Tell a Nurse Chapters 20-40 Flashcards
1
Q
What to look out for when a person is being treated with CPAP Therapy?
A
- Person refuses to put on the mask or takes it off
- Hissing noise coming from or around the seal of the mask or tubing
- CPAP machine is not working properly
- Mask or straps are causing irritation of the person’s skin
2
Q
What to look for when a its nighttime and patients are sleeping
A
- Person is awake frequently during the night
- Person lies awake for periods of long time before falling asleep again
- Person report wakefulness or difficulty sleeping
- Person seems sleepily during the day
- Person gets up frequently during the night to urinate
- Person tells or shows discomfort or signs of pain
- Person reports inability to sleep or stay asleep as a result of the environment
- Person expresses worry or anxiety about something.
3
Q
What to look for when assisting a person with Oral Care?
A
- Dry, red, cracked or bleeding lips , gums, mucous membranes
- Cold sores on lips or mucous membrane
- Red. irritated, swollen, or bleeding gums
- Cracked, chipped teeth, loose teeth or blackened teeth
- Chipped, cracked or poorly fitting dentures
- Red sores or canker sores inside the mouth, white spots, or signs of pus or infection
- Bad breath that does not improve after oral care
- Fruity smelling breath (possibly of diabetes)
- Red or swollen tongue or white coating on the tongue
- Complaints of pain or sensitivity.
4
Q
What to out for when observing for skin breakdowns?
A
- Reddened skin especially over bony areas
- Pale, white or shiny skin over a bony area
- Areas of skin that are hot to the touch
- Areas of skin that is painful or tender
5
Q
While providing foot care or hand care, what do you need to look for regarding infections or illness?
A
- Nail beds are either very pale or blue or bruised
- Nails that are unusually yellow or white
- Nails that are unusually thick
- Nails that are broken or have been cut too short
- Nails that are overgrown
- Cuticles that are torn, red, swollen
- Skin that is blistered, red or tender
- Any unusual rashes or odors
6
Q
While providing hair care, what do you need to look for?
A
- Flaking, crusting, scaling of the scalp
- Redness, itching, tenderness of the scalp
- Unusual hair loss especially if it is occurring in patches
- A foul smell
- Severely matted or tangled hair
- Nits
7
Q
What to look for when a collecting urine?
A
- Is cloudy or contain particles. has abnormal color or odor
- Complains that urine is difficult or painful to pass (if the person has dysuria)
- Experiencing frequency, urgency, or both
- Person needs to get up more frequently than usual to use the bathroom during the night
- Person having incontinence accidents or more frequent incontinence accidents
7
Q
What to look for when a person has enteral nutrition and might be chocking?
A
– Nausea or bloating or pain during feeding
- Coughing, gagging or vomiting during the feeding
- Abdominal distention
- Drainage from around the tube insertion site
- Disconnected tubing
8
Q
What to look for when providing catheter care?
A
- Changes in color, clarity, odor or the urine
- Failure to urine to flow freely through the tubing
- Person is complains of pain or discomfort as a result of catheter
- Redness, swelling, or discharge from the catheter insertion site
- Leaking of urine around the catheter insertion site
9
Q
What to look for when assisting with a Bedpan?
A
- Person has diarrhea or constipated
- Blood or mucus in the stool
- Stool is black or dark green
- Stool is foul smelling
- Person complains of that the feces are painful or difficult to pass
- There is bleeding from the anus during or after bowl movement
- Person has swollen abdomen or complains of abdominal pain
- Person complains of liquid feces seeping from the anus
- Person has excessive flatus (gas)
10
Q
What to look for when a person is terminally ill ?
A
- Person refuses medications or other medical treatment
- Person cries constantly, refuses food, or cannot sleep
- There is tension and disagreement within the family
- The person or family member request the assistance of a religious leader or grief counselor
- Person expresses interest in making or changing legal documents related to end of life care
11
Q
What to look for when a person is dying?
A
- Person seems to be in pain
- Trouble breathing
- Asks to see a religious leader
- Overwhelmed by the number of visitors or the length of time they are staying
- Family member has a question about the person’s care or condition that you are not qualified to answer
- The person has died
12
Q
What to look for when doing skin care?
A
- Skin looks abnormally pale or flushed or has a bluish or yellowish hue
- The person has a new rash, or changes in an existing rash
- The person has a mole that has changed in appearance
13
Q
What should you look out for when caring for pressure ulcers?
