Set 1 Flashcards
Nursing Process
ADPIE Assessment Diagnosis Planning Implement/Interventions Evaluation
Establishing goals is part of which phase of the nursing process
Planning
Normal Calcium levels lab values
8-10
Normal Protein levels lab values
6.4-8.3
Foods with protein
Meat, eggs, milk, cheese
Bioavailability
How much drug is available in the body after absorption
Brand names and generic drugs
Bioequivalent, however they can have some different inert ingredients causing differing effects. Get approved from healthcare provider before using!
Feeding tube feed after surgery
Usually not initiated until BS are present which is around 24 hours after placement
May infuse water at a slow rate 2 hours after but only with order from HCP
Serosanguinous drainage
Pale, Red watery
Sanguinous drainage
Bright red. Indicates active bleeding
Purulent drainage
Thick, yellow, green, tan or brown
Almost always sign of infection
Serous drainage
Clear, watery, plasma
Oz to mL
1 oz = 30 mL
Correct order of assessment
Inspect, auscultate, percuss, palpate
Correct position to auscultate BS
Which quadrant do you begin with
Supine
RLQ
Normal bowel sounds
Hypoactive BS
5-35 sounds heard per minute
Heard after 3 min
Paralytic Ileus
Intestinal blockage… absence of BS
Upper GI series
Swallow Barium, Then X-rays are taken of esophagus, stomach and duodenum
Lower GI series
Barium inserted through the rectum, xrays are taken at different angles of the colon
Laxatives MOA
Soften the stool and stimulate rectal mucosa to produce soft or liquid stool
Rectal tube
Used to remove gas or liquified stool
Radiographic examination
Used to determine presence of fecal impaction
Vagal nerve stimulation
Can decrease pulse
Verbal orders
Verbal prescriptions must be signed within 24 hours
Good fiber sources
Whole grain, kidney beans
Lisinopril Teaching food
Avoid excessive intake of potassium
Milrinone
Vasodilator, used to treat HF and reduce BP.
Side effect: Hypotension
Can cause ventricular dysrhythmias… monitor EKG during administration
Side effects of Digoxin
Digoxin administration
Nausea and anorexia
Check apical pulse. Hold if <60
Ipratropium is contraindicated when
Ipratropium administration
In people with soybean or peanut allergies
Use at the same time each day
Albuteral
Rescue inhaler
Use 15-30 minutes before physical exercise
Elderly body changes that affect drugs
Decreased hepatic blood flow. This decreases drug metabolism
Protein level significance
Decrease in protein levels could mean an increase in free drug
Hep B and Hep A transmission
Hep A: spread through saliva
Hep B: Sharing needles or sex
Gastric contents PH levels
<4
Feeding tube and coughing
coughing could dislodge the feeding tube up the esophagus and is a risk for aspiration. If a patient has bouts of coughing, check the ph levels of contents to ensure correct placement.
Confusion in the elderly
Not an expected finding.
Often follows relocation to new surroundings
Myasthenia Gravis diet
High calorie but also semi solid foods. Things like graham crackers and apple slices are too difficult to chew and swallow. Chocolate pudding would be a good answer.
High cholesterol diet
Limit saturated fat from animal foot sources to 4 oz a week
Don’t need to completely restrict protein and red meats, but should restrict to lean cut red meats and small portions
Proper use of inhaler when to administer
During the inhalation
Trachea suctioning
Should not last for greater than 15 seconds at a time. Allow for re-oxygenation in between
Compartment syndrome
Occurs from a cast or internal pressure (such as subcutaneous infused pressure)… results in decreased blood flow to extremity.
Assess pulse and cap refill distal!
Patient on bed rest…
Be careful of sheering. Gently lift pt when moving into desired position.
Why do we start IV infusions in upper extremities more often
Risk for thrombosis in lower extremities
NG tube medication administration
Flush with water before and after. Then clamp tubing for 20 minutes.
Mix each medication individually
Who has greatest need for additional protein intake?
Lactating woman
How to best measure total muscle mass of adolescent
Upper arm cirucmferance
Battery
Unwanted touching
Auscultating abnormal heart sounds
Use the bell of the stethoscope
Closed ended questions when to use
Use when needing to obtain specific information such as s/s of a problem.
