General Flashcards
What is the priority for a psy patient who is upset, paranoid, angry, potentially violent?
Allow them to vent
This may diffuse the situation
Which of the following potential nursing actions would be undertaken with an 11 month old with possible bacterial meningitis
Incentive spirometer q2h
Oxygen via nasal canual
Continous pulse Ox monitoring
Droplet precautions
Seizure precautions
Neurological checks daily
Type & cross match for 2 units of PRBCs
Vital signs every hr
Contact HCP if temp > 102.4
Blood cultures
Oxygen via nasal canual
Continous pulse Ox monitoring
Droplet precautions
Seizure precautions
Vital signs every hr
Contact HCP if temp > 102.4
Blood cultures
Select if the findings are consistent with
Acute pancreatitis or Dehydration or Both
Fever
Tachycardia
Ab pain
Hypotension
Vomiting
Fever Both
Tachycardia Both
Ab pain Acute pancreatitis
Hypotension Both
Vomiting Acute pancreatitis
Acute abdominal pain
N/V
Blue-Gray discoloration of umbilicus area
Classic signs of..
Acute pancreatitis
Risk factors for CKD are…
Chronic Kidney disease
Diabetes
HTN
Other risk factors include:
Heart disease
Family history of CKD
Obesity
Pregnancy-related disorder that involves persistent high blood pressure, proteinuria, and poor placental perfusion
Preeclampsia
When can preeclampsia occur?
What are some consequences
Pregnancy or after giving birth
Potentially serious.
Liver and kidney damage, and a decrease in platelets
Dangerous to Mother & Child
HELLP syndrome AKA
What is it?
Also called: hemolysis (RBC breakdown), elevated liver enzymes, low platelet
A serious complication of high blood pressure during pregnancy.
Which are immediate concerns for a newborn?
RR 40 - 60
Intermittent expiratory grunting
Fine crackles
Occasional apenic episodes
Arms & legs relaxed
Crying
Relaxed body posture
Diminished reflexes
Skin molted (Reddish-purple streaks, spots)
Axillary temp 96.7
HR 132
Presence of a murmur
Expiratory grunting & apenic episode
Relaxed muscles / Posture is abnormal. Possible sign of respiratory compromise
Axillary temp is too low.
Normals
New born RR = 30 - 60
Fine crackles are normal / COURSE CRACKELS ARE NOT
HR = 100 - 160
54 yr admitted to ED with severe, watery diarrhea, weakness, occasional muscle twitching. No N/V, A&O X3
Has stage 3 CKD which is well managed by diuretics, diet, fluid restriction. Not receiving Kidney Replacement Therapy.
HR 59 & irregular. ECG Tall peaked T waves, flat P, widened QRS.
Labs
NA 145
K 5.9
Hg 11
Hct 35%
BUN 34
Creatine 2.8
Which findings need immediate follow-up?
54 yr admitted to ED with severe, watery diarrhea, weakness, occasional muscle twitching.
HR 59 & irregular. ECG Tall peaked T waves, flat P, widened QRS.
Labs
K 5.9
BUN 34
Low Hg & Hct are expected in stage 3 CKD.
Elevated creatinine is associated Only with Kidney function Not Fluid levels. Elevated is to be expected in Stage 3 CKD
Airway Clearance Therapy is needed in CF patients due to Thick Mucus production that can block bronchi & bronchioles.
Treatments include: (5)
Chest physiotherapy
Percussion & postural drainage
PEP Positive Expiratory Therapy
High frequency chest compressions
Exercise
CF causes thick mucus to block the pancreas.
What kind of problem will this have on the health
Type of diet for CF
Medications / Supplements needes?
Pancreatitic enzymes unable to reach duodenum - fats & protiens will be be properly absorbed
Diet: High protein, high calorie, Unrestricted Fatsneeded?
Meds: Pancreatic Enzymes with food
Multivitamin, esp (A,D,E,K) - Fat soluble
Why should clients with CF seperate 6’ from other clients with CF?
Reduced Infections
The stagent mucus is a Breeding Ground for BACTERIA INFECTIONS
Why is diabetes (CFRD) common with CF?
How is it diagnoses?
Reduction in Islets of Langerhan - where beta cells produce Insulin
OGTT
2 hrs after glucose administration 240 BS = Diabetes
CF patient requires more of this electrolyte?
