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Remar Quick Facts

Terms in this set (270)

How do precautions change w/AIDS?
Pt. has low CD4 & is at risk for infection: -private room - reverse isolation RN wears gown, goggles, mask when direct contact w/ bodily fluids
Causes of acute renal failure
Infection, obstruction, shock
3 phases of Acute Renal Failure
Oliguric, Diuretic, Recovery
During the Oliguric phase what will you see?
Low urine output, hyperkalemia, HTN, elevated BUN/creatinine, fluid overload, elevated Sodium & Potassium
The diuretic phase is 2nd, what will you see?
Urine output slowly returns, hypokalemia, hypotension, BUN/ creatinine decreases but still elevated
What does recovery phase mean?
Kidneys are recovering through a slow process, urine vl & BUN is normal
What are nursing interventions for Acute Renal Failure?
Daily weights, I&O's,treat the cause & diuretics
What is the best diet for a client w/ acute renal failure?
High carb & low protein
What allergy is contraindicated for contrast?
Iodine/Shellfish
What are the major complications of having an amputation performed ?
Infections, skin breakdown, phantom limb pain, joint contractures
What is the positioning for care?
AKA-(above the knee) amputation
Elevate 1st 24hrs then prone position to prevent hip flexion
What is the positioning for care?
BKA-(below the knee) amputation
Elevate foot of bed 1st 24hrs then prone position twice daily to prevent hip flexion
Aneurysm
Dilation formed at a weak point on the wall of an artery
Aneurysm: what sound would be heard on auscultation?
Blowing bruit
What are risk factors for aneurysm?
Arteriosclerosis, infection ( syphillis), smoking, HTN
Signs of a ruptured Aneurysm?
Severe pain, N/V, tachycardia, decreased LOC, hypotension
Aneurysm: client teaching
Avoid straining, lifting, or exerting take, melds on schedule, Report severe back/ flank pain
Appendicitis, commonly seen in what age range?
10-30
Classic sign of appendicitis?
Acute Right Lower Abdominal Pain
S/S of Appendicitis
Loss of appetite, N/V, low grade temp.
In appendicitis , localized tenderness is found in?
McBurney's point
Treatment for Appendicitis
Immediate surgery to remove appendix, IV antibiotics, semi-fowlers position, NPO to rest gut
General treatment for any acute abdominal pain
NPO status, no heat on abdomen, assess abdominal distention, IV fluid therapy
ABG: where are most samples drawn from?
Radial artery in wrist
After ABG sample, how long should pressure be applied to the site?
5 minutes
Which test should be performed before collecting an ABG on a pt.?
Allen's Test
Asthma
An obstructive airway disease caused by spasms and inflammation of the bronchioles.
Signs of Asthma
SOB, tachycardia, expiratory wheezes, cough
Primary treatment goal of asthma
Identify the allergen
Asthma: What medications work best for treatment
Anti-inflammatory
Corticosteroids
Bronchodilators
Leukotriene modifiers
Metered dose inhalers
Tx-Asthma: What should you give first?
Steroid or Bronchodilator
Bronchodilator
What are Leukotriene modifiers?
Drugs used to block the chemical Leukotriene reduces inflammatory
Ex. Montelukast (Singulair)
Autonomic Dysreflexia occurs in clients w/ what kind of injury?
Spinal cord injury ( T-5 or above)
Why is autonomic dysreflexia so serious?
Life threatening due to clients becoming extremely hypertensive
Signs of autonomic dysreflexia
Increase in BP 40mm Hg, headache, bradycardia,
Blurred vision, sweating
Autonomic dysreflexia: what should be done during an episode?
Place client in High-Fowlers, Check for bladder distention, Loosen restrictive clothing
Autonomic dysreflexia: Treatment
Removal of the stimuli, Pt. needs to void/ bowel movement
Bell's Palsy affects which cranial nerve?
Cranial nerve #7
What does the client with Bells Palsy suffer from?
Temporary facial paralysis that affects chewing, eating, and closing their eyes
Treatment for Bell's Palsy
Wear eye patch @ night
Use artificial tears
Wear glasses to protect eyes
*steroids to reduce edema
Benign Prostatic Hyperplasia (BPH)
Enlargement of the prostate gland
Cause unknown
Because the prostate blocks the urethra opening clients will feel and see what when they urinate?
Straining to urinate
Decreased stream
Feeling like they have to go all the time
Dribbling
Who gets BPH?
Men usually >50
What is the best way to assess for BPH?
Rectal exam, will feel pea sized nodule
What is the common surgical treatment for BPH?
Transurethral resection of the Prostate (TURP)
How is transurethral resection of the prostate (TURP) performed?
Scope goes through the penis and removes parts of the prostate
After a TURP procedure what is client at risk for?
Bleeding; monitor for hemorrhage
Before a TURP, what will all clients get?
3way (lumen) Foley catheter
What are the three lumens for in a 3way lumen Foley catheter?
Inflating the ballon, inflow of solution, outflow of urine
What will the Dr. order to be done afte a TURP?
Continuous bladder irrigation (CBI)
What is the goal of the bladder irrigation? ( after a TURP )
Reduce/prevent blood clot formation
What type of fluid is used to irrigate the bladder?
Isotonic sterile saline
After a TURP , what do you want the urine to be?
Light pink
During a continuous bladder irrigation, what must the client be monitored for?
Bladder distention
Fluid overload/ hyponatremia
Blood loss
After a TURP, if bladder spasms occur give...
