QB 3 Flashcards
Arteriosclerotic Heart Disease (ASHD) and heart failure both require what kind of diet
a low fat, low sodium diet.
A client with arterial and heart disease should adhere to a low-fat, low-sodium diet.
Processed foods, such as hot dogs and ham, and canned foods such as canned soup, are high in sodium. Avocados are high in fat. Fresh or frozen fruits and vegetables, including wild rice, are naturally low in fat and sodium and should be encouraged.
Low sodium is defined as
Low fat diet is defined as
any product containing 140 mg of sodium or less
A diet in which 25% of daily calorie intake comes from fats. It is recommended in managing cardiovascular diseases, elevated cholesterol levels, and diabetes mellitus.
When caring for a client with a cast, the nurse should perform a thorough neurovascular assessment of both lower extremities, focusing on _________________(the 4 Ps)
pain, pallor, pulse, and paresthesia
Heat under a cast is a sign of _______________.
The nurse should first perform a ____________assessment to evaluate circulation
pressure; neurovascular
Fracture Assessment - what would you expect to see ?
Swelling, pallor, ecchymosis, Loss of sensation, crepitus, decreased or absent pulses, deformity
Complications of a fracture
Fat Emboli- occur after fracture of a long bone such as the femur. Fat globules may move into the bloodstream and occlude major vessels. S/S - tachypnea, dyspnea, cyanosis, petechial rash, fever
Delayed Unioned, Malunion, nonunion of the bone
Sepsis
Compartment Syndrome- high pressure within a muscle compartment of the extremity that compromises circulation. Results from bleeding or swelling. high pressure impedes blood flow to the tissue. S/S -swelling, tightness, numbness/tingling in extremity, severe pain (unrelieved pain)
Emergency Care of client with a fracture
nurse should begin to immobilize the joint above and below the fracture. Open fracture should be covered with a sterile dressing. Nurse should check color, temperature, sensation and capillary refill distal to fracture
Fracture Care Implementation- This is immobilization to prevent movement
Splinting
___________________ fixation uses screws, plates and nails to stabilize
Internal
________________ reduction uses surgical dissection for reduction and alignment
Open
_________________ reduction uses manual manipulation or traction
Closed
What is traction?
What are the two types?
A nonsurgical method to correct a fracture
reduces the fracture
alleviates pain and muscle spasms
Prevents or correct deformities
Promotes healing
Skin Traction - pulling force applied to skin
Skeletal Traction - pulling force applied to bone
What is Buck’s tractions?
A form of skin traction used to relieve muscle spasms of the legs and back.
Russell’s traction
combines suspection and traction to immobilize the extremity. Used to treat fractures and contractures of the lower extremity
What are cervical tongs used for ?
To hyperextend the head and neck of a client with a fracture of the cervical vertebrae. Will align the vertebrae and immobilize it
What is a Halo fixation device ?
Prevents immobilization of the cervical spine
Casting immediate care
Don’t cover until dry
handle cast with palms of hands, not fingertips
don’t rest cast on hard surface
keep cast above the level of the heart
Check pulses, color, sensation
Intermediate care for client with the cast
Perform isometric exercise
Check for odors
Don’t put anything into cast
After cast care
wash area gently
apply baby powder, cornstarch to extremity
swelling is very common after removal of cast- elevate legs on pillows and apply elastic bandage
A bruit heard over the abdominal aorta can indicate an ________________.
aneurysm
This finding should be immediately reported to the health care provider for further assessment and intervention.
Abdominal aortic aneurysms (AAA) may be ________________-However, the client may present with__________- onset of pain that occurs in the back or lower abdomen, a feeling of abdominal fullness, shortness of breath, or difficulty swallowing or hoarseness. A common contributing factor is hypertension._________________ is a serious risk for the client with AAA. The client may report severe pain, and use pain descriptors such as “sharp,” “tearing,” “ripping,” or “stabbing.” Nausea and vomiting, diaphoresis, faintness, and apprehension are other manifestations. Aortic dissection is a medical emergency.
asymptomatic; sudden
Aortic Dissection- A tear in the inner layer of the large blood vessel branching off the heart (aorta)
Cachexia
weakness and wasting of the body due to severe chronic illness.
Pubic symphysis .
The pubic symphysis is a secondary cartilaginous joint (a joint made of hyaline cartilage and fibrocartilage) located between the left and right pubic bones near the midline of the body. More specifically, it is located above any external genitalia and in front of the bladder
Communication between a client and health care provider that results in the client’s authorization or agreement to undergo a specific medical intervention. The health care provider must make every effort to ensure the client understands the purpose, benefits, risks, and other options of the test or treatment.
Informed Consent
Pre-operative teaching does not occur a few minutes before surgery. Pre-operative skin preparation begins the night before the surgery
TRUE OR FALSE
TRUE
A temporary reduction in blood flow to the brain resulting in a brief loss of consciousness and muscle tone.
