Mark k Flashcards
clarifying an order vs questioning
one of the answers is INCOMPLETE, NOT WRONG
questioning:
WILL HARM THE PATIENTS
wrong med, dose, route, amount
+
wrong documentation, wrong abbreviation (like QID, TID, qd, BID, 2.0, 2,000)
3 colon areas
valve locations 5
aoritc: 2nd right of sternal border
pulmonic: 2nd left of sternal border
tricupsid: 4th left of sternal border
mitral/apical pulse: 5th midclavicular
4 food rules for peds
NEVER casseroles for children
Don’t mix meds with food
Finger food for TODDLERS
LEAVE PRESCHOOLERS FOOD ALONE – 1 meal good
don and doff PPE
don:
gown, mask, goggle, gloves (REVERSE ALPHABETICAL + mask 2nd)
doff:
gloves, goggle, gown, mask (ALPHABETICAL ORDER)
3 expected vs unexpected s.s in sepsis
Sepsis EXPECTED s/s:
- Inc WBC
- Warm and flushed
- Hyperglycemia
UNEXPECTED: DIC!!!!!
- Bleeding
- Low coag
preg weight gain calculation
Number of weeks of gestation minus 9
If within +- 1 or 2 then NORMAL
If within +- 3 then ASSESS patient
If within +- 4 or more – do BIOPHYSICAL PROFILE of fetus
BMI <18 -> 25-40 lbs
BMI 18-25 -> 25-35
BMI 25-30 -> 15-25
when can fundal height be palpated?
20-22 weeks when it is midway between the umbilicus and the pubic symphis
4 positive preg signs vs probable
positive:
- Fetal skeleton on xray
- Presence of fetus on ultrasound
- Auscultation of heart via doppler
- EXAMINER palpates fetal movement and outline
Maybe signs are:
- Positive pregnancy test
- Chadwicks sign (blue cervix, vagina and vulva)
- Goodells sign (softening of cervix)
- Hegar sign (softening of uterus)
**these occur in alphabetical order!!!!!!
when first hear the fetal HR
when most likely
when should you
1st: 8-12
most: 10
should: by 20
when first notice quickening
when most likely
when should you
1st: 16
most likely: 18
should: by 20
prenatal visit frequency
- 1x/month until week 28
- Every other week between 28 – 36 weeks
- Once a week after week 36 until delivery (or week 42 if that comes first)
If a woman comes in for her 12th week prenatal checkup, when is her next prenatal visit?
16 weeks
when can a patient be induced for a c section
42 weeks
what lab will decrease during pregnancy
Hgb - it is concerning if < 9 (need anemia assessment)
education for dyspnea in preg
get in a tripod position – hands on knees or surface of table
most reliable sign of labor and birth
regular and progressive contractions
labor vs false contractions
T: timing that INC in freq, duration, and intensity
R: radiating to abdomen
U: unable to relieve with activity
E: exam changes - cervical dilation
vs
F: fails to cause cervical change
a: activity alleviates contractions
k: keep feeling same area , no radiation
e:erratic timing of contractions
5:1:1
every 5 min, lasting 1 min for more than 1 hour = go to hospital
after birth what constitutes post partum infection
> 100.4 for 2 consecutive days
fetal kick count
counted 3x/day
If the mother has felt fewer than four movements, she should count for 1 more hour. Fewer than four movements in that hour warrant evaluation
station is
vs engagement
the relation of fetal presenting part and the mother’s ischial spines (know
this)—the narrowest part of the pelvis
- Engagement is station zero—this means the presenting part is at the ischial spines (smallest diameter part of the pelvis)
Lie
relationship of spine of mother and spine of baby
Desired = VERTICAL lie (mother and baby spines are parallel) -> BABY COMIN
NOT desired = TRANSVERSE lie (mother and baby spines are perpendicular (Trouble -> NEED C SECTION)
presentation is
part of the baby thats in the canal - usually ROA
estrogen vs oxytocin vs prostaglandin vs relaxin
- Estrogen -> makes utuerus more susceptible to oxytocin
- Oxytocin -> contractions
- Prostaglandin -> cervix softening and stretching
- Relaxin -> cervix relaxation
for laboring or preg patient who is priority
IF question asks what patient to check on first – patient with contractions no longer than 90 seconds and no closer than 2 minutes – STOP PTOCIN
What parameters regarding uterine contraction would make you stop Pitocin?
