Fundamentals - Chapter 2 in Basics Flashcards
1
Q
exaggerated concavity in the lumbar region
A
lumbar lordosis
2
Q
exaggerated convexity in the thoracic region
A
kyphosis
3
Q
Physical assessment includes what?
A
a. Body build, height, weight— proportioned within normal limits b. Posture, body alignment— erect c. Gait, ambulation— smooth d. Joints— freely moveable e. Skin integrity— intact f. Muscle tone, elasticity, strength— adequate
4
Q
Psychosocial History includes?
A
Psychosocial assessment 1) Exercise level 2) Rest and sleep patterns 3) Sexual activity 4) Job-related activity
5
Q
b. Health history includes
A
1) Pregnancy 2) Structural or functional defects of the nervous system 3) Structural or functional defects of the musculoskeletal system 4) Diagnostic procedures and medical or surgical treatments that require activity restriction 5) Conditions or treatments that result in pain 6) Endocrine disorders that affect rest and activity
6
Q
What are some gerontoligic consideration for mobility?
A
- Bones– less dense; less strong; more brittle; decreased mineralization; elderly females have increased osteoclatic bone resorption; osteoporosis incidence higher in women; high incidence of deformity, pain, stiffness, fractures; increased osteoporosis with smoking, decreased calcium intake, alcohol use, physical inactivity 2. Joints– rigid, fragile cartilage; decreased water content in cartilage; decreased intervertebral disk height; limited or painful stiff movement; crepitation with movement3. Muscles– loss of muscle mass, tone, agility and strength; slowed reaction time; muscle fatigue; muscle function can be maintained with exercise
7
Q
_______Rotate the ankle and sole of foot inward ______Rotate the ankle and sole of foot outward
A
Inversion
Eversion
8
Q
_________Point the toes toward the head______ Point the toes away from the head
A
Dorsiflexion
Plantarflexion
9
Q
How can we prevent injuries related to mobility?
A
a. Motor vehicle accidents— use of seat belts and helmetsb. Job-related accidents— following safety proceduresc. Contact sports— proper body conditioning and use of protective devicesd. Aging— rugs should be secure; stairways lit and clear of debris e. Pregnancy— bathtub grips; low-heeled shoes
10
Q
How can we prevent injuries related to mobility?
A
a. Motor vehicle accidents— use of seat belts and helmetsb. Job-related accidents— following safety proceduresc. Contact sports— proper body conditioning and use of protective devicesd. Aging— rugs should be secure; stairways lit and clear of debris e. Pregnancy— bathtub grips; low-heeled shoes
11
Q
How often should the gerontologic population exercise?
A
30-minute, 5 times a week
12
Q
What are the benefits of activity and exercise?
A
- Activity a. Maintains muscle tone and posture b. Serves as outlet for tension and anxiety
- Exercise a. Maintains joint mobility and function b. Promotes muscle strength c. Stimulates circulation d. Promotes optimum ventilation e. Stimulates appetite f. Promotes elimination g. Enhances metabolic rate
13
Q
What is the importance of positioning?
A
- Purpose a. To prevent contractures
b. To promote circulation
c. To promote pulmonary function d. To relieve pressure on body parts
e. To promote pulmonary drainage - Common client positions and their corresponding therapeutic functions (see Table II-4 )
14
Q
What are some important point about ambulation?
A
a. Weight bearing on long bones to prevent decalcification, resulting in weakening of the bone and renal calculi
b. Stimulate circulation to lower extremities
c. Use elastic stockings to prevent postural hypotension
d. Should be done gradually; blood pressure should be checked during the procedure
e. If blood pressure goes down and dizziness, pallor, diaphoresis, tachycardia, or nausea occurs, stop procedure
15
Q
What are some important point about ambulation in rehabbing mobility?
A
a. Weight bearing on long bones to prevent decalcification, resulting in weakening of the bone and renal calculi
b. Stimulate circulation to lower extremities
c. Use elastic stockings to prevent postural hypotension
d. Should be done gradually; blood pressure should be checked during the procedure
e. If blood pressure goes down and dizziness, pallor, diaphoresis, tachycardia, or nausea occurs, stop procedure
16
Q
What are some adverse effects of immobility?
A
Integumentary:
Decubitus ulcer, Decreases wound healing
Osteomyelitis, Tissue maceration, Infection
Musculoskeletal:
Osteoporosis, Decreased muscle mass/strength, Atrophy Contractures, Pathological fractures, Loss of endurance, Deformities, Decreased stability
Respiratory:
Change in lung volume, Atelectasis, Stasis of secretions, Decreased lung expansion, Decreased hemoglobin, Respiratory muscle weakness, Pneumonia
Cardiovascular:
Increased cardiac workload, Thrombus formation, Orthostatic hypotension, Tachycardia, Pulmonary emboli ,Weakness, faintness, dizziness
Metabolic:
Decreased basal metabolic rate,Altered nutrient metabolism,Hypercalcemia,Decreased cellular activity
Weight gain,Loss of lean body mass,Negative nitrogen balance,Anorexia, weight loss, debilitation, Slow wound healing and tissue growth, Increased diuresis, Increased excretion of electrolytes
Elimination:
Constipation, Urinary stasis, Fecal impaction, Urine retention, urinary infections, Renal calculi
17
Q
What are some adverse effects of immobility?
A
Integumentary:
Decubitus ulcer, Decreases wound healing
Osteomyelitis, Tissue maceration, Infection
Musculoskeletal:
Osteoporosis, Decreased muscle mass/strength, Atrophy Contractures, Pathological fractures, Loss of endurance, Deformities, Decreased stability
Respiratory:
Change in lung volume, Atelectasis, Stasis of secretions, Decreased lung expansion, Decreased hemoglobin, Respiratory muscle weakness, Pneumonia
Cardiovascular:
Increased cardiac workload, Thrombus formation, Orthostatic hypotension, Tachycardia, Pulmonary emboli ,Weakness, faintness, dizziness
Metabolic:
Decreased basal metabolic rate,Altered nutrient metabolism,Hypercalcemia,Decreased cellular activity
Weight gain,Loss of lean body mass,Negative nitrogen balance,Anorexia, weight loss, debilitation, Slow wound healing and tissue growth, Increased diuresis, Increased excretion of electrolytes
Elimination:
Constipation, Urinary stasis, Fecal impaction, Urine retention, urinary infections, Renal calculi
Psychosocial:
Depression Sensory deprivation Confusion Increased dependence Insomnia, restlessness
18
Q
What are some adverse effects of immobility?
