Test 2 Flashcards
How do you check for homans sign?
To asses for DVT, client forcefully dorsiflexes the foot. If pain is present, it may indicate a positive result. Warm tender reddened hardened area of calf indicates thrombophlebitis.
Some is normal as lubricant to help pump effectively. If excess fluid, it is called pericardial effusion S1 and S2 will be muffled and hard to hear because of the fluid.
Fluid in pericardial space
Cardiac tamponade
Discharge teaching for thombrophelbitis
Anticoagulant such as Coumadin. Drink 2-3 quarts of h2o daily
Do not cross legs, elevate legs while sitting, avoid sitting or standing long periods, wear support, shift weight back and forth or circulation. Notify PCP ASAP if assumed DVT or PE.
This is used for the function of
Sensory, protection, maintain fluid and electrolytes
(Protect body from harmful microorganisms, keep in fluid and electrolytes, maintain body temperature)
Function of skin
Causes of dysrhythmias?
CAD, HF, MI. Asymptomatic or MI. Syncope, fatigue, decreased energy, dyspnea, angina, palps
Carbuncle causes?
(An infection) Diabetes, obesity, malnourished, poor hygiene , infect d hair follicle
Nursing diagnosis for burn patients ?
Maintain body alignment with splints , not circulation, promote healing, dressing changes, debridement, restore function, pain levels , abx, surgery, infection control and fluid loss
What to know about latex allergy?
Avoid latex? Cross reactivity in bananas , avocados, chestnuts, kiwi
Use latex free cart- careful with gloves and tip of vials
Document allergy and report to surgeon
Assessment of pallor ?
Lower conjunctival sac, tip and dorsum of tounge of tounge, soft palate, nail beds, palm or plantar creases, skin
Treatment of V-fib?
Defibrillation and CPR
Oxygen, amiodarone (cordarone) given through IV, lidocaine hydrochloride, mag sulfate, can also be cardioverted if peripheral pulses are present or defib if peripheral pulses are absent
Lack of blood
Anemia
PTT on heparin
Partial thromboplastin time. Serum test the identifies abnormalities in clotting pathway.
Normal time is 60-70 sec clot time. If >100 higher clot risk. If taking heparin, do PTT test 30-60 mins before dose
Heparin will prolong PTT
Placement of defib pads ?
Right sternum below clavical at apex of heart.
Lubed with gel as done by cardiac doc or nurse.
Everyone should stand clear to prevent shock.
(Left lower infra-scapular region chest )?
Function of platelets in body?
The primary function is to prevent bleeding and clot blood
Nonnucleated cells, granular ovoid , or spindle shapes cell fragments.
Thromboplastin clots in needed areas
Secret prostaglandins and serotonin which vasoconstrict.
Fibrin is formed and seals opening.
HR lower than 60.
Causes include myocardial ischemia, electrolyte imbalances, vagaries stim, beta blockers , drug toxicity, intracranial tumors, sleep, vomiting.
Treatments:
Bradycardia
- atriphine , pacemaker , athletes usually not treated
Nursing care for someone with immune deficiency?
Asses for infection, fever white patches in oral cavity, adenopathy , persistent diarrhea, frequency, urgency , pain with urination , redness, drainage, swelling of skin.
Monitor labs, sputum, urine , CBC, vitals
Diet for A-fib?
Liquid diet , low fat, low cholesterol, low sodium diet.
Eat frequent small meals
Avoid caffeine, fatty foods, and extremely hot or cold foods
People with A-Fib are 5 times for likely to get what?
A stroke
this is why they are often in anticoagulants
Inflammatory condition of the skin where the skin reacts to external irritants such as harsh chemicals like detergents or insecticides, allergens like cosmetics, metals such as nickel , mechanical irritation from wool or glass fibers, body substances like urine or feces.
(Itching (puritis), burning , redness)
Contact dermatitis
How to treat contact dermatitis
Corticosteroid ointment
Oral antihistamines such as Benadryl
Pacemaker discharge teaching to client?
Teach client to take accurate apical and radial pulses
Inform client to report dizziness, fainting , or fever
Regular pacemaker checks or trans telephonic monitoring
Treatment for tachycardia?