A
- Person has paleness or redness over a pressure point that does not go away within 5 minutes
- Area over a pressure point that was previously red has become pale, white, shiny
- Area over a pressure point that was previously red is hot to the touch or painful
- A pressure ulcer has changed in size or depth
14
Q
What should you look for when caring for wounds?
A
- A person complains of increased pain or discomfort
- Increased in redness, swelling or warmth around the wound
- The person has a fever
- Drainage from the wound has changed in amount or appearance or has developed a foul odor
- The dressing is excessively wet or soiled
- the drain tubing has pulled out or has become disconnected
- The V.A.C ATS therapy System is not functioning properly
15
Q
What should you look for when caring for musculoskeletal system?
A
- The person has fallen
- Area has become swollen, red, bruised tender or painful to the touch
- Person complains of pain when moving a joint
- Person has usual range of motion of a joint has decreased
- Person limps or has pain while walking or makes excuses to avoid walking
- Person guards or rubs a joint even when not moving
-Person has decreased muscle strength
16
Q
What should you look for when caring for the respiratory system?
A
- Person experiences the sudden onset of chest pain or difficulty breathing
- Person develops noisy breathing (wheezing or barking or crowing)
- Person begins to make a fluid like gurgling sounds
- Oxygen flow rate on the flow meter does not match the ordered amount of oxygen
- Gauge on the pressurized oxygen tank indicates that the oxygen level is low
- The screen on pulse oximeter shows a reading less than 90%
- A person’s skin has a blue or gray tinged either at rest or while exercising
- Person coughs up sputum that is discolored (green, frothy, brown or red streaked)
- Person’s tracheostomy or endotracheal tube becomes dislodged
- A person becomes short of breath during physical activity that they have performed without effort in the past.
- Person respirations become very slow and shallow or they stop
17
Q
What should you look out for when doing vital signs on the cardiovascular system?
A
- Complaints of chest pain or pressure
- Labored or difficult breathing
- Rapid or erratic pulse
- Slow or weak pulse
- Blood pressure reading that either much higher or much lower than the person’s usual reading
- Cyanosis of the face, lips, or fingers
- Decreased tolerance for usual exertion
- Red, painful or swollen areas in the extremities especially the calves of the legs
- Unusual swelling of the legs especially if it is accompanied by red, shiny skin
- “Dusky” (blue or grayish) coloring of the legs especially if it is accompanied by a diminished pulse and coldness of the skin
18
Q
What should you look out for when caring for someone with diabetes?
A
- Person has signs or symptoms of hypoglycemia or hyperglycemia
- Person refuses a meal or snack or only eats part of it
- Person has vomited
- The person has received gifts of food from visitors
- The person is taking food from others
- The person activity level has changed significantly (either less or more)
19
Q
What should you look for in the urinary system?
A
- Complaints of sharp, sudden pain of the abdomen, side or back
- Blood in the urine
- Significant increase or decrease in the amount of urine voided in a period of time
- Changes in a person’s voiding habit, especially increased or decreased frequency or a new onset of incontinence
- Pain or burning when urinating
- Urine that appears cloudy or has a strong ammonia smell
- Increased in confusion, decreased alertness or unusual behavior especially in older people.
20
Q
What should you do when assisting female patients with hygiene and toileting?
A
- Person has an unusual vaginal discharge
- Person has vaginal bleeding but they have already gone through menopause
- Person has very heavy vaginal bleeding during their menstrual period
- Person has pain or cramping in their lower abdomen
- Person complains of a feeling of pelvic pressure or fullness
- Person complains of problems emptying their bowl or bladder
- There is protrusion from the vaginal opening
- Person reports itching or burning around the vulva
- The skin around the vulva is inflamed or irritated
- Changes in skin color, sores that do not heal lumps, unusual swelling or thickened areas around vulva
- Lump or thickened areas around vulva
- There is discharge from the nipples or puckering of the skin of the breasts.
21
Q
What should you look for when assisting a male with toileting?
A
-Person has unusual discharge from penis especially if it contains blood or discolored secretions.
- Person has pain or burning when urinating
- Lump or thickened area in the testes
- Changes in the skin surrounding the scrotum or penis
- Reddened or irritated skin in the genital area
- Person complains of pain or aching in the scrotum or rectal area.
22
Q
What should you look for when caring for rehabilitation patients?
A
- A supportive device or assistive device is broken or not working properly
- The person has a change in vital signs during or after the rehabilitation or restorative care activity
- The person has pain, swelling, redness or signs of inflammation around supportive devices or prosthetic devices
- The person is showing signs of depression or excessive frustration like crying or withdrawal anger or talk of suicide .
- Having excessive difficulty with new rehabilitation technique or treatment
