Final Flashcards
How to use a cane
- Elbow should be flexed 30 degrees
- Pt. should hold cane in hand opposite to affected extremity
- Cane and affected leg should be moved together at same time
- Pt. should bear down on cane when unaffected extremity is moved
Using a cane on stairs
- Down: 1. Affected extremity 2. Cane 3. unaffected extremity.
- UP: 1. Unaffected extremity, 2 Cane and affected extremity
How to use crutches
- Crutch length should be 5 cm (2 in) below axilla
- 20 – 30 degrees of flexation should be allowed at elbow
Using crutches on stairs
- Down: 1. Crutches 2. Affected 3. Unaffected
- Up: 1. Unaffected 2. Crutches and affected
Using a walker
- Adjust height so patient arms have 20 – 30 degrees of flexion
- Instruct pt. to never pull self up using walker and to look up when walking
Primary Prevention
- Aims to prevent health disorders from occurring in the first place by decreasing risk factors and increasing protective factors
Examples of primary prevention activities include youth groups and clubs, which help to increase community bonds and support; parenting classes; and education to prevent substance abuse
Secondary Prevention
- As this level a patient already has a disorder; secondary prevention aims at detecting the disorder early to intervene promptly
Essentially, this means screening. Screening patients for depression or suicide risk, for example, can lead to the early intervention ― and prevention — of a more dire outcome.
Tertiary Prevention
- Focus is on period after mental health disorder or crisis has occurred; tertiary prevention aims to promote patient recovery and to prevent further complications.
Examples of tertiary prevention include outpatient support for a patient following a hospitalization related to a mental health disorder or crisis. It can include pharmacological therapy. And it can include support groups for family and friends of a patient who has committed suicide as a way for them to begin the healing process.
What to do before administering Zyprexa/Olanzapine (2)
- Assess mental status (orientation, mood, behavior) before and periodically during therapy
- Monitor BP
Clozaril/Clozapine – When to notify MD
If fever develops
Patient teaching for lithium
- Weight gain is expected
- Be careful to eat healthy diet
Medications which require blood level monitoring (4)
- Lithium
- Clozapine/Clozaril
- Valproic acid
- Carbamazepine
Priority nursing diagnosis for patient with bipolar, insomnia and weight loss
- Imbalanced nutrition: less than body requirements
The parents of a teenage son who was recently diagnosed with bipolar disorder ask the nurse to provide them with information about this illness, since they had previously been told their son had ADHD. Which of the following is evidence-based information that can be shared with the family? Select all that apply.
1) ADHD is the most common comorbid condition in children and adolescents with bipolar disorder.
2) Bipolar disorder in children and adolescents is an acute condition that they usually outgrow.
3) There is evidence to support that psychosocial therapy enhances the effectiveness of pharmacological therapy in treatment of bipolar disorder in children and adolescents.
4) Stimulants used in the treatment of ADHD can exacerbate mania in children and adolescents with bipolar disorder.
5) Medication discontinuation can be considered after the patient has been in remission for two months.
1) ADHD is the most common comorbid condition in children and adolescents with bipolar disorder.
3) There is evidence to support that psychosocial therapy enhances the effectiveness of pharmacological therapy in treatment of bipolar disorder in children and adolescents.
4) Stimulants used in the treatment of ADHD can exacerbate mania in children and adolescents with bipolar disorder.
Nursing diagnosis for patient twisting and pulling hair
Ineffective impulse control
What to monitor in patient taking Zoloft/sertraline (SSRI antidepressant)
Suicidal ideation
Education for patient who missed a dose of Wellbutrin/bupropion (antidepressant)
Missed doses should be omitted. Do not double dose
Therapeutic communication technique to get information from patient
Open ended questions
Medication for patient presenting with alcohol withdrawal (diaphoresis, nausea, tremors)
- Ativan/lorazepam (antianxiety benzodiazepine)
- Librium (antianxiety benzodiazepine)
S&S of avoidant personality disorder
- Social isolation
- Fear of rejection
Teaching for patient taking beta blockers
Change positions slowly
Why is thiamine given for alcohol detoxification?
- To treat/reduce risk of Wernicke’s disease
- To maintain neuronal activity
Wernicke’s disease is a brain and memory disorder. Caused by thiamine (b1) deficiency it causes cause ataxia, confusion and visual change; it must be treated immediately.
What can type 1 diabetes lead to?
Blindness
What should the nurse do first if a urinalysis tests positive for glucose?
Finger stick
