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Final Flashcards

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1
Q

S/s of immobility

A

effecting respiratory: decreases O2 & CO2 exchange, leads to atelectasis, which can further lead to pneumoniac

effecting muscles & bones:
pt is confined to bed:
7-10% of muscle strength (atrophy) is lost per week

effecting GI system:
Slows peristalsis, which leads to constipation & gas, bed sores , reposition, walk around

Psychological effects due to Immobility:
Leads to isolation, mood changes, depression, anxiety

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2
Q

?Physiological changes if the older adult?

A

the skin loses it’s resilience and moisture. Wrinkly, thinner skin is normal as well as “Age spots”

Facial features become more pronounced because of loss of fat and subcutaneous tissue

Visual and hearing decline

Vocal changes occur

Older adults are less able to taste salty, sweet, sour and bitterness.

The sense of smell is decreased in older adults

Salvitory secretion is reduced in older adults.

respiratory muscle strength begins to decline.

Thinning hair

Slower nail growth,

Decreased cough reflex.
-Decreased removal of airway irritants

Thickening of blood vessel walls
-Narrowing of vessel lumen

decrease in height

  • Decreased muscle mass and strength
  • Degenerative joint changes
  • Decalcification of bones
Fall risk
Less movement 
Tolerance for medication goes down 
Metabolism decreases 
Skin breakdown 
Loose weight 
Comorbidities
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3
Q

?Teaching points of osteoarthritis

A 
Risk factors for Osteoarthritis
Aging
Obesity
Genetics
Joint injury
Occupation (those that use same joints continuously, for example athletes)

Treatment of Osteoarthritis
*2 main goals are to provide comfort & maintain function/mobility

Application of heat
TENS unit
Weight loss
Nonpharmacological techniques for pain relief

Medications: acetaminophen, meloxicam, cortisone (orally, injections), arthritic rubs

If function is completely lost joint replacement surgery would then have to be explored

*get up and move! Rest periods

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4
Q

Physiological Changes in Elderly

A
  • Frailty
  • Comorbidities
  • Reduced physiolgical reserve
  • Slower processing time
  • Recent memory loss
  • Decreased sensory perception of touch
  • Changes in perception of pain
  • Change in sleep patterns
  • Altered balance and/or decreased coordination
  • Increased risk for infection
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5
Q

Teaching Interventions for Osteoarthritis

A

Position joints in their functional position

  • Rest balanced with exercise
  • Heat/cold applications
  • Weight control
  • Teach him or her to check that the heat source is not too heavy or so hot that it causes burns
  • Teach pt about adverse effects from NSAIDS and need to report them to doctor
  • Teach pt to use cold packs that aren’t too heavy
  • Use of glucosamine (decrease inflammation)
  • Use of chondroitin (strengthens cartilage)
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6
Q

Risk Factors for Falls

A
  • History of falls
  • decrease in sensory
  • Osteoporosis
  • Advanced age (>80)
  • Multiple illnesses
  • Generalized weakness or decreased mobility
  • Gait and postural instability
  • Disorientation/confusion/delirium
  • Use of drugs that can cause increased confusion, mobility limitations, or orthostatic hypotension
  • Urinary incontinence
  • Communication impairments
  • Decrease in sensory
  • Major visual impairment or visual impairment without correction
  • Alcohol or other substance use
  • Location of patient’s room away from the nurses’ station (in the hospital or nursing home)
  • Change of shift or mealtime (in the hospital or nursing home)
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7
Q

Teaching Interventions for Fall Risk

A

Monitor the patient’s activities and behavior as often as possible, preferably every 30 to 60 minutes.

  • Teach the patient and family about the fall prevention program to become safety partners.
  • Remind the patient to call for help before getting out of bed or a chair.
  • Help the patient get out of bed or a chair if needed; lock all equipment such as beds and wheelchairs before transferring patients.
  • Teach patients to use the grab bars when walking in the hall without assistive devices or when using the bathroom.
  • Provide or remind the patient to use a walker or cane for ambulating if needed; teach him or her how to use these devices.
  • Remind the patient to wear eyeglasses or a hearing aid if needed.
  • Help the incontinent patient to toilet every 1 to 2 hours.
  • Clean up spills immediately.
  • Arrange the furniture in the patient’s room or hallway to eliminate clutter or obstacles that could contribute to a fall.
  • Provide adequate lighting at all times, especially at night.
  • Observe for side effects and toxic effects of drug therapy.
  • Orient the patient to the environment.
  • Keep the call light and patient care articles within reach; ensure that the patient can use the call light.
  • Place the bed in the lowest position with the brakes locked.
  • Place objects that the patient needs within reach.
  • Ensure that adequate handrails are present in the patient’s room, bathroom, and hall.
  • Have the physical therapist assess the patient for mobility and safety.
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8
Q

Teaching interventions for Fibromyalgia

A

limit intake of caffeine, alcohol, and other substances that interfere with sleep

teach pt to develop routine for sleep

Do not take NSAIDS on an empty stomach

SNRI to decrease nerve pain; no alcohol while on the medicaation
————————
Chronic pain- stiff and tender

Pain worsens with stress , activity, and weather

May cause fatigue, sleeping disturbances, numbness, tingling , headache, jaw pain, sensitive to noises, odors, lights

Most common in women 30-40

Limit alcohol and caffeine

Take meds such as gabapentin, lyrica (anticonvulsants), cymbalta (SNRIs), amitriptyline (tricyclics), tramadol, NSAIDs , muscle relaxants , and physical therapy

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9
Q

self-determination or self-management.

When pt is not capable of self-determination, you are ethically obligated to protect him or her as an advocate within the professional scope of practice

A

Autonomy

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10
Q

promotes positive actions to help others.

Encourages the nurse to do good for the patient

A

Beneficence

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11
Q

do no harm and prevent harm to ensure pt wellbeing

A

Nonmaleficence

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12
Q

agreement that nurses will keep their obligations or promises to patients to follow through with care.

A

fidelity

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13
Q

the nurse is obligated to tell the truth to the best of his or her knowledge.

A

Veracity

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14
Q

all patients should be treated equally and fairly, regardless of age, gender identity, sexual orientation, religion, race, ethnicity, or education

A

Social justice

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15
Q

most fundamental all human life is sacred

A

Respect for people

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16
Q

right to (private information)

A

Confidentiality

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17
Q

OT comply with the law and rules,documentation

A

Procedural justice

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18
Q

Postoperative bowel sounds?

A

No bowl sound/ileus will be considered normal post op, but should return. Anesthetics will slow peristalsis. Routine toileting.

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19
Q

Glomerulonephritis risk factors

A

inflammation of the kidneys, group A strep, respiratory infections, GI infections, hep b and c, endocarditis, HIV, some cancers, some drugs. Inflammation of the tiny filters in your kidneys that remove excess fluids, wastes, and electrolytes from the bloodstream and pass through urine. Conditions leading to inflammation can be infections, immune disorders, high BP, and diabetes. “Immune compromised patients.”

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20
Q

problem-solving approach to clinical decision-making within a healthcare organization. It integrates the best available scientific evidence with the best available experiential (patient and practitioner) evidence.

A

EBP

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21
Q

Bowel sounds - splashing noise with absent around

Crampy, coliky, abd pain

Nausea and dark green/yellow bilious vomiting

Constipation

Loud growling abd noise

A

succession splash heard proximal to a bowel obstruction in the early stages. Diminishes as obstruction becomes complete bowel obstruction.

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22
Q

Tx of bowel obstruction?

