Need To Know Flashcards
Priority Nursing
O2, Immuno-compromised, Bleeding, Safety, Infection
HIPAA
Health Insurance Portability and accountability Act
Delegating to UAP or Aide
Baths, ambulation, Routine tasks, DONT require Critical thinking
Float Nurse
DO NOT: Assess, Plan, evaluate, no specialized care (beyond Knowledge) assign age appropriate clients
Evacuating Patients
Ambulatory the bedridden then critical care
Triage Methods
Trauma (Breathing,Bleeding,Broken, Burns) and Cardiac, then ICP then infection (fever) then GI and Glucose then elimination
Medication Rights (8)
Right: Client, Drug, Dosage, Time, Route and also Rationale, Documentation and pt Refusal
Negative Room Pressure
Keeps Patient infection in room
Positive Room Pressure
Keeps Patient protected from Germs, Infection
MRSA - Hospital acquired
Methicillin Resistant Staph Aureus Requires Gown, gloves, goggles and mask if respiratory Tx : Tetracycline and Bactrm
C.Difficle (usually Hosp acquired)
DT too many antibiotics = abd cramps foul Diarrheaa
Room assignments
Watching for Radiation tx, Infection/Isolation, Safety (sex of pt) and Pt developmental age
G&D Infancy
1-3 mos = Recliner, 3-6 Sitter upper, 6-9 Bouncer-Crawler, 9-12 Crawler-Cruiser
Toddler
1 - 3 Years Autonomy Vs Shame & Doubt Parallel Play
Preschooler
3 - 6 Years Initiative Vs Guilt Cooperative Play
School Age
6 - 12 Years Industry Vs Inferiority,
Adolescent
12 - 18 Years, Peers! Identity Vs Role Confusion
Rt CVA - Left Sided Effects
Strong side always leads…
Most “Inclusive” answer
Lean towards those if not sure
Normal Heart Rate Adult
60 - 100 bpm (5-6 Lt/Min), Resp 12 - 18
Normal Heart Rate Neonate
140 bpm, Resp 40
Dx Testing of Patient (ACT NOW)
Allergies, Consent, Teach, NPO, Position, VS ????
Hyper tension
Sustained—–> 140 systolic > 90 Diastolic
Cardiac Issues? Semi-Fowlers
O2, ASA, Nitro, Morphine, Low Na (2 gram), low cal, low anxiety, Troponin Levels Ind. Heart attack
High BP??? Cardiac Reduction
ACE Inhibitors, All The “PRIL” Drugs may cause Hyper Kalemia
Hypo-Calemia (Skinny Cat)
Edgy, Tetany (muscles), Hyper Reflexia
Hyper-Calemia (FAT CAT)
Slow, Drowsy, CNS depression
Pacemaker???
Can NOT go below set rate! NO MRI
Pulmonary Edema???
TX: Morphine to expand vessles, epi, dig, Dieretics, O2, ABG’s
Shock??????
Modified Trendelenburg, (Supine with feet elevated) TX: IV fluids >HR and Resp, < in Bp
Cardiogenic Shock?
Fluid overload! TX: Diuretics, Semi Fowlers to High Fowlers
COPD Interventions
Corticosteroids, broncho-dialators, Chest Physiotherapy, O2 @ 2L, Expectorants and force fluids, Chest X-Ray & ABG’s
Asthma
TX: O2, epinephrine, Broncho-dialators first, then steroids 2nd. Rince inbetween SE: > HR and Anxiety
Ventilators???
High alarm, needs suctioned or waer in the ubing..Low alarm LEAK
Chest Tube??
Wheelchair? Hemovac can’t be above, best place hand from seat rail between Pt Legs
Teburculosis????
PPD for exposure 10mm or more induration, DX: Sputum Sample then xray, TX: Rifampin Once daily on empty belly, Turns secretion orange and Isoniazid give b6 for SE
optic neuritis
Central vision lose…
Wilms Tumor
On or around Kidneys, do not palpate, or push on
Burns????
Push Fluids first 8 to 24 hours, High Protein diet, daily weights, reverse Isolation, pain control, rule of 9, TX: Silvedin
S.I.A.D.H (High Specific Gravity)
too much ADH, Edema in trunk, not in limbs, < Electrolytes, > BP
Hyper Thyroid???
Graves Disease, Heat intolerance, Hi Vitals, Expothalomos, Agitated, moody, Flushing, Protect with eye drops, hi cal diet
Hypo Thyroid???
Cold intolerance, hair loss, Weight gain, fatigue, low vitals, Slow periods, TX: Synthroid on empty belly, Fluids and colace, low cal diet
Diabetes Mellitus (glucose not getting into cell)
> Hunger (Polyphagia), >Thirst (Polydipsia), >Urine (PolyUrea) DX: 2 fasting glusose >125 or gtt >200
INSULIN….Give at room temp, exp in 30 days
NPO, need IV c dextrose, Give in arm, thigh, belly, Tray or food available?
Insulin Peaks
Humalog (SHORT) onset 15 mins, last 4 hours, REGULAR 30mins to 1 hours, last 6 to 8 hours, NPH 1 to 2 hours lasts 18 to 24 hours, No peak, Humulin (Long acting) Onset 4 to 5 hours, lasts 36 hours
Hypo Glycemia , <50
Rapid Pulse, then tremors, irritable, restless, excessive hunger and sweating, cold and clammy
Cushing’s Syndrome (round moon face/humpback (dowangers)
usually from Long term steroid use, Body holds glucose and sodium, >HTN, slow healing. TX: <Na, FSBS, Infections?, I&O, FX d/t weak bones
Addisons disease (lack of cortisone)
FATIGUE! Weight loss, emotional, crave Na, low BP, NVD, <FSBS, Orto HTN, Electrolytes
Thyroidectomy????
Trache set on hand, Bleeding? Hoarsness, Calcium Gluconate on hand! SEMIFOWLERS
Physical Assessment???
In Order: Inspection (Skin, condition..) Auscultation, Percussion, Palpation..
Braden Scale
Pain scale 1-10
illeostomy
Liquid stool, >vitamins & Fluids, Check electrolytes
Colostomy
Soft formed stool, BODY IMAGE?, HIGH Fiber and fluids
