fundamentals Flashcards
right brain damage
left side weakness
spatial perceptual def
-impulsivness
-high risk for falls
rise from suttting (crtuches)
hold hand grips on borth crutches in the hand of the affacted side
- move to chairs edge
- hold armrest with the hand on the unaffected side
- use crutces, armrest, and unaffected leg to support when rising
to sit
back up to the chair and move both of the crutches into the hand on the affected side and then holds arm rest with other hand and lowers body
before sitting the clien
back up to the chair till the unaffected leg touches the chair
caring for unconsious pt during admission
dont remove medical patches until consulting with HCP because clients are often prescribed transdermal patches for chronic conditions
- remove contact lenses
- tampons should be removed to prevetn toxic shock or infection
- rings and jewlery should be removed to prevent constrictive injury if edema dev
absoulte contrindications for MRI
cardiac pacemaker
- inplantable cardioverter defillator
- choclear inplant
- retained metallic forign body such as in the eye
relative contrindication:
- metal pins
- prostehtic heart value
med patches before MRI
should be removed but not contrindication but can cause burns so replace after MRI
when determining most app method of safetly transfer assess
wether the client can bear weight
-whether client is copperative
if client is cooperative and able to particallt bear weight
one person stand and pivot techniquie with gait belt
-
if client is copperative and can bear full weight
stand by
no weight bearing abilty but can follow commands
2 person stand assist lift
motoized assist device
no weight bearing and not following commands
2 person assit with full body sling
types of error
Diagnostic (delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring)
Treatment (error in performance of procedure, treatment, dose; avoidable delay)
Preventive (failure to provide prophylactic treatment, inadequate follow-up/monitoring of treatment)
Other (failure of communication, equipment failure, system failure)
trach tube in infalted cuff is used in clients
ho are at risk for apsiration (unconsous, mechanical ventilation)
the cuff is delated when
the client is iporving and not to be at risk for aspiration
-is awake
before cuff can be delated
the client is asked to cough to exporate secretions that is built above the inflated cuff
-then suction is applieid through the trach tube and then the mouth and it is then deflated
aditional interventions to deccrease the risk of aspiration
sit upright with chin flexed slightly toward chest
-mointor wet or garbled sound
hypextension of the neck
increases risk for aspiraiotion
it should be flexed toward the chest
if a client is up and awake and isnt at risk for apsiration
then deflate the cuff to prevent aspiration
droplet precaution
mentigits diphtherpia MMR pertussis grpup a step (strep throat) viral influenza
protective euq for dropley
surgical
provate
as needed for procedures with risk of splasm: gloves gown googles anf face shield (suctioning, wound care)
-equip should stay in room
sterile technique when
collecting urine sample
perineal hygeine
soap and water not antisepectic cleansers
irrgation of catherter
routine irrgation with atimicrobial soltiion or adm of atnimicrobials is not recommends
contact precaustions
MRSA
c diff
VRE (vancymycin resistant enteroccus)
scabies
compact precations include
private roomo (preffered) or cohoring clients with same infection
- using dedicated equip
- door notice for vistors
- if xray is needed try to arrange for portable one
etoh hand rubs vs hand wash
MRSA and VRE- etoh
cdiff- soap
nitroglycerine
vasodilator and headache is expected so take ecta
felodipine
ca channel blocker and causes vasodilation
ca channel
vasodilation and causes peripheral edema and this si an expected freq side effect and not allergic reaction
-tell clients to elevate their legs when lying down and to use stockings
latex-
allegries can happen 3-4 days after
common latex
kiwi, banaa, avacoda, tomator, peaches, grapes,
- baloon tupped catherers (arterial cath)
- blowing up toy balloons
- use of bottle nipples and pacifiers
- confoms or diaphragmns
who is at risk for catherter related bloodstream infections
those with comprimised immune system
CLABSI risk
higher when using lower ext
-higher infection when using wrists or upper arm compared to hands
antecubial fossa
commly use in emergency sitautoiins due to its size and ease of cannulation
