random Flashcards
how should the nurse approch someone wit hearing impairement
approch from the front and visbily gain the clients attention before speaking
- face directly so the speakers face can be seen
- use facial expression and gestures
- put sign outside door
- turn lights on because a lot of people will lip read
- sppech should be directed toward the least affected ear and should be a normal volume
- hearing aids should be in place
muslim care
-face kabba in the holy ciy of mecca- toward northwast during prayer
-ritual prayer occurs 5X day and dying clients pray more
-modesty (same sex)
-halal and if not availble josher and veg are accetable
-
ramadan
the sick and dying are not required to fast with other muslims from dawn until sunset
-if they chose to fast meals and meds should be rescheduled
postmortem care for muslin
ritual washing (usually by fam) -burial occurs quickly after death sometimes event he same day (so provide fam with supplies for postmortem care)
islam unit
family most important and should allow them to visit unles they intefer with care
pressure injury repoistioning care
LIFT not pull
turn every 2-4 hours! not 6!!
-avoid donut type decides and dyntheic sheepskin
-use foam pads
-use emollients and barrier creams to hydrate
massage is ontrinidcated in
presence of inalmamtion, thin skin, dmaged skin, damged blood vessels
infiltration is
complication that occurs when solution infuses into the surrounding tissues
intervention for infiltration
discontinuing the IV imm, start new iv on oppsite ext f poissble
- elevate
- cold or warm moist compress based on the solution infiltrated. Heat is avoided when extravasation of a vesicant (ie, drug capable of causing tissue necrosis) occurs.
flush saline locks
every 8-12 hours
signs of ifiltration
coolness warmth hardness drainage edema
venturi mask
high flow device that deliver a guarnteed o2 conenttration regarless of the clients RR, DEPTH OR TIDAL VOLUME
venutri mask is app when
tacypnea, shallow breathing with decresed tv, hypercabia, hypoxemia or rapid chanes in ocentration such as COPDDDD
nasal cannula and copd
good for clients with normal vital signs and TV
-not best choice for unstable COPD client with varying tv
non breather normally used
short term
low sat resulting from asthma, pnuemonia, trauma, severe sepsis
oxymier
nasal cannula
postermortem care typically
performed imm following death
- cannot delay jusr bc dam isnt here unless they request it
- fam does not have to be present for postmorem care unless they notify for relgious
circumstances when postmortem care can be delayed
cultural or relgious reasons
- relgious cermonies
- state or agency polcies (on nonnatural (sucide), traumatic, criminal)
learning technq
using pics and simplified text if low ltieracy
- including fam mem in teaching process
- progessionally produced prgoams
- reuptuable internet sites so dont discourage them
outcomse of quality improvment program should be
objectiive measurable
cervical caera
higher among hisapanis, american indians, African americans
-twice as high of mortality rate in african america
-
HTN
african american
- more women than men
- more death amond amfrican american than american women
ischemic stroke
african americans higher change than whites or hispanics
riskf actors for stroke
HTN
DM
SICKLE CELL ANEMIA
osteoporeiss common among
white and asian
melanoma
white 10X more than african
light skinnened
over age 60
negative pressure wound therpy
application of nengative pressur to a wound to enhance bacteria and exudate removal
netgative pressure promtoes
healing by stimulating cell grwoth and vessel perfusion
negative pressure wound therpy care
- meds preprocedure
- after wound cleansing, skin protctant applied around the wound
- sterile foam dressing is cut to fit the wound size
- icculsive dressing large enough to go beyond the wound edges
- vaccum assist closure unit connected to cretate negative pressure
- the foam dressing is placed used sterile technique not clean techinue to prevent wound contamination
- the foram fressing is cut to the size of the wound bed but never cut directly over it because material can call
- the foam dressing should ompress/shrink when deice turned on
ear irrgation prescribed to
remove impacted or exces cerbumen
ear irgration technique