Sodium.
It is lost in the sweat , parents describe their child as tasting Salty
Laparotomy vs laparoscopy.
Laparotomy: Open exploratory procedure to examine the abdominal organs. Large incision, quicker & easier.
laparoscopy: lighted camera is inserted into the abdomen through a “Key-Hole” to examine the organs in the abdomen
Colectomy is….
Why is it preformed?
Surgical procedure that removes part or all of the colont
Cancer, inflammatory disease, or diverticulitis.
Minimum urine voided per hour?
30 mL
Atelectasis can occur after surgery due to: Anesthesia, analgesics, or Immobility.
Name (5) S&S
Elevated RR
Dyspnea
Fever
Crackles
Productive cough
Hemorrhage/ Bleeding after surgery due to slipping of suture or dislodged clot
S/S
Hypertension/ Hypotension
Bounding Pulse/ Weak Pulse
Skin: Cool & Clammy / Hot & Dry
RR: Decrease/ Increase
Hypotension
Weak Pulse
Skin: Cool & Clammy
RR: Increase
Tamoxifen is this type of medication
Used for…
How does it work
Estrogen modulator that blocks estrogen in breast tissue.
Use to treat breast cancer & prevents breast cancer
Works by blocking estrogen receptors Inhibit growth and proliferation of cancer cells
Tamoxifen blocks the effects of estrogen in breast tissue (Prevent / Treat) breast cancer.
Has the serious adverse side effect
List SE:
Cause endometrial cancer
S&S
Hypercalcemia (Bone Pain) / Fractures / Bone Metastasis
Menstrual bleeding post menopause
Pelvic pain
Vaginal discharge
Vasomotor (Hot Flashes)
Chorioamnionitis, also known as intra-amniotic infection …
Common pregnancy complication
Inflammation & infection of the fetal membranes and placenta
( Gravida / Para)
Number of times a female is or has been pregnant, regardless of the pregnancy outcome.A current pregnancy, if any, is included in this count. A multiple pregnancy (e.g., twins, triplets, etc.) is counted as 1.
(Gravida / Para “Parity”)
Number of births (including live births and stillbirths) where pregnancies reached viable gestational age. A multiple pregnancy (e.g., twins, triplets, etc.) carried to viable gestational age is still counted as 1.
Gravida
Number of times a female is or has been pregnant, regardless of the pregnancy outcome.A current pregnancy, if any, is included in this count. A multiple pregnancy (e.g., twins, triplets, etc.) is counted as 1.
Para “Parity”
Number of births (including live births and stillbirths) where pregnancies reached viable gestational age. A multiple pregnancy (e.g., twins, triplets, etc.) carried to viable gestational age is still counted as 1.
Prelabor rupture of membranes (PROM) - Spontaneous rupture of amniotic sac with subsequent leakage of amniotic fluid
Preterm prelabor rupture of membranes (Same as above) but happens < ___ week of pregnancy
Risk Factors include
37th
Cigarettes
urinal / gential tract infection, previous Preterm birth
history of cervical cerclage (surgical procedure: Stitches around the cervix to help prevent preterm birth)
Short cervix length
Contractions during pregnancy
Uterine overdistension
Bleeding 2nd / 3rd trimester
Pulmonary disease
Connective tissue disorder
Low BMI
Nutrition deficiency
Placental abruption …
S/S
When the placenta becomes dislodged from the uterus (womb) Serious Problem
Bleeding from vagina
Stomach / Back pain
Contractions
Retained placenta ..
All or part of the placenta or membranes remain in the uterus during the third stage of labor.
It’s not common, but it can be serious and lead to severe infection or life-threatening blood loss for the mother
Intrauterine infection, also known as chorioamnionitis…
Infection that occurs in the uterus during pregnancy, when the placenta, amniotic fluid, or membranes become infected.
It can also develop after birth, when the lining of the uterus becomes infected
Umbilical Cord Prolapse
Umbilical cord comes out of the uterus before the baby
Effects on baby:
Factors that cause Umbilical Cord Prolapse
Bradycardia <120
Hypoxia
Factors:
Umbilical Cord seen as water breaks
Drop in babies HR
Change in blood pressure
Pulmonary hypoplasia (PH)
Rare congenital malformation that causes incomplete lung development
Small or abnormally low numbers of alveoli or bronchopulmonary segments.
