Milestone 2 Flashcards
CA intractable (hard to deal with) pain- plan of care
most common?
- Opioid therapy (morphine, fentanyl, codeine, oxycodone, hydromorphone). IV and oral.
- Most common plan of care is palliative sedation
Valve replacement teaching
pig vs cow life expectancy
INR draws
what to report
what to monitor
teach necessity for what before any invasive procedure- even to dentist
- Pig- lifelong; cow 3 months.
INR- NR test measures the time for the blood to clot.
done weekly to determine if dose should be increased or decreased to maintain therapeutic range
- Report bruising and excessive bleeding
-Teach the necessity for prophylactic antibiotic therapy before any invasive procedure (Even to the dentist)
-Weight monitoring
Cushing syndrome
what happens to cortisol
physical appearance- sx
effects on glucose levels
meds for tx
-Hypersecretion of cortisol (hydrocortisone) by the adrenal gland
- Moon-faced appearance
- Hyperglycemia
- Weight gain, slow healing of minor cuts, and bruises.
- Thin skin
- Muscle wasting and osteoporosis
- Hirsutism (excessive growth of hair on the face)
- Ecchymoses (bruises) and striae develop
-Dexamethasone
-Ketoconazole (adrenal enzyme inhibitor)
End of life plan of care
-Make them comfortable
-Manage pain.
-Palliative and hospice care.
-No life saving efforts.
Acute respiratory distress priority findings
-**Ineffective Breathing Pattern related to decreases in lung function
-Secondary to ARDS as manifested by difficulty breathing, restlessness, increased respiration rate, shortness of breath, arterial pH of less than 7.35, and increased PaCO2 in arterial blood.
-Respiratory assessment
-Sp02
-Hypoxia
-Retractions
-Cyanosis
-Decreased or no breath sounds
-Possibility for mechanical breathing
Acute renal failure priority
-Correct or eliminate any reversible causes of kidney failure
-I&O
-Monitor vital signs
-Weighing
-Maintain proper electrolyte balance
Meningitis 1st step
Collect specimen show to confirm pathogen
Multiple sclerosis & urinary retention
how does the urinary retention occur
med used to tx
what may develop
holistic way to decrease retention
-Muscle weakness/spasticity cause urinary retention
-May need to self cath
-Baclofen (antispasmodic medication) reduce spasms and bladder spasm
-Chronic UTI
-Toileting schedule
Chemo side effects
- Nausea and vomiting
- Bone marrow suppression
- Alopecia and nail loss
- Weight gain or loss
- Anorexia
- Fatigue
- Decline in functional status
- Mucositis
- “Chemo” Brain
Addison’s crisis hypoglycemia
what is used to tx
sx
pt teaching
5% dextrose and normal saline (0.9%)
- The loss of glucocorticoids results in hypoglycemia with complaints of muscle weakness, lethargy, and GI symptoms including anorexia, weight loss, nausea and vomiting.
-Must take medications daily
Fractured femur dim pulses
-Difficulty moving the leg.
-Inability to stand or walk.
-Pain
-Edema
-Bruising.
-Deformity (abnormal shape) of the thigh
Dialysis –> HTN –> edema
why does this occur?
What labs to monitor
- Kidneys are no longer removing wastes and extra fluid from the body effectively, edema will arise.
- Swelling
-SOB
-Weight gain
HTN
-Monitor the Na and K
Cirrhosis –> ascites –> dyspnea
how does this happen?
- Ascites enlargement causes difficulty breathing
-Edema will have fluid trapped in the body closes to affected area leading to dyspnea
Alcoholic hepatitis teaching
- Start detox in order to completely stop drinking alcohol and may need an alcohol treatment program.
- Eat a low sodium diet, avoid infections, use over the counter medications carefully
Acute pancreatitis assessment
how to tell if caused by gallstone
turners vs cullens sign
when is pain worse?
amylase/lipase levels high or low?
-Severe abdominal pain radiating to the back
-If caused by gall stone, jaundice
-Abdominal guarding and distention
-N/V
-Fever, agitation
-Ecchymosis in the flank (turners sign) or umbilicus (cullens sign)
-Respiratory distress, renal failure, and shock are possible
-Pain worsens with eating and supine position
-Serum amylase and/or lipase levels at least three times the normal level
Stroke areas of effects
Compartment syndrome- care
sign of damage?
if suspected, what should I do?
-Loosen restrictive clothing
-Perform neurovascular check for the 6 P’s
-Notify the physician
-If numbness and tingling is a sign damage
Cardiomyopathy care plan
-Administer supplemental oxygen
CVA expressive aphasia
what is it
how to speak to pt
Occurs when there is damage to the part of the brain that controls speech production (Broca’s area)
-Language disorder that affects your ability to communicate
-Left side of the brain that control speech and language.
-Keeping your language clear and simple.
-Giving the person time to speak and formulate thoughts = give the person time to take in what you say and to respond.
-Using short phrases and sentences to communicate.
-Reduce background noise/distractions.
