med surge 1 - Week 1 Key Points
Terms in this set (65)
Teach patients about modifiable (weight, smoking, sex practices and diet) and non-modifiable risk factors (age, genetics E. Interventions
and sex) (Page #7)
What should you do prior to a health teaching?
Conduct a culture assessment
In order to provide an individual care that is evidence based what should you use?
Use the nursing process to provide individualized care that is evidence based (Page #9)
What is the purpose of nursing?
The purpose of nursing is to treat the patients response to illness and use evidence based practices to improve outcomes
Determine how to prioritize the needs of the patient by using Maslows hierarchy of needs (physiological integrity, safety and security, belongingness and affection, esteem and self-respect, self-actualization) and remember that physiologic needs (basic need) and life threatening issues are a priority (Page #5)
Healthy People 2020 identifies health promotion and disease prevention goals and lists strategies along with resources in an attempt to improve the nation's health (Page #6)
What should nurses comply with?
states nurse practice act since it governs nursing practice and is a law that's put in place to protect the public (Page #11)
The quality and safety education for nurses (QSEN) institute seeks to strengthen the knowledge, skills and attitudes of nurses in providing continuous quality improvement in health care (Page #12)
Confirm that physiologic integrity, safety and security, belongingness/affection, esteem/self-respect, and self-actualization are met in that order (Page #5)
the Institute of Medicine's report on the Future of Nursing recommends ways to strengthen the practice of nursing in order to improve health care. (Page #6)
The National Patient Safety Goals lists the top patient safety concerns and includes medication safety, infection prevention, surgery-related mistakes, patient identification and improving staff communication. (Page #9)
What is pain?
Pain is whatever the patient says it is
What is pain associated with?
Pain is associated with actual or potential tissue damage
What is the most reliable indicator for pain?
The most reliable indicator is the patient's self report
What does pain stimulate and what does it cause?
Pain stimulates the sympathetic nervous system and increases BP, HR and Respirations
What can unrelieved pain cause?
increases glucagon production, decreases insulin secretion, depresses immune function, and can lead to addictive behaviors
What does prostaglandin's initiate?
it can initiate inflammation, and can contribute to tissue swelling and pain - page 214
What do NSAIDs primarily do?
produce pain relief by preventing prostaglandin formation
does not have anti-inflammatory properties
What does tissue damage do?
stimulates the inflammatory response and puts the patient at risk for pain
What should you manage nociceptive pain with?
local anesthetics, nonopioids or opioids (Page #215)
What can nerve route injuries lead to?
allodynia (pain that is associated with a nonnoxious stimulus) (Page #218)
What does a comprehensive pain assessment include?
duration (includes when it started), type (incudes intensity, associated factors, influencing factors (what makes it better or worse), location
Visual Analog Scale
is a 10 cm line that represents no pain to worst pain on opposites sides of the line and the individual place a mark somewhere between the two ends depending on the severity of pain (Page #219)
Numeric Rating Scale
ranges from 0 to 10 with 0 representing no pain (Page #219)
The Wong-Baker Faces Scale
(ages 3 and up) consists of cartoon faces that the patient selects to report their pain.
Verbal Discriptor Scale
uses words to help individuals describe the intensity of pain (Page #219)
When should the Wong-Baker Face Scale not be used?
should never be used by the provider to match the patient's facial expression
produce a local effect
produces drug absorption into the systemic circulation
What medication should be avoided for thrombocytopenic patients
Rectal route med administration should be avoided
What could NSAIDS cause?
could result in gastric ulcers or contribute to cardiovascular events (myocardial infarction/stroke)
What could Nsaid's lead to?
acute renal failure in patients with volume depletion or who take it for chronic pain (Page #223)
What is needed for renal blood flow?
What do opioids cause?
constipation, nausea, pupil constriction and respiratory depression
Physical dependence and tolerance are not the same as addiction
neuropathic pain can be treated with........
with adjuvant medications like antidepressants or anticonvulsants
non-pharmacological pain management strategies
such as physical modalities, mind-body methods, biologic and energy based therapies (Page #232)
What does vomiting increase the risk for?
What does diarrhea increase the risk for?
metabolic acidosis (Page #269)
What does calcium help regulate?
muscle contraction and relaxation (Page #258) Think of a baby who is hungry you give them milk (calcium) and then they relax.
What type of diet is needed for hypoparathyroidism?
Provide a diet high in calciium and low in phosporus (Page #260)
What determines osmotic pressure?
Chloride works with Na to determine osmotic pressure (Page #266)
Chloride has an inverse relationship with bicarbonate (if chloride levels drop, bicarbonate is retained and results in hypochloremic metabolic alkalosis) (Page #266)
What happens with changes in electrolytes?
action potentials impair resulting in weakness or excitability
Children have a higher percentage of fluid volume to surface area and small shifts in intravascular volume increases their risk for fluid volume deficit (FVD) (Page #238)
Proteins like albumin create an oncotic pressure which pulls fluid from the interstitial compartment into the intravascular compartment to maintain volume. (Page #239)
D5W becomes a hypotonic solution as the cells absorb the dextrose and should not be given to patients with a head injury (Page #273)
Magnesium has an inverse relationship with Calcium (low Magnesium stimulates parathyroid hormone secretion) (#258)
Magnesium helps with carbohydrate and protein metabolism, affects neuromuscular function and produces vasodilation
Magnesium sulfate is a calcium antagonist and can be given to relax smooth muscle (Page #262)
The antidote for tetany or hypermagnesemia is calcium gluconate (Page #264)
Phosphorous is required for the formation of ATP and helps to maintain the acid-base balance (Page #264)
Potassium is necessary for neuromuscular and cardiovascular function (Page #254)
Potassium is the ion for repolarization (membranes reset). Tall tented t waves occur with hyperkalemia and inverted t waves occur with hypokalemia (Page #255)
Hypokalemia lowers the resting membrane potential and makes cells less irritable which could result in an ileus. (#256)
Potassium sparing diuretics should NEVER be used in the presence of renal injury (Page #258)
Check renal function prior to administering potassium (Page #258)
Hydrogen ions are exchanged for potassium ions during alkalosis or acidosis (i.e. metabolic acidosis results in hyperkalemia as H ions are shifted into the cell to raise the pH and potassium leaves the cell and enters the bloodstream)
Water follows salt so an increase in sodium typically results in an increase in water (Page #238)
Sodium is the primary factor for osmolality and intravascular fluid volume (Page #240)
Clinical manifestations of hyponatremia consist of headaches, seizures, lethargy, tachycardia, decrease in blood pressure, thready pulse, hyperactive bowel sounds and abdominal cramps (Page #246)
What type of changes can result with hyper or hyponatremia?
can result in neurological changes (Page #253)
What should be assessed when a patient has vomiting, diarrhea or suctioning?
Assess patients for electrolyte imbalance
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