A
Integumentary:
Decubitus ulcer, Decreases wound healing
Osteomyelitis, Tissue maceration, Infection
Musculoskeletal:
Osteoporosis, Decreased muscle mass/strength, Atrophy Contractures, Pathological fractures, Loss of endurance, Deformities, Decreased stability
Respiratory:
Change in lung volume, Atelectasis, Stasis of secretions, Decreased lung expansion, Decreased hemoglobin, Respiratory muscle weakness, Pneumonia
Cardiovascular:
Increased cardiac workload, Thrombus formation, Orthostatic hypotension, Tachycardia, Pulmonary emboli ,Weakness, faintness, dizziness
Metabolic:
Decreased basal metabolic rate,Altered nutrient metabolism,Hypercalcemia,Decreased cellular activity
Weight gain,Loss of lean body mass,Negative nitrogen balance,Anorexia, weight loss, debilitation, Slow wound healing and tissue growth, Increased diuresis, Increased excretion of electrolytes
Elimination:
Constipation, Urinary stasis, Fecal impaction, Urine retention, urinary infections, Renal calculi
Psychosocial:
Depression Sensory deprivation Confusion Increased dependence Insomnia, restlessness
19
Q
List the purpose of clients positions: Flat (supine) Side side with leg bent (Sims) Fowler's Head and knees elevated slightly Feet elevated 20 ° and head slightly elevated (modified Trendelenburg) Elevation of extremity Flat on back, thighs flexed, legs abducted (lithotomy) Prone
A
Flat (supine) Minimizes hip flexion
Side Allows drainage of oral secretions
Side with leg bent (Sims’) Allows drainage of oral secretions (abdominal tension)
Head elevated (Fowler’s) Increased venous return; allows maximal lung expansion
Head and knees elevated slightly Increased venous return; relieves pressure on lumbosacral area
Feet elevated 20 ° and head slightly elevated (modified Trendelenburg) Increased venous return; increased blood supply to brain
Elevation of extremity Increases venous return
Flat on back, thighs flexed, legs abducted (lithotomy) Exposes perineum
Prone Promotes extension of hip joint
20
Q
How do you properly transfer a patient?
A
Transfer:
Definition— to move a client from one surface to another. (i.e., from a bed to a stretcher)
Basic guidelines
1) If client has a stronger and a weaker side, move the client toward the stronger side (easier for client to pull the weak side)
2) Use the larger muscles of the legs to accomplish a move rather than the smaller muscles of the back
3) Move client with drawsheet; do not slide a client across a surface
4) Always have an assistant standing by if there is any possibility of a problem in completing a transfer
Kaplan (2014-03-03). The Basics (p. 27). Kaplan Publishing. Kindle Edition.
21
Q
What is the technique for sitting client at edge of bed?
A
a. Place hand under knees and shoulders of client b. Instruct client to push elbow into bed; at same time lift shoulders and bring legs over edge of bed, or use one leg to move other leg over edge of bed
22
Q
What is the technique for assisting client to stand?
A
a. Place client’s feet directly under body; client should wear nonskid slippers
b. Face client and firmly grasp each side of rib cage
c. Push one knee against one knee of the client
d. Rock client forward as client comes to a standing position
e. Ensure that client’s knees are “locked” while standing f. Give client enough time to balance while standing
g. Pivot with client to position and transfer client’s weight quickly to chair placed on client’s stronger side
Kaplan (2014-03-03). The Basics (p. 27). Kaplan Publishing. Kindle Edition.
23
Q
How can we encourage our patients when it comes to ADLs?
A
Give immediate positive feedback after every act of accomplishment
Kaplan (2014-03-03). The Basics (p. 27). Kaplan Publishing. Kindle Edition.
24
Q
When pt is going up or down stairs with crutches, which food leads? when do crutches go?
A
To go up stairs: advance good leg first, followed by crutches and affected leg.
To go down stairs: advance crutches with affected leg first, followed by good leg.
(“ Up with the good, down with the bad.”)
Kaplan (2014-03-03). The Basics (p. 28). Kaplan Publishing. Kindle Edition.
25
When walking with crutches, should the patient bear wait on axillla or handpiece?
Client should support weight on handpiece, not in axilla— brachial plexus may be damaged, producing “crutch palsy”
Kaplan (2014-03-03). The Basics (p. 28). Kaplan Publishing. Kindle Edition.
26
How far to each side should crutches be positioned?
Position crutches 8– 10 inches to side
Kaplan (2014-03-03). The Basics (p. 28). Kaplan Publishing. Kindle Edition.
27
How can we prevent constipation?
1. Ambulation as appropriate 2. Increase fluid intake 3. Ensure privacy in use of bedpan or commode 4. Administer stool softeners, e.g., Colace
Kaplan (2014-03-03). The Basics (p. 29). Kaplan Publishing. Kindle Edition.
28
How can we prevent constipation?
1. Ambulation as appropriate 2. Increase fluid intake 3. Ensure privacy in use of bedpan or commode 4. Administer stool softeners, e.g., Colace
Kaplan (2014-03-03). The Basics (p. 29). Kaplan Publishing. Kindle Edition.
29
How can we prevent urinary stasis?
1. Have client void in normal position, if possible 2. Increase fluid intake 3. Low-calcium diet— increase acid-ash residue to acidify urine and prevent formation of calcium stones 4. Evaluate adequacy of urine output
Kaplan (2014-03-03). The Basics (p. 29). Kaplan Publishing. Kindle Edition.
30
How can we prevent pressure ulcers?
1. Frequent turning, skin care, keep skin dry
2. Ambulation as feasible
3. Use draw sheet when turning to avoid shearing force
4. Balanced diet with adequate protein, vitamins, and minerals
5. Use air mattress, flotation pads, elbow and heel pads, sheepskin
6. Assist with use of Stryker frame or Circ-O-Lectric bed (these beds are rad! The move in all types of directions with the patient strapped in. Google it!)
