Final Exam Review Flashcards
Health promotion for young adults
You want to educate them on STI, substance abuse, personal hygiene.
Vaccines are the biggest health promotion for young adults.
Physical exams
Every 1 to 3 years
Dental exams
Every 6 months
Tuberculosis screening
Every 2 years
Visual acuity
Age 40 and under every 3 to 5 years
Ages 40 to 64 every 2 years
Ages 65 and older every year
Colonoscopy
Every 10 years after the age of 50
Cervical cancer screening
Ages 21-65 years every 3 years
At age 30 can decrease to 5 years
After 65 no testing is needed
Breast cancer screening
Ages 20=39 every 3 years
40 - 54 annual mammogram
Blood glucose screening
Starting at age 45, minimum every 3 years
Normal aging for older adults over 65
Loss of subq fat
Decreased liver and kidney function
Slower gastric emptying
NOT COMMON process of normal aging
Dementia
Depression
Delirium
Shingles vaccine
Adults over the age of 50 should get shingles vaccine
Pneumococcal vaccine
Adults over the age of 65 should get this vaccine
Presbyopia
Is an age related change
A decrease ability to focus on objects that are close
Priority for a client with sensory deficit
Keep the clients environment free from clutter
Those with sensory deficit have an increased risk for injury. Therefore the priority is safety, by removing things that may increase clients risk for fall.
Manifestation of dementia
Difficulty problem solving
Manifestations of delirium
Difficulty maintaining attention
Agitation
Rambling speech
Hallucinations
Braden scale
Pressure ulcer risk
1. Sensory perception
2. Moisture
3. Activity
4. Nutrition
5. Friction and shear
Presbycusis
Age related hearing loss
Changes in inner ear as you age (common for older adults)
Expressive aphasia
Can occur for stroke patients
Means the absence of speech
-people with this might signal speech
-use hand motions
-communicate non-verbally
Receptive aphasia
Patient can understand
They can speak well but they dont make sense (they say a lot of meaningless words)
May get frustrated because no one can understand what they are saying
Stagnation
Occurs in middle adulthood
- this is a state of being unconcerned about the welfare of others and feeling unproductive, uninvolved in the world, and dissatisfied with one’s life.
Integrity
Occurs during late adulthood
- this is achieved if individuals accept their life choices and have little desire to relive or redo their life.
This stage can occur during earlier life stages if the person feels they are near the end of life such as receiving terminal illness diagnosis.
Gabapentin
Gabapentin
• Treats seizures by slowing down activity of the brain
** Important to know side effects include drowsiness, dizzy, blurred vision*
Acute pain
Typical manifestations are guarding, let’s say if someone’s abdomen hurts they are going to come in with their arms across their abdomen. If they’re diaphoretic their vital signs are going to be increased so tachycardia, rapid respirations, hypertension.
Chronic pain
Vital signs can level out so you might not be able to tell just based off of their vitals signs that they are having this immense amount of pain it can cause a lot of patients to go into depression, fatigue from the chronic pain. These patients are on around the clock pain medications instead of just as needed.
Foods high in potassium
Choose baked potato!
This has more potassium than bananas or avocados
Foods low in potassium
Yogurt and orange juice
- so if there is a patient on a potassium restricted diet it is good to avoid these
What medication to use to treat high levels of potassium (hyperkalemia)
Polystyrene sulfonate
What medications help with incontinence?
Anticholinergic
- this is because these drugs are very drying
- also anticholinergics block nerves that control the bladder’s muscle contractions, which cause urine to be released.
-decreases urine and the urge to void
If a person has urinary retention
- Patient may complain of urinary frequency, or they can’t go
- Can get a bladder scan (do not need a drs. Order)
Bladder scanner
- The nurse should instruct the client to urinate 10 minutes before the scanning procedure
- Pt. Should be in supine position with head slightly elevated
- The scanner head should be about 1-1.6 inches above the symphysis pubis.
Electrolytes are low.
Metabolic alkalosis
Patients who are experiencing hypoxia
the first action to take is to elevate the clients head, this will promote effective breathing and chest expansion
Following then it is good to monitor spo2
For 24 hour urine collection
Flush the first void then collect all urine following
the nurse will instruct the client that the urine is to remain refrigerated between collection.
Clean catch urine specimen technique
Client must first wash hands with soap and water.
Female clients are instructed to wipe from front to back.
Client will start to urinate to flush out any contaminates and then stops.
Client holds the urine cup under then will continue to urinate until the appropriate amount of urine is collected.
Where to secure catheter
secure the catheter upper thigh or lower abdomen
Fecal occult blood test
Used to determine if blood is present or absent.
** Foods such as beets, red meat, broccoli can give a false positive result.**
Nurse should also instruct the client to avoid medications such as aspirin, ibuprofen, and vitamin C supplements.
Purpose of bladder irrigation
Promotes elimination
This intervention is intended to prevent blood clots from forming in the bladder or remove any clots that may be present. Can be uncomfortable.
Pain is not an expected finding and should be reported immediately to the provider
Bladder training
• Sets a schedule to use the bathroom.
• Focuses on accident avoidance in clients with overactive bladders by gradually increasing the time between bathroom visits to urinate.
• Attempting to set times with or without the urge and slowly increasing the time between these sessions.
• Record times for each bathroom visit.
• First attempt to extend the time between bathroom visits by 15 minutes then advancing the time slowly.