assess contrindication (fever, ear infection)
use an otoscope to inspect external ear
-explain procedure and sensations such as vetigo fullness and warmth are common
-place client in sitting poistion or side lying wih head tileted toward the affected eat
- place towel or emesis basin under ear
-solution should be at body temp 98.6
-pull ear up and back if
or down if e ≤3
-irragte by slowly directing the syringe up toard the top ear
- stop imm if the client exp severe pain , nausea or dizz
-repeat as tolerated
-document type, temp, volume of siltion, exudate characterisic
muslim client
private room not necesary, cna be assigned to a room with another muslim or a women with similar practices regarding modesty
-husband often request to be with the wife but most important is female care workers should be preesnt
absoultete nuerophil count
2200-7700
less than 500 neutrophil
indicates severe neutropenia and increases the risk of infection
nutropenia eduaction
avoid gardening and contact with fresh flowes, plants because soil contains pathogens
- private room
- visotrs should wear mask
- they can consume raw cooked veg but not RAW or unwashed
- fullycooked meat
- mostuizer to prevent dry skin
mal de ojo
evil eye
- latin american culture
- caused when stranger or someone percieved as powerful admires or coomplicments a child
- illness or ucrse can be broken if the admirire touches the child when speaking or imm afterwards
mal de ojo manesifest by
vomiting
fever
crying
lmited life ex[ectany clients have concerns
about completly personal busniess such as ensuring the possessions go to app peeople
nasoenertic tube used when
necessary to bypass the esophagus and the stomach
nasoenteric tubes have decreased risk for
aspiration compared to nasogstric tubes however, a nagoenteric tube can become disloged to the lungs causing aspiation of enternal feeedings
aspiration penumonaia signs
crackles
wheezing
dyspnea
prod cough
aspiration penumonia from tube feeding intervention
STOPPPP the feeding asap-inital step
tube placement should be checked (measuring insertion depth, xray, aspiratie PH)
pulse oximete estimates the
sao2 (arterial blood sat) by attching senor to finger, toe, foreheadm earlobe, or nose
what can decrease spo2 readings
low blood flow or decreased perfusion (dythemia, pvd, hf, edema, hypotension, )
- eelvated temp not one
- dehydration not one
after mastectomy surgery
semi fowler (not high folwer because it might cause low bp and dixx) with affected arm and hand elevated on severeal pillows to pomrote drainage -
apositioning after anesthesia
avid high folwer becuse it will cause the bp to drop and dixx
unilateral wekaness education
- first clothe the affect side
- approch them from the unaffected side to avoid startling
receptive aphsia (wenicke)
impairment of verbal and written langague so use visual and hand gesturs
when using intrepeter
- try to get same gender
- maintain eye contact with the clilent
- speak slowly, pause after 1-2 sentences
- simple instructors
- dont ask them to nod
- make them teah back
- teach one inervention at a time and in the order it will occur
arab culture
man is not allowed to be alone with a women other than his wife but some times it is okay if a third party is present
eye contact as sign of directful
arab
asian
native american
comfortable with silence
native americans
and asisns
-they view it as a sign of respect pviacy and respectful of elders
touching head is disrectful
asian and hisapnic
heat exposure signs
hyperthermia intravasular volme depletion -electroyle inbalances -dizz -wakeness -sweting -flsuhing -tayccardia -nasuea -mucle cramping
if heat exhaustion suspected
move the client to a coller temp and provie cool sports drink (gadorate) or water
prioty in heat exhaustion
lower body temp to prevent head stroke
if clients temo ruses after moving to cooler temp
ince packs palced on axilla and groint
if heat exhuastion sytmosmr resolves
dont need to viti HCP
but they should not leave till the symtoms subside
what is a copliation in clients who are dyring
anorixia
end of life care
they can refuse food and drink
- but ca give appetite stimulants such as dexmathson
- invovle the client in meal plannig
- provide opp to eat meals with fam and friends
proper use of crutches