Goniometer
The instrument that measures angles
Frontal lobe of the brain controls what
Higher mental activities such as memory, intellect, language, emotions, and personality
Hypothalamus controls what
Regulates body temp, appetite, maintains wakeful state
Parietal lobe controls what
Location of sensory and motor function
Huber-point needle
Used when accessing an implanted infusion port for pt on long term IV
Normal cardiovascular age related findings
Heart murmurs and widening pulse pressures
Common side effects of atorvastatin (Lipitor)
Diarrhea, headache
Older adult male sexual function
Not a normal change in aging. Decreased sexual function may be due to some medications
Manifestations of R sided HR
Jugular vein distention, pitting edema, ascites`
Normal pulmonary function change in older adults
Reduced vital capacity
Normal renal function change in older adults
Decreased GFR and decreased blood flow through kidneys
Normal age findings related to taste
Often dull due to atrophy
Glascow Coma Score includes what
Verbal response, motor response, eye opening
DOES NOT INCLUDE PUPILLARY REACTION
Expected findings with COPD
Anemia
Respiratory acidosis due to CO2 that is retained
Barrel chest
O2 levels between 88-92%
AV fistula for dialysis expected finding
Enlarged vein
Feeling of urgency with catheter
Irrigate first to push blood clots to determine if that was cause. If urgency still there, report finding to provider.
Addison’s disease expected findings
Hyperpigmentation.
When Adrenal glands don’t produce enough corticosteroid hormone
Cushing’s disease expected findings
Moon face, acne
Ethnic group of women with highest risk of osteoporosis in order
Caucasian, Asian, Hispanic, African American
Symptoms for decreased arterial blood flow
Skin cool to touch, diminished hair on legs
Speaking to client with hearing loss
REPHRASE question not REPEAT
OTC decongestant
Can increase ocular pressure
Can increase BP and pulse
Peptic ulcer disease expected findings
Hematemesis, gastric pain on empty stomach, intolerance of spicy food
What is diverticulosis
It is caused when chronic constipation causes weakening of colon walls which result in out-pouching sacs
Sarcoidosis most commonly occurs in what ethnic group
African American
Haloperidol side effect
Dystonia (Involuntary muscle control when a persons muscles contract or twist)
MAOI food interactions
No alcohol or tyramine containing foods. Interaction causes hypertensive crisis
Incomplete fracture
Occurs through part of the thickness of the bone.
Paroxysmal nocturnal dyspnea
Characteristic of HF secondary to fluid overload.
Sudden awakening in the middle of the night with SOB
Amylase lab value
Associated with acute pancreatitis
Pursed lip breathing
Promotes CO2 elimination
Liver biopsy
Potential for bleeding. Take vitals every 10-20 min. Position pt on R side and maintain bedrest for several hours after
Bedridden client early sign of complication related to immobility
Stiff joints
Irritable bowel syndrome
irregular bowel movements with constipation
Ulcerative colitis S/S
Tenesmus
Early stages of shock
Lethargy and other changes in LOC
Oral glucose tolerance test
Used to screen for Diabetes
Feeds rich in Vit B12
Cheese, Eggs, fish
Foods with zinc
Meats and shellfish
Kosher diet
Cannot mix meat and dairy in the same meal
No pork or shellfish
No blood in meat
Foods enriched with calcium and Vit D
Fortified Soy Products
Dumping syndrome
diarrhea, nausea, feeling lightheaded after eating due to food moving too quickly to your duodenum.
To mitigate, don’t drink more than 8 oz of water during meals
Pernicious anemia vitamin deficiency
B12
Clostridium botulinum
Occurs with inappropriate preparation of canning foods
Samonella typhi
Occurs with undercooked meats
Lysteria
Common in unpasteurized dairy
Jar of peanut butter
Can age and spoil creating toxins and mold that are carcinogenic to humans
New mother breastfeeding tips
Increase caloric intake by 500
Drink fluids liberally between 2-3 liters
Avoid spicy foods
What foods not to eat with PKU
Chicken, Fish, cows milk, products with artificial sweeteners, nuts, beans
Any protein or diary should be avoided
Pregnant women protein needs
Estimate by taking PRE pregnancy weight and divide by two
Magnesium
Need increases during pregnancy
Mg increases protein, nucleic acid, and fat synthesis