7. Gerontologic considerations:
a. Increased risk– poor nutritional status and weight loss, vitamin and protein deficiencies, decreased peripheral sensation, moisture
b. Identify clients at risk– Braden scale (for predicting pressure sores), weight loss greater than total body weight, serum albumin less than 3.5 g/ dL, pressure areas
c. Avoid friction during position change, eliminate moisture, move weight bearing from pressure areas, e.g., heel protectors, include high protein, vitamins, and carbohydrates in diet
Kaplan (2014-03-03). The Basics (p. 29). Kaplan Publishing. Kindle Edition.
31
How often should a patient do leg exercises to prevent thrombus (or DVT)?
1. Leg exercises— flexion, extension of toes and feet for five minutes every hour
Kaplan (2014-03-03). The Basics (p. 30). Kaplan Publishing. Kindle Edition.
32
How can we prevent thrombus?
Prevent thrombus formation 1. Leg exercises— flexion, extension of toes and feet for five minutes every hour 2. Ambulation as appropriate 3. Frequent change of position 4. Avoid “gatching” bed or using pillow to support knee flexion for extended periods 5. Use of TEDs or elastic hose
Kaplan (2014-03-03). The Basics (p. 30). Kaplan Publishing. Kindle Edition.
33
How can we prevent stasis of respiratory secretions?
1. Teach client the importance of turning, coughing, and deep breathing 2. Administer postural drainage as appropriate 3. Teach use of incentive spirometer
Kaplan (2014-03-03). The Basics (p. 30). Kaplan Publishing. Kindle Edition.
34
How can we prevent stasis of respiratory secretions?
1. Teach client the importance of turning, coughing, and deep breathing
2. Administer postural drainage as appropriate
3. Teach use of incentive spirometer
Kaplan (2014-03-03). The Basics (p. 30). Kaplan Publishing. Kindle Edition.
35
In Maslow's hierarchy of needs, which is the top priority? What is second to that?
Physiological is the number one: breathing, eating, fluid, excretion.
After that, safety is next.
36
T or F: Nursing has primary responsibility for ensuring the safety of clients in health care facilities and influencing the safety of persons in the home, work, and community environments
True
Kaplan (2014-03-03). The Basics (p. 31). Kaplan Publishing. Kindle Edition.
37
List factors affecting safety for age groups:
```
Children
TOddlers
Preschoolers
School ages
Adolescents
Adults
```
a. Children— accidents constitute leading cause of death in all age groups except infancy
1) Infants— accidents occur primarily in second half of first year a) Mouthing any object that they handle b) Unsupervised/ unrestrained rolling over, crawling, walking can result in falls and enhance accessibility to small objects, electric cords, poisonous substances, etc.
2) Toddlers— high incidence of accidents a) Increasing curiosity; exploring using all senses (especially taste and touch); learning by trial and error b) Increasing gross and fine motor activity, climbing, running, grasping, etc. c) Totally uncomprehending and fearless of consequences; increasing negativism as part of autonomy
3) Preschoolers— continued risk a) lncreasing imitative behavior b) Refining fine and gross motor ability without cognitive ability to foresee potential dangers
4) School-ages— although better muscular control, increased cognitive capacity, and more readiness to respond to rules, there continues to be increased risk of accidents related to identification with “super heroes,” increased involvement and competitiveness in sports, and sensitivity to peer pressure
5) Adolescents— high incidence; caused by motor vehicles, physical awkwardness related to growth changes, conflict over dependence/ independence; peer orientation and approval seeking; increasing goal orientation and risk-taking behavior; and inner perception of omnipotence and immortality
b. Adults— disregard for safety regulations
c. Elderly— diminished muscular strength and/ or coordination, diminished sensory acuity, and impaired balance create special problems
Kaplan (2014-03-03). The Basics (p. 31). Kaplan Publishing. Kindle Edition.
38
List factors affecting safety for age groups:
```
Children
Toddlers
Preschoolers
School ages
Adolescents
Adults
```
a. Children— accidents constitute leading cause of death in all age groups except infancy
1) Infants— accidents occur primarily in second half of first year a) Mouthing any object that they handle b) Unsupervised/ unrestrained rolling over, crawling, walking can result in falls and enhance accessibility to small objects, electric cords, poisonous substances, etc.
2) Toddlers— high incidence of accidents a) Increasing curiosity; exploring using all senses (especially taste and touch); learning by trial and error b) Increasing gross and fine motor activity, climbing, running, grasping, etc. c) Totally uncomprehending and fearless of consequences; increasing negativism as part of autonomy
3) Preschoolers— continued risk a) lncreasing imitative behavior b) Refining fine and gross motor ability without cognitive ability to foresee potential dangers
4) School-ages— although better muscular control, increased cognitive capacity, and more readiness to respond to rules, there continues to be increased risk of accidents related to identification with “super heroes,” increased involvement and competitiveness in sports, and sensitivity to peer pressure
5) Adolescents— high incidence; caused by motor vehicles, physical awkwardness related to growth changes, conflict over dependence/ independence; peer orientation and approval seeking; increasing goal orientation and risk-taking behavior; and inner perception of omnipotence and immortality
b. Adults— disregard for safety regulations
c. Elderly— diminished muscular strength and/ or coordination, diminished sensory acuity, and impaired balance create special problems
Kaplan (2014-03-03). The Basics (p. 31). Kaplan Publishing. Kindle Edition.
39
T or F: Noise-induced hearing loss is hearing loss due to exposure to either a sudden, loud noise or exposure to loud noises for a period of time. A dangerous sound is anything that is 85 dB (sound pressure level – SPL) or higher.
True
Sound— chronic exposure to loud noises can lead to permanent hearing loss, interfere with work performance, precipitate sleep problems and psychological stress
Kaplan (2014-03-03). The Basics (p. 32). Kaplan Publishing. Kindle Edition.
40
T or F: Noise-induced hearing loss is hearing loss due to exposure to either a sudden, loud noise or exposure to loud noises for a period of time. A dangerous sound is anything that is 85 dB (sound pressure level – SPL) or higher.
