FINALS Flashcards
WHAT IS PHARYNGITIS ?
- INFLAMMATION OF THE PHARYNX (THROAT )
- CAUSING A VIRUS - STREP THROAT
HOW IS STREP THROAT DIAGNOSED ?
-THROAT CULTURE TO CONFIRM DIANOSIS
-
HOW DOES THE NURSE ASSESS BREATH SOUNDS ?
- ASCULATION IN A ZIG ZAG PATTERN
- IF SOUND DEMINISH -TAKE A DEEP BREATH
WHAT SHOULD THE NURSE DO WHEN THE PATIENT HAS COARSE CRACKLES AND DYSPNEA ?
- PLACE THE PATIENT IN HIGH FOWLER
- ASK THE PATIENT TO TAKE A DEEP BREATH AND COUGH
- SUCTION IF NEEDED
WHAT IS COR PULMONALE ?
-RIGHT SIDED HEART FAILURE
S/S: - JVD , LOWER EXTREMITY EDEMA
WHAT IS PNEUMOTHORAX AND HOW IS IT TREATED ?
-AIR BULID UP IN THE PLEURAL CAVITY , CAUSEES LUNG TO COLLAPSE causes lung t
Treatment: NEEDLE COMPRESSIONS
CHEST TUBE
Indicator: Absent breath sounds
WHAT IS THORACENTESIS ?
- INCISION TO WITHDRAW PLEURAL FLUID
- Needle aspiration used to remove fluid from the -pleural space
- too much fluid in lung–>Pleural effusion
- Postion in High fowlers, observe for hemorrhaging
HOW DOES THE NURESE PREPARE THE PATIENT FOR A THORACENTESIS ?
NPO FOR 6HRS BEFORE PROCEDURE
WHAT IS HEMOPTYSIS ?
Cough up sputum with blood in it
-Common w/TB pt
WHAT IS STRIDOR ?
- High pitch sound during inspiration
- associated with upper airway obstruction
- can be caused by allergies, lymph node enlargement, swelling of the throat area or tonsillectomy
how does the nurse care for a patient with tuberculosis ?
Negative Pressure Room
- N95* mask
- give them a mask if they need to leave room
- Antibiotics as prescribed
How is an ABG drawn ?
- From radial artery
- pressure to puncture site for 5 min to prevent hematoma
- Allen Test—> check for circulation
If a patient is in respiratory distress what intervention should the nurse employ ?
- raise HOB high fowlers
- max lung expansion
- O2 (O2 sat)
- assess resps rate & breathing sounds
- let the MD know
what should the nurse monitor for after a tonsillectomy ?
- Monitor for patent airway
- bleeding s/s( frequent swallowing, vomiting blood)
what equipment should be available during a tonsillectomy ?
-suction equipment available
what care would be important after a laryngectomy ?
- 1st priority is patent airway
- alternative communication
- assess for stridor
what is spo2?
Pulse oximeter (pulse ox) reading
-% of hemoglobin satured w/O2
Normal value–> high 90’s
*PO2 value–> 80-100
What is the most important chemical regulator of respiration?
- C02
- too much CO2, breathing is increased
- too little CO2, breathing is decreased
When a ventilator alarm goes off what is the nurses first response?
-
- Assess patient first
- High pressure alarm indicates occlusion ( pt cough, blockage somewhere(mucous)
- Low pressure alarm tubing got disconnected
What is pleural effusion?
- Excessive build up of fluids between the visceral and parietal pleura
- a thoracentesis is done to remove fluid
What is asthma?
What are the s/s and treatment?
Hyper-reactive airway disease
-Triggers: smoking, allergies, dust, exercise
- S/S: Wheezing, SOB, bronco constriction, bronco-spasm
- TX: bronco-dilator (albuterol), steroids
What is a pulmonary embolism?
clot in lung
-comes from DVT in legs( lower half body)
- s/s: acute chest pain, tachypnea, dyspnea,SOB
- Tx: anticoagulants, resp distress–>O2
What is emphysema?
