Reduction Of Risk Flashcards
Drug of choice for trigeminal neuralgia
Carbamazepine along with analgesics
Trigeminal neuralgia affects the ___th cranial nerve, and Bell’s Palsy affects the ___th cranial nerve
5; 7
What virus is associated with Bell’s Palsy?
HSV (antivirals frequently prescribed for this condition)
Bell’s Palsy nursing consideration
Teach client about eye protection, especially when sleeping (d/t inability to close eye)
Benign tumor of the 8th cranial nerve that is typically unilateral
Acoustic neuroma
S/S of acoustic neuroma
- Unilateral, progressive sensorineural hearing loss
- unilateral tinnitus
- dizziness
Definitive treatment for acoustic neuroma
Posterior fossa craniotomy to excise the tumor
NOTE: if tumor >3 cm, there is a chance the client will have permanent hearing loss and experience facial paralysis
S/S of meningitis in infants
Bulging fontanels, shrill, high-pitched cry, refuse to food, vomiting and diarrhea
Early sign of increasing intracranial pressure
Diminished level of consciousness
The client with bacterial meningitis is at risk for developing
SIADH & dilutional hyponatremia
Meningitis prevention
Hib vaccination (infants), meningococcal vaccine
Intervention for nonpenetrating abrasion of the eye
Instruct patient to patch the affected eye to allow it to heal for 24 hours
Interventions for nonpenetrating contusion/blunt injury to the eye
Cold compress for edema and discomfort, prescribe analgesics
Intervention for penetrating eye wound
Cover the eye with dry, sterile patch immediately, do NOT attempt to remove penetrating/foreign object
Post-operative complication related to cataract surgery characterized by sudden, intense eye pain
Hemorrhage
NOTE: client should experience little to no pain post-operatively. Any pain should be relieved by analgesic
Cataract post-operative patient education
Wear night shield, sleep on unaffected side, avoid straining/heavy lifting
Retinal detachment post-op patient education
- Avoid strenuous activity for 3 months
- avoid work that is close up such as reading, writing, sewing for the first week
- avoid stooping, straining
What are the 5 danger signs of glaucoma?
- Brow arching
- Halos around lights
- Blurring vision
- Diminished peripheral vision
- Headache or eye pain
Hearing loss characterized by a physical obstruction of sound wave transmission
Conductive
Permanent hearing loss resulting from inner ear damage
Sensorineural
Instilling ear drops in adults and children
Adult: pull ear up and back
Child 3 or younger: pull ear down and back
Three features of Meniere’s Disease
Tinnitus, sensorineural hearing loss, and vertigo
Ménière’s disease lifestyle modifications
Follow low-sodium diet <2000 mg/day, avoid alcohol, nicotine, and caffeine — These measures prevent endolymphatic fluid accumulation
Medications that can lead to diabetes
Corticosteroids, thiazides, phenytoin, and atypical antipsychotics such as clozapine
Normal fasting blood glucose
60-110 mg/dL
Normal HbA1c
4-6%
Describe the process of the oral glucose tolerance test (GTT)
- client receives 75 g oral glucose loading dose
- glucose levels assesses at timed intervals: fasting blood glucose should be between 60-100 mg/dL. At the 1 hour mark, glucose should be less than 200 mg/dL. At the 2 hour mark, glucose should be less than 140 mg/dL
Diagnostic criteria for diabetes
- HbA1c >/= 6.5%
- fasting blood glucose >/= 126 mg/dL
- 2 hour OGTT >/= 200 mg/dL
- “classic symptoms” + random plasma glucose > 200 mg/dL
Diabetic sick day rules
- Take insulin as ordered
- Check blood glucoses q3-4h. If glucose > 240 mg/dL, check for urine ketones
- Notify HCP if vomiting, diarrhea, or fever
- Consume liquids every 30 min to 1 hr to prevent further dehydration
How often should diabetics check their glucose throughout the day?
If the client takes insulin, instruct them to check their glucose every 2-4 hrs. Check at least 2-3 times per week if managing Type II diabetes with oral hypoglycemics or lifestyle modifications
Hypoglycemia is classified as blood glucose less than ___-___ mg/dL
50-60
Intervention for conscious hypoglycemic client
- Administer oral liquids with 10-15 g of glucose (skim milk ideal, 4 oz juice)
- Hard candies
Interventions for unconscious hypoglycemic client
- administer dextrose 50% IV, 1 mg glucagon IM/SQ
- follow up with carbohydrates in 15 min
Dietary modifications for gout
Low-purine diet avoiding fish, organ meats, beef, pork, lamb, seafood, beer, and breads
What medications should be avoided by the client with gout?
