Unit 11 Flashcards
Describe nursing actions for a client who had a total mastectomy with lymph node dissection
Monitor for drainage
Don’t use arm
Take VS
HOB at 30 degrees, affected arm on pillow to elevate
Mediation and repositioning until pain stops
Notice risk factors that place individuals at risk for thermoregulation and cellular regulation problems.
Cognitive impairment
Malnourishment
Traumatic brain injury
Genetics
Environmental exposures
Diabetes
Heart failure
Recognize when an individual has problems with thermoregulation and signs of cellular regulation problems.
Hypo: cool, pale skin; shivering; sluggish thoughts; dysrhythmias
Hyper: seizurers; confusion
What are the consequences of impaired thermoregulation
Hypo: vasoconstricts and then dilates at the end (burst of warmth)
Hyper: low BP, high HR, dehydration, low perfusion, organ necrosis
Discuss risk factors for breast cancer
High economic status (kids later in life, more alcohol)
Age (>65)
Family history
Breast density
Hormone replacement therapy
Lack of physical activity
Jewism heritage
What can clients do to decrease colon cancer risk?
Decrease smoking and alcohol use
Decrease fat, low-fiber, and refined carb foods
Get tested regularly for FAP and lymph syndrome
Discuss those at risk for heat-related illnesses.
Geographic location
Exercising
Age
Occupation
Burn victims
Drug users
Compare and contrast fever vs hyperthermia.
Fever: 101, response to infection
Hyperthermia: 104 degree, body response to change in environment when natural cooling mechanisms aren’t enough
WHEN SHOULD ANTIPYRETICS BE USED?
Only in a fever
Recognize cues of hyperthermia.
Elevated body temp
Hot/dry skin
Mental status changes
Low BP, tachycardia, and increased RR
Abnormal clotting
Decreased renal function
Pulmonary edema
Crackles
Electrolyte imbalance (hyperkalemia)
Little to none urine output
Discuss interventions for hyperthermia.
Administer 15L on NRB
Watch output throught a catheter
Monitor VS every 15 min
Renal tremp every 15 min
Cooling interventions
What is normal creatinine values?
0.6-1.2
What is a normal urine gravity? What do the values mean?
1.005-1.030 (lower is dilute and higher is dehydrated)
What is key for breast cancer?
Prevention
Discuss ostomy care, including when to empty the ostomy bag
Assess skin
Empty when 1/3-1/2 full
Educate patient and family about care
Assess stoma (red, beefy, moist)
Increase fluids
Monitor for bleeding
Describe the risk factors for BPH.
Male
Age
Race (blacks and hispanic)
Family hx
Diet
Coffee and caffeine
Smoking/alcohol
Diet (high fat, protein and carb; low fiber)
Discuss the non-surgical management of BPH
Avoid drinking large amounts at a singular time
Limit caffiene and alcohol
Avoid urinary retention
Give doxazosin, finasteride
Frequent sexual activity
Discuss the surgical management of BPH.
TURP
Dissuss management of continuous bladder irrgation after a TURP
Maintain the flow to keep urine clear, use a 3-way catheter
Discuss methods for early detection of breast cancer.
mammography, ultracsound, MRI
Self-examnation
Clinical breaet examination
When should a patient get screening for breast cancer
If a family member has been diagnose, start going at 10 yrs earlier than the ag eewhen diagnosed
What is the only way to definitively diagnose breast cancer?
breast biopsy
Discuss management of breast cancer and nursing interventions for the client postoperatively.
Hormone therapy
Radiation/chemo
Surgeries
Complementary and integrative therapy (prayer, vitamins, aromatherapy)
Doxorubucin (given to reduce reoccurance of breast cancer
Discuss the risk factors for colon cancer.
DIET (high fat, low fiber)
Age
Family hx
Smoking, alcohol
physical inactivity
African-American
crohns
Familial adenomatous polypoosis (FAP)
Recognize cues of of colon cancer.
changes in bowel elimination (blood present, change in consistency)
Abdominal pain
Abnormal fullness
Fatigue
Unintentional weight loss
ANEMIA, RECTAL BLEEDING, AND CHAGNE IN STOOL CONSISTENCY OR SHAPE
Describe the management of colon cancer.
Radiation therapy for regional control
Chemotherapy for stage 2 or 3
Bevacizumab (drug blocks blood from reaching tumor, limiting growth)
Surgical removement of tumor
What is the consitency of stool depending on placement of ostomy bag?
Ascending = liquid
Trans = pasty
Descending/sig = formed
What should you do for abnormal clotting with TURP?
get vitals, irrigate the cath, notify provider
What should you do for TURP syndrome?
Notify provider, decrease irrrigation
How do you calculate output for a 3 way cath?
Output (incath) - irrigation fluid used = true output
