Physiological Adaptation Flashcards
CPR compressions for adults and children
Use heel of hand, at least 100/min, depth 2 inches
CPR compressions for infants
Use 2-3 fingers, at least 100/min, depth 1.5 inches
CPR compression to ventilation ratio for adults
30:2 with one or two rescuers
CPR compression to ventilation ratio for children/infants
30:2 with one rescuer
OR
15:2 with 2 HCP rescuers
The nurse cares for the client diagnosed with a flail chest following an automobile accident. Which type of respiratory pattern should the nurse anticipate when making a respiratory assessment?
Paradoxical chest movements — affected side goes down with inspiration and up with expiration
Key manifestations of croup syndrome
Bark-like cough, inspiratory stridor
Assessment of skull injury
Battle’s sign, raccoon eyes, rhinorrhea, otorrhea
Assessment of contusion
- slight depression of consciousness to coma
- decorticate posturing: flexion and internal rotation of the arms and hands
- decerebrate posturing: extension and external rotation of forearms and hands
- generalized cerebral edema
Score < ___ on Glasgow coma scale indicates the client is comatose
7
Score of ___ on the Glasgow coma scale indicates the client is alert and oriented
15
Earliest sign of increased ICP
Altered LOC
Cushing’s triad
Bradycardia, irregular respirations, widened pulse pressure
Thrombolytic therapy such as streptokinase and t-PA must be given with ___ hours of onset of an MI
6
What type of diet suppresses many types of seizures
Ketogenic diet — high fat, low carbs
Respiratory paralysis may occur if the client experiences a spinal cord injury above ___
C4
Patients with a spinal cord injury above T6 are at risk of developing
Autonomic dysreflexia
BEFAST stroke scale
B- sudden loss of BALANCE
E- Vision loss in one or both EYES
F - uneven FACE
A - weakness or numbness in one ARM
S - slurred SPEECH
T - no TIME to waste! Seek immediate help (if ischemic stroke, thrombolytic therapy must be initiated within 3 hrs of onset of symptoms)
Addison’s disease nursing implementations
- monitor for hypoglycemia, hyponatremia
- provide high protein, high carb, high sodium, low potassium diet
- teach about life-long hormone replacement
Cushing’s Syndrome nursing implementations
- provide low calorie, low carbs, high protein, high potassium diet
- monitor glucose level, hyperactivity, GI bleed, and fluid volume overload
Rule of nines for adults
Entire head: 9%
Entire trunk: 36%
Entire arm: 9%
Entire leg: 18%
Genitalia: 1%
Characteristics of superficial partial thickness/1st degree burns
- pink to red, painful
- involves epidermis and dermis
Characteristics of deep partial thickness/2nd degree burns
- red to white blisters, painful
- involves epidermis and dermis
Characteristics of full thickness/3rd degree burns
- charred, waxy, white, painless
- involves all skin layers
Characteristics of deep full thickness/3rd degree burns
- black, painless
- all skin layers involved, possibly muscles and tendons
Nursing implementations for burns
- provide high calorie, high carb, high protein diet
- increase intake of vitamin B, C, and iron
Where is skin turgor assessed in elderly clients?
Sternum or forehead
Normal calcium levels
8.6-10.2 mg/dL
Calcium has a _________ effect on the CNS
Sedative
NOTE: hypocalcemia would have an excitable effect, and Hypercalcemia would have a sedative effect
Potassium-rich foods
Bananas, oranges, apricots, beans, potatoes, carrots, celery, raisins
Magnesium acts as a __________
Depressant
NOTE: hypomagnesemia results in CNS stimulation, and hypermagnesemia results in CNS excitability
Magnesium-rich foods
Green vegetables, nuts, bananas, oranges, peanut butter, chocolate
Sickle cell anemia patient education
Avoid illness, high altitudes, and temperature extremes. Stay adequately hydrated!
Arterial PVD assessment
- dependent rubor
- cool, shiny skin
- ulcers/gangrene
- intermittent claudication
- impaired sensation
- decreased peripheral pulses
- pallor with extremity elevation
Venous PVD assessment
- cool, brown skin
- edema
- ulcers/pain
- normal or decreased pulses
Why is low-flow oxygen administered to the client with COPD?
Low-flow oxygen prevents CO2 narcosis in clients with emphysema
Contraindications to organ donation
- current IV drug use
- septicemia
- HIV infection
- active tuberculosis
- any malignancy other than a brain tumor