True
Sound affects safety— chronic exposure to loud noises can lead to permanent hearing loss, interfere with work performance, precipitate sleep problems and psychological stress
Kaplan (2014-03-03). The Basics (p. 32). Kaplan Publishing. Kindle Edition.
41
Why would you avoid leaving a 3 months old baby unattended on a flat surface higher than the floor?
Babies can roll over by about 3 months.
NEVER EVER leave a crib rail down even for a second in peds. EVER EVER! Not even to turn around and reach for something. Not worth the risk.
42
T or F: You should expect turbulent temperament or tantrums from 6 month olds?
False, this type of behavior is from 1 year to 3 years.
"Expect turbulent temperament; tantrums common, (therefore) Control environment; be consistent in expectations"
Kaplan (2014-03-03). The Basics (p. 33). Kaplan Publishing. Kindle Edition.
43
T or F: You should take special care in explaining all actions in advance when caring for a 3-6 year old.
True.
Illness and procedures are seen as punishment, body mutilation is feared
Kaplan (2014-03-03). The Basics (p. 33). Kaplan Publishing. Kindle Edition.
44
T or F: You should take an authoritarian approach with adolescents.
False.
Noncompliance is the norm; attempt to impose as few orders as possible Independence is important to their emotional growth.
Kaplan (2014-03-03). The Basics (p. 33). Kaplan Publishing. Kindle Edition.
45
T or F: At night time, you should turn off all lights.
False.
Never leave the client in total darkness— use night light when room lights are off
Kaplan (2014-03-03). The Basics (p. 33). Kaplan Publishing. Kindle Edition.
46
What are the hourly rules for restraints?
Restrain client only as necessary; restraints used only as long as necessary; padded to prevent undue pressure/ constriction; checked every 1– 2 h; removed every 2 h while client is awake; never tied to side rail; health care provider order necessary
Kaplan (2014-03-03). The Basics (p. 34). Kaplan Publishing. Kindle Edition.
47
In a high environmental temperature — __ to __L of fluid/ day (precautions when heart failure or renal failure present), wear natural fiber clothing, use tepid or cool baths or showers, fan, or air conditioning 13.
Low environmental temperature— avoid alcohol, keep room temperature greater than ___ ° F, eat a nutritious, high _____ diet
Kaplan (2014-03-03). The Basics (p. 34). Kaplan Publishing. Kindle Edition.
2 to 3 L of fluid
greater than 65 degrees F
high protein diet
48
What measures can we take to keep the elderly population safe?
Plan/ implementation– floor mat or mattress by bed, cleared debris from area, call light within reach, lights in room or bathroom, assistive device within reach, elevated toilet seat, sit on edge of bed before getting up, minimize use of hypnotics and sedatives, wear glasses as needed, wear proper footwear, grab bars in bathroom
Kaplan (2014-03-03). The Basics (p. 34). Kaplan Publishing. Kindle Edition.
49
What is the definition of pain?
Definition of pain—“ whatever the person says it is, and it exists whenever the person says it does”
Kaplan (2014-03-03). The Basics (pp. 34-35). Kaplan Publishing. Kindle Edition.
50
T or F: 7. If pain-relief measure is ineffective the first time, try it one more time before abandoning the measure
True
III
A
#7
Kaplan (2014-03-03). The Basics (p. 37). Kaplan Publishing. Kindle Edition.
51
List nursing goals and interventions for pain management...
Nursing goals and interventions (A modified old cart)
1. Establish a relationship
a. Tell client you believe description of pain experience b. Listen and allow client to verbalize
2. Establish a 24-h pain profile
a. Location and radiation:
1) External 2) Internal 3) Both external and internal
4) Area of body affected
b. Character and intensity:
1) Acute/ chronic 2) Mild/ severe 3) Allow client to use own words in describing pain 4) Use same pain scale consistently a) Number rating scale (0 to 10) b) Visual analogue scale (no pain to unbearable pain)
c. Onset 1) Sudden 2) Insidious
d. Duration
e. Precipitating factors/ aggravating factors (e.g., What makes pain worse?)
f. Identify associated manifestations, as well as alleviating or aggravating factors
g. Relieving factors
Kaplan (2014-03-03). The Basics (p. 37). Kaplan Publishing. Kindle Edition.
52
_______ is a bacterial skin infection with involvement of connective tissue
Kaplan (2014-03-03). The Basics (p. 41). Kaplan Publishing. Kindle Edition.
Cellulitis
53
_______ is a bacterial skin infection with involvement of connective tissue
Cellulitis
Kaplan (2014-03-03). The Basics (p. 41). Kaplan Publishing. Kindle Edition.
54
Which WBC increases during an allergic reaction?
eosinophils
55
Which WBC increases during most bacterial infections?
Neutrophils
neutralize the bacterial infection
Macrophage/phagocytosis
56
Which WBC increases during most bacterial infections?
Neutrophils
neutralize the bacterial infection
Macrophage/phagocytosis
57
Which WBC increases during most bacterial infections?
Neutrophils
| neutralize the bacterial infection- macrophage/phagocytosis
58
What is a "shift to the left" in diagnostic testing?
A "Shift to left” is increased number immature neutrophils
Kaplan (2014-03-03). The Basics (p. 41). Kaplan Publishing. Kindle Edition.
Just a little more information....
From allnurses.com:
One nurse says:
A left shift refers to the relative increase in IMMATURE forms of blood cells. The term actually comes from the fact that, if you go back to a patho book and look at the entire cascade diagram of how blood cells mature, the immature cells are on the left side of the old, standard diagram.
So, left shift typically means there are more band cells (% bands) in a CBC with differential. I personally think of bands as baby white cells. If the body is producing and mobilizing a large number of new white cells, then the body is attempting to fight off a very active infection. Normally, we only have 2-6% of our white cells as bands. If that percentage increases, then the infection is such that the body feels it's necessary to kick the baby white cells out of the nest before their time in order to join in the fight.
A second nurse says:
It was called a shift to the left because back in the Ole' days the CBC lab slips were short and wide. The immature cell counts were on the "left" of the lab report and so if the increase in immature cells occurred, there was a shift from the mature cell count on the right of the lab report to the left
59
What is a "shift to the left" in diagnostic testing?
