Random Flashcards
Post op for a spinal fusion which interventions will the nurse priortize.
SCD
Trapeeze bar above bed
Teach log rolling technique
Assist up to use bathroom
Spinal flexion exercise
Change surgical dressing
SCD - to prevent DVT
Teach log rolling technique
Assist up to use bathroom - Early ambulation prevents urinary retention & promotes venus return
DONT
Spinal flexion exercise
Change surgical dressing only when solied
Trapeeze bar above bed - Contradicted
Disequilibrium Syndrome
Which of the following should the nurse monitor for during dialysis.
Headache
Bradycardia
NV
Confusion
Hypoxemia
Muscle Cramps
Headache
NV
Confusion
Muscle Cramps
Disequilibrium Syndrome Causes cerebral edema.
Treatment for Disequilibrium Syndrome- a rare and severe complications of hemodialysis that causes cerebral edema- due to rapidly shifting extra cellular fluid composition.
More common in pts new to hemodialysis
Stop infusion
Infusion
Adminster high osmolality solutions:
Albumin
Mannitol
Hypersaline solution
Progessive & Painless- leads to peripheral vision loss
Develope slowly & lead to blurry vision & trouble with glare
Sudden painless loss of vision, floaters & flashes
Central vision loss can be rapid or progressive.
Sudden eyepain, redness, and halos
Acute closed angle glaucoma
Cataracts
Retinal Detachment
Age-related macular degeneration
Acute open angle glaucoma
Progessive & Painless- leads to peripheral vision loss - Acute open angle glaucoma
Develope slowly & lead to blurry vision & trouble with glare -Cataracts
Sudden painless loss of vision, floaters & flashes - Retinal Detachment- Surgery Required
Sudden eyepain, redness, and halos - Acute closed angle glaucoma
Central vision loss can be rapid or progressive - Age Related Macular Degeneration - 2 types
Dry AMD (Most Common – 85-90%) Yellow deposits (drusen) under the retina, gradual vision loss Slow
Wet AMD (More Severe – 10-15%) Abnormal blood vessel growth under retina, leaking fluid & blood Rapid, severe
Fragile X syndrome (FXS) is a genetic disorder that causes intellectual disability, behavioral challenges, and distinct physical features.
Describe behavior & appearance.
Autism like behavior
Long face with a prominent jaw and forehead
Large ears
Flexible joints (especially fingers)
Flat feet
Macroorchidism (enlarged testicles) after puberty in males
Paget’s disease of bone is a chronic disorder that disrupts normal bone remodeling, leading to enlarged and weakened bones.
Pain assessment
Gait problems
Monitor for nerve compression symptoms….
Labs…
Use NSAIDS, HEAT, (walkers & braces)
Weight exercise encouraged if able.
Meds…
Nerve compression symptoms (e.g., hearing loss, headaches, tingling).
ALP & Calcium elevated
Meds.
Bisphosphonates (e.g., alendronate, zoledronic acid): First-line treatment to slow bone turnover.
Educate on proper administration (take on an empty stomach with water, remain upright for 30-60 min).
Calcitonin: Used if bisphosphonates are contraindicated (helps reduce bone resorption and pain).
Calcium & Vitamin D: Ensure adequate intake to support bone health.
Purple spots in mouth associated with clopidogrel use…
TTP
Thrombocytic - Thrombocytopenic
Purpura
Blood clots , less platelets , damaged red blood cells.
Fatal if no intervention
CKD patient misses hemodialysis appointment. Which finding must be reported to HCP immediately.
Gain 3 lbs in 1 week
+2 edema in lower extremities
BP 165 /96
ECG with tall peaked T waves & widened QRS complex
ECG with tall peaked T waves & widened QRS complex
Vfib:
Tall peaked T waves
Widened QRS
No P waves
Notice how 3 of them involve fluid overload & 1 is cardiac rhythm.
Chose the different one in the test if unsure
Naegele rules for estimating due date…
Date of 1st day of last menstrual period.
Plus, 7 days & 9 months
LMP Aug 11 - 15
May 18 due date.
Left Hemisphere Stroke
Deficits:
- (Right or Left-sided) weakness/paralysis (right hemiparesis/hemiplegia)
Aphasia (difficulty speaking and understanding language)
- Broca’s aphasia….
- Wernicke’s aphasia….
Impaired comprehension of language and math
Slow cautious behavior
Emotional changes (anxiety, depression)
- _______visual field deficits
Right Hemisphere Stroke
Deficits:
- Left-sided weakness/paralysis (left hemiparesis/hemiplegia)
- ______deficits
- ____sided neglect (ignores the ____ side of body/environment)
Impulsive behavior, poor judgment
Lack of awareness of deficits (anosognosia)
- ____ visual field deficits
Right sided weakness / paralysis
- Broca’s aphasia (expressive) – difficulty forming words
3.Wernicke’s aphasia (receptive) – difficulty understanding speech
- Right-sided visual disturbance
5.Left-sided weakness/paralysis (left hemiparesis/hemiplegia)
- Spatial-perceptual deficits (difficulty judging distance, depth perception issues)
- Left
- Left-sided
- _____ position refers to the head-first presentation of the fetus during childbirth, which is the most common and safest position for a vaginal delivery.
