Milestone 2-2 Flashcards
-Chemo Side Effects
o Nausea/vomiting (24-48 hr, can be delayed up to 1 week)
Meningitis first step
o Antibiotics - penicillin (ampicillin) AND cephalosporin
o Corticosteroids
Multiple sclerosis and urinary retention
o Sensation of void heeded immediately (bed pan/urinal @ bedside)
o Voiding schedule (start 1/5-2hr then extend)
o Drink specific amt every 2 hour; urinate 30 min after w/ timer
o Self-catherization
Acute renal failure priority
o Maintain fluids
o Avoid fluid excess
o Renal replacement therapy
o Reduce metabolic rate
o Promote pulmonary function
Acute Respiratory distress priority findings
o Hypoxia
o Intercostal retractions
o Crackles
o BNP levels
(alveoli collapse because small airways are narrowed due to interstitial fluid and bronchial obstruction)
End of life plan of care
o Signs and symptoms of impending death are recognized and communicated in developmentally appropriate language for children and patients with cognitive disabilities with respect to family preference. Care appropriate to this phase of illness is proved to the patient and the family
Cushing Syndrome
o Can result from corticosteroids
***Attempt to reduce/taper medication while still treating underlying disease
o Alternate day therapy decrease symptoms and allows adrenal glands to recover
Valve replacement teaching
o Anticoagulant therapy (frequent follow-up/lab tests)
§ Pt on warfarin has specific normal ratios
o Prevent infection
o ANTIBIOTIC PROPHYALXIS FOR DETAL PROCEDURES!!!
Cancer intractable pain plan of care
o Pain, other symptoms and side effects are managed based on the best available evidence, with attention to disease-specific pain and symptoms, which are skillfully and systematically applied. ??????
Schizophrenia nursing diagnoses and interventions
- Dx: 2 or more S&S for over 6 mo (Positive= delusions, hallucinations, disorganized speech or Negative= 6 A’s Anhedonia, Flat Affect, Apathy, Anergia, Algogia, Avolition)
-Establish rapport and trust, ask about hallucinations, distract, lower environmental stimuli, monitor suicidal ideation, 1st or 2nd generation antipsych
Grief process therapeutic response
Allow the 5 steps of grieving (DABDA), active listening and offer a supportive presence
Dementia action refusing ADLs
Encourage finger foods, distraction, speak therapeutically
Alcohol withdrawal
- Needs to be done under medical supervision b/c can be deadly
- VS Q4, onset of symptoms 4-6 hours after last drink, give lorazepam, reduce temp.
- Tremors, nausea, vomiting
Methadone overdose
S&S= constricted pupils, resp. depression, circul. depression, LOC decreased
Give naloxone
Domestic violence screening tool
- Don’t probe, write evidence down verbatim, provide a safe environment
- Increase in violence during pregnancy
- Cycle of violence= tension building, violent, honeymoon
Aggression response
5-phase cycle= Triggering (event), Escalation (movement toward a loss of control), Crisis (loss of control), Recovery (regain control), Postcrisis (reconciliation)
***Hx = likely to occur again
Violence handling
- Engage in dialogue to prevent escalation, intervene early in the cycle
- Approach as non threatening, calm manner and convey empathy
- Encourage the client to express their anger, build trust, anticipate need for meds, be consistent
Medication adverse reactions care (schizophrenia)
Constipation is a common side effect of antipsych meds, polydipsia occurs after years of treatment
Nurse can help minimize effects of delusions with distraction techniques, music, tv, writing and talking to friends, positive self-talk and positive thinking
Self care Maslow
- Physiologic, safety, love and belonging, self esteem, self-actualization
- Basic drive and needs that motivate people
Anxiety Suicide Risks:
Restless, difficulty concentrating, irritability
- “Have you had any suicidal thoughts since starting bupropion?”
Elder Abuse
Someone stating “I no longer have time to do anything for myself or anyone else” would be someone @ risk for abusing elder.
Bruising around breasts and pelvic area = abuse
Watch behavior toward family and document
Make caregiver leave room during questioning
*** include nonconsensual contact
Grief Priority
Priority should be based on SHOCK!
