VN 15 TEST 5 Study Guide- DONE Flashcards
- Manifestations for hypovolemia? (ch.16 pp & Ati pg.355)
-tachycardia
-thready pulse
-hypotension
-dry mucous membranes
-tachypnea
-no change in lung sounds
1b. Nursing Actions for hypovolemia(ch.16pp slide 8)
-treating the cause of hypovolemia
-increase oral intake
-administer IV fluid replacements
-controlling fluid losses
-using combination of these measures
1c.Priorities for hypovolemia(ATI pg. 356)
-monitor vital signs
-administer supplemental oxygen as prescribed
-provide oral & IV rehydration therapy as prescribed
-check neurologic status to determine level of consciousness
-monitor I&O’s
-check urinalysis, CBC & electrolytes
-measure cleint’s weight daily at the same time of day w/same scale.
- When would the following solutions be used? (pg.311)
a. Colloid
-are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments.
Ex: blood, blood products like albumin and solutions known as plasma expanders.
-blood transfussion
-bleeding/hemorrage (stabbing,gunshot wound)
2.When would the following solutions be used?
b. crystalloid
-most common solution (salt,sugar)
-are classified as isotonic, hypotonic, hypertonic
-fluid resuscitation in the prescence of hypovolemia,sepsis and dehydration
2.When would the following solutions be used? (pg.311 & ch.16 pp slide12)
c. isotonic
-administered to maintain fluid blance in clients who may not be able to eat or drink for a short period.
-hypotension
-hemorrage
-calories
-increase fluid volume
- When would the following solutions be used?
d. hypotonic(pg.311)
“CELLS SWELL”
Administered to clients w/fluid losses in excess of fluid intake such as those who have:
-diarrhea
-vomitting
-hypernatremia (high sodium concentration in the blood)
4.Understand the three phases of the nurse-client relationship and be able to identify examples. (Pg.93)
-introductory phase(period of getting acquainted) : after initial formalities client initiates the relationship by identifying one or more health problems for which they are seeking help.
-working phase(period which tasks are performed) : mutually planning the clients care & implementing the plan. Both the nurse & client participate. Nurse avoids impeding the client’s independece(doing too much for the client is as harmful as doing too little)
-terminating phase(period when relationship comes to end) :occurs when the client & the nurse agree that the client’s immediate health problems have improved.
5.Understand and identify examples of the following therapeutic communication techniques
provided in your Brightspace handout
-giving broad openings: “what would you like to discuss?” “Is there anything you’d like to talk about?”
-exploring: “how many times have you been in the hospital?” “Tell me more about that”
-accepting: nodding the head “uh huh” “i follow what you are saying” “yes”
-offering general leads: “and then.” “Really.” “Go on.” “Oh.”
-giving recognition: “Good morning mrs.jones” “i noticed you combed your hair.” “You walked in the hallway today.”
-giving information: “i am a student from SJVC” “im going to be caring for you today” “my name is..”
-seeking clarification: “help me understand this” “what did you mean when you said?”
-verbalizing the implied: “it sounds like”
-using silence: allow silence for client to respond or continue converstation
-offering self: “ill accompanyyou to x-ray”
-making observation: “you look very sad today.” “You appear very happy”
-placing the event in time or sequence: “when did this happen?” “Was this before or after”
-encouraging comparison: “was it something like..?” “has anything similar happened to you?”
-reflecting: directs questions, concerns or feelings back to the patient, encouraging patient to accept their ideas & feelings.
-restating: the main idea of whatthe patient says is repeated.
-summarizing: brings up the important points of the discussion. “weve discussed some of your concerns about placing your mother in a nursing home…?”
6.Understand and identify non-therapeutic techniques: see slide 8 in PP
-giving advice: “if i were you, I wouldnt..”
-minimizing or discounting feelings: “dont worry im surethings will work out for you”
-deflecting: “my whole family hates me” nurse “im sure your family doesnt hate you”
-interrogating “why”
-sparring: going back and fourth, being argumentative w/the client.
7.Review key points in the Muslim and Asian culture (from presentations)
Muslim:
- after death pt. should be turned west or towards Mecca
-be mindful of different times they need to do prayer
-once pt dies they shouldnt be touched by someone who is not muslim.
Asian:
-value body language
-dont necessary like eye contact or touch
-like a hand length of space prefer soft touches, no firm handshake.
-respectful of healthcare professionals, wont reject advice from healthcare proffessionals
-open ended questions are good for getting info
-ask for permission to touch above the head, knees & hip
-involve family when talking about plan of care
-always use mr.(last name)/mrs.
-speak to the point, dont blabber
-hot foods treat a cold, cold foods treat a fever
-won’t self express emotions (won’t say they’re in pain when they really are)
8.What are nursing considerations when monitoring TPN via infusion pump? (Pg.318 & 323, pp slide 22)
-weigh client daily
-use tubing that contains a filter
-tape all connections in the tubing & central catheter
-clamp the central catheter & have client bear down whenever seperating the tubing from its catheter connection.
-replace TPN tubing daily(replace solution & tubing at the same time.)
-infuse intial TPN solution gradually(25-50mL/hr)
-inspect IV site for infiltration or phlebitis
-change dressing over site every 24-72hrs
-monitor I&O’s
-Monitor capillary blood glucose levels (at risk for hyperglycemia)
-wean the client from TPN gradually
-if there is a reaction to TPN it would be 2-5 hrs after it would include fever, nausea & vomitting.
-gravity doesnt matter when on TPN infusion pump
3a. Understand manifestations of hypervolemia(ch.16 pp slide7)
*higher-than-normal volume of water in the intravascular fluid compartment
-bounding pulse
-hypertension
-moist mucus membranes
-crackles in the lungs
-pitting edema
3b.Nursing actions for hypervolemia(ch.16 pp slide9)
-discontinuing IV fluid infusions or reducing the infusing volume
-administering drugs that promote urine elimination
-reducing salt consumption
-using a combination of above interventions
3c. Nursing priorities for hypervolemia(pg.309)
-Treating the disorder contributing to the increased fluid volume
-Restricting or limiting oral fluids
-Reducing salt consumption (mrs dash, canned soups, dairy products like cheese, salted snacks ect.)