Clients with paraplegia (which kind of catheter will be used)
Clients with paraplegia will utilize intermittent catheters in conjunction with bladder training to avoid urinary accidents due to lack of bladder sensation.
Dysphagia
Difficulty swallowing
Actions- Sour foods can be given to stimulate saliva production which can assist a client with dysphagia
Signs of infiltration at IV site
Taut skin and cool to the touch.
-Nursing actions: stop the infusion, elevate the extremity, and apply a warm moist compress or a cold compress.
Sign of phlebitis at IV site
Erythema (redness surrounding skin)
Safest site for injection for all adults
Ventrogluteal site because it doesn’t have any major nerves or blood vessels.
Chvostek sign
Manifestation of hypocalcemia
- facial muscle twitching when touched.
Sterile technique
It is good to hold packages above by 6 inches before opening the package then dropping them into the sterile field
Hold sterile drape above the waist and away from the body
Anything within one inch border of sterile field is considered non sterile
Therapeutic relationship
Sit in front of the client not next to them
Assume an open position (legs crossed suggest a defensive posture)
Maintain direct eye contact
Lean towards the client to convey interest and involvement
Hand hygiene
Wash for at least 15 seconds normally and up to 2 minutes when hands are more soiled.
Airborne precautions
o Examples: Measles, Tuberculosis, Varicella
o A private room
o Use an N95 or HEPA
o Negative airflow room (at least 6 to 12 exchanges per hour)
Contact precautions
o Example: C. Difficile, RSV, shigella, MRSA
- a private room or room with other clients with the same infection
-gloves and gowns worn by the caregiver and visitors
-disposal of infectious dressing material into single non porous bag without touching the outside of the bag
Colostomy care
How it should look and how many times it should be changed
Should change when less than ¾ full so about ½ to ¼ full.
Good to change colostomy bag before a meal so drainage is less likely to occur.
Clean around the stoma with warm water (soap can leave residue).
Know about the 1/8 bigger for the border
You don’t want the pouch to be too full
Tracheostomy
- Patients are going to be on humidified air
Rationale: For a patient with a lot of mucous, dried air would make it hard to eliminate mucous from the mucous membrane. - Suction the patient 10-15 seconds and maximum is 3 passes within 5 minutes.
Hyperglycemia manifestations
-polyuria
-polydipsia (extreme thirst)
-lethargy
-headaches
-polyphagia (hungry)
-blurred vision
What do you do if a patient is experience abdominal pain with tube feedings
With abdominal pain and they are receiving tube feedings
You wanna slow down the rate until their pain goes away.
What makes a full liquid diet
- Can be clear diet plus diary
- Can be liquid at room temperature
- Example is yogurt
What should a nurse do if the patient starts feeling dizzy or weak while walking halfway to hallway? Or if they feel nauseous for faint?
Send the patient back to their room. Help him or her return to bed or to a chair, whichever is closer to the patient.
Know how to draw and administer insulin
Sanitize the injection site
Roll vials
Aspirate the amount for the cloudy vial, inject into the vial.
Aspirate the amount for the clear vial, inject into the vial.
Then aspirate from the clear vial, remove needle
Aspirate from the cloudy vial, remove needle.
Inject into the client subcutaneously.
Judaism/Jewish
With death rituals someone often stays with the body until burial
Practice a kosher diet: foods with scales and fins
They cannot have meat and dairy together.
Islam/Muslim
Dietary Rituals
Clients often avoid alcohol and pork
Clients can fast during Ramadan
Health and Illness
Avoid organ transplantation
Make decisions with family
Might permit withdrawal of life support
Have a belief in faith healing
Jehovah Witness
Health and illness
Clients might not accept blood transfusions even in life threatening situations
Dietary Rituals
Avoid foods having or prepared with blood
Death
Clients can choose burial or cremation
Hypervolemia
Over hydration: too much fluid
ABG: respiratory alkalosis
— due to dyspnea (slow breathing aka shortness of breath)
— increased pH > 7.45
— decreased CO2 <35 mmhg
Hyperventilation
ABG: respiratory alkalosis
— increased pH > 7:45
— decreased CO2 <35 mm Hg
Nasogastric suctioning and vomiting cause what
Metabolic alkalosis
— this is because you’re losing a lot of hydrogen ions causing the GI to become more basic.
Those who have kidney failure causes what?
Metabolic acidosis
- this is because the kidneys excrete acid from body through urine if the kidneys aren’t functioning properly then acid is getting built up
Hyponatremia
Cells are over hydrated.
Administer hypertonic IV
Hypernatremia
Increased sodium causing the cells to be dehydrated
Administer hypotonic OR isotonic solution
Hypertonic solutions
3% Saline.
5% Saline.
10% Dextrose in Water (D10W)
5% Dextrose in 0.9% Saline.
5% Dextrose in 0.45% saline.
5% Dextrose in Lactated Ringer’s
Isotonic solutions
0.9% Saline
5% dextrose in water (D5W)**also used as a hypotonic solution after it is administered because the body absorbs the dextrose BUT it is considered isotonic)
5% Dextrose in 0.225% saline (D5W1/4NS)
Lactated Ringer’s
Hypotonic solutions
0.45% Saline (1/2 NS)
0.225% Saline (1/4 NS)
0.33% saline (1/3 NS)
Dehydration nursing actions
Wanna report any urine output less than 30 mL/ hr
And check the clients weight each morning
Trough levels
Taken 30 minutes before medication is given.