ADHD Exam/Assessment
- failure to listen/follow direction
- difficulty playing quietly/sitting still
- disruptive, impulsive behavior
- distractibility to external stimuli
- excessive talking
- shifting from one unfinished task to another
OCD
- Patient checks where car keys are 8 times
- Patient has persistent thoughts about bacteria, germs and dirt
- Help encourage participation in social activities
Questions to ask someone with OCD
- are there other in your family who must do things a certain way
- is it difficult to keep certain thoughts out of your awareness
- do you do certain things over and over again
Therapeutic communication abuse victim
- Physical manifestations of abuse
- Client safety
- Legal responsibilities of the nurse
- For children, the nurse is legally responsible for reporting all suspected cases of abuse. In intimate-partner abuse, it is the adult’s decision; the nurse should be supportive of the decision. Remember to document objective factual assessment data and the client’s exact words in cases of sexual abuse and rape
Therapeutic Relationship Stages- TERMINATION
Unresolved feelings related to loss most likely may be recognized during this stage.
A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase?
Making appropriate referrals
Which features are prominent in anorexia nervosa?
-Amenorrhea for three cycles
-Perfectionism
-Powerlessness
-Rigid food rituals
Describe the clinical symptoms of anorexia nervosa:
Weight loss of at least 15% of ideal or original body weight; hair loss; dry skin; irregular heart rate; decreased pulse; decreased BP; amenorrhea; dehydration; electrolyte imbalance
A client with anorexia has her friend bring her several cookbooks so she can plan a party when she is discharged. What nursing intervention is appropriate in addressing this behavior?
Discuss activities that don’t involve food that can take place after discharge. Discuss the cookbooks with the treatment team, and if the treatment plan so indicates, take the books from the client.
Bizarre social behavior
- assess physical needs, suicide risk, ensure safety at all time
- sit w/ client, silence, tell when leaving
- limit stimuli / 1-1 interaction
Complication Hypertension Risk
Elevated BUN = kidney dysfunction = associated with hypertension
The nurse is reviewing blood pressure readings for a group of client’s on a medical unit. Which client is at the highest risk for complications related to hypertension?
B. Middle-aged African-American male who has a serum creatinine level of 2.9 mg/dL
Hypothyroidism - Sleep/ Depression
- Depression can result from untreated hypo
- falling/staying asleep difficult = avoid sedation
- frequent rest but stay action
Diverticulosis S/S
LLQ abdominal pain (descending/sigmoid colon)
Bloating
Fever
Nausea/Vomiting
Constipation alt. w/ diarrhea
Anorexia
Gout Medication- Allopurinol
- bone marrow depression, vomiting, abd. pain
- avoid starting/increasing med during active flare up
- AFTER MEALS!
Gout Medication- Allopurinol teaching
- avoid alcohol
- purine-rich foods (red meat/shellfish/fructose drinks)
- increase fluids
- reduce stress
Diabetes Mellitus- Poor compliance
- The patient may use a urine dipstick (Ketostix or Chemstrip uK) to detect ketonuria. The reagent pad on the strip turns purple when ketones are present. → unmanaged diabetes or control over DM is deteriorating
DKA: complication of type 1 diabetes, serum glucose >250, ketonuria in large amounts
Left-Sided Heart Failure
(Left is LUNG)
congestion, dyspnea, crackles, fatigue, pink/frothy sputum
Right-Sided Heart Failure
(Systemic)
congestion, peripheral edema, ascities, jugular vein distention, hepatomegaly
Osteoarthritis Exercise
- Use correct posture/body mechanics, use of assistive devices, walking, physical therapy, strength training, yoga, tai chi.
Small Bowel Obstruction Actions:
- Auscultate bowels
- Measure correct length, advance decompression q1-2hr, reposition client q2hr, connect to suction, irrigate with NS, note amount, color, consistency, assess for dehydration, monitor electrolytes
- IV fluids will be given to replace depleted water, sodium, chloride and potassium
Pneumonia Vaccines:
- PCV13: >65, >19 with conditions that weaken immune system
- PPSV23: >65, 19-64 year olds who smoke/have asthma
Pneumonia Treatment:
- oxygen therapy, hydration, bed rest, positioning to facilitate breathing, deep breathing, humidified air, chest physiotherapy, suctioning prn,
COPD oxygen therapy
-Max of 3L via NC
- low concentration are better!!
- do not want pH to fall