A

NG down throat into stomach decompression - bowel Resection or laparoscopic surgery

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23
Q

acute inflammation of the kidney due to a bacterial infection

A

pyelonephritis

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24
Q

S/s of pyelonephritis

A

Infection of the upper urinary system

Infection Goes to kidney

6 Symptoms of pyelonephritis:

Fever, blood in Urine, urgency, chills, flank pain, n/v, headaches, increase HR and Resp., HTN, nocturia, hyperkalemia, acidosis, inability to develop sodium.

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25
Q

What does RACE stand for?

A

Rescue, Alarm, Contain, Extinguish

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26
Q

What does PASS stand for?

A

pull the pin, aim at the base, squeeze the lever, sweep from side the side.

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27
Q

S/s with immobility 2

A

Skin breakdown, clots (swelling, edema, redness), constipation

Incomplete bladder emptying, dehydration, UTI, Renal calculi

Pressure ulcers-Skin breakdown

Decreased cardiac contraction
Decreased contractibility, blood pooling in distal areas; monitor vitals, promote activity, elevate the feet, turn patient onto left side, use TED hose, SCD’s

Orthostatic hypotension
Get up slowly, sit before standing, increase fluids

Bronchial secretions
Bronchial stasis, atelectasis; educate the client, use incentive spirometer, deep breathing technique and coughing exercises/hold cough

Decreased muscle mass and strength:
ROM is decreased, atrophy & contractures
To prevent, do ROM exercises, turning, bring in PT and nutrition

DVT formation- do not massage or elevate - Homans sign

GI system
Decreased motility/peristalsis: constipation

Psychological effects of immobility
monitor for signs of depression, promote activity, create achievement goals, encourage support groups, validate their feelings

Immobility of the Respiratory System
Decreased respiratory movement resulting in atelectasis, hypostatic pneumonia, and decreased cough response.

Immobility of the Metabolic/Endocrine System

  • Decreased appetite and altered nutritional intake, - Decreased protein - muscle and weight loss
  • Alterations in calcium/fluid/electrolytes,
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28
Q

Electrical safety

A 
?
Can occur in hospital environment 
Electrical outlets
Cause fires 
Infants

Multiple outlets of separate circuits are required to avoid overloads that prevent short circuits and loss of power
Ensure it meets standards
Must be functional and properly working condition
Proper placement of grounding pads, inspection of device, avoid pt contact with metal components, other equipments or pooling preparation solutions prevent surgical burns

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29
Q

PrioritiZation

A

ABCDE

Airway/cervical spine (low O2, SOB)

Breathing (crackles in lungs)

Circulation (bp, skin)

Disability (neurological)

Exposure

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30
Q

Infant safety

Cribs , cars seats , know rules to keep them safe

A

Keep baby on back with nothing in crib
Crib railings two finger with apart?

Away from water

No small objects

Away from heat

Away from chemicals/meds

Faced rear in car seat until 2 years old or until HT and WT is reached. MVAs leading cause of death

Mistreatment

Electrocution

Falls

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31
Q

Leading cause of death through out lifespan

A

Motor vehicle accidents

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32
Q

Medication rights

A 
Right Patient.
Right Drug.
Right Route.
Right Dose.
Right Time.
Right Documentation.
Right To Refuse.
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33
Q

Sentinel events

A

Never mistakes that should never happen in healthcare

Clearly identifiable, preventable, and serious for patients such as death, physical or phycological injury, or major permanent loss of function

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34
Q

What to do if there is a medication error?

A

Take vitals/check patient
Notify physician
Incident report

Never chart in record that you filled out an incident report

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35
Q

S/s of osteoporosis

A

Inspect vertebral column - kyphosis present

Back pain, movement restriction, deformed spine , constipation , abd distended, reflux, reps compromise , swelling

More in women

It is progressive and chronic and causes by low bone mass and bone tissue deterioration
May cause fractures

S/s include back pain, fractured vertebrae, height loss, kyphosis, compressed fractures

Must diagnose with dual X-ray most common in spine and hip
QCT or lateral radiographs

Bone density 2.5 or lower increased creatinine, T-SHIRT and lower calcium

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36
Q

Teaching points with osteoporosis

A

Fosomax- take on empty stomach in am with water 30 min before breakfast sitting upright

Calcium and vit D

Weight bearing exercises, walking, jogging , resistance

Screen bone density if 65 and older

Drink occasionally and no smoking

Inspect vertebral column - kyphosis present

Reposition every 2 hits or PRN
ROM
Assist with transfer and ambulating 
Encourage exercise 
Balanced diet
More in women

It is progressive and chronic and causes by low bone mass and bone tissue deterioration
May cause fractures

Must diagnose with dual X-ray most common in spine and hip
QCT or lateral radiographs

Bone density 2.5 or lower increased creatinine, T-SHIRT and lower calcium

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37
Q

Delegation ? What can you delegate?

A

?

RNs can delegate to other RNs, LPns and UAPs but it must be with in their scope , can not diagnose

LPNs can not teach clients what has not already been taught, no IVs, assessments, or care plans

UAPs- can not pass meds or do anything medical besides take vitals on stable clients, help with cares, feeding, transforming, bathing, toileting

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38
Q

Respiratory function in immobilized patients teaching points

A

Bronchial secretions
Bronchial stasis, atelectasis; educate the client,

use incentive spirometer, deep breathing technique and coughing exercises/hold cough, adequate fluid intake

Immobility of the Respiratory System
Decreased respiratory movement resulting in atelectasis, hypostatic pneumonia, and decreased cough response.

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39
Q

Patient rights

A

1.Right to considerate and respectful care
2.the right to information such as diagnosis, prognosis and treatment as well as:
a. Risks & benefits
b. Identity of care providers
c. Cost ($)
3. right to refuse care and to make decisions about the plan of care and be informed of the medical consequences if refuses
4. right to have an advance directive such as a living will or POA
5. right to every consideration of privacy
6. right to keep records confidential.
7. right to review their records
8. right to receive a reasonable response to their requests from facility such as:
a. The hospital must provide service indicated by the urgency of the care
b. Transferred
9. right to ask and to be informed of business relationships of the hospital, educational
institutions, other health care providers, and payers that may influence the patient’s treatment of care.
10. right to consent to or decline to participate in research studies- and right to have them fully explained before consent.
11. right to expect continuity of care and to be informed of available and realistic patient care options when hospital care is no longer appropriate.
12. right to be informed of hospital policies & practices that relate to patient care, treatment, and responsibilities. (Conflict, charges)

Does not change for terminally ill clients

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40
Q

What is palliative care?

A

Comfort care or end of life care. Managing symptoms of pain, dyspnea, depression.

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41
Q

Lasix teaching and side effects and how it lowers bp ?

A

Loop Acting Diuretics-

Cause the kidneys to excrete more urine by reabsorbing less water in the body & lowers blood pressure.

S/E-
increased urination
Loss of minerals/electrolytes such as sodium, potassium, magnesium
Cause dehydration, gout (joint disorders), dizziness, lower BP with postural change, and syncope (fainting), impotence, reduces edema, causes headaches, muscle cramps, and impotence

Can cause tinitius (ringing in ears) can drink caffeine/tea

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42
Q

Normal urine output

A

Adult: 1500-2000 ML in 24 hours

Minimum Output should be at least 30ML/Hour

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43
Q

HIPPA

A

Health Insurance Portability and Accountability Act

  • Federal law
  • Protects patient information in the medical record, conversations, personal insurance and billing information.
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44
Q

S/s of kidney stones

A 
Elevated bp  
Tachycardia  
Restlessness 
Note location duration and intensity of pain
Blood in urine
Flank pain
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45
Q

Difference between strains and sprains

A

Sprain- affects a ligament

Strain - affects muscle and tendon

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46
Q

How to treat strains and sprains ?

