected post op symptoms: minimal discomfort, eye discharge (in am), redness, a scratchy feeling
  • Call doctor if new floaters (dots) in vision, flashing lights, decrease in vision, and pain (All indicators of retinal detachment)
44
Q

Understand patient care/education for Meniere’s disease

A
  • Treat with a low sodium diet
  • May experience: Episodic vertigo (comes and goes), Tinnitus- ringing in ear, Fluctuating hearing loss, Feeling of fullness in ear, Nausea/vomiting
  • Surgery only gets rid of vertigo
45
Q

Understand colonoscopy prep, and know clear liquid and low fiber foods

A
  • 3 days to surg = low fiber
  • 2 days to surg = liquids only
  • 1 day to surg = clear liquid
  • NPO after midnight
  • No red foods/drinks
  • Day before prep includes: 4 Dulcolax tablets, 64 oz (1 entire bottle) Miralax mixed in fluid – drink 8 oz every 15 minutes until finished
  • Goal = passing clear, yellow, liquid stool without sediments
  • Special consideration needed for diabetic patients
46
Q

Understand nursing interventions for NG tubes

A
  • Clearing Tube Obstructions – irrigate with warm water
  • Monitoring/Maintaining Tube Function – xray, aspirating, air bolus
  • Providing Oral/Nasal Hygiene
  • Monitor/Managing Potential Complications (fluid volume deficit, pulmonary complications)
47
Q

Understand treatment, nursing interventions, and patient education for GERD, Barrett
Esophagus, Gastritis, and Diverticular disease

A

Gerd

  • Acid controlling meds
  • H. pylori – antibiotics
  • Don’t lay down
  • Small frequent meals
  • Head of bed elevated

Barrett Esophagus

  • Acid controlling meds
  • Reducing symptoms of GERD
  • Surveillance with biopsies

Gastritis

  • Reducing Anxiety
  • Promoting Optimal Nutrition
  • Promoting Fluid Balance
  • Relieving Pain

Diverticular disease

    • fiber, - fat
  • Avoid foods that trigger
  • Bulk lax
  • Surgery – bowel resection
48
Q

Know risk factors for peptic ulcer disease

A

*H. pylori
*NSAID use
Men
Type O blood

49
Q

Know clinical manifestations of peritonitis

A

Diffuse pain which becomes more localized
Movement aggravates pain
Abdominal tenderness, distension, and rigidity
Nausea and vomiting
Fever
Tachycardia

50
Q

Understand nursing interventions for post-op appendectomy

A 
High fowlers 
Pain meds
Prevent fluid volume deficit 
Relieving Pain
Preventing/Treating Surgical Site Infections
Preventing Atelectasis
Maintaining Skin Integrity
Obtaining Optimal Nutrition
51
Q

Patient education related to managing kidney stones

A 
Increase fluids (3L/day)
Strain all urine for stones
Ambulation, not bed rest
NEVER massage
Diet→ restrict protein “animal meats”, limit purines: red meats, organ meats, beer
52
Q

Nursing interventions when caring for a patient with renal calculi

A

Administer analgesics
Encourage fluid intake
Strain all urine for stones
Encourage ambulation

53
Q

Nursing interventions for the prevention of UTIs

A 
Increase Fluid intake
Void after sex
Void when you feel the urge
Clean from front to back
Hang foley bags below bladder level
Wear cotton underwear
54
Q

Management of patients with hyper and hypocalcemia

A

Hypocalcemia

  • Caused by: decreased parathyroid function, poor intake, osteoporosis
  • Increase calcium intake
  • Treat with calcium gluconate & Vitamin D

Hypercalcemia

  • Caused by: bone degradation (out of bones into blood)
  • Treat with calcitonin salmon; removal of parathyroid gland; IV fluids, laxatives
55
Q

Management of patients with potassium imbalances

A

Watch for EKG changes

Hypokalemia: due to vomiting/diarrhea
Treatment: IV fluids, increase consumption of foods high in K+, treat the symptoms

Hyperkalemia: due to K+ sparing diuretics & kidney disease
Treatment: administer potassium wasting diuretics, calcium, insulin

BOTH: Monitor serum potassium levels
Normal Potassium: 3.5-5!

56
Q

Clinical manifestations of fluid volume overload

A

Cramping, edema, abdominal distention, SOB, high BP, rapid weight gain, crackles in lungs

Adult Health 1 (2 decks)

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