A "Shift to left” is increased number immature neutrophils (immune system uses them before they are mature if infection is bad enough)
Kaplan (2014-03-03). The Basics (p. 41). Kaplan Publishing. Kindle Edition.
Just a little more information....
From allnurses.com:
One nurse says:
A left shift refers to the relative increase in IMMATURE forms of blood cells. The term actually comes from the fact that, if you go back to a patho book and look at the entire cascade diagram of how blood cells mature, the immature cells are on the left side of the old, standard diagram.
So, left shift typically means there are more band cells (% bands) in a CBC with differential. I personally think of bands as baby white cells. If the body is producing and mobilizing a large number of new white cells, then the body is attempting to fight off a very active infection. Normally, we only have 2-6% of our white cells as bands. If that percentage increases, then the infection is such that the body feels it's necessary to kick the baby white cells out of the nest before their time in order to join in the fight.
A second nurse says:
It was called a shift to the left because back in the Ole' days the CBC lab slips were short and wide. The immature cell counts were on the "left" of the lab report and so if the increase in immature cells occurred, there was a shift from the mature cell count on the right of the lab report to the left
60
What is A highly sensitive C-reactive protein (hsCRP) test for?
Marker for inflammation
From webMD:
A C-reactive protein test is a blood test that measures the amount of a protein called C-reactive protein in your blood. C-reactive protein measures general levels of inflammation in your body.
High levels of CRP are caused by infections and many long-term diseases. But a CRP test cannot show where the inflammation is located or what is causing it. Other tests are needed to find the cause and location of the inflammation.
61
What are ways we can prevent HAIs?
Prevention of hospital-acquired infections
a. External environment— handwashing
b. Internal environment— good nutrition and personal hygiene
c. Prevention of UTI— strict aseptic technique during instrumentation
d. Prevention of surgical wound infections— handwashing, surgical asepsis
e. Prevention of respiratory infections— clean nebulizers f. Prevention of bacteremias— excellent sterile technique with intravascular systems
Kaplan (2014-03-03). The Basics (p. 42). Kaplan Publishing. Kindle Edition.
62
Use _______ precautions with pathogens smaller than 5 microns that can travel on air currents.
airborne
63
Use _______ precautions with pathogens smaller than 5 microns that can travel on air currents.
airborne
64
Use _______ precautions with pathogens smaller than 5 microns that can travel on air currents.
airborne
Keep patient door closed
Wear n-95 HEPA filter mask
65
Use _______ precautions with pathogens smaller than 5 microns that can travel on air currents.
airborne
Keep patient door closed
Wear n-95 HEPA filter mask
66
Should you mask a client during transport if they are on airborne precaution?
Yes
67
What type of mask do you wear when treating a TB patient?
Fit test mask
68
What are examples of diseases that we should use airborne precaution with?
Example of disease in category: measles (rubeola), M. tuberculosis, varicella (chicken pox), disseminated zoster (shingles)
Disseminated shingles means "more than twenty skin lesions appearing outside either the primarily affected dermatome or dermatomes directly adjacent to it."
Kaplan (2014-03-03). The Basics (p. 43). Kaplan Publishing. Kindle Edition.
69
For Droplet precaution, Maintain spatial separation of _____feet between infected client and visitors or other clients; visitors wear mask if less than _____ feet
three ; three
Kaplan (2014-03-03). The Basics (p. 43). Kaplan Publishing. Kindle Edition.
70
Should you mask a client during transport if they are on airborne or droplet precaution?
Yes
71
For Droplet precaution, Maintain spatial separation of _____feet between infected client and visitors or other clients; visitors wear mask if less than _____ feet
three ; three
7) Examples of disease in category: diphtheria, Group A Streptococcus pneumonia, pneumonia or meningitis caused by N. meningitidis or H. influenzae Type B, Rubella, mumps, pertussis
Kaplan (2014-03-03). The Basics (p. 43). Kaplan Publishing. Kindle Edition.
72
_______ precautions are used to prevent infection among clients with immunosuppression; absolute neutrophil count ≤ 1000 mm3
(below min 4500 norm)
Neutropenic
(Typical for kids with cancer when I was in peds)
Kaplan (2014-03-03). The Basics (p. 44). Kaplan Publishing. Kindle Edition.
73
What are some example diseases/infections that we should use contact precautions with?
Example of diseases in category: infection caused by multidrug-resistant organisms (e.g., MRSA and Vancomycin-resistent organisms), herpes simplex, herpes zoster, clostridium difficile, respiratory syncytial virus, pediculosis, scabies, excessive wound drainage, fecal incontinence, discharge which suggests increased potential for environmental contamination, rotavirus, hepatitis type A (diapered or incontinent clients), localized herpes zoster
Kaplan (2014-03-03). The Basics (p. 44). Kaplan Publishing. Kindle Edition.
74
_______ precautions are used to prevent infection among clients with immunosuppression; absolute neutrophil count ≤ 1000 mm3
Neutropenic
(Typical for kids with cancer when I was in peds)
Kaplan (2014-03-03). The Basics (p. 44). Kaplan Publishing. Kindle Edition.
75
Because patients in neutropenic precaution are immunosupressed and their health is "fragile," we need to take additional steps in monitoring them. List examples:
a. Assess skin integrity every 8 hours; auscultate breath sounds, presence of cough, sore throat; check temperature every 4 hours; report if greater than 101 ° F (38 ° C); monitor CBC and differential daily
b. Private when possible
c. Thorough hand hygiene before entering client’s room
d. Allow no staff with cold or sore throat to care for client
e. No fresh flowers or standing water
f. Clean room daily
g. Low microbial diet; no fresh salads, unpeeled fruits and vegetables
h. Deep breathe every 4 hours
i. Meticulous body hygiene
j. Inspect IV site; meticulous IV site care
Kaplan (2014-03-03). The Basics (p. 44). Kaplan Publishing. Kindle Edition.
76
The zoster vaccine is given in one single dose and is recommended for people ages ____+ regardless of a prior episode of herpes zoster (shingles).
60+
77
What are some therapeutic baths we can use to treat skin?