A

RICE

Rest , ice, compression, elevation

MONIC??

How long to ice? 20-30
Min

Heat then ice

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47
Q

Diagnostic tests used for kidney stones

A

(caused by too much calcium, dehydration, and hypernatremia)
Blood calcium, phosphorus, uric acid and electrolytes off

LABS/Tests:  
Bun 
Creatinine 
Urinalysis  
Ultrasound

K, U, B, X-ray *****

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48
Q

S/s of IBS and what to give for loose stools

Tx options?

What is the number one cause?

A

S/S of IBS and TX options
Stress is the #1 cause-
IBS: Treatment
no cure. anticholinergics, antidiarrheal agents, increase fiber, increase mobility, laxatives, decrease stress, low fat diets, don’t drink alcohol or smoke.
S/S: gas, abdominal pain, bloating, diarrhea, and constipation.

Imodium

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49
Q

failure to use ordinary or reasonable care or the failure to act in a reasonable and prudent(careful) manner.

A

Malpractice

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50
Q

unreasonable and preventable risk of harm to patient.

A

Negligence

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51
Q

being responsible by law- which malpractice and negligence can lead to.

A

Liability

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52
Q

PSDA

A

PSDA- Patient Self Determination Act of 1990, patient legally have a right to autonomy and veracity

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53
Q

EMTALA

A

EMTALA-Not transferring a patient, but providing them care even if they cannot pay in the emergency room at least until they are stable?
EMTALA stands for?
Emergency medical treatment and labor act

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54
Q

Types of ostomies and care for them

A

??
Subtotal colectomy, ileocecectomy, proctocolectomy with ileostomy

Have bag on right and measured correctly when cutting around

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55
Q

Advanced directives and what it includes

A

A legal document that people use to decide how their healthcare should be carried out when they are no longer able to due to illness. (CPR/DNR) It includes Living Wills, healthcare proxy, treatment directive, and POA. Can be oral or written. POA must be at least 18 years of age and not an owner of healthcare facility which the patient resides. A copy should be given to POA, provider, and hospital.

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56
Q

involuntary escape of larger amt of urine with strong urge to void.

A

Urge incontinence

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57
Q

Involuntary escape of urine with cough, sneeze

A

Stress incontinence

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58
Q

Protects rescuers from being sued for giving emergency care.

A

Good Samaritan law

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59
Q

Nurses are mandated reporters

What items need to be reported?

A

People who are required to report suspected or observed abuse or neglect. It includes reporting certain events, acts, and situations. Reportable events are determined by local law. Notify manager immediately.

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60
Q

Informed consent

When it’s needed?

When it’s not needed

A

Statement stating that the patient has the capacity to consent and that they have been informed of information regarding tx/procedure and has agreed and has given permission to treatment. Nurse must witness informed consent and ensure provider gave information and they are competent to give consent, document and inform pcp of any questions.

It is needed- verbal or written consent Unless emergency-implied
Include the diagnosis, predicted course with or with out tx, costs, need for tx, advantages and disadvantages, risks, long term effects, time, effect on job performance.
Forms- implied, expressed, and written consent
Send letter to pt if refusal occurs- document date, signed by PCP, pt and witness- document pcp info goven to pt. , pts understanding of risks, pt reasons for refusal.

5th grade reading level

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61
Q

S/s of malignant hyperthermia

How to treat

A

is an inherited muscle disorder acute life threatening complication of anesthesia

  • characterized by increased body temp, potassium, calcium, uncle metabolism
  • Acidosis, heart dysthymias

MH can start immediately, few hours into surgery or after completion.-

depends on diagnosis and actions of surgical team.

**dantrolene is a muscle relaxant which is the medication of choice for MH.

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62
Q

Accountability

A

Responsibility

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63
Q

IV gauges sizes and when to use

A

24-smallest and shortest inch - used in kids and peds

22 used in elderly or kids

20-radiology patients

18-16-14: biggest for trauma patients

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64
Q

Cardinal s/s of infection

A

Warmth, redness, swelling, pain, decreased function

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65
Q

ABG lab values

PH-

CO2

HCO3

A

pH: 7.35-7.45.

PaCO2): 35-45 mmHg.

HcO3: 22-26

Look back at webex at her explanation

Tic tac toe method

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66
Q

VRE stands for

A

Vancomycin-resistant Enterococcus

bacteria’s strains that are resistant to vancomycin

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67
Q

immune functions of inflammation response that involves interaction of B lymphocytes with antigen and their differentiation into antibody-secreting plasma cells.

A

AMI

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68
Q

The immune function of inflammation that involves several subpopulations of T lymphocytes that recognize antigens on the surfaces of cells. TH cells respond to antigen with the production of lymphokines.

A

CMI

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69
Q

Neutrophils segs bands

A

Segs are good, bands are bad… (immature neutrophils)

Segs shift to the left when you have too many neutrophils..thats when you start to see the bands..if too many bands then you may be worried that your body will not be able to fight off infection.

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70
Q

immunity which results from the production of antibodies by the immune system after responding to an antigen.

Example: fighting off a sickness on one’s own after being exposed to bacteria. Building up resistance sue to immunizations

A

Active immunity

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71
Q

transfer of ready-made antibodies.

Example:
protection against infections by drinking colostrum.

A

Passive immunity

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72
Q

4 types of hypersensitivity reactions and examples of each

A

Type I: Immediate Hypersensitivity (Anaphylactic Reaction) These allergic reactions are systemic or localized, as in allergic dermatitis (e.g., hives, wheal and erythema reactions).

  • Type II: Cytotoxic Reaction (Antibody-dependent) (blood transfusion reaction, RH, autoimmune disease)
  • Type III: Immune Complex Reaction.-inflammation

• Type IV: Cell-Mediated (Delayed Hypersensitivity)
rash from poison ivy or nikel

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73
Q

6 links of chain of infection

What they stand for?

A 
infectious agent, 
reservoir, 
portal of exit, 
mode of transmission, 
portal of entry, 
and susceptible host.
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74
Q

something that infiltrates another living thing, like you. When an infectious agenthitches a ride, you have officially become an infected host.

There are four main classes of infectious agents: bacteria, viruses, fungi, and parasites.

A

Infectious agent

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75
Q

place where fluid collects, especially in rock strata or in the body. (like a pool)

A

Reservoir

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76
Q
  • is the site from where micro-organisms leave the host to enter another host and cause disease/infection.
    For example, a micro-organism may leave the reservoir through the nose or mouth when someone sneezes or coughs, or in faeces.
A

Portal of exit

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77
Q

the route or method of transfer by which the infectious microorganism moves or is carried from one place to another to.

A

Mode of transmission

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78
Q

is the site through which micro-organisms enter the susceptible host and cause disease/infection. Infectious agents enter the body through various portals, including the mucous membranes, the skin, the respiratory and the gastrointestinal tracts.

A

Portal of entry

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79
Q

a member of a population who is at risk of becoming infected by a disease.

Example- elderly people. frail people. people with certain medical conditions, such as diabetes. people with low immunity – such as people with diseases that compromise their immune system or people who are being treated with chemotherapy or steroids.

A

Susceptible host

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80
Q

Majority of digestion occurs here ?