Aspirin and diuretics
Diet for renal failure
High calorie, low-protein diet with restrictions on fluid, sodium, potassium, and phosphorus
Cystic fibrosis diet
High protein, high calorie diet with pancreatic enzyme replacement
Appendicitis nursing considerations
- No heating pads, laxatives, or enemas
- hold analgesics until diagnosis is confirmed
- keep client NPO
Diet for cholecystitis/cholelithiasis
- smaller, more frequent meals
- low fat, high fiber diet
Diet for Crohn’s Disease and Ulcerative Colitis
- high protein, high calorie, low fat, low fiber
- parenteral nutrition my be required for bowel rest during exacerbations
Foods to avoid for Crohn’s Disease
Cocoa, chocolate, citrus juices, cold or carbonated drinks, nuts, seeds, popcorn, or alcohol
Characteristics of duodenal ulcers
- occur in the first 1-2 cm of the duodenum
- more common in males 30-60 years old
- pain 2-3 hours after eating and at night; described as burning, cramping, or painful pressure
- food intake and antacids relieve pan
Characteristics of gastric ulcers
- can occur anywhere within the stomach, but predominantly seen in the antrum
- common in both males and females 50 years and older
- pain 30 min to 1 hr after meals
- pain worsens with ingestion of food
- hematemesis
GI ulcer dietary modifications
- eat 3 meals/day
- avoid coffee, alcohol, caffeine, milk/cream
- avoid foods at extreme temps (either really hot or cold)
Antacids should be administered _________ before/after meals
1 hour
When should H2 Blockers be administered?
With meals
When should anticholinergics be administered?
30 min before meals
When should cytoprotective agents (sucralfate) be administered?
1 hour before meals
When should PPIs be administered?
At bedtime
Diet for dumping syndrome
Low carb, low fiber
What electrolyte imbalance is the client with an intestinal obstruction located higher in the GI tract likely to experience? Lower in the GI tract?
Metabolic alkalosis; metabolic acidosis
Tracheoesopageal fistula and esophageal atresia post-op nursing consideration
Provide infants with nonnutritive sucking (pacifier) to prevent feeding aversion and difficulty with PO feeding
Assessment of Hirschsprung Disease
- failure of newborn to pass meconium within 48 hours
- poor feeding
- foul smelling, ribbon-like stools
- visible peristalsis
Hallmark symptoms of pyloric stenosis
- eagerness to feed and weight loss
- projectile vomiting
- palpable olive-shaped tumor in epigastrium
- visible peristaltic waves
Impetigo characteristics
- bacterial skin infection
- pruritic, reddish macula becomes vesicle then crusts. Crust is thick and honey-colored**
- commonly seen on face
Untreated impetigo can lead to the development of
Acute glomerulonephritis
Herpes zoster characteristics
- vesicular eruption in a linear distribution along a nerve root or dermatome
- painful, pruritic
- usually unilateral on face, thorax, trunk
Herpes zoster prevention
Herpes zoster/shingles vaccine at age 60 and over
Tinea characteristics
erythematous, ring-like lesions with central clearing
Psoriasis characteristics
- thick, itchy, erythematous papules/plaques
- silvery, white scales
- symmetrical distribution commonly occurring on the scalp, knees, and/or elbows
- NOT contagious
Eczema (atopic dermatitis) patient teaching
- elimination diet: milk, eggs, wheat, citrus
- wear cotton clothing
- avoid harsh, overly drying soaps
- use emollient lotions
- keep nails short and clean
Systemic Lupus Erythematosus (SLE) diagnostic indicators
- rheumatoid factor
- ANA
- decreased C3 and C4 complement levels
- increased immunoglobulin levels
- increased anti-DNA levels
- increased CRP
How frequently should client vital signs be monitored postoperatively?
Every 15 min x 4, every 30 min x2, every hour x2, then as needed
Normal WBCC for adults and children
Adults: 5,000-10,000
Children: 5,000-13,000
Normal RBC for men and women
Men: 4.6-6. Million
Women: 4.2-5.4 million
Normal Hgb for men and women
Men: 13-18 g/dL
Women: 12-16 g/dL
Normal Hct for men and women
Men: 42-52%
Women: 35-47%
Normal platelet count
150,000-450,000 mm3
T-Tube drain characteristics
- placed after gallbladder surgery in the common bile duct
- drainage: initially 500-1,000 mL/day, bright red blood that transitions to darker color
- nursing consideration: keep drainage bag below waist
When should suction surgical drains be emptied?