Syncope
Older adults have lower ____________reserve and have an increased risk for fainting, or syncope. Serious heart conditions, such as___________________, may lead to syncope. The nurse should examine this client first. Serious cardiac conditions (e.g., atrial fibrillation, heart failure) can cause ______________syncopal episodes in older adults, with a sharp increase after ________years of age. The nurse should obtain a 12-lead ECG and send specimen for cardiac markers. The client should be placed on bed rest and the vital signs frequently monitored.
cardiac; bradycardia, tachycardia, or blood flow obstruction’ recurrent; 70
Dysrhythmias are cardiac rhythm disturbances that affect ________________-.
perfusion
The dysrhythmias may be fast, slow, regular, or irregular. Life-threatening dysrhythmias lower cardiac output and are unable to maintain adequate perfusion. Dysrhythmias are caused by ischemia, hypertrophy, electrolyte imbalances, hypoxia, and valvular disorders.
Clinical manifestations include palpitations, skipped beats, syncope, confusion, dyspnea, chest pain, and fatigue.
Treatment for dysrhythmias includes medications, pacemaker insertion, internal cardioverter/defibrillator insertion, external cardioversion, external defibrillation, and ablation
Difference between Defibrillation and Cardioversion
defibrillation is an emergency procedure
cardioversion is an elective procedure (need informed consent)
Risk factors for breast cancer
Family history of mother, sister, daughter developing premenopausal breast cancer
- women over the age of 50
- menses before the age of 12
- no children, 1st pregnancy after 30
- menopause after age 55
Breast cancer assessment
small, fixed, painless lump
puckering or dimpling of the skin
nipple retraction
discharge
Breast cancer implementation
mammography
surgery
radiation or chemotherapy
A breast examination should be performed____________—after the menstrual cycle has finished.
monthly
A procedure performed after a radical cystectomy. Urine is diverted through an ileal passageway to a stoma formed on the abdomen. It requires placement of a urostomy bag for the collection of urine.
Ileal Conduit
Fever, abdominal rigidity and pain are indications of ___________
peritonitis.
What is an enema ?
An enema is the administration of solution into the rectum or sigmoid colon. The purpose is to relieve constipation and promote defecation.
To administer an enema, assist client to left side-lying position and gather supplies (waterproof pad, enema, gloves and lubricant) and bedpan if needed. If an enema bag is used, fill bag to ordered amount of warm tap water and release clamp to fill tubing. Lubricate the tip of tube and gently insert into the rectum approximately 3 to 4 inches for an adult or 2 to 3 inches for a child. Never force the tubing. Once in position, unclamp tubing and instill the fluid. Instruct the client to hold the fluid as long as possible. Assist the client to the bathroom or position on a bedpan. Observe and document results.
Types of enemas
Oil retention - softens feces. We want our client to retain the solution for several hours
Soapsuds enemas- we use castile soap and tap water or normal saline. Only soap that is safe for this enema. Irritates colon and stimulates peristalsis
Tap water - hypotonic so moves from bowel into interstitial spaces and stimulates defecation.
How should we position the adult client for enema administration ?
Sim’s position - left side with right knee flexed
Left Lateral Sims
Enema implementation
1) Explain procuedure
2) position in Sim’s position with right knee flexed
3) Use tepid solution
4) Hold irrigation set at 12-18 inches above rectum for high enema, 3 inches for low enema (holding 3 inches above hip)
5) Insert tube no more than 3-4 inches for adult, 2-3 inches for child, 1-1.5 inches for infant
6) Ask client to retain solution for 5-10 minutes
7) Do not administer in presence of abdominal pain, nausea, vomiting or suspected appendicitis
Symptoms of Alcohol Withdrawal
Tremors,
Insomnia
Anxiety
Anorexia
Alcoholic hallucinations
Easily startled
Symptoms of Delirum Tremens
Tremors
Anxiety
Panic
Disorientation, confusion
Hallucination
Vomiting
Diarrhea
Paranoia
Delusional symptoms
ideas of reference
suicide attempts
Grand mal convulsions (especially first 48 hr after drinking stopped)
Potential Coma/death
Alcohol WIthdrawal
Many institutions have an alcohol withdrawal treatment protocol, an algorithm to follow to prevent adverse events like seizures during withdrawal. This usually includes symptom monitoring every 1 to 4 hours for tachycardia, tremors, hallucinations, hypertension, and fever. The central nervous system has worked hard to maintain adequate neurological activity, but when the alcohol level drops, the central nervous system continues to work hard, creating a state of neurological over-excitability. Based on a score of these symptoms, the nurse administers a benzodiazepine to reduce the client’s symptoms.
Symptoms of alcohol withdrawal include restlessness, irritability, agitation, nausea, vomiting, confusion, tremors, increased heart rate and blood pressure, increased sensitivity to sounds, hallucinations and delusions, hyperthermia, and seizures 1 to 3 days after the last drink. Risk factors for alcohol withdrawal are related to length of time drinking and amount of alcohol ingested daily.
How will the patient with Trigeminal Neuralgia present ?
How do we care for this client ?