A

Small intestines

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81
Q

Insertion of female Foley catheter

A

female foley catheter

  1. check doctors orders
  2. Gather supplies, (cath. kit, a bath blanket, and additional light,)
  3. familiarize yourself with the anatomic landmarks
  4. Close the door and pull the privacy curtain.
  5. Raise the bed to a high position.
  6. Wash your hands or perform an alcohol-based hand rub
  7. Cover the client with a bath blanket and pull the top linen to the bottom of the bed
  8. Position an additional light at the bottom of the bed or ask an assistant to hold a flashlight.
  9. Use the corners of the bath blanket to cover each leg.
  10. Place the client in a dorsal recumbent position
  11. Remove the wrapper from the cath kit and position it nearby.
  12. Unwrap the sterile cover (on bed between legs)to maintain the sterility of the supplies inside
  13. Remove and don the packaged sterile gloves
  14. Remove the sterile towel from the kit and place it beneath the client’s hips
  15. If male, place a fenestrated drape over the perineum
  16. Test the balloon on the catheter by instilling fluid from the prefilled syringe; then aspirate the fluid back within the syringe
  17. Spread lube on tip of catheter
  18. Use swabs to cleanse both sides of labia top to bottom
  19. Separate the labia majora and minora with the thumb and fingers of the nondominant hand, exposing the urinary meatus
  20. Consider the hand separating the labia to be contaminated
  21. Keep the clean tissue separated
  22. Pick up the catheter, holding it approximately 3-4 in. from its tip
  23. Insert the tip of the catheter into the meatus approximately 2-3 in. or until urine begins to flow
  24. Hold the catheter in place with the fingers and thumb that were separating the labia.
  25. Pick up the prefilled syringe with the sterile, dominant hand, insert it into the opening to the balloon, and instill the fluid
  26. Withdraw the fluid from the balloon if the client feels pain or discomfort, advance the catheter a little more, or try again.
  27. Tug gently on the catheter after the balloon has been filled.
  28. Wipe the meatus and labia of any residual lubricant.
  29. Secure the catheter to the leg with tape or other commercial device
  30. Hang the collection bag below the level of the bladder; coil excess tubing on the mattress.
  31. Discard the cath tray and wrapper with soiled supplies.
  32. Remove your gloves and perform hand hygiene.
  33. Remove the drape, restore the top sheets, make the client comfortable, and lower the bed.
82
Q

Insertion of male catheter

A

male foley catheter

  • check doctors orders
  • gather supplies(cath kit, bath blanket light)
  • pull privacy curtain
  • wash hands
  • raise bed
  • assist client to supine position
  • remove the wrapper from the cath kit and position it nearby
  • unwrap the sterile inner cover between legs
  • remove and don the packaged sterile gloves
  • place the fenestrated drape over the client’s penis without touching the upper surface of the drape
  • Test the balloon on the catheter by instilling fluid from the prefilled syringe; then aspirate the fluid back within the syringe.
  • use swabs and wipe the penis in a circular manner from the meatus toward the base; repeat using a different swab each time
  • Apply gentle traction to the penis by pulling it straight up with the nondominant gloved hand
  • (Instill the contents of a prefilled syringe containing lubricant directly through the meatus into the urethra)
  • insert, but never force the catheter; rather, rotate the catheter, apply more traction to the penis, encourage the client to breathe deeply, or angle the penis toward the toes
  • Continue insertion until only the inflation and drainage ports are exposed and urine flows
  • .Pick up the prefilled syringe with the sterile, dominant hand, insert it into the opening to the balloon, and instill the fluid
  • Withdraw the fluid from the balloon if the client describes feeling pain or discomfort, advance the catheter a little more, and try again.Prevents internal injury
  • Tug gently on the catheter after the balloon has been filled.
  • (Connect the catheter to a urine collection bag)
  • Wipe the meatus and penis of any residual lubricant
  • Secure the catheter to the leg or abdomen with tape or other commercial device
83
Q

Insert and remove a cath

A
  1. Introduce yourself.
  2. Verify patient.
  3. Explain procedure.
  4. Ask if allergic to iodine.
  5. Wash hands.
  6. Apply non-sterile gloves.
  7. Get towels, wash clothes, basin, warm water, soap, and catheter kit.
  8. Close curtains.
  9. Raise bed.
  10. Lower side rail.
  11. Uncover patient.
  12. Position patient into dorsal recumbent position.
  13. Place towel under buttocks.
  14. Wash perineal area with soap and water, then pat dry.
  15. Dispose of towel.
  16. Move patient’s legs back onto bed.
  17. Cover patient.
  18. Raise side rail.
  19. Lower bed.
  20. Remove supplies.
  21. Remove gloves.
  22. Wash hands.
  23. Raise bed.
  24. Lower side rail.
  25. Uncover patient.
  26. Position patient into dorsal recumbent position.
  27. Place catheter kit between the patient’s legs toward the end of the bed.
  28. Open outer wrapper of kit away from self.
  29. Remove sterile gloves and place on side table.
  30. Remove under-drap and place beneath the buttocks.
  31. Remove top-drap and place over perineal area.
  32. Apply sterile gloves.
  33. Remove tray and place in sterile field.
  34. Open lubricant and squirt into tray.
  35. Remove covering from catheter without contaminating it.
  36. Attach syringe into port.
  37. Hold onto lower end of catheter.
  38. Inflate balloon and check for leaks.
  39. Remove water but leave syringe in port.
  40. Lubricate the tip of catheter.
  41. Open iodine swabs.
  42. Open labia minor with non-dominant hand.
  43. Clean right labia major, discard swab.
  44. Clean left labia major, discard swab.
  45. Clean right labia minor, discard swab.
  46. Clean left labia minor, discard swab.
  47. Clean center, discard swab.
  48. Grasp 3 to 4 inches from tip of catheter.
  49. Tell patient to take a deep breath.
  50. Insert catheter until urine appears.
  51. Advance another 1 to 3 inches.
  52. Move non-dominant hand from labia minor and grasp catheter to hold it in place.
  53. Inflate balloon using dominant hand.
  54. Remove syringe.
  55. Tug on catheter to make sure it is in the bladder.
  56. Let go of catheter.
  57. Clean iodine from perineum.
  58. Discard supplies.
  59. Raise side rail.
  60. Lower bed.
  61. Remove gloves.
  62. Wash hands.
  63. Put on non-sterile gloves.
  64. Raise bed.
  65. Lower side rail.
  66. Tape tubing to thigh.
  67. Coil extra tubing on the bed.
  68. Attach bag to bed below the bladder.
  69. Put patient’s legs back on the bed.
  70. Cover patient.
  71. Lower bed.
  72. Place call light in reach.
  73. Open curtains.
  74. Tell patient that you will return in 2 hours.
  75. Verbalize that (1) urine output should be at least 30 mL/hr, (2) if urine output is between 800 to 1000 mL, then I will clamp the tubing and return in 1 hour, and (3) if output is still high after 1 hour, I will reclamp tubing and call the physician.
    76-A. Document the (1) date, (2) time, (3) size and type of catheter, (4) type of technique used, (5) whether tube is taped to abdomen or thigh, (6) amount of water inserted into balloon, (7) color and characteristics of urine, and (8) your signature.

76-B. 9/15 1130 No. 12 Fr Foley inserted using sterile technique. Closed drainage system attached. Taped to right thigh. Patient showing slight discomfort during insertion. 10 mL of sterile water inserted into balloon. 350 mL of yellow, clear urine in collection bag. BDA, SPN
77. Introduce yourself.

