nurse in the making study guide Flashcards
airborne precaution
measles
tuberculosis
varicella
*airbone precaution is no longer needed once all lesions have crusted over
droplet precaution
wear surgical mask, mask on client when they leave the room
adenovirus diphtheria epiglottitis influenza meningitis mumps parvovirus b19 pertussis pneumponia rubella scarlet fever sepsis streptococcal pharyngitis
contact precaution
gloves and gown whenever going into room
multidrug-resistant org enteric infections (c.diff) respiratory infection (RSV, influenza) wound/skin infection (cutaneous diphtheria, herpes simplex, impetigo, pediculosis, scabies, staphylococci, varicella zoster) eye infections (conjunctivitis)
when to give hypertonic solution
cerebral edema low levels of sodium (hyponatremia) metbolic alkalosis maintenance fluid hypovolemia
5% dextrose in 0.9% saline
5% dextose in 0.45 saline
5% dextrose in LR
when to give isotonic solution
expands intravascular fluid volume and replaces the fluid loss associated with…
- burns
- hemorrhage
- surgery
- dehydration (vomitting and diarrhea)
- fluid maintenance
* *used with blood products (0.9% saline)**
lactated ringers
5% dextrose (D5W)
when to use hypotonic solutions
intracellular dehydration such as DKA
NEVER give to clients with burns or liver disease
helps kidneys excrete excess fluids
think fluid goes OUT of the vessel and into the cell to make the cell swell… water will flow where sodium goes
- 45% NS
- 5% Dextrose
- 33% NS
s/s and treatment of circulatory overload
s/s
- incr blood pressure
- distended neck veins
- dyspnea
- wet cough and crackles
tx
- decr flow rate
- elevate HOB
- keep client warm
- notify HCP
s/s and tx of phlebitis
**inflammation of the vein –> can lead to a clot (thrombophlebitis)
s/s
- heat, redness, tenderness at site
- decr flow of IV
tx
- remove IV
- notify HCP
- restart IV on opposite side
s/s and tx of hematoma
s/s
- ecchymosis
- blood, hard and painful lump at site
tx
- elevate extremity
- apply pressure and ice
info about blood transfusions
- insert an IV line using 18/19 gauge IV needle
- run w NS
- use largest catheter port
- begin transfusion SLOWLY
- document tolerance
- *VS every 30 min-1 hour
- after 15 mins flow can be increased unless reaction occurred
- *type/screen/cross-match is good for 72 hours
- *you have 30 mins from the time you receive blood to the time you infuse it
- *four hours all blood must be transfused
s/s of septicemia of transfusion reaction
rapid onset of chills high fever vomiting diarrhea hypotension shock
NI to transfusion reaction
- stop the transfusion
- change the IV tubing down to IV site
- keep the IV open w/ NS
- notify HCP and blood bank
- DO NOT LEAVE CLIENT ALONE… continue to monitor VS
Intradermal administration
TB testing
allergy sensitivities
needle size: 25-27
length: 1.4-5/8 in
subq admin
uses: non-irritating, water soluble med (insulin/heparin)
needle size: 25-27
length: 3/8-5/8
IM admin
uses: irritating, solutions in oils and aqueous suspensions
size: 18-25
* * do not inject more than 3 mL for deltoid divide into two syringes & use two diff sites
IV admin
needle size:
16 - clients w trauma
18 - blood admin + surgery
22-24 - children, older adults, clients who have med issues or are stable post op
things to remember w inhaled meds
rinse mouth after use of steroids
20-30 seconds btw puffs
2-5 minutes btw diff meds
use spacer to prevent thrush
things to remember when instilling meds in ear
warm the solution before adm to prevent vertigo and dizziness
adults: pull ear upward and outward
under age 3: pull ear down and back
things to remember when instilling meds in nose
client lies supine
do not blow nose for 5 mins after drop instillation
type 3 pressure ulcer
full thickness skin loss (damage to or necrosis of subcut tissue… no exposed muscle or bone)
- ulcer extend down to the underlying fascia but not through it
- deep crater with or without tunneling
type 4 pressure ulcer
full thickness tissue lost
- destruction of tissue
- damage to muscle and bone
- deep pockets of infection and tunneling
unstageable ulcer
stage cannot be determined d/t eschar or slough covering the visibility of wound… making depth unknown
braden scale
assessing clients skin every shift for pressure injuries using the braden scale
- sensory perception
- moisture
- activity
- mobility
- nutrition
- friction and shear
low risk 22-23
less risk 19-21
high risk <18
causes of hypervolemia
heart failure
kidney dysfunction
cirrhosis
incr sodium intake
**high fowlers/semi-fowlers would help w breathing