When full or every 8 hours
Stomach/Esophagus Endoscopy considerations
- instruct client that they will be sedated during the procedure
- NPO for at least 8 hrs
- expect numbness after the procedure; keep NPO until gag reflex returns
- expect sore throat for 3-4 days; use warm, saline gargle to address discomfort
Sigmoidoscopy considerations
- clear liquid diet before procedure; administer laxative night before exam; enema or suppository morning of exam
- NPO after midnight
- client will be positioned on tilt table; encourage client to take deep breaths during insertion of scope; may have urge to defecate during this part of the procedure
Post-upper GI Series Barium Swallow patient education
- increase fluid intake (barium can be constipating)
- laxatives may be administered to prevent constipation
- stool may be light-colored/white from barium for up to 72 hrs
Client preparation for paracentesis
- obtain baseline vitals and weight client
- position client in semi-fowler’s or sitting upright on edge of bed
- empty bladder (prevents injury/perforation of bladder)
How high should enema irrigation be set above the rectum?
No more than 18 in (45 cm)
How deep should enema rectal tube be inserted in an adult?
No more than 3-4 inches (7.5-10 cm)
Enemas should NOT be administered if
Client is experiencing abdominal pain, N/V, or is suspected to have appendicitis
NG tube measurement
Measure from the tip of the nose to the earlobe, and down to the bottom of the xiphoid process
NG tube placement confirmation
- X-Ray (definitive)
- aspirate for gastric contents (gastric pH </= 4)
Hold enteral feeding if NG tube residual exceeds ___ mL
100
NOTE: indicates delayed gastric emptying. Report to HCP
The nurse should instill ___-___ mL of water before and after each dose of medication and each tube feeding, after checking residual, and every 4-6 hours with continuous feeding
15-30
How often should enteral feeding bags be changed?
Every 24-72 hrs
How is removal of an intestinal tube different than an NG tube?
Unlike removing an NT tube in one swift, continuous motion, the intestinal tube must be removed 6 inches every 10 min (small segments at a time) until you reach the stomach, THEN you remove it completely with smooth, continuous pull
Liver biopsy client preparation
- Administer vitamin K (d/t risk for bleeding)
- NPO 6 hours prior to procedure
- medicate with sedative
- position client supine or laterally with arms elevated
- instruct client to exhale and hold breath for 5-10 seconds during needle insertion
Post-liver biopsy nursing care
- position client on right side for 2-3 hours
- gradually elevate HOB, 30 degrees first hour, 45 degrees second 2 hours
- bed rest for 24 hours
- client should anticipate experiencing mild local pain that can radiate to the right shoulder
- instruct client to avoid activities that increase intra-abdominal pressure for at least one week
Post-lumbar puncture considerations
- client should be positioned flat in bed for 4-12 hours
- encourage fluids to prevent headache
EEG client preparation
- hold tranquilizers, stimulant meds, and stimulants (cigarettes, caffeine) for 24-48 hours prior to procedure
- client may be asked to hyperventilate during procedure or watch bright flashing lights (increases likelihood of seizure activity)
- client may be instructed to be sleep deprived
Post-laparoscopy considerations
- quick recovery; client can get out of bed after procedure
- client can resume regular diet
- client may experience shoulder/back pain (d/t CO2 introduced during procedure)
Central Venous Pressure (CVP) normal reading
2-6 mm Hg
Elevated CVP reading
> 6 mm Hg
NOTE: this indicates hypervolemia or poor cardiac contractility
Low CVP reading
< 2 mm Hg
NOTE: this indicates hypovolemia
Prevention of air embolism in the client with a central venous line
Instruct the client to hold their breath/perform valsalva maneuver when tubing is inserted, withdrawn, or changed
In which position should the nurse place the client to ensure accurate CVP measurements?
Supine with the HOB elevated no more than 45 degrees and the zero (0) point of the manometer level with the phlebostatic axis
Bronchoscopy patient preparation
- NPO 6 hours prior
- premedicate w/ diazepam, midazolam, atropine (decreases gastric secretions)
- advise patient they may have a sore throat after procedure
Post-bronchoscopy considerations
- instruct client to sit or lie on their side to prevent aspiration
- keep NPO until return of gag reflex
Thoracentesis procedure considerations
- instruct the client to remain still, avoid coughing and talking
- do not aspirate more than 1000 mL at one time
Cardiac catheterization post-procedure consideration
Keep affected leg straight for 6-8 hours