Types of ____ Positions:
_________- Ideal Position
Baby’s head is down, facing the mother’s spine, with the occiput (back of the head) leading.
- ______ “Sunny-side Up”
Baby is head-down, but facing the mother’s abdomen.
Back labor & prolonged labor.
May need delivery help.
- Baby’s head is turned sideways, facing the mother’s hips.
- Vertex
- Occiput Anterior (OA)
- Occiput Posterior (OP)
4.Occiput Transverse (OT)
Ml in 1 oz…
30
Early Signs of Sepsis
Fever (>38.3°C or 100.9°F) or hypothermia (<36°C or 96.8°F)
Tachycardia / Tachypnea
Hypotension (SBP < 100 mmHg)
Altered mental status
Elevated WBC count (>12,000 or <4,000 cells/µL)
Warm, flushed skin
Increased blood glucose levels in non-diabetics
Late signs:
- MAP Value
- Skin
- Pulses
- Urine output
- Organ dysfunction ?
- Acidosis?
- Severe hypotension (MAP < 65 mmHg despite fluids)
- Cool, clammy, pale, or mottled skin
- Weak or absent peripheral pulses
- Oliguria (<0.5 mL/kg/hr urine output) or anuria
5.Multi-organ dysfunction (renal failure, liver dysfunction, coagulopathy)
- Lactic acidosis (serum lactate >2 mmol/L)
Early warning signs for sepsis.
Early Signs of Sepsis
- Body temperature
- HR / RR
- BP
- LOC?
- WBC
- Skin
- BS
- Fever (>38.3°C or 100.9°F) or hypothermia (<36°C or 96.8°F)
- Tachycardia / Tachypnea
- Hypotension (SBP < 100 mmHg)
- Altered mental status
- Elevated WBC count (>12,000 or <4,000 cells/µL)
- Warm, flushed skin
- Increased blood glucose levels in non-diabetics
Immediate Actions – “Sepsis Six” (Within 1 Hour)
Immediate Actions – “Sepsis Six” (Within 1 Hour)
Oxygen therapy: Maintain SpO₂ > 94%.
Obtain blood cultures before starting antibiotics.
Start broad-spectrum IV antibiotics ASAP.
Administer IV fluids aggressively (30 mL/kg crystalloid within 3 hours).
Check lactate levels: Guides severity and fluid resuscitation.
Monitor urine output: Maintain >0.5 mL/kg/hr (insert Foley catheter if needed).
With an IV push of furosemide beware of this adverse reaction…
Push rate…
Ototoxicity - tinnitus/ hearing loss
4mg /min
Measure orthostatic hypotension
Check BP how long after each posistion change…
Define BP / HR vlaues for orthostatic hypotension…
2 minutes
Systole reduction of 20
Or
HR increase 20
This measurement is taken in the standing posistion and compared to sitting/laying
When are crackles from fluid overload heard in the lungs…
(Which part of respiration)
End of inspiration
Edema Chart Define…
+1
+2
+3
+4
+1 <2mm slight pitting
+2 2 - 4mm last 10 - 15 sec
+3 4 - 6mm last >60 sec
+4 6 - 8 last 2 - 5 minutes
Before giving Digoxin measure apical pulse and hold for these values.
Adult…
Child…
Infant…
Apical Pulse: Always check for 1 full minute before administration. Hold if:
Adult: HR < 60 bpm
Child: HR < 70 bpm
Infant: HR < 90 bpm
Digoxin
Therapeutic range…
SE
Early….
Late…..
Digoxin Levels: Therapeutic range = 0.5–2.0 ng/mL. Toxicity can occur above 2.0 ng/mL.
Early: Nausea, vomiting, anorexia, fatigue, confusion
Late: Yellow-green vision changes (halos), bradycardia, dysrhythmias
Digoxin
Oral: Can be taken with or without food, but avoid high-fiber meal
T or F
T
Reduces absorption
Which electrolyte imbalances increase the risk of Digoxin toxicity ….
Which condition…
Hypokalemia
Hypomagnesemia
Hypercalcemia
Hypothyroidism
Ejection Fraction (EF) Categories:
Normal EF: ≥50-70% (heart pumps normally).
Borderline EF: 41-49% (mild dysfunction).
Reduced EF (HFrEF): ≤40% → Digoxin may be prescribed to improve symptoms and reduce hospitalizations.
What is ejection Fraction…
Why Digoxin is prescribed…
What else may Digoxin be prescribed for…
Percentage of blood pumped out of the left ventricle during each heartbeat.
Digoxin slows heart rate & makes it contract better. Increasing Ejection Fraction
Digoxin maybe prescribed for A Fib