Depends on cause
Calcium channel blockers, beta blockers , anti arrhythmic meds, pacemaker / cardioversion
A chronic progressive, incurable autoimmune disease affecting multiple body organs.
Occurs most commonly in in women during childbearing years and African American women.
SLE ( Systemic lupus erythematosus)
Tests for lupus ?
THere is no single test for lupus
Molar rash (over checks ), Photosensitivity, oral ulcers, arthritis , seizures , false positive syphilis test
Reduced sodium , avoid direct sunlight , eat healthy diet
Bleeding problem where there is a lack of clotting factors. Inherited
Hemophilia
What does pain with hemophilia indicate?
What to do / take for pain?
Hemarthorosis - bleeding into joints causing pain redness swelling and fever
Don’t take anti inflammatories or aspirin. Take acetaminophen
Use soft bristled tooth brush and electric razor
Avoid contact sports and wear long sleeves
Wear med tag
What is pediculosis?
Head lice
Attach to hair shaft or seams of clothes , have grey pearly appearance. Resembles a tiny crab.
Bite causes severe Pruritis.
Permethrin lotion applied topically
Lice
What can alter wound healing ?
Low hemoglobin levels, hemocritt levels , RBCs, NSAIDs
Older population at risk for ?
Atrial fibrillation As a result of CAD, heart failure, hypertension
Immunocompromise disease such as tuberculosis HIV
Respiratory acidosis when taking narcotics
Respiratory distress, COPD, respiratory failure , seasonal illness , pneumonia, influenza
What does DIC stand for ? And what is it ?
Disseminated intravascular coagulation
A condition of altering clotting and hemorrhaging
that stimulates the clotting mechanism causing many very small clots to block arteries and capillaries / Attempt to stop the clot information and causes hemorrhaging which can be a fatal condition
A syndrome that Can occur because of diseases such as burns, acute leukemia, metastic cancer, polycythemia Vera , pheochromocytoma, shock , acute infections, septic abortion, abrupto placenta , blood transfusion reactions , and trauma.
It is a condition of altering clotting and hemorrhaging
DIC
How is DIC treated ?
It is treated by Administering her blood or blood products to normalize the clotting factor level
Platelets and packaged red cells are given to replace those lost during hemorrhaging. Plasma is given to normalize clotting factor levels.
What to ask patient with bee stings?
first determine whether the pt has a hx of allergic reactions and if they carry an epinephrine kit
Ask yes or no questions???
What to do for a DVT patient that is on bed rest?
Omg they improve - below the knee compression stockings are recommended.
Best rest is recommended in early stages to prevent clot from dislodging and clotting - elevate legs later - never massage because clot could dislodge
Drink 2 to 3 quarts of water per day, do not sit with legs crossed, elevate both legs when sitting, avoid sitting or standing for long periods of time, wear support hose, when standing shift wait frequently and occasionally stand on tiptoes to stimulate the calf muscles to pump blood, notify the doctor is like pain tenderness or swelling or difficulty breathing or chest pain is occurring. To prevent stay ambulatory and deep breathing
Narrowing of the heart valve opening that blocks blood flow from the left atrium to the left ventricle.
Usually results from rheumatic fever, but infants can be born with it. Doesn’t cause symptoms unless severe.
IV drugs use, immunosuppressed, dental caries , abscesses, hx of heart disease
Mitral stenosis
A massive release of inflammatory mediators such as histamine, prostaglandins causing hypersensitivity reaction when allergen comes in contact with the body through ingestion, skin contact, or inhalation
Anaphylactic shock
Treatment for anaphylactic reaction?
Restore fluid volume by blood transfusion and IV hydration, oxygen , sodium chloride to normalize electrolytes
Meds - epinephrine, norepinephrine , phenylalanine, dobutamine , dopamine. Are he most commonly used (vassopressors ) help reduce vasoconstriction
Inflammatory disease that occurs 2 to 3 weeks after improper treated pharyngitis Caused by streptococcus
Symptoms are mild fever, probably arthritis, carditis, courier, and rash.