Stabbing, buring facial pain - brief but intense attacks that can be debilitating
Twitching/grimacing of facial muscles
Identify and avoid stimuli that exacerbate the attacks
Administer medications - carbamazepine is drug of choice for this condition. Analgesics also
Treatment - Carbamazepine, alcohol injection to nerve, resection of the nerve, microvascular decompression
Avoid rubbing eye
Chew on opposite side of mouth
A decrease in secretion of antidiuretic hormone (ADH or vasopressin) by the pituitary, which leads to excessive fluid excretion and dehydration.
Diabetes Insipidus
The nurse provides care for a client who had a hypophysectomy. The client reports being thirsty and having to urinate frequently. Which action does the nurse take?
- Assess for glucose in the urine.
- Increase fluid intake.
- Assess urine specific gravity.
- Document the client’s concerns.
1) INCORRECT - Glucose in the urine points to diabetes mellitus. Diabetes mellitus is not a complication of this procedure.
2) INCORRECT - Increased fluid intake will not address the problem.
3) CORRECT — After this procedure, diabetes insipidus can temporarily occur because of an antidiuretic hormone deficiency.
4) INCORRECT - This records but does not address the complication of the procedure.
A _________________- is the removal of a part or the entire pituitary gland, which controls specific hormones. One hormone is the ______________, which controls fluid balance. After surgery and due to the lack of this hormone, the client will have ___________-urine output, which is indicative of the complication _______________-The nurse should expect to find ___________urine specific gravity due to high urine output and high serum sodium (hypernatremia) due to low fluid volume.
Content Refresher
hypophysectomy; antidiuretic hormone; increased; diabetes insipidus; low
When caring for a client that is post-hypophysectomy, the nurse should assess for potential complications. An example includes diabetes insipidus. Assess color, amount, and specific gravity of urine. Assess intake and output. Ask client about thirst, urinary frequency, and nocturia. Signs of diabetes insipidus include excessive urine output, decreased urine osmolarity and specific gravity (less than 1.005), increased serum sodium and osmolarity, weight loss, dehydration, hypotension, tachycardia.
Medical therapy is directed at increasing antidiuretic hormone levels by administration of desmopressin (synthetic form of vasopressin), preventing further dehydration, and promoting fluid and electrolyte balance.
On the NCLEX, teaching is psychosocial.
TRUE OR FALSE
TRUE
_____________syndromes are all conditions in which foreign matter is inhaled into the lungs
Aspiration
A swallow evaluation can be used by the nurse to screen and refer for further testing in children, adolescents, and adults at risk for dysphagia (using the Toronto Bedside Swallowing Screening Test or the 3-oz Water Swallow Screening Test). Determine underlying risk condition, history, and treatment plan.For those at risk of aspiration, the nurse should place the client in a high-Fowler position. Do not allow the client to consume foods or fluids until risk evaluation is completed.
Before identifying the client who is priority, the nurse should stop and review each client’s acuity level, disease process, and risk for infection or life-threatening situation. Any client with a______________ need should be addressed first
physical
non-specific manifestations of myocardial ischemia.
Nausea, vomiting, diaphoresis
Use the “PQRST” mnemonic to collect information regarding a myocardia infarction
Precipitating events; Quality of pain; Radiation of pain; Severity of pain (using a 0 to 10 scale, with 0 being no pain and 10 being the worst imaginable pain); Timing (onset of symptoms)
______________is a common, subjective response to a perceived or actual threat. It may range from vague discomfort to total panic leading to loss of control. Assess for agitation, restlessness, tachycardia, hypertension, and tachypnea
Anxiety
_______________________differs from the typical sense of anxiety that each person occasionally experiences. Physical symptoms associated with GAD may include fatigue, diarrhea, diaphoresis, and insomnia. This disorder routinely interferes with daily activities and the anxiety does not always have an identifiable cause. Without proper treatment, GAD may lead to or exacerbate conditions such as depression and substance abuse.
Generalized anxiety disorder (GAD)
The root of anxiety for generalized anxiety disorder is the conflict between expressing unacceptable impulses and the need to hold onto social approval.
A ______________is a condition in which an individual experiences bizarre thinking associated with one of the following: erotomania, grandiosity, jealousy, persecution, and/or somaticism.
How should the nurse deal with delusions ?
delusion
The nurse needs to acknowledge the client ’s concern about false belief(s), but does not agree with them. The nurse does not argue about delusions, but reorients the client. The nurse focuses on feelings such as fear or anxiety and offers alternative thoughts and behaviors to reduce negative feelings. The nurse should make brief, frequent contact and offer orienting information.
Risk factors for a pressure injury include
malnutrition, diabetes mellitus, moisture, immobility, loss of sensory perception, chronic steroid use, immunosuppression, and poor perfusion and oxygenation.
Elevating the head of the bed no more than 30 degrees will decrease the chance of pressure injury development from shearing forces.
________________-leaders communicate their vision in a manner that is so meaningful and exciting that it reduces negativity and inspires commitment in the people with whom they work.
Transformational
A chancre
A chancre is a painless genital ulcer most commonly formed during the primary stage of syphilis. This infectious lesion forms approximately 21 days after the initial exposure to Treponema pallidum, the gram-negative spirochaete bacterium yielding syphilis.