  1. Verify patient.
  2. Explain procedure.
  3. Wash hands.
  4. Apply non-sterile gloves.
  5. Get towel and washcloth.
  6. Close curtains.
  7. Raise bed.
  8. Empty collection bag.
  9. Note color, odor, and amount of urine.
  10. Lower side rail.
  11. Uncover patient.
  12. Position patient into dorsal recumbent position.
  13. Place towel beneath perineum.
  14. Remove tape from thigh.
  15. Attach syringe to remove water from balloon.
  16. Grasp catheter.
  17. Ask patient to take a deep breath.
  18. Gently remove catheter.
  19. Place catheter on towel.
  20. Wrap towel around catheter.
  21. Clean perineum.
  22. Move patient’s legs back onto bed.
  23. Raise side rail.
  24. Lower bed.
  25. Place call light in reach.
  26. Open curtains.
  27. Remove gloves.
  28. Wash hands.
  29. Instruct patient to drink extra water.
  30. Warn patient that there may be mild burning with the first few voidings.
84
Q

Foley cath Care

A

Wipe front to back, clean hose from body outward.

Irrigate the catheter every shift to ensure patency

Label the catheter with the date it was inserted

Ensure tubing is secured to patient

Hang the collection bag on the side rail of bed.

85
Q

Abdominal post op teaching

A

Educate patient on the agenda on the day of surgery, including respiratory exercises, pain management techniques, the possibility of drainage tubes, dressings, casts, IV lines, and monitoring or oxygen equipment

*Coughing and deep breathing, flinch belly - pay attention to surgical site, drainage , transferring, peristalsis (intestine digestion movement)

86
Q

Know what to ask for in a health hx and assessment for evaluating a patient’s elimination status

A

Determine usual elimination status, stool characteristics, diet hx, appetite, fluid intake, hx of surgery or illnesses affecting GI tract, medication hx, exercise, emotional hx, mobility, dexterity. Asses mouth, teeth, tongue, gums, ability to chew, abd shape/color, rectum, anus for lesions, discoloration, inflammation, hemorrhoids. Lab tests, x-rays, hx of tumors, bleeding, parasites, infection.

87
Q

Leakage of a nonvesicant IV solution or medication into the extravascular tissue

Intervention-

A

Infiltration

Stop infusion and remove short peripheral catheter immediately after identification of problem.
Apply sterile dressing if weeping from tissue occurs.
Elevate extremity.
Warm or cold compresses may be used according to the solution infiltrated and organizational policy.
Warm compresses increase circulation to the area and speed healing. Cool compresses may be used to relieve discomfort and reduce swelling. Insert a new catheter in the opposite extremity. For all central venous catheters, obtain a study to determine the cause of the problem. For implanted port, remove and insert a new port access needle. Rate the infiltration using the INS Infiltration Scale and document

88
Q
  • Leakage of a vesicant IV solution or medication into the extravascular tissue Can occur with both peripheral and central catheters

Intervention

A

Extravasation

Stop infusion and disconnect administration set.

Aspirate drug from short peripheral catheter or port access needle.
Leave short peripheral catheter or port access needle in place to deliver antidote, if indicated by established policy.
If possible, aspirate residual drug from the exit site of a central venous catheter.

Administer antidote according to established policy.
Apply cold compresses for all drugs EXCEPT vinca alkaloids and epipodophyllotoxins. Photograph site. Monitor at 24 hrs, 1 wk, 2 wks, and as needed.
Surgical interventions may be required. Provide written instructions to patient and family.

89
Q
  • Inflammation of the vein Post-infusion phlebitis presents within 48-96 hrs after the catheter has been removed

Intervention

A

Phlebitis

Remove short peripheral catheter at the first sign of phlebitis;

use warm compresses to relieve pain.

Monitor frequently.

Document using Phlebitis Scale.

Insert a new catheter using the opposite extremity. Mechanical phlebitis occurring in the first week after PICC insertion may be treated without catheter removal.

Apply continuous heat; rest and elevate the extremity. Significant improvement is seen in 24 hrs, and complete resolution is seen within 72 hrs. Remove catheter if treatment is unsuccessful.

90
Q

Thrombosis

Blood clot inside the vein (infusion)

Intervention

A

Stop infusion and remove short peripheral catheter immediately.

Apply cold compresses to decrease blood flow and stabilize the clot.
Elevate extremity.
Surgical intervention may be required. For central venous catheters, notify the physician and obtain requests for a diagnostic study.

Low-dose thrombolytic agents can be used to lyse the clot.

91
Q

Stages of wound healing

How wounds heal??

A

Inflammatory phase - bleeding, clot/scab 2-5 days

Proliferative- 5 days to 3 weeks - granulation - contraction-epithialization, new tissue growth

Maturation - collagen forms
Scar tissue is 80% as strong as original tissue
3 weeks to 2 years

Wounds heal by regeneration, primary intention, secondary intention or tertiary intention.
Invloves epithelial, endothelial, and inflammatory cells, platelets, and fibroblasts that migrate into the wound to bring about tissue re- pair and regeneration.
Regenerative/Epithelial healing: wound affects only the epidermis and dermis, no scar forms, new skin cells can’t be distinguished from the intact skin.

92
Q

How wounds are classified

A

Wounds are classified according to
the degree of skin integrity,
length of time the wound has been present, level of contamination,
and depth or severity of the wound.

Skin integrity: open or closed

Length of time for healing: acute or chronic

Level of contamination: clean, clean-contaminated, contaminated and infected

Depth of wound: Superficial (epidermis), partial-thickness, and full-thickness (through every layer)

93
Q

Metabolic acidosis causes?

A

occurs when the body produces too much acid.

Causes: It can also occur when the kidneys are not removing enough acid from the body.

Symptoms include nausea, vomiting, fast breathing, and lethargy.

94
Q

Metabolic alkalosis causes and s/s

A

Metabolic alkalosis is a metabolic condition in which the pH of tissue is elevated beyond the normal range
Common causes: include prolonged vomiting, hypovolemia, diuretic use, and hypokalemia.

s/s:
• Confusion (can progress to stupor or coma)
• Hand tremor.
• Lightheadedness.
• Muscle twitching.
• Nausea, vomiting.
• Numbness or tingling in the face, hands, or feet.
• Prolonged muscle spasms (tetany)
95
Q

Respiratory alkalosis causes s/s

A

a disturbance in acid and base balance due to alveolar hyperventilation. Alveolar hyperventilation leads to a decreased partial pressure of arterial carbon dioxide (PaCO2

Causes: occurs when you breathe too fast or too deep and carbon dioxide levels drop too low. This causes the pH of the blood to rise and become too alkaline. When the blood becomes too acidic, respiratory acidosis occurs.

  • Symptoms:
  • anxiety.
  • chest pain.
  • lightheadedness.
  • muscle stiffness.
  • numbness around the mouth.
  • tremors.
96
Q

Respiratory acidosis causes s/s?

A

is a condition that occurs when the lungs can’t remove enough of the carbon dioxide (CO2) produced by the body.

Excess CO2 causes the pH of blood and other bodily fluids to decrease, making them too acidic.
Causes: impaired respiratory drive (eg, due to toxins, CNS disease), and airflow obstruction (eg, due to asthma, COPD, sleep apnea, airway edema).

Symptoms: headache, confusion, and drowsiness. Signs include tremor, myoclonic jerks, and asterixis

97
Q

Teachings of hypervolemia

A

Excessive fluid in the ECF

  1. Body tries to defend by urinating more, and edema formation
  2. Daily weight
  3. Ensure safety, restore normal fluid balance, provide supportive care, prevent future overloads
  4. Risk for skin breakdown: Turn and Repo Q2H
  5. May need O2
  6. Diuretics (If Kidney function is good)
  7. Fluid and Na+ restrictions
  8. Monitor I & O
98
Q

Hypovolemia teaching points?