- No longer than 90 seconds and no closer than 2 minutes
What is uterine hyperstimulation?
- No longer than 90 seconds and no closer than 2 minutes
What is a sign of uterine tetany?
- No longer than 90 seconds and no closer than 2 minutes
frequency vs duration vs intensity
- “Frequency” = beginning of one contraction and beginning of next
- “Duration” = beginning of one to end of another
- “intensity” = tell her to PALPATE WITH ONE HAND OVER FUNDUS WITH PADS OF FINGERS
painful back labor tx
– ROP or AOP (think “Oh pain”) LOW PRIORITY
Tx: POSITION THEN PUSH
- Position in knee chest
- Push with fist into sacrum to counter pressure
normal FHR - tx for high, low, low baseline variablity, and high baseline variability
1 STOP PITOCIN!!!!!!!!! If running
120-160
<110:
L -> left side
I -> IV
O -> oxygen
N –> notify HCP
> 160:
- document finding
- take moms temp
“low baseline variability” = BAD
Not changing
L -> left side
I -> IV
O -> oxygen
N –> notify HCP
“high baseline variability” = GOOD
Always changing
-document finding
what to assess post partum
EVERY 4-8 HOURs
BUBBLE HEAD
B: breasts
U: UTERINE FUNDUS -> boggy is massage, displaced is cath, HEIGHT of fundus related to UMBILICUS (fundal height should be at umbilicus after delivery and then it is equal to the day post partum) = 4 days = 4th line in the middle of the belly
B/B: bladder and bowel
L: LOCHIA -> vaginal drainage -> rubra (red), serosa (pink), alba (white)
- Moderate lochia amount = 4-6 inches on pad in 1 hour
- Excessive = 100% sat in 15 min
E: episiotomy
H/H: hgb/hct
E: EXTEMITY -> look for thrombophlebitis -> measure the bilateral calf circumference
A: affect
D: discomfort
Cephalohematoma vs Caput succedaneum:
Cephalohematoma:
- ONE side of head
- Over occipital bone
- Develops within 24-48 hours
Caput Succedaneum:
- Crosses Sutures and is Symmetrical
Which of the following 4 children will be able to manage his own care?
A 7-year-old with Cystic Fibrosis
b. An 8-year-old with Diabetes Mellitus
c. A 10-year-old with a scraped knee
d. A 13-year-old with Chronic Renal Failure
MANAGE not treat
D!!!!!
*** it is not about severity of problem, it is about age
12 OR OLDER!!!!
motor function ages
piagets stages of cog
congenital Heart defects + education (7)
T: trouble defects start with T – except ventricular hypoplastic syndrome
R: shunts blood R to L
B: patient blue
- Need surgery now
- Slow development
- Short life
- Grief
- Cardiac monitor
- Hospital stay
- Need cardiologist referral
- ALL DEFECTS WILL HAVE A MUMUR and need an echo
4 characterisitics of tetrology of fallot
- Pulmonary artery stenosis
- RVH (right ventricular hypertrophy)
- Overriding aorta
- VSD (ventricular septal defect)
ischemic vs hemorrhagic stroke
- Ischemic:
Caused by an OBSTRUCTION
Give tPA within 3 hours!!!!!
- Hemorrhagic:
Caused by HYPERTENSION
NO TPA
earliest sign of inc ICP
irritability
condition with Inc IOP
glaucoma (sudden is closed angle, gradual is open angle)
3 examples of high pressure alarms
5 actions
s/s
increased resistance
Kink in tubing
Condensed water in tube
Mucus plug
High pressure alarm going off?
- Unkink
- Empty water out of tubing
- Turn patient
- Ask them to cough, deep breathe
- Suction AS NEEDED!!!!!!