Lung disease
-s/s: SOB, air trapping, barrel chest, diminished breath sounds
-Tx: do pursed lip breathing-->forcing more air out. Be. What is emphysema? • Over inflated alveoli • Air trapping • Diminished breath sounds • Caused by smoking often
What is tuberculosis? How is it spread?
Mycobacterium tuberculosis /bacterial infection that attacks lungs
-spread airborne, sputum culture for diagnosis
- s/s: coughing up blood , ever, night sweats
- prevent spread–> wash hands–>neg pressure room, N95 mask
- At risk: Immuno compromised people (AIDS)
- Tx: Long term combination drug therapy
What is a mantoux test
PPD, TB test, given intradermal
-check 48-72hrs after injection
-positive result–>5-10mm reddened raised wheal or induration
How does the nurse care for a chest tube drainage system?
keep system lower than chest
- monitor drainage and water seal, bubbling, indicated air leak
- clamping–>causes tension pneumothorax–> can cause mediastinal shift
How many column in system? 3 chambers
• Drainage collection chamber
• Water seal chamber and see bubble to move up and down called tidaling.
• Do not want to see contant bubbling in water seal chamber
• Suction control chamber and when suction is on you should see a continuous bubbling. This is normal.
• System is upright and you do not want to clamp the chest tube.
What is a pneumonectomy?
• Removal of the lung
• If I have removed a lung monitor for ABC’s
• No breath sounds where lung was removed
• Monitor for medial stinal shift
• Follow Dr’s order and do not roll pt onto the operated side
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What nursing interventions are important following a pneumonectomy ?
- monitor for infection, hemorrhage
- do not roll patient on the unapproriate side
How much oxygen should be administered to a COPD patient and why?
- 2liters or less
- too much can knock out resp drive/ respiratory depression
What techniques for pain management are effective
Medication
- electrical stimulation(TENS)
- light therapy
- biofeedback & relation training
- acupuncture
- heat and cold therapy
When are medications best administered for ongoing severe pain?
administer on a schedule before pain gets too serious
What is the purpose of for coughing and deep breathing exercises?
-prevents atelectasis(collapsed lung)
How often should they be done?
-cough/deep breath every 1-2hrs
What if a pt recently broke a rib or had surgery?
-use pillow to splint when excersize
What is the proper technique for tracheostomy suctioning? CHECK
auscultate lungs, put pt in semi-flower, check your equipment, moisten 6-8cm of the catheter with water soluble lube, intermitterly close suction with thumb
-NO MORE THAN 3 TIMES
DO NOT SUCTION FOR MORE THEN 10-15 SEC AND WHEN PULLING OUT ROTATE
Scabies
- contagious skin condition caused by a tiny mite burrowing into the skin, where it lays eggs
- causes intese itching and a skin rash that may look like brown tracks
- isolation
- antiparsitic creams for treatment
pediculosis
head lice; may also be found in the pubic region and other parts of the body
-Tx: Nix shampoo, comb out lice
Herpes Zoster
-commonly known as shingles, viral disease
-painful skin rash w/blisters in a limited area on one side of the body,
often in a stripe,
initial infection w/varicella zoster virus causes chickenpox
-Tx: antiviral, Zovirax
Tinea
itchy, patchy lesions with raised edges
•athletes foot
•overgrowth of fungi
•Tx: antifungal
dermatitis
- inflammation of the skin characterized by erythema, pruritis (itching), and various lesions
- Tx: corticosteroids
Whats the priority assessment and care for a client with burns?
- ABC’s/ airway first priority
- fluid and electrolyte loss, dehydration, infection and pain, swelling
- prevent scarring- long term
-sterile care
Tx: silverdene
What is Stasis Dermatitis?
Skin irritation on the lower legs usually due to circulatory problems.
