istudentnurse.com Flashcards

Question

Compartment Syndrome Signs and Symptoms: 5 P’s

Answer 1

``` Pain Pallor Pulse declined or absent Pressure increased Paresthesia ```

Answer 2

``` Cardiac Ruptured AAA (abdominal aortic aneurysm or “triple A”) Aortic stenosis Pulmonary embolism (PE) SAH ```

Answer 3

Hypotension Tachycardia Tachypnea

Answer 4

``` Cold, clammy skin Hypotension Oliguria Rapid, shallow breathing Drowsiness, confusion Irritability Tachycardia Elevated or reduced central venous pressure Multi-organ damage ```

Answer 5

Cardiac Hypovolemia Obstructive (tension pneumothorax, tamponade, PE) Respiratory/medical (hypoxia, acidosis, hypothermia, hyperkalemia, OD) Distributive (spinal shock, anaphylaxis, sepsis)

Answer 6

``` Septic Hemorrhagic Respiratory Insulin- hypoglycemia from insulin overdose or extreme hyperglycemia -diabetic ketoacidosis (DKA) Metabolic Psychogenic Cardiogenic Anaphylactic Neurogenic ```

Answer 7

``` Respiratory Neurogenic Cardiogenic Hemorrhagic Anaphylactic Metabolic Psychogenic Septic ```

Answer 8

``` Tissue perfusion issues Respiratory problems Anxiety Unstable clotting factors Malnutrition Altered body image Thromboembolism Infection Crush syndrome and coping problems ```

Answer 9

``` Allergies Medications Previous medical history Last meal Events surrounding the injury or what happened ```

Answer 10

``` K+ (potassium) Insulin Nasogastric tube: if the patient is comatose Glucose: once serum levels drop Urea: monitoring Fluids: crystalloids Creatinine: monitor and catheterize ```

Answer 11

Frequency: 3 times a week Intervals: 30 minutes a day Time

Answer 12

Hot and dry: sugar high | Cold and clammy: need some candy

Answer 13

``` REnal failure EXogenous Pituitary Liver failure Alcohol Infection Neoplasm ```

Answer 14

``` Tachycardia Irritability Restlessness Excessive hunger Depression and diaphoresis ```

Answer 15

Clear before cloudy | Cloudy before clear

Answer 16

``` Metabolic Inflammatory Degenerative Neoplastic Infectious Trauma ```

Answer 17

``` Flush skin and fever (low-grade) Restless, irritable, anxious, confused Increased blood pressure and fluid retention Edema: peripheral and pitting Decreased urine output and dry mouth Skin flushed Agitation Low-grade fever Thirst ```

Answer 18

``` Meals (high intake) and medications Osmotic diuresis Diabetes Insipidus Excessive loss of water Low intake of water ```

Answer 19

Convulsions Arrhythmias Tetany Stridor and spasms

Answer 20

Meds: ACE inhibitors, NSAIDS, Diuretics (potassium sparing) Acidosis: metabolic and respiratory Cellular destruction: burns, traumatic injury Hypoaldosteronism and hemolysis Intake: excessive dietary (eg: salt replacements that contain potassium) Nephrons: renal failure Excretion: impaired

Answer 21

Muscle cramps that progress to weakness Urine abnormalities: oliguria or anuria (output less than 30 mL/hour or no output) Respiratory distress Decreased cardiac contractility EKG changes Reflexes: hyperreflexia or areflexia (flaccidity)

Answer 22

``` Calcium Bicarbonate Insulin Glucose Kayexalate Diuretics and dialysis ```

Answer 23

``` Alkalosis Shallow Respirations Irritability Confusion and drowsiness Weakness and fatigue Arrhythmias: tachycardia or bradycardia, irregular rhythm Lethargy Thready Pulse (Other signs: decreased intestinal mobility, vomiting, and ileus) ```

Answer 24

``` Skeletal muscle weakness U-wave on EKG Constipation Toxicity to digoxin Irregular and weak pulse Otostasis Numbness paresthesia ```

Answer 25

``` Lethargy Leg cramps Limp muscles Low, shallow respirations Lethal cardiac dysrhythmias Lots of urine (polyuria) ```

Answer 26

``` Gallstones Ethanol Trauma Steroids Mumps Autoimmune (PAN) Scorpion bites Hyperlipidemia Drugs such as azathioprine and diuretics ```

Answer 27

``` Bathing Ambulation Toileting Transfers Eating Dressing ```

Answer 28

``` Razor blades and electric blades Aspirin Needles: particularly smaller gauges (which are larger in diameter) Decrease number of needle sticks Injury risk prevention ```

Answer 29

Cane Opposite Affected Leg

Answer 30

Collaboration Cooperation Compromise

Answer 31

Coronary artery disease (CAD) Congestive heart failure (CHF) Chronic renal failure (CRF) Cardiovascular accident (CVA): brain attack or stroke

Answer 32

Intake and output (urine) Take blood pressure Ischemia attack, transient (TIAs): monitors for signs Respiration and pulse monitoring Electrolytes: obtain orders for blood work and monitor values Daily weights (morning time with clothes of similar weight)

Answer 33

Shopping Cooking Using the telephone and transportation (driving, public, or ability to independently arrange transportation services) Money and medication management

Answer 34

``` What Provokes the pain What is the Quality of the pain? Does the pain Radiate? What is the Severity of the pain? What is the Timing of the pain? ```

Answer 35

Assess for pain and ask about the pain Believe the patient’s account of pain description (subjective data) Choices: inform patients of their options for pain relief Deliver possible therapeutic interventions when you said you would Empower and enable the patient to have pain control

Answer 36

Frequency Amount Color and consistency Timing

Answer 37

Walk With Affected Leg

Answer 38

``` Ascites Bleeding (hematemesis, piles) Caput medusa Diminished liver Enlarged spleen ```