Settting is too high = resp. alkalosis (pt panting) -
The physician wants to wean pt off vent in the morning. At 6 am, the ABGs say respiratory ALKALOSIS. What would you do next?
IF PATIENT IS ALKALOSIS – THEY CAN BE WEANED OFF
low pressure vent alarm
decreased resistance
Examples:
MAIN Tube disconnection
O2 sensor tube disconnection
Low pressure alarm going off?
- Reconnect the tubing unless tube is on the floor
- Bag patient and call resp therapist
Setting too low = resp. acidosis
“respiratory = ventilate” / “acidosis= under”
The physician wants to wean pt off vent in the morning. At 6 am, the ABGs say respiratory ACIDOSIS. What would you do next?
NOTIFY HCP BECAUSE THEY ARE NOT READY TO BE WEANED – THEY ARE UNDERVENTILATING
high aPTT
high PT
high INR
high d dimer
aPTT: high = heparin, DIC
PT: high = DIC, factor deficiency
INR: high = warfarin, LOW vit K
Ddimer: >0.4 blood clot
amylase/lipase number lab for pancreatitis
> 220
normal ESR
<20
shock s/s
cool, moist, pale skin, restless, scant urine
need fluids
levels of HTN
6 risk factors for T2D
- Fam Hx of type 2
- > 45 years old
- Obesity BMI>28
- Dec HDL
- HTN
- NOT TYPE 1 !!!!
best indicator of long term glucose control
HgbA1c
functional psychosis
***Functional: schizophrenia, major depression, mania, schizoaffective
- They CAN learn reality and we must teach them
Tx: Acknowledge, present reality, set limits and enforce them
dementia based psychosis
senile/dementia/stroke
- They CANNOT learn reality
Tx: Acknowledge, redirect!!! Give them something to do
delirium psychosis
: SUDDEN AND DRAMATIC EPISODICdue to UTI, thyroid imbalance, adrenal crisis, electrolytes, meds
Tx: Acknowledge, reassure about safety and temporariness of condition
tolerance vs dependence
tolerance: need higher doses for same effect, NO WITHDRAWAL
dependence: need it to feel normal , YES WITHDRAWAL
nurse pt relationship phases
Preinteraction: GOALS
Orientation: purpose, time, trust
Working: problem solving
Termination: achieved goals
if Q has quotes and all A are quotes -empathy question
· Choose the answer that reflects their FEELINGS, not their WORDS -ignore what is said and go with what is felt
I see you feel angry
4 features of crutches (one is stairs)
- Length of crutch measured by placing tip on the ground and have 2-3 fingers widths bellow the axillary
- Tip should point 6 inches side and 6 inches in front
- Elbow flexion 30 degrees
“up with good leg and down with the bad” + CRUTCHES MOVE WITH BAD LEG
types of gaits
*even number gait for even number legs affected
*use odd when one leg is affected
*use swing through if both legs affected OR AMPUTATION
- 2 point gait for mild bilateral weakness= move 1 crutch and opposite foot together
- 3 point gait – move 2 crutches and bad leg together
- 4 point gait- move crutch-> move opposite foot -> move wnd crutch -> move opposite foot
- Swing through for non weight bearing (amputee) -> affected leg never touches the ground
A pt affected with early stages of rheumatoid arthritis. What gait should the pt use?
- Both legs affected (because it is a systemic disease)
- Early stage—mild
- 2-point gait
Pt is first day postop, right knee, partial weight bearing allowed. What gait should the pt use?
- One leg affected
- Odd-numbered gait
- 3-point gait
Pt is in advanced stages of ALS. What gait should the pt use?
- Bilateral leg weakness (because it is a systemic disease)
- Even-numbered gait
- Advanced stages = Severe
- 4-point gait
Pt with left hip replacement, 2nd day postop on non-weight bearing instruction. What gait should
the pt use?
- Non-weight bearing of 1 leg
- Swing-through gait
Pt with bilateral (B/L) total knee replacement first day postop. Weight bearing is allowed. What
gait should the pt use?