-should have 3-4 fingers width space between axilla and the pad (1-2 in)
-handgrip location should allow 20-30 degree of flexion
-
3 point
partial or no weight bering on the affected ext
2 point
partial
4 point
full weight bearing
progressing of gait
3-2-4
walking with crutches
advance curthces and the affect leg and then advance the unaffected leg
when elder abuse is suspected
perfrom further assessment to validate and confirm any inital findings (geeneral hygine, clothing, nutrtional hydration status, )
hgb in male
13-17
hct in male
39-50
judaism diet
no pork, shellfish, fish without scales
-separte meat from diary (3-6 hours)
garlic appliciation
crushed garlic to the skin
-thought to heal infection but can cause dermatitis and burns on the wrists
cupping
remove illness from the body
-burished belmishes
coining
chines and vitnemis to remove illness
- a sound surgace such as coin or spoon
- weltlike linear lesions
postmortem care
clos the eyes
- maintain standard or isloation precaustions in place at the time of death
- remove tubes and dressing unless autpsy is needed
- straigten body and wash
- leave denutres in palce
- towel folded under the chin to keep jaw closed
- pad under perinum incase stool or urine from relaxed sphincters
- place pillow under the head to prevent blood from pooling and discoloring the face
- give clients belongs to a fam mem or send with the body
best culturally comeptent care principles
ask them what they think caused the disease
enternal feeding ubes become obstructued if
the tube is not flushed frequently enough
meds are not curshed
-
how di dislodge the clogged feeding tube
use large barrel dydrdine to flush and spirate warm water back and fofrth motion hrough the tube
- if the feeding tube cannot be unclog with warm water, attempt to use an digestive enzyme soltion (but these noramlly require to sit for 30-1 hour before flushing and apsiration)
-DO NOT INSTILL DARK COLOA OR CRNBERRY juice because it will make it worse and can mask GI bleeding
-
WHy do you want to flush wuth harge barrel syndringe instead of small
small barrel sydnrine causes too much pressure and can rupture the tube
people of american indian and asian culture
dont make eye contact
american and european culture
love direct eye contact
most reliable indicator of pain
self report of symtoms
changes in vital signs
not relaible source when determining pain
when there is new sudden onset of restlness or agitation the nurse should look at
o2 or bg
if the cllient can speak or breathing is effortless and quiet
the pt doesnt need help with opening airway
if client is snoring
then open the airway
incisoins take how long to heal
4-6 wk
how to take care of incision
- itching, tingling and nulbless are common for several weeks
- tub baths should be avoided-dont apply lotions or powers-wear eleastic hose on the legs
what is normal after incision
itching
numbess
tingling
complicatino of poor wound healing
dehiscnce
dehiscne
occurs when the edges of a surgical wound fail to approximate and seperate
dehiscine internveiton
stool softerns
- antiemetics
- abdominal binder to provide hemostasis and supprot the incision
- mointor glucose to prevent infection risk <140 for fasting and <180 for random glycose
- splinting the abdomen by holding pillow or folded blanket
non kosher foods
most capsules because they contain gelatin which is made from teh collagen of animals
-use tablets instead
extended release capsules
should be swllowed whole and curshing or breaking the capsule can cause uncontrolled dilvery of the meds
clients who undergo suregy may expiercne
post op cognitive dysfunction such as memory impairment and probelms with concentraion, language comprehension and social integration
-some clients might cry easily or become teary
risk of post cog dysfunction
increases with age, longer operative times, complications, post surgical infectoins
POCD time frame
can occur days to weeks(4-6) following surgery
walking with a client who is blind
uses slighted guide technique by walking slightly ahead of the client and the client holds the nurses elbow
-nurse should describe the env while ambulating the client
on the first post op day
nurse assists client with ambulation to evaluate alertness, pain level, signs of hypotesnion, gait and abiliity to ambulte safetly