-Pooling of blood in veins ( causes varicose veins)
- Risk for skin breakdown
- Tx: turing pt, ROM, compression stockings
know the onset peak , duration of various types of insulin ?
short acting (regular ) -
30-1hr
peak -1-3hrs
duration 6-10hrs
when would be the best time to monitor for hypoglycemia ?
peak
how is hypolglycemia treated ? If the patient is not alert what would you give them
4oz orange juice *6oz regular soda *miniature box of raisins *glucose tablets *6-8 lifesavers Assess pt after 15 mins If pt isnt alert glucagon can be given IM or IVj
Describe care following a thyroidectomy.
- monitor airway and check for s/s of hypocalcemia
- Have pt say”AHHH “ if there voice is progressingly hoarse could indicate damage to laryngel nerve
What is necessary to keep by the bedside during thyroidectomy ? check
Trach kit -suction -calcium gluconate (IV)• -ABC’s • Monitor for hypocalcemia • Twitching twitch , seizure seizures and tetany • Voice can be affected. Asses for hoarse voice • Keep trach kit at bedside
Describe patient teaching for a newly diagnosed diabetic.
- basics of diabetes
- effects of diet & insulin
- self monitoring
- refer to nutritionist
- feedback from patient
What are the cardinal s/s of diabetes mellitus?
- weight loss
- polyuria -excessive urination
- polydipsia-thirst
- polyphasia-eating
What is DKA and what are s/s ?
Blood glucose >250-300 High blood ketone (fruity breath & confusion) Tachycardia, Hypotension Anorexia, N/V, Abdominal pain Kussmals resps *In severe cases can cause coma
*Tx: Insulin, Regular (IV)
What is hemophilia and what are the s/s?
A hereditary blood disorder that results from a severe lack of specific clotting factors
-factor VIII or Factor IX
-s/s: bruising, hemarthrosis ( bleeding into muscles and joints) joint deformities, especially in the elbows, knees and ankles, which decrease the patients ability to walk
What are the side effects of chemotherapy?
bone marrow depression
- low RBC (Anemia)
- Low WBC( Infections)
- thrombocytopenia( low platelets, Risk for bleeding)
- Immunosuppression
- N&V, anorexia, alopecia(hairloss)
Polycthemia Vera
•increase in number of circulating erythrocytes & concentration of HGB in the blood
•increased production of myelocytes (leukocytes within bone marrow) and thrombocytes
•monitor for s/s symptoms of bleeding, force fluids( 3-6L per day) and record I&O’s
Increase fluid to thin the blood
Leukemia
-cancer of the WBC (immature and cannot fight )
- monitor for s/s of infection/bleeding
- observe for fatigue, offer frequent rest periods and pace activities
- maintain fluid and electrolyte balance
What is the appropriate nursing care following a bone marrow biopsy?
- observe the aspiration site for bleeding and infection
- apply pressure for 5mins to avoid bruising, hematoma
- provide emotional support to the patient
What is the cause of essential hypertension?
90-95% idiopathic (no known cause)
What are the s/s of hypertension?
headache
- blurred vision
- vertigo
- nose bleeds
What is peripheral arterial disease and what are the s/s?
-plaque formation in the arteries.
gradual onset
-s/s: develop gradually, intermittent claudication is classic sign(aching, cramping, tired and weakness in leg), absence of peripheral pulses at affected leg.
brittle nails, thin skin, tingling or numbness, cold, pale and possible muscle atrophy.
Why does pain occur with coronary artery disease?
Decrease O2 to myocardium
What is Raynaud’s disease?
- vasoconstriction in toes and finger tips, tingling, very painful
- Mostly effects women, cold and stress trigger it
What is CHF?