0but prob when longer termr needs because it is at the bend of the elbow
-bending of the arm can move cather and increase infection risk
using foot for IV
infection
thromphebitis
DVT
radial
severe pain
nerve dmage
infection
cellutis
inflammation of the subq tissues due to bacterial infection resulting from insect bite
cut
abrasion
open wound
cellutis characteristic
redness
edema
pain
fever
nursing care for cellutlist
ensure the affected ext is elevated when sitting or lying down
-flat or dependednt position can worsen edema
–protect cliients with weeping or draining woudnds from prolonged exposure to moist or soiled linens –>infection
-warm compresses promote circulation and reduce edema
-daily marking and dating
-
unsterile field
one inch margin at the edge
when tb client leaves room
surgical mask ONLY
scrub foley collection port
with elcholol or chlohexdine for 15 seconds before drawing sepecimens
middle east resp syndrome
viral resp illness caused by coronavirus
middle east resp syndrome symtoms
fever cough sob
precaution for midle east resp syndrome
standard
contact
aurborn (n95)
eye porection
midle east resp sydrome spread through
resp sections
hital hernia
abnormal movement of stomach into the chest due to weakness of the diaphrgmn
signs of hital hernia
asymtoamic
- heart burn
- CP
- dysphagia
- SOB
- intrabsominal pressure
hital hernia management
lose weight by perfomraing LIGHT actv such as short walks
- avoid actv that strain (weight lifting)
- sit up for several hours afte meals
- sleep with HOB elevated 6 in at least
- surgical if home management fails
gastric residual should be check
no less than every 4 hours
when dose is outside range
ask HCP
hydromorphone
5-10 X the strength
before sugery
consent
assessment
clients staus
preop checklist
conact precaution measures
nonsterile gown
gown
private room preferrred
hand hygenigene (cdiff)
romberg test
assess clients preception of their head in spsace (vestibular function)
-body in space
how to perform romberg test
stand with feet togegther and hands by side of the body
-close eyes
inernal radiation inplant (bracytherpy)
emits radition in or near tumor to treat certain malignicies
when caring for pt with brachyterpy mointor for
implant dislgement
what should be kept in the room of t who had radiactive inplant
long hande forceps
lead lined container
in case of dislogement
WRapping the inplant in linens and placing it within bihazard bag does not reduce radiation
restrints are tied to the
bed frame
elbow restaints used to temporaily immoblize child (<30 mins)
not a restraint
misconcccpetion of bed bugs
darn to dirty env
bed bugs treatment
treat the entire house for bed bugs
- washing a single pillowacse of blanket doesnt stop the infestations
- get pest control
bed bugs signs
rash that is itchy
-pets can get it and other hosehold memebers
MRSA or drug resistant organisms are bathed in
premoistened cloths or warm water containg chlorihexindine
app uses of indewlling catherter
n. Appropriate use includes urinary obstruction or retention, some perioperative circumstances, required prolonged immobilization, end-of-life comfort, and facilitating healing of an open perineal or sacral wound. Indwelling urinary catheters should not be used for convenience or as a substitute for nursing care
needlestick injury
remove gloves wash hands wihth soap and water -tell supervisor -then go to employee health clinic -ppost exposure prohalysix will be given
postexposure prolhaxis for hiv infection most effective when
given within 2 hours of exposure incident
which pt should get isloation room the most
airborne first then dropley
contact are only contagious if tyou touch them
ebola precaution
standard
contact
droplet
airborne
(, impermeable gown/coveralls, N95 respirator, full face shield, doubled gloves with extended cuffs, single-use boot covers, single-use apro)
-vistors are probhited
-log everyone who enters and exits the room and all logged indv are mointored for symtoms
-procedures and use of sharps and needles are limited whenever possible
treatment for ebola
no meds or vaccines apporved by FDA
PREVENTION is curcia;
PPE removal process
strict mointoring byb trained observer
-outer gloves are first cleaned with dsiinfected and removed
the inner gloves are wiped bwtween removal of every subquent piece of PPE (resp and gown) and removed last
highest risk for hospital acquired MRSA
older adults immunsupressed long HX of abx invasive tubes or lines (hemodialsys pt) ICU pt
PICC
longterm IV
mesd (parental, chemo)
PICC line managemnt