The endocardium, myocardium, and epicardium can be inflamed and leave damage to the mitral valve
Non contagious Fever/disease that commonly affects young people with inflammation of and pain in the joints that often results from strep throat or scarlet fever infection
Rheumatic fever
Red blood cells with patients - what to report?
? Hemocrit , iron , oxyhemoglobin, methemoglobin , caroxyhemoglobin
Immunosuppressive medication adverse reaction?
Make the client more prone to infections and cancers
What is an auto immune disorder and what types are there ?
When the body identifies it’s own cells as foreign, so then the body tries to destroy them
Rheumatoid arthritis, systemic lupus, myasthenia Gravis
Effects of skin with aging?
Blood flow to the skin is reduced
Skin becomes thinner and more easily injured
Loss of skin tissue can cause sagging and wrinkles, sweat glands diminish , which result in dry skin and decreased ability to adapt to temperature
Skin cancer is more common
Number of hair follicles and growth of nails decrease
Age spots
Hyperthermia hypothermia
Grey hair from lack of melanin production
Treatment for burn patient ?
Oxygen, fluid, electrolytes, chest X-ray, pain control , cleansing of wound or debridement
Skin graft ( auto graft, homo graft, hetero graft, artificial skin graft )
Calories and high protein diet
Symptoms in burn patients
Hypovolemic shock ( a life threatening condition caused by loss of blood and fluids)
Infection
Damage to respiratory tract, respiratory tract damage includes facial Burns, singed nasal hairs, changes in the boys, difficulty breathing, wheezing, coughing, carbon tinged sputum
High level of carboxyhemoglobin in blood (O2 is not being delivered to vital body tissues)
Types of burns :
Epidermis -Red dry skin-
Epidermis and dermis -Blistered moist pink or red skin-
Down to subcutaneous tissue- charring, skin black, brown, red -
Down to muscle and bone - charring skin white to black with networks of thrombosed capillaries
First degree, Superficial
2nd°, partial thickness
3rd°, full thickness
4th°, full thickness
Blood transfusions what solution can be used ?
0.9% normal saline (sodium chloride) can be used with a blood product
Stop if itching rash or fever occur
What how long should a nurse observe client for a transfusion reaction After first starting it?
Vitals are taken before infusion ,15 minutes and every hour while blood is infusing and at completion
Closely observed the client for a transfusion reaction within the initial 15 minutes
And monitor vitals every 15 minutes for 4 hours
Diet for wound healing?
increased amounts of calories, protein, vitamins A and C, and sometimes the mineral zinc.
What can alter wound healing in some one ?
Deficiency in protein, Low HGH, diabetes, rheumatoid arthritis, vascular arterial disease, zinc deficiency, B 12 deficiency, medications such as NSAID’s, corticosteroids, immunosuppressive’s, anticoagulants
MI/heart attack treatment
Depends on the severity
Lifestyle changes, cardiac rehab, medications such as blood thinners, heart meds, beta blockers, Statin, ace inhibitors, stents, bypass surgery
Burns and effect on survival?
?
20 % of Body burn can survive
15% or more with infant or elderly may not survive
Impaired skin/ infection / best action for nurse ?
? ABCs Ask pain level Assist to comfort and elevate extremities Administration of analgesics as ordered
High protein foods, vit A, C, zinc, copper
Snacks between meals
This is the most commonly used test to monitor heparin therapy
1.5-2.5 the normal value
APTT
Who is priority to prevent infections ?
Burn patients and immunosuppressed pts
Burn admit chance of survival ?
If burns are on head, chest, upper back it usually means lung damage.
Location could indicate chance of survival
Most common type of anemia
When body doesn’t have enough iron to synthesize hgb
Diet-
Iron deficiency anemia
High in iron and increase vit c
Bone marrow decreases it stops functioning
Treatment -
Aplastic anemia
Bone marrow transplant
Auto immune disease in which parietal cells are destroyed and the gastric mucosa atrophies
Treatment
Pernicious anemia
Topical anesthetics
Destruction of RBCs , iron and hemoglobin is released
Hemolytic anemia
Genetic disorder has abnormal hemoglobin S rather than hemoglobin A in RBCs
Sickle cell anemia
Factors that affect wound healing
Age Oxygen Smoking Drugs Obesity Diseases
