Final Care Of Complex Flashcards
The transfer of heat from the body to moving liquid or air is called what
Convection
The transfer of heat via electromagnetic waves is called what
Radiation
The transfer of heat from the body to a cooler surface by direct contact is called what
Conduction
Clinical manifestations of hyperthermia
Flushing warm skin increased MBR, increased need for fluids.
Skin rash, loss of appetite, confusion, dizziness, fatigue, vomiting, diarrhea.
What heat related injury occurs because of loss of body fluid volume cause by loss of body fluid and salts. Due to heat
Heat exhaustion.
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
Heatstroke
Treatment is urgent cooling
Symptoms of malignant hyperthermia
Dangerously high body temperature, rigid muscles/spasms, dysrhythmia, tachycardia, hypotension, cyanosis.
Cardiac arrest algorithm.
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)
If PCO2 levels are increase what does it suggest. What if they are decreased
Increased = respiratory acidosis
Decreased = respiratory alkalosis
If HCO3 levels increase what does it suggest? What about if they decrease
Increase= metabolic alkalosis
Decrease =metabolic acidosis
What is a never event
A surgical procedural error that should never have occurred.
What type of assessment does a nurse do pre operatively
Full head to toe
What is the nurses role with informed consent
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)
What is the earliest sign of increased intracranial pressure
Change in LOC
What is Cushing triad
Bradycardia
Respiratory rhythm change
Widened pulse pressure.
what clinical manifestations would you expect with heatstroke
dizziness
fatigue
nausea/vomiting
hypotension
muscle cramps
late signs: irritability, confusion, stupor, coma
what happens to a patients electrolytes with hyperthermia? what will we do?
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.
what clinical manifestations would you expect with a fever?
flushing
warm skin
increased metabolic rate
tachycardia/ tachypnea
increased need for fluids
fatigue. malaise, weakness
mental status changes, decreased responsiveness
what interventions will the nurse implement with frostbite?
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.
systemic responses to cold
decreased metabolic rate
hypotension, bradycardia/irregular rhythm, bradypnea/irregular respiration,
shivering
decreased urinary output
increased blood viscosity.
what are some examples of interventions to prevent venous thromboembolism (VTE)
SCDs
antiembolism/compression stockings
early ambulation
anticoagulant meds (heparin, lovenox…)
list these post op findings inpriority order by most concerning :
copious oral secretions, hoarseness, sore throat, stridor.
stridor
copious oral secretions
sore throat
hoarseness
what are some benefits of administering opioids to post op patients?
pain relief
wound care
early ambulation
cough, deep breathing, incentive spirometry
sleep
what are some recommendations to prevent aspiration perioperatively
NPO prior to procedure
Advance diet appropriately post op
what are some clinical manifestations of hypovolemia
decreased fluid volume=
decreased BP
increased HR
increased RR
decreased urinary output
what is the priority nursing action if a hemolytic reaction occurs?
STOP the infusion immediately no matter how mild.
symptoms may include: decreased BP, tachycardia, tachypnea, nausea, fever, chills, lower back pain.
what clinical manifestations would you expect with increased ICP?
nausea, vomiting
HA
fatigue
light sensitivity
decreased LOC, restlessness, irritability.
irregular respirations, bradypnea
hypertension
what nursing interventions might you implement for a patient with IICP
elevate HOB
fluid restriction/management
reduce environmental stimuli
pharmacological
seizure precautions
what pharmacological nursing interventions might you expect to administer with IICP
diuretics (mannitol) to decrease edema
IV fluids (MAP and electrolyte management)
anticonvulsants (seizure management)
vasoavtive medication (MAP management: (epi, dobutamine, vasopressors).
antibiotics (infection prevention.)
what is the difference between decorticate and decebrate posturing?
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.
what changes with a patient diagnosed with IICP would prompt you to notify the MD?
change in LOC
CHange in GCS
clear fluid drainage from ear or nose
change in hemodynamics (abnormal vitals)
what number range is considered mild on the GCS
-13-15=mild
9-12= moderate
3-8= severe
a patient presents to the ED after a trauma. WHat is the priority action?
maintain a patent airway
pH lower than 7.35 and pCO2 higher than 45= what
respiratory acidosis. caused commonly by respiratory depression COPD, pneumonia.
pH higher than 7.45 and pCO2 lower than 35= what
respiratory alkalosis. caused commonly by hyperventilation (emptions/pain).
contraindications to oral contraceptives
pregnancy
heavy smoking
acute or chronic liver disease
history of thromboembolism
hypertension
what are some signs the nurse needs to massage the fundus 2hrs postpartum
patient appears ashen
soaked perineal pad
patient reports weakness/lightheadedness
fundus boggy
a nurse suspects anaphylaxis. what is the priority action?
Assess ABCS
what diet recommendations would you provide to a patient with iron deficiency anemia
iron rich foods=
beef, chicken, eggyolk, clam,pork, turkey, veal
bran, brown rice, whole grain, beans, dried fruit, leafy greens
what are potential complications for newborns with small gestational age (SGA)?
polycythemia (elevated RBC count)
cold stress
asphyxia
hypothermia
hypobilirubinemia
a newborn has both nose and mouth secretions. which do you suction first and why>
mouth because aspiration
what clinical manifestations would you expect with SLE
dry scaly raised rash on face
unexplained fever
malaise
muscle atrophy, arthralgias
loss of appetite
what early clinical manifestations would you expect with HIV/AIDS
flulike symptoms
general malaise and fatigue
night sweats
fever
opportunistic infections
what is immune thrombocytopenic purpura and what priority assessment would the nurse monitor
rare autoimmune (cytotoxic) disorder wher blood doesnt clot properly.
thrombocytopenia= low platelets
purpura= petechiae
monitor and assess for BLEEDING
what will the nurse include with droplet precautions
hand hygiene
basic isolation face mask
possibly gown gloves goggles if coming into contact with secretions
what are education points for patients with neutropenia (leukopenia)
eat cooked foods
avoid large crowds
wash hands frequently
monitor for infections
who should get a colonoscopy
45-75 every ten years
what clinical manifestations would you expect with hypoxia
tachypnea (rapid and shallow breathing)
restlessness agitation
cyanosis
tachycardia
what does coffee ground emesis indicate?
bleeding in the GI tract
what is DIC
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.
indications for omeprazole
duodenal and gastric ulcers
prolonged dyspepsia
GERD
Esophagitis