- sterile dressing changes every 48 hours with guaze dressing or 7 days with tranparent semiperamible dressing (biopatch) as well as immediately if dressing is loose/torn, soiled, or damp
- flush line before and after med
- bp and venipuncutre should not be perfomred on the affected arm as compression of the vein can alter its integrity
- all infusing meds except vasopressors must be paused before drawing blood form picc line to prevent false intrepertation
- scrub the hub with etoh or clorhexdine for 10-15 sedconds
AMA
inform HCP
- remove IV
- client cannot be held against his or her will if the client refuses to sign an AMA
nosocomial infection occur
occur 48 hours after admission
or up to 90 says after
noscoomial clients who are at risk
young children
elderly
compromised immune systems
most common noscomial infection
UTI
INFECTION
PNEUMONIA
BLOODSTREAM INF
netrophill count
2200-7700
nursing resp prior to surgery
informed consent and place the signed document in the clients chart
- void before surgeyr
- NPO
- witness site marked
treating bed bug
Laundering clothing in hot water and using the highest temperature setting on a dryer will kill any bed bugs attached to clothes. The clothing should then be stored in tightly sealed plastic bags to prevent additional infestation
steps to operate fire extinguisher
PASS
dqueeze and sweeep
colonized MRSA client
contact precaution
private room
hep c precaustion
CDCCCC
restraint care
skin care ROM -skin integrity, neuro status -pad bony prominseces -determine need for cotined restraint by releasing restraints briefly and assessing clients reaction
restrant straps should be attached to areas
that move with bed frame (hob)
dont tie restaints to
base or side rails, the frame should never be used
poistioning for restraint
never shoud be supine because of apsiration risk
-side lying or semi
chemical restraints are
meds (benzo or psychotrpics)
use of pscychotrops is not considered
standard treatment for clients with hx of falls
benzo are considered standard treatment to
control agitationi in etoh withdrawl
anitpsychotics are app for
schizo
profol is standard treatment
to sedate client reciving mech ventaltion
preggo women are no to be exposed to
TORCH (Toxoplasmosis, Other [VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus
airbrone diseases
shingles (herpes zoster)
rubeola (measels)
isloation for airborn
negative pressure with hepa filters
n95
gown is only needed if you suscpt body fluid splash not routine care such as meds or assessments
sleep hygiene clients should avoid
non sleep elated actv (reading, television, working) other than sex
relaxed reading before bed is helpfult o stimulate sleep but
should not occur in bed and should be in another setting
healthy sleeping habits
avoid caff, nictonie, and etoh within 4-6 hours of sleep
- excercise daily but avoid excercise or strenous actv within 4-6 hours of sleep
- avoid going to bed hungry or eating heavy meal just before bed
- practice relaxation tech (deep brethhing) if stress is causing isomnia
- avoid naps and naps should only be 20-30 mins
- room should be kept slightly coolm quiet and dark
- same bedtime and wake up time everyday
donning
gown
mask
goggles
gloves
central venous lumen require
anticogulation in heprain flush to maintain patency and prevent clotting when not in use
dose for CVC flush
. Doses of 2–3 mL containing 10 units/mL–100 units/mL are the standard of care for flushing a CVC.
—doses of Doses of 1000–10,000 units are given for cases of venous thromboembolism; therefore, this prescription is an error and should be clarified by the nurse.
what is a high alert med
heprain
tpn should be adm though
CVC bc of its high viscoity and high glucose lips electro minerals
-PICC
occuslive dressing should be changed every
7 days
what port shuld be used for CVP measure
distal port of the trupple lumen CVC
key feature of petusssis
rapid coughing that lead to vomiting
impeigo not congeious after
24 hours after ABX
posion ivy
not congeious and canot spread person to person
HIV pt
stadard precation
- wear gloves when exposure to blood and body fluids
- isoltation gown when splashing body fluids
- googles if spalshing possiblity
safety when using crutches
- look forward not at feet when walking to maintain upright poistion
- use small backpack , fanny pack or shoulder bag to hold personal items
- wear RUBBER or nonskd soled slipper shoes with leaves
- rest curtches upside down on axilla crutch bads
- keep crutch rubber tips dry and replace if worn out
