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Spring > Final Care Of Complex > Flashcards

Final Care Of Complex Flashcards

1
Q

The transfer of heat from the body to moving liquid or air is called what

A

Convection

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2
Q

The transfer of heat via electromagnetic waves is called what

A

Radiation

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3
Q

The transfer of heat from the body to a cooler surface by direct contact is called what

A

Conduction

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4
Q

Clinical manifestations of hyperthermia

A

Flushing warm skin increased MBR, increased need for fluids.
Skin rash, loss of appetite, confusion, dizziness, fatigue, vomiting, diarrhea.

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5
Q

What heat related injury occurs because of loss of body fluid volume cause by loss of body fluid and salts. Due to heat

A

Heat exhaustion.

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6
Q

What heat related injury occurs due to high environmental temperatures accompanied by high humidity leading to a dysfunction in the brains thermoregulation center resulting in loss of ability to cool itself

A

Heatstroke
Treatment is urgent cooling

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7
Q

Symptoms of malignant hyperthermia

A

Dangerously high body temperature, rigid muscles/spasms, dysrhythmia, tachycardia, hypotension, cyanosis.

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8
Q

Cardiac arrest algorithm.

A

Start cpr, give o2, attach to defibrillator

If in pulse less vtach or vfib- admin shock

Return to cpr, ensure IV access, (epi Q3-5min eventually)

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9
Q

If PCO2 levels are increase what does it suggest. What if they are decreased

A

Increased = respiratory acidosis
Decreased = respiratory alkalosis

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10
Q

If HCO3 levels increase what does it suggest? What about if they decrease

A

Increase= metabolic alkalosis
Decrease =metabolic acidosis

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11
Q

What is a never event

A

A surgical procedural error that should never have occurred.

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12
Q

What type of assessment does a nurse do pre operatively

A

Full head to toe

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13
Q

What is the nurses role with informed consent

A

Ensuring that consent is obtained, witnessing the signed consent, and making sure all questions have been answered by appropriate persons (by notifying surgeon if questions arise)

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14
Q

What is the earliest sign of increased intracranial pressure

A

Change in LOC

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15
Q

What is Cushing triad

A

Bradycardia
Respiratory rhythm change
Widened pulse pressure.

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16
Q

what clinical manifestations would you expect with heatstroke

A

dizziness
fatigue
nausea/vomiting
hypotension
muscle cramps
late signs: irritability, confusion, stupor, coma

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17
Q

what happens to a patients electrolytes with hyperthermia? what will we do?

A

there will be a loss of fluids and electrolytes with hyperthermia.
we treat the underlying cause. Asess I/Os, provide fluid replacement
be alert for signs of dehydration or electrolyte imbalance.

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18
Q

what clinical manifestations would you expect with a fever?

A

flushing
warm skin
increased metabolic rate
tachycardia/ tachypnea
increased need for fluids
fatigue. malaise, weakness
mental status changes, decreased responsiveness

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19
Q

what interventions will the nurse implement with frostbite?

A

rewarm the affected areas in circulating warm water.
do not rub or massage
bedrest
elevate affected limb
analgesics and anti-inflammatory agents
whirlpool therapy to clean skin, debride necrotic tissue, necrotic tissue may require amputation.

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20
Q

systemic responses to cold

A

decreased metabolic rate
hypotension, bradycardia/irregular rhythm, bradypnea/irregular respiration,
shivering
decreased urinary output
increased blood viscosity.

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21
Q

what are some examples of interventions to prevent venous thromboembolism (VTE)

A

SCDs
antiembolism/compression stockings
early ambulation
anticoagulant meds (heparin, lovenox…)

22
Q

list these post op findings inpriority order by most concerning :
copious oral secretions, hoarseness, sore throat, stridor.

A

stridor
copious oral secretions
sore throat
hoarseness

23
Q

what are some benefits of administering opioids to post op patients?

A

pain relief
wound care
early ambulation
cough, deep breathing, incentive spirometry
sleep

24
Q

what are some recommendations to prevent aspiration perioperatively

A

NPO prior to procedure
Advance diet appropriately post op

25
Q

what are some clinical manifestations of hypovolemia

A

decreased fluid volume=
decreased BP
increased HR
increased RR
decreased urinary output

26
Q

what is the priority nursing action if a hemolytic reaction occurs?