A

a. Circulating blood volume is decreased = decreased perfusion
b. Body defends by vasoconstriction & peripheral resistance
c. Daily weight
d. Orthostatic BP (lying, sitting, standing), monitor HR
e. Prevent further fluid loss, increase fluid volume back to normal and provide safety
f. Mild-Mod deficit: PO Fluids
g. Severe deficit: IVF (monitor HR and output)

99
Q

Best indicator for fluid loss or gain/edema?

A

Weights

100
Q

S/s of Hypovolemia

A

Hypovolemia:

HTN, WT loss, tented dry skin, increased resp and pulse, cool skin, oliguria (little urine), flat neck veins, lethargy, subjective cues.

101
Q

S/s of hypervolemia

A

Hypervolemia:

HPN, WT gain, crackles, frothy sputum, distended neck vein, edema, increased CVP, bounding pulse, subjective cues. Confusion , SOB

102
Q

Standard precautions ? used for?

A

applies to the care of all patients
Transmission based precautions: outlines precautions to take based on the mode of transmission of the infection.

  • Gloves • For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and nonintact skin
  • Gown • During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated
  • Mask, eye protection (goggles), face shield* • During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions, especially suctioning, endotracheal intubation

Remember that gloves are an essential part of infection control and should always be worn as part of Standard Precautions.

Either handwashing or use of alcohol-based hand rubs should be done before donning and after removing gloves.

103
Q

Airborne precautions?

A
  1. Private room required with monitored negative airflow (with appropriate number of air exchanges and air discharge to outside or through HEPA filter); keep door(s) closed
  2. Special respiratory protection: • Wear PAPR for known or suspected TB • Susceptible people not to enter room of patient with known or suspected measles or varicella unless immune caregivers are not available • Susceptible people who must enter room must wear PAPR or N95 HEPA filter*
  3. Transport: patient to leave room only for essential clinical reasons, wearing surgical mask Diseases that are known or suspected to be transmitted by air:

• Measles (rubeola) • Mycobacterium tuberculosis, including multidrug-resistant TB (MDRTB) • Varicella (chickenpox)†; disseminated zoster (shingles)†

104
Q

Droplet precautions

A
  1. Private room preferred: if not available, may room patient with same active infection with same microorganisms if no other infection present; maintain distance of at least 3 feet from other patients if private room not available
  2. Mask: required when working within 3 feet of patient
  3. Transport: as for Airborne Precautions Diseases that are known or suspected to be transmitted by droplets:

• Diphtheria (pharyngeal) • Streptococcal pharyngitis • Pneumonia • Influenza • Rubella • Invasive disease (meningitis, pneumonia, sepsis) caused by Haemophilus influenzae type B or Neisseria meningitidis • Mumps • Pertussis

105
Q

Contact precautions

A

Contact Precautions

  1. Private room preferred: if not available, may cohort with patient with same active infection with same microorganisms if no other infection present
  2. Wear gloves when entering room
  3. Wash hands with antimicrobial soap before leaving patient’s room
  4. Wear gown to prevent contact with patient or contaminated items or if patient has uncontrolled body fluids; remove gown before leaving room
  5. Transport: patient to leave room only for essential clinical reasons; during transport, use needed precautions to prevent disease transmission
  6. Dedicated equipment for this patient only (or disinfect after use before taking from room) Diseases that are known or suspected to be transmitted by direct contact: • Clostridium difficile • Colonization or infection caused by multidrug-resistant organisms (e.g., MRSA, VRE) • Pediculosis • Respiratory syncytial virus • Scabies
106
Q

Know aldosterone, NP, RAS and ADH and how they work to regulate fluid balance in the body.

ADH:(Antidiuretic hormone)

RAS: renin angiotensin system

NP??? natriuretic peptide

A

Antidiuretic hormone (ADH) is a hormone that helps your kidneys manage the amount of water in your body.

holds onto H2O. nonapeptide that is synthesized in the hypothalamus. regulate the amount of water excreted by the kidneys.

RAS- renin angiotensin system: a hormone system that regulates blood pressure and fluid and electrolyte balance, as well as systemic vascular resistance. When blood volume or sodium levels in the body are low, or blood potassium is high, cells in the kidney release the enzyme, renin. Renin converts angiotensinogen, which is produced in the liver, to the hormone angiotensin

NP: natriuretic peptide hormone secreted from the cardiac atria.
The main function of ANP is causing a reduction in expanded extracellular fluid (ECF) volume by increasing renal sodium excretion.

107
Q

Know isotonic, hypotonic and hypertonic solutions. Know when to use them and some examples of each.
—————————-
same osmolality as blood

stays in vascular space)

When to use? Fluid and ltye replacement Is needed

Example? is diffusion, the movement of molecules from an area of high concentration to an area of low concentration.

A

Passive transports

Isotonic solutions

108
Q

lower osmolality(chemistry)than blood

(moves from vascular space into cells)

When to use? When Cellular hydration is needed

Example? A hypotonic solution is any solution that has a lower osmotic pressure than another solution.

A

Hypotonic solutions

109
Q

: higher osmolality than blood

moves from the cells into the ECF

When to use?
To increase urine output post op, DKA, hypovolemia, vascular expansion , third spacing

Example? Corn syrup, gluose, Saline solution, or a solution that contains salts, is hypertonic. …
A solution of 5% dextrose (sugar) and 0.45% sodium chloride is an example of a hypertonic solution - so is a solution of 5% dextrose and 0.9% sodium chloride.

A

Hypertonic solutions

110
Q

Magnesium levels

A

1.8-2.6

111
Q

Calcium levels

A

9-10.5

112
Q

Sodium levels

A

135-145

113
Q

Potassium levels

A

3.5-5

114
Q

Hyponatrenia s/s

A

Hyponatremia causes: diuretic use, diarrhea, heart failure, liver disease, renal disease, and the syndrome of inappropriate ADH secretion (SIADH).

affects the brain
Lethargy
Headache 
Confusion 
Apprehension 
Seizures 
Coma

Too much sodium loss or too much water (dilution)

115
Q

Hypernatremia s/s

A

Affects the brain

Wherever sodium goes, water follows. (headache) *affects the brain
Caused by dehydration, vomiting, diarrhea, medications
(too much sodium in the blood)

FRIED - Fever/Flushed, Restless, Increased fluid retention/BP, Edema, Decreased urinary output
Or
SALT- Skin flushed, Agitation, Low-grade Fever, Thirst

Hypernatremia causes: Dehydration or a loss of body fluids from prolonged vomiting, diarrhea, sweating or high fevers. Dehydration from not drinking enough water.

116
Q

Hyperkalemia s/s

A

Affects the heart

MURDER

M uscle weakness 
U rine, oliguria, anuria 
R espiratory distress 
D ecreased cardiac contractility 
E CG changes 
R eflexes, hyperreflexia (twitching increased reflexes), areflexia (absent reflexes)

caused by kidney disease (check potassium drip continuously) can affect heart and numbness as well.
Kidney disease is the most common cause of hyperkalemia, Addison’s disease, can lead to hyperkalemia, and Too much potassium in the diet

117
Q

Hypokalemia s/s

A

Affects the heart - threads pulse, arrhythmias/bradycardia/tachycardia

Shallow respiration’s

Decreased intestinal mobility

Alkalosis

Confusion

Weakness ,lethargic, fatigue

The heart and sensory/numbness is affected
Can be caused by diuretics (main cause), or vomiting, diarrhea, dehydration

118
Q

Hypocalcemia s/s

A

Very awake and muscles are affected and twitching- may cause trousseaus sign or Chvostek’s sign

Hypoparathyroidism is a main cause of hypocalcemia

S/s: 
Muscle cramps 
Increased DTR
Numbness/tingling 
Convulsions 
Arrhythmias 
Both signs 
Increased QT interval (increased risk of heart attack or abnormal rhythms)
119
Q

Hypercalcemia

A

person is very SEDATED also affect muscles

S/s: 
muscle weakness 
Decreased DTR
Polyuria 
Anorexia 
Nausea/vomiting
Arrhythmias 
Heart block
Hypertension

Shortened QT interval (increased risk of heart attack or abnormal rhythms)

Hypercalcemia: person is very SEDATED also affect muscles
Need Vitamin D to retain calcium

Hypercalcemia is usually a result of overactive parathyroid glands.