When does this happen on fetal development
<20 weeks
32 yr old G²P¹
First delivery unremarkable
History of mitral valve stenosis, monitored
No medication
Post delivery
Peripad soaked with blood
Abdominal cramps
Fundus is soft & 4 fingerbreaths above the umbilicus, devianted right.
HR: 120
BP 98/ 62
RR: 24
SpO²: 92% RA
The nurse would immediately plan for (1.) _______ and (2.) _____
1.
Uterine massage
Rapid administration of blood
Administration of methylergonovine
Manual exploration if Uterine cavity
- Hysterectomy
Uterine tamponade
Oxygen administration
IV infusion of oxytocin
The nurse would immediately plan for Uterine massage and IV infusion of Oxytocin
Initial interventions for excessive postpartum bleeding = Contract the uterus & stop bleeding
Immediate interventions (Uterine Atony) Firm massage of fundus, expression of clots in uterus, Elimination of bladder distention, Continous IV Oxytocin.
Methylergonovine admin IM produces sustained Uterine Contractions, However, it is contradicted with HTN or Cardiovascular disease due to vasoconstriction.
Methylergonovine is used for what?
admin IM
Sustained Uterine Contractions
Contradicted with HTN or Cardiovascular disease due to vasoconstriction.
uterine balloon tamponade
Stops post-partum hemorrhage due to a ________.
It’s inserted inside the uterus, filled with fluid and works by compressing the bleeding vessels
Relaxed uterus
Postpartum hemorrhage
First: Massage Fundus (if it is soft)
Admin Oxytocin IM
Admin methylergonovine
If bleeding continues
PHCP will perform….
If this is ineffective, then….
Manual explanation of uterine cavity for retained clots or placental fragments
Uterine tamponade/ Surgical Management
Hysterectomy maybe needed
Which of the following are indicated directly following an ischemic stroke
Complete swallow screen
Allow thickened liquids only
Administer fibrinolytic therapy
Obtain electronic infusion pump
Perform cardiovascular assessment
Insert indwelling urinary catheter
Admin IV Antihypertensive meds (BP = 152 / 84)
Perform frequent neurological assessment
Complete swallow screen
Administer fibrinolytic therapy
(break up blood clots)
Obtain electronic infusion pump
(Used to deliver fibrinolytic therapy / must be 2 RN check)
Perform cardiovascular assessment
Perform frequent neurological assessment
Ischemic Stoke BP of 150/100 is needed to maintain Cerebral perfusion
Ischemic stroke is caused by a blockage of a cerebral or carotid artery.
Fibrinolytic therapy No Invasive tubes placed 24 hrs or until stable (bleed risk)
Exclusion for this therapy include
> 4.5 hrs from onset of symptoms
80 yrs
Anticoagulant use
Ischemic injury to > 1/3 of brain
Significant neurological impairment
History both Stroke & DM
Fibrinolytic therapy
Evisceration is most common 5 - 10 days after surgery in obese, diabetic, malnourished, immune deficit, steroid using clients.
What nursing actions will be taken: (5)
Cover with sterile,warm saline soaked dressing
Stay with patient & notify rapid response team
Place supine HOB 15 - 20 °
Assess VS q10min
Prepare for surgery
3 month old with heart failure due to Ventricular Septal Defect
Prescribed: digoxin, enalapril, carvedilol, furosemide
RR: 64
HR: 164
T: 97.8
BP: 78/ 48
SPO² 91% RA
Which intervention would the nurse plan for this baby
Maintain fluid restrictions
Admin Sodium Bicarbonate
Admin K supplements
Plan feeding around infants sleep schedule
Allow baby to cry for 5 minutes before feeding
Monitor for Bradycardia, Bradypenea, HTN
Plan feeding around sleep schedule
Metabolic needs are higher in infants with Heart Failure and require more calories
K level will probably be fine
Even though furosemide (K wasting diuretic) is given
ACE inhibitors blocks Aldosterone, blocking of Aldosterone leads to Hyperkalemia
The Modified Early Warning Score (MEWS) is a bedside scoring system that evaluates a patient’s physiological state using six vital parameters: (Name Them)
Critical MEWS score
systolic blood pressure, heart rate, respiratory rate, axillary temperature, mental status, and urine output
For a critical total MEWS score of ≥5 or a single physiological parameter score of 3
In the following patient 80 F, UTI. MEWS preformed to monitor warning signs of Sepsis
VS: RR: 12, HR: 110, Systolic BP: 92, Temp 100.5, A&Ox3
Indicated or Contradicted
Hourly VS, I&O, neurological, and cardiopulmonary
Admin prescribed BP meds
Administration of Ibuprofen for fever
Administration prescribed antibiotics
Notify physician of increases MEWS score
Hourly VS, I&O, neurological, and cardiopulmonary
Administration prescribed antibiotics
Notify physician of increases MEWS score
Contradicted:
Admin prescribed BP meds
Systolic BP = 90, THIS WILL GIVE HYPOTENSION
Administration of Ibuprofen for fever.