Guillain barre- what to assess
-Deep tendon reflexes
-Breathing (SpO2)
-Degree of muscle weakness
-Neurosensory for numbness and tingling
-Ability to swallow and speak
-Bowel and bladder
-History of viral illness
Glaucoma signs and symptoms
-Pressure or pain in the eyes
-Visual disturbances
-Headaches
-Seeing halos around lights
-Loss of peripheral vision
PE report findings
-Shortness of breath. This symptom typically appears suddenly and always gets worse with exertion.
-Chest pain. You may feel like you’re having a heart attack.
-Cough. The cough may produce bloody or blood-streaked sputum.
-Decreased O2
Diabetes insipidus
labs na+
sx- Urine specific gravity
-Lack of ADH
-Polydipsia
-Nocturia
-Low urine specific gravity
-Polyuria
-Dehydration
-Confusion
-Hypernatremia
-Tachycardia
-Hypotension
Normal Sinus Rhythm
Pulmonary edema first action
Administer O2
ABG findings- respiratory acidosis
-Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg
-Respiratory acidosis is due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations
Chronic kidney disease & metabolic acidosis
Healthy kidneys remove acid from the body through urine and they keep the right amount of bicarbonate (base) in the blood. But in CKD, the kidneys can’t remove enough acid, which can lead to metabolic acidosis.
Tetralogy of fallot complications
-Blood clots (which may be in the brain causing stroke)
-Infection in the lining of the heart and heart valves (bacterial endocarditis)
-Abnormal heart rhythms (arrhythmias)
-Heart failure.
-Blue baby
-Death
Hemophilia safety
-No contact sports
-Exercise to strengthen joint and protect
-Soft bristle toothbrushes
-Medical alert bracelet
-Medication administration routine
24-hour baby with jaundice- how to care
When cleared up- formula vs breast fed
Devices used
-Usually clears up within 2 weeks in formula-fed babies
-More than 2 to 3 weeks in breastfed babies
-Close monitoring - lab draws
-Billi lights or blanket
-No clothes only diaper when using therapy devices
RhoGam refusal- what to teach mom
when is given
what happens if baby is Rh positive
-Can impact the health of your baby and those of future pregnancies
-given Between 26 and 28 weeks of pregnancy
-If your baby is Rh-positive at birth the mother will need a second shot
Scoliosis post op
teaching- standing, driving, sleping
-Avoid standing for long periods of time doing ironing, cooking, washing, or other activities for 6 to 8 week
-No driving for a minimum of 8 weeks
-Sleeping on your back or your side as you heal from spine surgery
Slipped femoral capital epiphysis- sx
When child will be able to return to sports post op
-Problems walking.
-Limping.
-Mild pain in the hips, groin or around the knees.
-Severe pain that makes children stop putting weight on the leg that hurts.
-Stiffness in the hip.
-Less movement than usual in the hip.
-Will be able to return to most sports and activities at approximately 3-6 months post-operatively
Hydrocephalus
priority plan of care
common sx- infants
-Preventing injury.
-Maintaining skin integrity.
-Preventing infection.
-Maintaining growth and development.
-Reducing family anxiety.
-Poor feeding. The infant with hydrocephalus has trouble in feeding due to the difficulty of his condition.
-Large head. An excessively large head at birth is suggestive of hydrocephalus.
-Bulging of the anterior fontanelles. The anterior fontanelle becomes tense and bulging, the skull enlarges in all diameters, and the scalp becomes shiny and its veins dilate.
-Setting sun sign. If pressure continues to increase without intervention, the eyes appear to be pushed downward slightly with the sclera visible above the iris- the so-called setting sun sign.
-High-pitched cry. The intracranial pressure may increase and the infant’s cry could become high-pitched.
-Irritability. Irritability is also caused by an increase in the intracranial pressure.
Projectile vomiting. An increase in intracranial pressure can cause projectile vomiting.
Cystic fibrosis teaching
-Avoid lung infections
-Encourage washing hands with soap and water or sanitizer after using the bathroom, coughing, sneezing, or playing outside at recess.
-Balanced diet high calorie
Engorgement teaching
-Apply a frozen wet towel, cold gel or ice packs, or bags of frozen vegetables to your breasts for 15 minutes at a time every hour as needed
-Wear tight bras that press on your breasts
-Take NSAIDs for swelling
IUGR ultrasound (Intrauterine growth restriction)
how detected?
sx of fetus/infant
risk
A condition in which a baby doesn’t grow to normal weight during pregnancy.
-Will detect if the fetus has proper growth in accordance to amount of blood and oxygen supply
-low oxygen levels
-High level of distress during labor and delivery
-Increased risk of infectious disease after birth
Diarrhea diet
BRAT diet: Bananas, Rice (white), Applesauce and Toast
-Try to determine the underlying cause
-Slowly rehydrate
-Rehydrate with items rich in calories water may not be enough
-Do not give antidiarrheal medication want the virus run its course and not stay inside
Seizures child
-Padding of side rails and other hard objects
-Side rails raised on bed at all times when child is in bed
-Oxygen and suction at bedside
-Supervision, especially during bathing, ambulation, or other potentially hazardous activities
-Use of a protective helmet during activity may be appropriate.
-Child should wear a medical alert bracelet.