Other causes of hypercalcemia include cancer, certain other medical disorders, some medications, and taking too much of calcium and vitamin D supplements.

120
Q

Hypermagnesia s/s

A

person is very SEDATED also affect muscles

Decreased DTR (deep tendon reflexes)
Flushing 
Muscle weakness 
Lethargy
Decreased respiration’s 
Bradycardia 
Hypotension

Hypermagnesemia causes- kidney disease and liver failure
Ventilator if R < 12
Dialysis if in kidney failure
Watch kidney function and seizure precautions

121
Q

Hypomagnesia s/s

A

Causes:
hypomagnesemia are decreased gastrointestinal (GI) absorption and increased renal loss. Decreased GI absorption is frequently due to diarrhea, malabsorption, and inadequate dietary intake.

Watch kidney function and seizure precautions

s/s:
Increased DTR
Confusion 
Neuromuscular irritability 
Seizures 
Muscle cramps 
Tremors 
Insomnia 
Tachycardia

person is very alert and awake also affect muscle twitching

122
Q

What to watch for in Hypovolemia

A
  • Weight, heart rate and orthostatic BP
123
Q

Complications of wound healing?

Hemorrhage-

Infections-

Dehiscence

Evisceration

Fistula

A

Hemorrhage-The release of blood from a broken blood vessel, either inside or outside the body.

Infection-fever, red, warm, yellow/green drainage, pain, swelling, malaise

Dehiscence - wound split open

Evisceration- protruding out of wound

Fistulas-abnormal, epithelialized connection between two body structures

124
Q

Different types of wound drainage

Serous-
Sanguineous-
Serosanguineous-
Purulent -

A

Serous - watery clear

Serosanguineous- bloody and clear/light pink

Sanguineous- bloody

Purulent- yellow, brown, tan, green (infection)

125
Q

Nursing interventions for patients at risk for infection

A

Assess patients for risk for infections.

Monitor for signs and symptoms of infection.

Monitor laboratory tests results such as cultures and white blood cell (WBC) count and differential.

Screen all visitors for infections or infectious disease.

Inspect skin and mucous membranes for redness, heat, pain, swelling, and drainage.
Promote sufficient nutritional intake, especially protein for healing.

Encourage fluid intake to treat fever.

Teach the patient and family the signs and symptoms of infections and when to report them to the primary health care provider.

Teach the patient and family how to avoid infections in health care agencies and the community.

126
Q

Diverse medical/health care systems, practices, and products not considered part of convention medicine

A

CAM (complementary alternative medicine)

Such as guided imagery , relaxation therapy , holistic , breathing, biofeedback, acupuncture, therapeutic touch, chiropractic, etc

127
Q

Difference between acute and chronic pain ?

A

Acute pain is short lived less than 6 months - rapid onset

Chronic is pain that lasts longer than 6 months
- intractable pain is a type of chronic pain- often have a hard time finding something that works - interferes with daily activities

Acute pain has signs and symptoms that are visual with elevated vitals,

chronic pain the body adapts and vitals are normal

128
Q

How is pain classified?

A

Location
Intensity
Quality
Onset and duration

What area of body

Causes the pain?

129
Q

Origins of pain?

A

Localized pain- site of origin

Projected pain- diffuse around site of origin

Referred pain- felt distant from the site of painful stimuli

Radiating pain- felt among nerves

Superficial pain- top

Phantom pain- amputation pain

Psychogenic pain- pain from mind

Visceral pain- deep

Deep somatic - ligaments, tendons

130
Q

Causes of pain?

A

Neuropathic pain- results from nerves , burning, numbness, prickling

Nociceptive pain- most common after trauma or surgery, aching pain - visceral and somatic

131
Q

Different pain scales?

A

Wong-Baker (Faces) children

Beyer Oucher Pain scale- children pictures of pain 0-100 scale

CRIES pain scale- neonates and infants 0-6months

FLACC pain scale- nonverbal -> F (faces)
> L (legs)
> A (activity)
> C (cry)
> C (consolability)
*****dementia/ confused (cant talk) or young infants

COMFORT scale-assess pain and distress in critically ill pediatric patients on :
6 behavioral & 2 physiologic factors

  • VAS (Visual Analog Scale) mark on scale from 0-10 what pain level
  • not done on a confused patient
132
Q

Pharmacological options for pain?

A

Mild to severe pain- topicals , analgesics, anticonvulsants, local anesthetics , muscle relaxants , neuroleptics, corticosteroids,Tylenol, NSAIDS, etc

Moderate pain- codeine and tramadol

Severe pain-morphine, oxycodone,opioids , fetynal , good for breakthrough pain

TCA Antidepressants may help along with anti-epileptics/ gabipentin - first line for neuroleptic pain

133
Q

Hyperthermia? What it is? How to treat? How your body tries to regulate?

A

Dantralene infusion to treat

The body has different coping mechanisms to get rid of excess body heat, largely breathing, sweating, tand increasing blood flow to the surface of the skin.

134
Q

Hypothermia? What it is? How to treat? How your body tries to regulate?

A

Body temp below 95

hypothalamus, the brain’s temperature-control center, works to raise body temperature by triggering processes that heat and cool the body. During cold temperature exposure, shivering is a protective response to produce heat through muscle activity. In another heat-preserving response – called vasoconstriction – blood vessels temporarily narrow.

135
Q

Best way to obtain a core temp?

A

Rectal

136
Q

Most Heat loss in infants ?

A

Head

137
Q

refers to a molecule that is capable of eliciting an immune response by an organism’s immune system, whereas an antigen refers to a molecule that is capable of binding to the product of that immune response.

A

An immunogen

Sometimes the term immunogen is used interchangeably with the term antigen. But only an immunogen can evoke an immune response.

138
Q

is an epidemic of world-wide proportions.

A

Pandemic

139
Q

Examples of primary defense mechanisms of the body?

A

Natural barriers and the immune system defend the body against organisms that can cause infection.

Natural barriers include the skin, mucous membranes, tears, earwax, mucus, and stomach acid, urine flow, good bacteria

140
Q

What is medical asepsis?

A

AKA Clean Technique
Hand Hygiene (#1)
Clean Environment

141
Q

removal of visible soil from object and surfaces

A

Cleaning

142
Q

removes virtually all pathogens on objects by physical or chemical means

A

Disinfecting

143
Q

elimination of all microorganisms (except prions) in or on an object.

A

Sterilization

144
Q

Compensating organs and if they are fast or slow to respond ?

A

Lungs and kidneys

Lungs - fast

Kidneys- slow

145
Q

How to treat diarrhea?

A

Immodium , pepto bismol

Drink plenty of fluids, and follow the “BRAT” diet (bananas, rice, applesauce, and toast)

Probiotics

146
Q

How to treat constipation?

A

Increase fluids

Walk exercise

Laxatives

Increase fiber

Vegetables

Probiotics

147
Q

Hepatitis? S/s ? tx?

A

is inflammation of the liver tissue.Some people with hepatitis have no symptoms, whereas others develop yellow discoloration of the skin and whites of the eyes (jaundice), poor appetite, vomiting, tiredness, abdominal pain, and diarrhea.