Hearts inability to pump sufficient blood to meet the needs of the tissue for oxygen and nutrient
What are the s/s and Tx? Of CHF
s/s: anxiety, angina, pallor/cyanosis, weight gain, edema, tachypnea, dyspnea, fatigue, JVD, N&V
-Tx: Raise HOB, Diuretics(Lasix,decrease blood volume), digoxin(increase contractibility of heart),vasodilators(nitroglycerin), Coumadin(reduce blood viscosity),O2e for oxygen and nutrients
what is cardiogenic shock?What are the s/s and the Tx?
- Heart fails as a pump. Usually happens after heart attack.
- s/s: tachycardia, hypotension, cool, clammy, weak, fine, thready pulse
-Tx: O2, diuretics, ballon pump
What are risk factors for cardiovascular disease?
-
- Modifiable: lifestyle, activity, smoking, diet
- Non-modifable:gender, race, heredity, family hx
What is a endarterectomy and what is the care following?
Surgical removal of atherosclerotic(plaque) material form carotid artery
After?: monitor for bleeding and neurological status, ABC’s
What is thrombophlebitis?
Inflammation of a vein with clot inside
What are the s/s and the Tx of thrombophlebitis ?
S/S: Homan’s sign, warmth, edema, red and shiny skin, pain, aching, cramping
Tx: anitcoagulants (i.e heparin), bedrest, warm compresses, elevate leg
know the 4 different types of acid -base imbalance and causes , how does compensation occur ?
hypoventilation
respiratory acidosis -ph decrase, co2 increase
hyperventilation
respiratiory alkalosis -PH increase co2 decrease
metabolic acidosis
Dka , renal failure ,diarreah
decrease hco3 decrease PH
metabolic alkalosis
GI suction , antiacids
increase HCO3 increase PH
What are buffer system ?
- Work to prevent acid base balance
* Controlled by lungs and kidneys
How should a nurse care for a client with fever and diaphoresis?
Keep them cool,
hydrate pt
Tylenol - antipyretics
What is post op ileus?
-Absence of movement of GI tract to make you pooooooo
-
absence of parastalis
-s/s: abdominal distention, lack of bowel sounds, lack of flatus,
How is it post op ileus prevented/treated?
-Tx: activity, ambulation
What is a clear liquid diet?
Anything you can see thru: Jello, clear broth, tea,
What is a full liquid diet?
Everything from the clear liquid diet plus milk and opaque liquids: yogurt, pudding ice cream, popsicles, cream soups
What is the nursing care for a patient receiving O2 via nasal cannula?
Assess for skin breakdown and patency
What are the s/s of hypokalemia?
muscle cramping, weakness, arrhythmia’s, constipation, N/V
What are the s/s of hyperkalemia?
muscle cramping, muscle twitches, N/V, diarrhea, tachycardia / bradycardia prolonged can cause cardiac arrest
What is fluid volume deficit? What are the s/s?
- Abnormal loss of body fluids( diarrhea, hemorrhage, polyuria, severe vomiting, inadequate intake
- s/s: tenting, poor skin turgor,weak thready pulse, fatigue,
What is fluid volume excess?What are the s/s?
Fluid volume excess occurs when the body retains water and electrolytes in proportion with the normal levels in the body.
s/s: tight skin, weight gain, elevated heart rate, bounding pulse, clear urine, elevated b/p
ADH
Anti-Diuretic Hormone (vasopressin)
-increase sodium and water reabsorbtion in the kidneys, decreases sweating, in large amounts causes vasoconstriction
When a patient have a chest tube , what do you want to keep at the bed side ?
Vaseline gauze
When a patient is having a thoracentesis what do you want them to sign ?
A consent
Pt in resp distress, how do you observe them?
2-3 resp cycles for one min
What condition puts you at risk for core pulmonel?
COPD
If I do bronchoscocipy what will cause resp arrest?
Stridor
What causes tetany ?
Hypocalcaemia
If I have mech ventilator what should be in room ?
Ambu bags
If I have copd chronic obstructive pulmonary disease what will we ?
Pace activities. Need naps, rest periods
How do you know a therocentesis is working ?
Patient is breathing better ?