Increase likelihood of Shock (NSAID)
Right sided cerebral stroke will cause weakness on which side of the body?
What field of vision will be diminished?
Right side stroke = left side weakness / paralysis
Left field of vision in both eyes
Right cerebral stroke
Which of the statements demonstrates UNDERSTANDING or FURTHER TEACHING
- Client places right arm into shirt first when dressing
- Spouse states “ it will help if vision if I approach him from the right side”
- Spouse “ I will talk to the home aids and be sure they get all the care done in the first hour after arrival “
- Client turns head to the left & right before taking on an activy.
- I know that I will need help to use the bathroom
- I can skip the stool softener if I have a BM
- Picks up washcloths with left hand to wash face.
- Client places right arm into shirt first when dressing FURTHER TEACH
(Affected side should be used first) - Spouse states “ it will help if vision if I approach him from the right side”
UNDERSTOOD: Approach from UNAFFECTED SIDE - Spouse “ I will talk to the home aids and be sure they get all the care done in the first hour after arrival.”
FURTHER TEACHING (Task should be broken into steps- Inability to concentrate after stroke) - Client turns head to the left & right before taking on an activity. UNDERSTOOD (Scanning will help to see the environment)
- I know that I will need help to use the bathroom UNDERSTOOD
- I can skip the stool softener if I have a BM FURTHER TEACHING
- Picks up washcloths with left hand to wash face. UNDERSTOOD
(Always use weak side for ADL and assist with strong side)
It is normal and expected that a new born have elevated bilirubin levels.
Levels must exceed ___ before jaundice is observed.
“Normal” levels are 0.2 - 1.4
5
New born will urinate up to ___ times daily due to bladder involuntarily empties at 15 mL
20
Transitional stools appear by the 3rd day in new borns initial feeding and are Greenish brown to Yellowish Brown, thin, and less sticky then ______ (1st Poop) - describe
Meconium
Composed of materials ingested during the time the infant spends in the uterus: intestinal epithelial cells, lanugo (Soft hair that can cover a new born), mucus, amniotic fluid, bile, and water.
Meconium, unlike later feces, is viscous and sticky like tar – its color usually being a very dark olive green and it is almost odorless
Normal temperature for a new born
97.7 - 98 Axillary
Apical HR newborn
120 - 140
RR for a new born
30 - 60
A change in drainage from darker red to brighter red is a positive sign that healing is improving.
T or F
F
It could mean a fresh bleed
Contact Surgeon
Purpose of the water seal chamber in a drainage collection system?
Prevent air from reentering
What does intermittent bubbles in the water seal chamber signify
Air is leaving the pleural space
Good thing
Water level stops “tidling” going up and down in waterseal chamber
What 2 things can this mean
- Displaced chest tube - Xray confirm
- Lung has reexpanded
Continous bubbling in water seal chamber
2 reasons
- Leak in system
- Pneumothorax
Constant bubbling in air chamber
How does nurse determine cause of the bubbling?
Which nursing interventions do you perform with these findings
Leak from placement
Leak from tubing / device
- Clamp tube closest to patient insertion site. If bubbling stops then bubbling is due to improper insertion of chest tube. Bubbling continues faulty tube,connection, device.
Intervention:
Improper Placement:
Check for subcutaneous crepitus (Snap, Crackles, Pop undernskin)
Put 3 sided petroleum gauze over insert point.