A

STOP the infusion immediately no matter how mild.
symptoms may include: decreased BP, tachycardia, tachypnea, nausea, fever, chills, lower back pain.

27
Q

what clinical manifestations would you expect with increased ICP?

A

nausea, vomiting
HA
fatigue
light sensitivity
decreased LOC, restlessness, irritability.
irregular respirations, bradypnea
hypertension

28
Q

what nursing interventions might you implement for a patient with IICP

A

elevate HOB
fluid restriction/management
reduce environmental stimuli
pharmacological
seizure precautions

29
Q

what pharmacological nursing interventions might you expect to administer with IICP

A

diuretics (mannitol) to decrease edema
IV fluids (MAP and electrolyte management)
anticonvulsants (seizure management)
vasoavtive medication (MAP management: (epi, dobutamine, vasopressors).
antibiotics (infection prevention.)

30
Q

what is the difference between decorticate and decebrate posturing?

A

Decorticate= flexor= C, arms are like Cs moves in towards the “cord”. indicates problems with cervical spinal tract or cerebral hemisphere.
Decerbrate= extensor= E, arms are like e’s and outwards. indicates problems with midbrain or pons.

31
Q

what changes with a patient diagnosed with IICP would prompt you to notify the MD?

A

change in LOC
CHange in GCS
clear fluid drainage from ear or nose
change in hemodynamics (abnormal vitals)

32
Q

what number range is considered mild on the GCS

A

-13-15=mild
9-12= moderate
3-8= severe

33
Q

a patient presents to the ED after a trauma. WHat is the priority action?

A

maintain a patent airway

34
Q

pH lower than 7.35 and pCO2 higher than 45= what

A

respiratory acidosis. caused commonly by respiratory depression COPD, pneumonia.

35
Q

pH higher than 7.45 and pCO2 lower than 35= what

A

respiratory alkalosis. caused commonly by hyperventilation (emptions/pain).

36
Q

contraindications to oral contraceptives

A

pregnancy
heavy smoking
acute or chronic liver disease
history of thromboembolism
hypertension

37
Q

what are some signs the nurse needs to massage the fundus 2hrs postpartum

A

patient appears ashen
soaked perineal pad
patient reports weakness/lightheadedness
fundus boggy

38
Q

a nurse suspects anaphylaxis. what is the priority action?

A

Assess ABCS

39
Q

what diet recommendations would you provide to a patient with iron deficiency anemia

A

iron rich foods=
beef, chicken, eggyolk, clam,pork, turkey, veal
bran, brown rice, whole grain, beans, dried fruit, leafy greens

40
Q

what are potential complications for newborns with small gestational age (SGA)?

A

polycythemia (elevated RBC count)
cold stress
asphyxia
hypothermia
hypobilirubinemia

41
Q

a newborn has both nose and mouth secretions. which do you suction first and why>

A

mouth because aspiration

42
Q

what clinical manifestations would you expect with SLE

A

dry scaly raised rash on face
unexplained fever
malaise
muscle atrophy, arthralgias
loss of appetite

43
Q

what early clinical manifestations would you expect with HIV/AIDS

A

flulike symptoms
general malaise and fatigue
night sweats
fever
opportunistic infections

44
Q

what is immune thrombocytopenic purpura and what priority assessment would the nurse monitor

A

rare autoimmune (cytotoxic) disorder wher blood doesnt clot properly.
thrombocytopenia= low platelets
purpura= petechiae
monitor and assess for BLEEDING

45
Q

what will the nurse include with droplet precautions

A

hand hygiene
basic isolation face mask
possibly gown gloves goggles if coming into contact with secretions

46
Q

what are education points for patients with neutropenia (leukopenia)

A

eat cooked foods
avoid large crowds
wash hands frequently
monitor for infections

47
Q

who should get a colonoscopy

A

45-75 every ten years

48
Q

what clinical manifestations would you expect with hypoxia

A

tachypnea (rapid and shallow breathing)
restlessness agitation
cyanosis
tachycardia

49
Q

what does coffee ground emesis indicate?

A

bleeding in the GI tract

50
Q

what is DIC

A

a cascade of abnormal coagulation that involves multiple small clots that use up all the clotting factors and then the person cannot clot and can bleed out.

51
Q

indications for omeprazole

A

duodenal and gastric ulcers
prolonged dyspepsia
GERD
Esophagitis

52
Q
A

Spring (11 decks)

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