Type -Purpose -Common Use
Colloidal, e.g., oatmeal, cornstarch - Antipruritic for
Chickenpox
Potassium permanganate - Antifungal for Slow-healing ulcers
Burow’s solution - Antibacterial - Soaks
Tar preparations- Antipruritic - Psoriasis Oils, e.g., Alpha-Keri Antipruritic Moisturizing
Kaplan (2014-03-03). The Basics (p. 49). Kaplan Publishing. Kindle Edition.
78
Apply dressings:
1) Open wet— antipruritic, vasoconstrictive
a) Soak non-residue cloth in tepid solution
b) Apply for ___ to ____ min
c) Reapply repeatedly for 15– 20 min
d) Dry skin
3– 5
Kaplan (2014-03-03). The Basics (pp. 49-50). Kaplan Publishing. Kindle Edition.
79
What is a nursing intervention for skin care of impetigo?
Skin isolation: careful handwashing; cover draining lesions; discourage touching lesions Antibiotics– may be topical ointment (Garamycin, Neosporin) and/ or PO Loosen scabs with Burow’s solution compresses; remove gently Restraints if necessary; mitts for infants to prevent secondary infection Monitor for acute glomerulonephritis (complication of untreated impetigo)
Kaplan (2014-03-03). The Basics (p. 51). Kaplan Publishing. Kindle Edition.
80
What is the common name for pediculosis?
Lice
81
Tinea causes...
Pedis (athlete's foot), capitis (ringworm) and corporis (ringworm of body)
Treatment:
Antifungal– topical ointment, creams, lotions include ketoconazole (Nizoral), miconazole (Micatin), terbinafine (Lotrimin) Keep areas dry and clean Frequent shampoos
Kaplan (2014-03-03). The Basics (p. 51). Kaplan Publishing. Kindle Edition.
82
What are some things people may want to eliminate if they have eczema?
Elimination from diet of common offenders, especially milk, eggs, wheat, citrus fruits, and tomatoes
Eliminate clothing that is irritating (rough/ wool) or that promotes sweating; cotton clothing is best
Avoid soap and prolonged or hot baths/ showers, which tend to be drying; may use warm colloid baths (e.g., Aveeno/ cornstarch)
Kaplan (2014-03-03). The Basics (p. 51). Kaplan Publishing. Kindle Edition.
83
What are some common changes in elderly skin?
a. Loss of subcutaneous tissue and melanocytes– skin tears more easily; increased risk ultraviolet damage
b. Degeneration of collagen and elastic fibers– wrinkling, skin tears more often
c. Increased capillary fragility; decreased circulation– increased bruising, decreased wound healing
d. Hormonal changes and decreased immune function– dry and more permeable skin
2. Intervention— Bathe every day or less often; avoid use of strong, scented, or alcohol-based soaps; avoid bath oil in tubs; keep room humidity at 60%
Kaplan (2014-03-03). The Basics (p. 53). Kaplan Publishing. Kindle Edition.
84
What are some common changes in elderly skin?
a. Loss of subcutaneous tissue and melanocytes– skin tears more easily; increased risk ultraviolet damage
b. Degeneration of collagen and elastic fibers– wrinkling, skin tears more often
c. Increased capillary fragility; decreased circulation– increased bruising, decreased wound healing
d. Hormonal changes and decreased immune function– dry and more permeable skin
Intervention— Bathe every day or less often; avoid use of strong, scented, or alcohol-based soaps; avoid bath oil in tubs; keep room humidity at 60%
Kaplan (2014-03-03). The Basics (p. 53). Kaplan Publishing. Kindle Edition.
85
Petechiae (pronounced PEH TEEK EE EE) is what?
small red or purple spot caused by bleeding into the skin
86
What is a wheal?
a localized area of edema; example: mosquito bite
87
Xanthoma and fibroma are nodules.
describe each....
xanthoma - irregular yellow patch or nodule on the skin
fibroma - benign fibrous tumor of connective tissue
88
A vesicle is an elevation of skin filled with clear fluid that is less than ____ cm in size.
1 cm
Example— blister, herpes simplex, herpes zoster, early chicken pox
Kaplan (2014-03-03). The Basics (p. 54). Kaplan Publishing. Kindle Edition.
89
A vesicle is an elevation of skin filled with clear fluid that is less than ____ cm in size.
1 cm
Example— blister, herpes simplex, herpes zoster, early chicken pox
Kaplan (2014-03-03). The Basics (p. 54). Kaplan Publishing. Kindle Edition.
90
Before surgery, there are some culturally sensitive issues to address. What are they?
a. Assess primary language spoken
b. Assess feelings regarding surgery and pain
c. Determine attitudes about pain management
d. Determine expectations of the intraoperative and postoperative periods
e. Evaluate client’s support system
f. Assess feelings about self-care
g. Use professional interpreters
h. Use pictures or phrase cards with various languages
i. Provide printed teaching materials in a variety of languages
Kaplan (2014-03-03). The Basics (p. 60). Kaplan Publishing. Kindle Edition.
91
True or False: Supplements should not be taken near the time of surgery because they may interact with anesthesia or affect coagulation parameters.
True.
Discontinue:
1) Echinacea 2) Ephedra (currently removed from the retail market in the United States) 3) Garlic 4) Ginkgo 5) Ginseng 6) Kava 7) St. John’s wort
Kaplan (2014-03-03). The Basics (pp. 60-61). Kaplan Publishing. Kindle Edition.
92
True or False: Supplements should not be taken near the time of surgery because they may interact with anesthesia or affect coagulation parameters.
True.
Discontinue:
1) Echinacea 2) Ephedra (currently removed from the retail market in the United States) 3) Garlic 4) Ginkgo 5) Ginseng 6) Kava 7) St. John’s wort
b. Eliminate all dietary supplements (other than multivitamins) at least 2 to 3 weeks before surgery c. May resume the supplements with the advice of the health care provider
Kaplan (2014-03-03). The Basics (p. 61). Kaplan Publishing. Kindle Edition.
93
Post operation, you can prevent aspiration by elevating the ____ of the bed and by _____ the head to the side unless contraindicated.
head
turning
94
Post operation assessment should include a full head to toes assessment because surgery can affect any system. For each system there are different interventions we should perform. List examples for neuropsychosocial.