Tx?

148
Q

Cirrhosis? S/s? Tx?

A

the liver does not function properly due to long-term damage

tired, weak, itchy, have swelling in the lower legs, develop yellow skin, bruise easily, have fluid build up in the abdomen, or develop spider-like blood vessels on the skin

149
Q

Cholelithiasis? S/s? Tx?

A

gallstone is a stone formed within the gallbladder out of bile components

150
Q

Pancreatitis? S/s? Tx?

A

is a condition characterized by inflammation of the pancreas

151
Q

Appendicitis? S/s tx?

A

Appendicitis is inflammation of the appendix.Symptoms commonly include right lower abdominal pain, nausea, vomiting, and decreased appetite

152
Q

Diverticular disease? S/s tx?

A

is when problems occur due to diverticulosis, a condition defined by the presence of pouches in the wall of the large intestine (diverticula).[1] This includes diverticula becoming inflamed (diverticulitis) or bleeding.

153
Q

SIADH what it stands for? What is it? S/s? Tx?

A

Syndrome of inappropriate antidiuretic hormone secretion

condition in which high levels of a hormone cause the body to retain water

154
Q

DI- what it stands for? What it is? S/S? TX?

A

Diabetes insipidus

155
Q

Hyperthyroidism? S/s? Tx?

A

?

The overproduction of a hormone by the butterfly-shaped gland in the neck (thyroid).
Hyperthyroidism is the production of too much thyroxine hormone. It can increase metabolism.

156
Q

Hypothyroidism ? Tx? S/s?

A

?

A condition in which the thyroid gland doesn’t produce enough thyroid hormone.
Hypothyroidism’s deficiency of thyroid hormones can disrupt such things as heart rate, body temperature, and all aspects of metabolism. Hypothyroidism is most prevalent in older women.

157
Q

Cushings? S/s ? Tx?

A

Cushing’s syndrome is a collection of signs and symptoms due to prolonged exposure to glucocorticoids such as cortisol.

158
Q

Addison’s? S/s? Tx?

A

?
Addison’s disease, also known as primary adrenal insufficiency and hypocortisolism, is a long-term endocrine disorder in which the adrenal glands do not produce enough steroid hormones.[1] Symptoms generally come on slowly and may include abdominal pain, weakness, and weight loss.[1] Darkening of the skin in certain areas may also occur

159
Q

Process of digestion?

A

?

The processes of digestion include six activities:

ingestion, propulsion, mechanical or physical digestion, chemical digestion, absorption, and defecation.

The first of these processes, ingestion, refers to the entry of food into the alimentary canal through the mouth.

160
Q

Tic tac toe method??

A

?

161
Q

occurs when a disease affects a greater number people than is usual for the locality or one that spreads to areas not usually associated with the disease.

A

Epidemic

162
Q

is how your body recognizes and defends itself against bacteria, viruses, and substances that appear foreign and harmful.

A

Immune response

163
Q

Gout medication / s/s medications acute vs chronic

A

Colchine for acute

Aloperidine- long term

164
Q

Important for fibromyalgia patients

A

Sleep!

165
Q

How to test for kidney stones

A

Aeub xray

166
Q

IBS

A

Active bowel sounds

Some constioated

Some gave diarrhea

167
Q

What to ask with Health history and assessment for evaluating a patient elimination status

A

What it looks like

Pain?

Frequency

168
Q

How are wounds classified

A

Wounds are classified according to
the degree of skin integrity,
length of time the wound has been present, level of contamination,
and depth or severity of the wound.

Skin integrity: open or closed

Length of time for healing: acute or chronic

Level of contamination: clean, clean-contaminated, contaminated and infected

Depth of wound: Superficial (epidermis), partial-thickness, and full-thickness (through every layer)

169
Q

How do wounds heal?

A

Wounds heal by regeneration, primary intention, secondary intention or tertiary intention.
Invloves epithelial, endothelial, and inflammatory cells, platelets, and fibroblasts that migrate into the wound to bring about tissue re- pair and regeneration.
Regenerative/Epithelial healing: wound affects only the epidermis and dermis, no scar forms, new skin cells can’t be distinguished from the intact skin.

170
Q

Minimal to no tissue loss and edges are well approximated and little scarring occurs.

A

Primary intention

171
Q

Wound involves extensive tissue loss that prevents the edges from approximating and it is open not closed.
Heals from the inside out. Heal slowly, prone to infection and develop more scar tissue

A

Secondary intention

172
Q

AKA delayed primary closure
Occurs when two surfaces of granulation tissue are brought together.
Less scarring than secondary intention but more than primary intention.

A

Tertiary intention

173
Q

How to close wounds

A

Sutures, staples, durabonds (glue)

Adhesive strips: skin tears, lacerations, support after staples or sutures are removed

Sutures (Stitches): absorbent (dissolve over time), nonabsorbent (need to be removed)

Staples: DO NOT use on hands, feet, neck or face

Surgical glue: skin tears (low-tension wounds)
Negative pressure wound therapy

174
Q

Priority to ask after taking NSAIDs ?

A

When’s the last time you took it?

175
Q

How to use spirometers?

A

Deep breath

Coughing

Sit up

Pillow

Do NOT have hands on sides

176
Q

What VRE stands for

A

Vancomycin resistant enterococci

177
Q

Example of hypotonic solution

A

Normal saline 0.45%

178
Q

Two tests for hypocalcemia

A

Trousseaus - bp Hand movement

chveskeks - tap by ear- smile/ smirk of lip

179
Q

How to take orthostatic bp?

A

Lying

Sit

Stand

180
Q

Chemotherapy precautions

A

Neutropenic

181
Q

Flank pain is sign of?

A

Kidney stones

182
Q

Imaging for kidney stones

A

KUB xray

183
Q

IO device stands for

A

Interosseous

184
Q

Type of immunity given by IV?

A

Passive immunity

185
Q

If PH is normal , what is the compensation?

A

Fully compensated

186
Q

When to follow up a medication

A

With in an hour

187
Q

Lupus what you see ?

Tx ?

A

Butterfly rash

Steroids immunosuppressive

188
Q

Correct way to put in and take out IV

A

?

189
Q

Make sure what with osteoarthritis

A

Person is loosing weight

190
Q

What to assess with wounds? Post op what to do

A

Drainage amount , write date and time to see how much and not loosing too much, circle area on wound

191
Q

What to expect with IBS

A

Active bowel sounds

May be constipated or diarrhea

192
Q

Bioterrism ?

A

*Anthrax
*?Smallpox
Botulism
*Tularemia
Plague /Yersinia pestis
Ebola/filovirus
hemorrhagic fever

Can treat - PAT *

193
Q

What to know with osteoarthritis

A

Move around

Rest

Know health promotion and maintenance

194
Q

What should a patient do before allergy testing ?

A

Stop antihistamines for 72 hours before allergy testing or false negatives will occur

195
Q

Toddlers most at risk for what type of death ?

A

Drowning

196
Q

Mechanical digestion begins where?

A

In the mouth

197
Q

When will one have a bag to catch bm

A

With an Ostomy

198
Q

What to know with ones urine ?

A

What it looks like , odor, frequency?

Do not need to know last time they went

199
Q

Which blood test shows inflammation?

A

blood test known as CRP (C-reactive protein) is a common way to measure inflammation.

200
Q

How long to rest, ice with strains and sprains , use compression, and how to elevate

A

Rest and immobilize above and below injury

Apply ice for 20-30 min at a time for 24 to 48 hours (heat can be used after)

Use compression for first 24-48 hours

Elevate the affected limb to decrease swelling

PN1-RN (4 decks)

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