System problem;
Replace system
When disconnecting system put tube underwater
Air leaks in chest tubes need to be resolved due to possible pneumothorax which can lead to this heart condition
Cardiac Tamponade
Fluid filled sac surrounding the heart compresses it.
Prevents proper filling
Low BP, SOB, lightheadedness
Non alcoholic steatohepatitis (NASH) an aggressive form of: Non alcoholic Fatty Liver Disease
(Too much fat is stored in the liver)
S/S liver inflammation leads to Cirrhosis & liver failure.
Tired,weak,weight loss & yellowing of skin & eyes, Web-like clusters of enlarged blood vessels under skin & Itching.
If NASH results in Cirrhosis what will be the S/S (4)
Fluid retention
Internal bleeding
Muscle wasting
Confusion
Risk factors for fatty liver disease (5)
Obesity, (pre)DM, >cholesterol & triglyceride levels, HTN
Liver biopsy shows:
Fat present, No inflammation/tissue damage
NAFLD nonalcoholic fatty liver disease
Fat present, No inflammation/tissue damage
NASH nonalcoholic steatohepatitis
Fat, Inflammation, Liver damage
Scar tissue (fibrosis) present
Cirrhosis
Can liver damage reverse itself
Yes
After birth
Fundus should be : Firm,midline, & involute 1 cm daily. If it is soft, boggy, or higher than expected this could mean… (this problem)
Uterine Atony
Uterus doesn’t contract enough after giving birth.
Most common cause of postpartum hemorrhage
Lochia is…
lochiais thevaginal dischargeafter giving birth, containingblood,mucus, anduterinetissue.[1]Lochia discharge typically continues for four to eight weeks after
Describe time frame and changes of lochia
1 - 3
4 - 10
> 10
1 - 3
Lochia rubra: Dark Red
4 - 10
Lochia Serosa: brownish red to pink
> 10
Lochia alba
Yellowish white
Over distended bladder post partum can lead to (3)
Fundal displacement
Uterine Atony
Excessive Locha
Is peripheral edema an expected finding post partum
Yes, lower extremities
Acute Post Streptococal glomerulonephritis happens 1 or 2 weeks post Strep Throat or 3 - 6 weeks post skin infection.
Give S&S of this disease
Facial puffiness - Morning, spreads to other areas of body.
Periorbital edema
Anorexia
Decreased urine output
BP elevated
Cola colored urine
Hematuria & Proteuria
NO BACTERIA PRESENT in Urine
Autonomic reflexia is…..
caused by…
Found in these patients…
Intervention….
Potentially life-threatening condition in which noxious visceral cause Sudden, Massive sympathetic reflex arch
Causes: Bladder distention, UTI, epididymitis, bowel distention/ obstruction
Found in: High level spinal cord injury patients
Interventions: ID noxious source & remove it.
Sit patient up right
Remove tight clothes
Monitor BP
Type of shock attributed to severe CNS damage
Hypotension
Bradycardia
Peripheral vasodilation
Neurogenic shock
Post partum
Scant amount of lochia is <2”
Excessive amount is soak pad in <____min
15
How long after post partum is the uterus not palpable
2 weeks
Day ___ the fundus is halfway way between the umbilicus & symposis process
6
Post partum
The fundus decends ___ cm daily
1 cm
12 hours after delivery, describe the fundus posistion
Firm, midline, and @ level of umbilicus
Fundus is laterally shifted
Which intervention would nurse take to correct this
Have client empty bladder
Less to most invasive means
Why does breastfeeding stop post partum hemorrhage
Baby suckling on nipples release oxytocin
Oxytocin contracts uterus
(Pre) eclampsia can happen during this window of time
Pregnancy
> 20wks - 6 weeks post partum
Eclampsia differs from pre-eclampsia how?
Eclampsia involves seizures
(Pre) eclampsia defining characteristics
New onset HBP
&
Protein urea
Severe pre-eclampsia >160/>110 can have these 2 serious side effects
- Hemorrhagic Stroke
- Detached placental abruption
During (Pre) eclampsia thrombin formations in blood vessels will cause hemolysis of RBCs.
Which condition has destruction of RBC, elevated liver enzymes, low platelet count
HELLP
How can (Pre) eclampsia be treated?
Delivery of baby & placenta