1. Stimulate client postanesthesia
2. Monitor level of consciousness
Kaplan (2014-03-03). The Basics (p. 62). Kaplan Publishing. Kindle Edition.
95
Post operation assessment should include a full head to toes assessment because surgery can affect any system. For each system there are different interventions we should perform. List examples for CARDIOVASCULAR.
1. Generally monitor vital signs q 15 min times 4 (1st hour), q 30 min times 2 (hour 2), q 1 h times 2 (3-4 hour), then as needed
2. Monitor I and O
3. Check potassium level
4. Monitor CVP (CENTRAL VENOUS PRESSURE)
Kaplan (2014-03-03). The Basics (p. 62). Kaplan Publishing. Kindle Edition.
96
Post operation assessment should include a full head to toes assessment because surgery can affect any system. For each system there are different interventions we should perform. List examples for CARDIOVASCULAR.
1. Generally monitor vital signs q 15 min times 4 (1st hour), q 30 min times 2 (hour 2), q 1 h times 2 (3-4 hour), then as needed
2. Monitor I and O
3. Check potassium level
4. Monitor CVP (CENTRAL VENOUS PRESSURE)
Kaplan (2014-03-03). The Basics (p. 62). Kaplan Publishing. Kindle Edition.
97
Post operation assessment should include a full head to toes assessment because surgery can affect any system. For each system there are different interventions we should perform. List examples for RESPIRATORY.
1. Check breath sounds
2. Turn, cough, and deep breathe (unless contraindicated; e.g., brain, spinal, eye surgery)
3. Splint wound (HOLD PILLOW TO ABDOMEN TO EASE PAIN WHEN COUGHING IS AN EXAMPLE)
4. Offer pain medication
5. Teach incentive spirometer
6. Get out of bed as soon as possible
Kaplan (2014-03-03). The Basics (p. 62). Kaplan Publishing. Kindle Edition.
98
Post operation assessment should include a full head to toes assessment because surgery can affect any system. For each system there are different interventions we should perform. List examples for RESPIRATORY.
1. Check breath sounds
2. Turn, cough, and deep breathe (unless contraindicated; e.g., brain, spinal, eye surgery)
3. Splint wound (HOLD PILLOW TO ABDOMEN TO EASE PAIN WHEN COUGHING IS AN EXAMPLE)
4. Offer pain medication
5. Teach incentive spirometer
6. Get out of bed as soon as possible
Kaplan (2014-03-03). The Basics (p. 62). Kaplan Publishing. Kindle Edition.
99
Post operation assessment should include a full head to toes assessment because surgery can affect any system. For each system there are different interventions we should perform. List examples for GASTROINTESTINAL.
1. Check bowel sounds in 4 quadrants 5 min each
2. Keep NPO until bowel sounds present
3. Provide good mouth care while NPO
4. Provide antiemetics for nausea and vomiting (PREVENTS VOMITING)
5. Check abdomen for distention
6. Check for passage of flatus and stool
Kaplan (2014-03-03). The Basics (pp. 62-63). Kaplan Publishing. Kindle Edition.
100
Post operation assessment should include a full head to toes assessment because surgery can affect any system. For each system there are different interventions we should perform. List examples for GASTROINTESTINAL.
1. Check bowel sounds in 4 quadrants 5 min each
2. Keep NPO until bowel sounds present
3. Provide good mouth care while NPO
4. Provide antiemetics for nausea and vomiting (PREVENTS VOMITING)
5. Check abdomen for distention
6. Check for passage of flatus and stool
Kaplan (2014-03-03). The Basics (pp. 62-63). Kaplan Publishing. Kindle Edition.
101
Post operation assessment should include a full head to toes assessment because surgery can affect any system. For each system there are different interventions we should perform. List examples for GENITOURINARY.
1. Monitor I and O
2. Encourage to void
3. Notify health care provider if unable to void within 8 h 4. Catheterize if needed
Kaplan (2014-03-03). The Basics (p. 63). Kaplan Publishing. Kindle Edition.
102
After surgery, notify health care provider if unable to void within ____ hours.
8 hours
103
Post operation assessment should include a full head to toes assessment because surgery can affect any system. For each system there are different interventions we should perform. List examples for GENITOURINARY.
1. Monitor I and O
2. Encourage to void
3. Notify health care provider if unable to void within 8 h 4. Catheterize if needed
Kaplan (2014-03-03). The Basics (p. 63). Kaplan Publishing. Kindle Edition.
104
Post operation assessment should include a full head to toes assessment because surgery can affect any system. For each system there are different interventions we should perform. List examples for EXTREMITIES.
1. Check pulses
2. Assess for color, edema, temperature
3. Inform client not to cross legs
4. Keep knee gatch flat (don't have bottom half of bed bent)
5. Prohibit pillows behind knee
6. Apply antiembolic stockings (TED hose) prior to getting OOB
7. Monitor for calf pain and/ or calf swelling
8. Pneumatic compression device
Kaplan (2014-03-03). The Basics (p. 63). Kaplan Publishing. Kindle Edition.
105
Post operation assessment should include a full head to toes assessment because surgery can affect any system. For each system there are different interventions we should perform. List examples for GENITOURINARY.
1. Monitor I and O
2. Encourage to void
3. Notify health care provider if unable to void within 8 h 4. Catheterize if needed
Kaplan (2014-03-03). The Basics (p. 63). Kaplan Publishing. Kindle Edition.
106
Post operation assessment should include a full head to toes assessment because surgery can affect any system. For each system there are different interventions we should perform. List examples for EXTREMITIES.
1. Check pulses
2. Assess for color, edema, temperature
3. Inform client not to cross legs
4. Keep knee gatch flat (don't have bottom half of bed bent)
5. Prohibit pillows behind knee
6. Apply antiembolic stockings (TED hose) prior to getting OOB
7. Monitor for calf pain and/ or calf swelling
8. Pneumatic compression device
Kaplan (2014-03-03). The Basics (p. 63). Kaplan Publishing. Kindle Edition.