- Even-numbered gait = Bilateral
- Weight bearing
- First day postop = Severe
- 4-point gait
Pt with bilateral total knee replacement 3 weeks postop. What gait should the pt use?
- Even-numbered gait = Bilateral
- Weight bearing
- 3 weeks postop = mild
- 2-point
walkers
o The walker is on the side of the pt, the pt “Picks it up … Sets it down … Walks to it”
o Once the walker is in front of the pt, the pt “Holds on to chair, Stands up, Then grabs
walker”
***no tennis balls or wheels on a walker
**tie belongings to the SIDE of walkers
If patient has fractured femur or pelvic
they are at high risk for fat embolism so must assess LOC
cervical spinal cord tx
A. Cervical – innervates diaphragm and arms
Preop assessment:
- Assess breathing THEN arm and hand function
Post op assessment:
- Pneumonia
thoracic spine tx
A. Thoracic – upper back – innervates gut and abdomen
Preop:
- Assess cough and bowels
Postop:
- Pneumonia/paralytic ileus
lumbar spine tx
A. Lumbar – lower back – innervates bladder and legs
Preop:
- Urinary retention or last time patient voided then leg functions
Postop:
- Urinary retention and legs
3 nerve root compression s/s
- Pain
- Parasthesia
- Paresis
post op laminectomy 3 nursing actions
- Do not dangle patient for 10-15 min, get them up and moving
- Question order for sitting for 1 hour (cannot sit for longer than 30 min)
- They can walk , lay down without restrictions
4 discharge teaching for spinal surgery/laminectomy + 3 PERMENANT restrictions
- Don’t sit longer than 30 min for 6 weeks
- Lie flat, log roll for 6 weeks
- Don’t drive for 6 weeks
- Don’t lift more than 5 lbs for 6 weeks
PERMENANT restrictions:
- Laminectomy can never bend at waist (they need to use knees) like everyone else
- Cervical lams cannot lift anything over their head ever for life
- No horseback riding, biking, jerking around ever for life
what is aortic regurgitation
2 features
contraindications
education
blood backed up into the L ventricle
· Wide pulse pressure
· Diastolic murmur
· No beta blockers because it decreases diastolic BP
Education: infection prevention because of infective endocarditis
- Abx before dental procedures
what to assess for hypertonic solutions
lung sounds
3 fludis for shock
NS, LR, hypertonic
If you see patient itching but NO rash and the patient has asthma
this is an attack - give albuterol
peak exp rate
<50% EMERGENCY / >79% fine
apical vs basilar chest tubes
· Apical chest tube removes Air
> 80ml/hour NOT EXPECTED
Bubbling EXPECTED
· Basilar chest tube removes Blood or fluid (due to gravity)
200mL/hour EXPECTED
Bubbling NOT EXPECTED
chest tube drainage device knocks over
- -> ask patient to take a deep breath and then set device up and DO NOT CALL HCP
water seal of chest tube breaks
- 1st clamp, 2nd . cut, 3rd . submerge in sterile water , 4th unclamp THIS MUST BE DONE IN 15 SECONDS
aka · FIRST ACTION IS CLAMP, PRIORITY ACTION IS SUBMERGE IN STERILE WATER
chest tube pulled from PATIENT
- 1st cover with gloved hand, best: sterile gauze
manipulation vs dependency
- Manipulating: causing harm to victim / illegal
- Dependency: does not cause harm
wernicke and korsakoff
3 characteristics
s/s
tx
psychosis caused by Vitamin B1 and Thiamine deficiency
- Preventable (can prevent it)
- Arrestable (can stop it from getting worse)
- IRREVERSIBLE (WILL KILL BRAIN CELLS)
s/s = amnesia and confabulation (making up stories WITHOUT awareness of it)
tx: redirect
alc withdrawal vs delirium tremens
dosage calculation
IV drip rates = Volume × Drop factor / Time
- Micro/Mini drip = 60 drops per mL
- Macro drip = 10 drops per mL