107
Post operation we must check the wounds. We need to assess dressing and incision. What are keypoint about DRESSING?
a. Document amount and character of drainage
b. Health care provider changes first postop dressing
c. Aseptic technique
d. Note presence of drains
Kaplan (2014-03-03). The Basics (p. 63). Kaplan Publishing. Kindle Edition.
108
Post operation we must check the wounds. We need to assess dressing and incision. What are keypoint about INCISION?
a. Assess site: edematous, inflamed, excoriated
b. Assess drainage: serous, serosanguineous, purulent
c. Note type of sutures
d. Note if edges are well approximated
e. Risk of infection 3– 5 d postop
f. Debride wound, if needed, to reduce inflammation
g. Change dressing frequently to prevent skin breakdown around site and minimize bacterial growth
Kaplan (2014-03-03). The Basics (p. 63). Kaplan Publishing. Kindle Edition.
109
What types of drains are used to prevent accumulation in tissues?
Penrose (Usually not sutured in place, but layered in gauze dressing) Expect drainage on dressing
T-tube (Used after gallbladder surgery) - Placed in common bile duct to allow passage of bile. Monitor drainage Initially 500-1,000 ml per day Usually bloody for first 2 h Keep drainage bag below level of gallbladder May be discharged with T-tube in place Teach client about care
Jackson-Pratt (Portable wound self-suction device with reservoir) Monitor amount and character of drainage Notify health care provider if it suddenly increases or becomes bright red
Hemovac (Larger portable wound self-suction device with reservoir) Used after mastectomy. Monitor and record amount and character of drainage. Notify health care provider if it suddenly increases or becomes bright red. Empty when full or every 8 h. Remove plug (maintain sterility), empty contents, place on flat surface, cleanse opening and plug with alcohol sponge, compress evacuator completely to remove air, replace plug, check system for operation
Kaplan (2014-03-03). The Basics (p. 64). Kaplan Publishing. Kindle Edition.
110
The nurse understands which of the following is helpful to facilitate a patient to have bowel elimination?
increase dietary bulk
111
To promote evening rest and sleep for patients who are immobilized in bed, it is MOST important for the nurse to provide whic of the folowing?
1. privacy
2. back rubs
3. daily baths
4. daytime activies
4. daytime activies
112
To promote evening rest and sleep for patients who are immobilized in bed, it is MOST important for the nurse to provide whic of the folowing?
1. privacy
2. back rubs
3. daily baths
4. daytime activies
4. daytime activies
pt naps less during day and sleeps better at night
113
The nurse identifies which diet BEST meet the needs of a person with multiple wounds?
high vitamin C, high protein, high carbs
114
The nurse identifies which diet BEST meet the needs of a person with multiple wounds?
high vitamin C (essential to wound healing), high protein (necesary for tissue growth), high carbs (needed for energy so that protein goes toward healing)
115
A client comes to the emergency room after puncturing foot on rust nail. Client states the last Td immunization was 6 years ago. WHich of the followig should be done first?
1. administer tetanus toxoid
2. determine how many Td immunz client has received
3. administer tetanus immune globulin (TIG)
4. monitor for lockjaw?
2. determine how many Td immunz client has received
If rec'd at ;east 3 doses of Td, give tetanus toxoid
if less than, adminster Td and TIG
116
THe nurse understand the purpose of a drain in a wound is to...
keep the tissues close together so that healing can occur.
117
What types of drains are used to prevent accumulation in tissues?
Penrose (Usually not sutured in place, but layered in gauze dressing) Expect drainage on dressing
T-tube (Used after gallbladder surgery) - Placed in common bile duct to allow passage of bile (prevents buildup of bile). Monitor drainage Initially 500-1,000 ml per day Usually bloody for first 2 h Keep drainage bag below level of gallbladder May be discharged with T-tube in place Teach client about care
Jackson-Pratt (Portable wound self-suction device with reservoir) Monitor amount and character of drainage Notify health care provider if it suddenly increases or becomes bright red. Negative pressure causes more drainage
Hemovac (Larger portable wound self-suction device with reservoir) Used after mastectomy. Monitor and record amount and character of drainage. Notify health care provider if it suddenly increases or becomes bright red. Empty when full or every 8 h. Remove plug (maintain sterility), empty contents, place on flat surface, cleanse opening and plug with alcohol sponge, compress evacuator completely to remove air, replace plug, check system for operation. NEGATIVE pressure. Used for increased drainage
Kaplan (2014-03-03). The Basics (p. 64). Kaplan Publishing. Kindle Edition.
118
The bag of drainage device should be below....
Insertion area
119
Before surgery allow the patient to tell you in their own words...
history of illness, purpose of surgery, type of surgery, client expectations (role, self care, finances, etc).
120
Why is it important to find out if a patient uses tobacco or alchohol before surgery?
They may experience withdrawal after. This needs to be addressed.
121
Why is it important to find out if a patient uses tobacco or alcohol before surgery?
They may experience withdrawal after. This needs to be addressed.
122
THe nurse identigies which finding is characeristic of chronic pain?
weight loss or gain, fatigue
123
ADD OBESE SCALE BMI
BMI
124
ADD DVT SYMPTOMS
ADD DVT SYMPTOMS
125
WBCS normal range 6500-11000
true
126
WBCS normal range 4500-10000
true
127
The nurse performs discharfe teaching for a client receiving warfarin. THe nurse determines further teaching is required if the client makes the statement...
I should look for yellow tinged complexion
128
The home care nurse cares for a client diganosed with a fractured humerus due to a fallin the home. Which of the following observations, if made by the nurse, requires an immediate intervention?
1. bathroom is equipped with grab bars
2. throw rugs have been removed
3. the client ambulates wearing socks
4. stairs are well lit.
3. the client ambulates wearing socks
Them shits are slippery. Make sure to get the pt some non skids
129
The nurse expects which of the following physiological changes to occur to a patient during episode of acute pain?
1. decresed BP
2. decreased skin temp
3. decreased HR
4. decreased respi
2. decreased skin temp
130
The nurse expects which of the following physiological changes to occur to a patient during episode of acute pain?
1. decresed BP
2. decreased skin temp
3. decreased HR
4. decreased respi
2. decreased skin temp
perspiration after pain starts causing cooling of skin