B&O suppositories or Ditropan
Best position for a pt. receiving a TURP, post-op?
Lying flat, sitting up puts pressure on the bladder
Discharge instructions after TURP
Drinking 2-3L of fluids daily
No lifting or straining
If bright red clots call MD
Do kegel exercises
What must be received before a transfusion is started?
Written consent
What is the most common infection spread through blood transfusion?
Hepatitis B
In order to determine donor compatibility what must be done?
Type and cross match
What must be done to determine clients baseline before starting the transfusion?
Vital Signs
For blood administration, what size IV is needed?
18G w/ filter needle
How many nurses confirm the unit of blood?
Two
How long after blood is removed from the banks refrigerator do you have to start it?
30 minutes
How long must you stay with the client after transfusion is started?
15 minutes
How many milliliters are in one unit of packed red blood cells
About 250 mL
Blood Administration:
What are the signs of an adverse reaction?
Restlessness, nausea, hives,
SOB ,fever, chills, back pain
Blood administration:
What do you do if an adverse reaction occurs?
Stop blood and run the normal saline that hangs with blood.
Take vitals notify the physician and blood bank
make sure urine and blood cultures are done
Why must you run blood at a slow rate?
Because running blood fast can cause fluid overload
What drug is also used to treat anemia because it increases red blood cell production?
Epogen (epoetin alfa)
Clients taking Epogen should be monitored for?
Hypertension & seizures
What are the risk factors for hypertension?
African American, obesity, anxiety
diabetes, smoking
What are the physical signs of hypertension?
Blurry vision, Headache, Chest pain
(but think that hypertension is called a silent killer because most people don't have symptoms)
How can the size of the blood pressure cuff affect the blood pressure reading?
If it is too small the blood pressure will be higher than it really is
if the blood pressure cuff is too big then the blood pressure will be lower than it actually is
What are some other factors that alter blood pressure?
Wrong size cuff or position, caffeine,anxiety, activity
Before you give a blood-pressure medication always check?
Blood pressure & pulse rate
Hold the medication if systolic blood pressure is less than ______
heart rate is less than_______
100, 60
What classes of medications are used for hypertension?
Diuretics, Beta Blockers, Calcium channel blockers, Vasodilators
Medications that end in '-pril'
Ace inhibitors
How do Ace Inhibitors correct heart failure?
Decrease after load
Promote vasodilation by inhibiting the production of angiotensin
___________ is an adverse reaction seen with the use of Ace inhibitors
Angioedema
Signs of Angioedema
Swelling of the lips and mouth
Ace Inhibitors
Clients may also have a persistent nagging ________.
Cough
Medications that end in " LOL"
Beta Blockers
What herbal medication is used to lower BP?
Garlic
What is the best diet for a hypertensive client?
Low-sodium low fat,
Abdominal cramps while breast-feeding is due to the release of?
Prolactin & Oxytocin
Buerger's disease (Thromboangiitis Obliterans)
Disease is obstruction of blood vessels mainly where ?
Hands & Feet
Buerger's Disease
Clients presents w/ what symptoms?
Pale, blue, cold hands and feet. May tingle or be painful
Who is most at risk for Buergers disease?
Males who smoke or chew tobacco
What are treatment goals for Buergers disease
No cure
Teach to stop smoking, dress for weather , reduce life stressors
What are two age groups most at risk to suffer a burn injury?
Children and elderly
What are the four types of burns?
Chemical, electrical, thermal, radiation
If the face or neck has been burned what is the nursing priority?
Airway obstruction
Burns: what is the best route for pain meds?
IV
What diet is appropriate for burn clients?
High calorie high-protein
What is a common electrolyte problem in clients with burns?
Hypokalemia ; potassium released due to cell destruction
Burns:
What should you give before a dressing changes?
Pain medication
When the cancer cell travels from that you original location to a new place it is called?
Metastasis
What acronym is used to describe the warning signs of cancer?
C.A.U.T.I.O.N.
What does C.A.U.T.I.O.N. stand for?
Change in bowel or bladder
Any sore that does not heal
Unusual bleeding/ discharge
Thickening in breast
Indigestion
Obvious change in wart
Nagging cough or hoarseness
What are two ways to describe a tumor?
By grading or staging
What is the difference between grading and staging
Grading describes a tumor by the cells
Staging describes the progression of a tumor by the clinical symptoms
What are the three types of radiation treatment?
-External
-unsealed internal
-sealed internal
What precautions must be taken for client receiving radiation treatment?
Private room/ bathroom
Limit visitors
rotate nursing staff who provide care
Place sign at door and bedside
What is the most dangerous type of radiation?
Sealed internal radiation
because solid radio active implant is placed inside the tumor
What additional precautions must be done for clients receiving sealed internal radiation?
All body fluids are radioactive; use hazardous cleanup,
wear gloves and gown
If a client sealed internal implant falls out what should you do?
Pick up with long handle
put in lead container
Chemotherapy works by destroying cell __________.
Wall
What are the side effects of chemotherapy?
Nausea, anorexia, alopecia, sterility,
decreased bone marrow and platelets
Why is Reglan (metocloperamide) given?
To reduce nausea
Is the alopecia from chemo permanent?
No, temporary
Is the sterility from chemo permanent ?
Yes
Clients with cancer will also need ___________.
Neutropenic precautions
What are Neutropenic precautions?
Strict hand washing
No visitors who are sick
No children
No raw food, no live plants
No free standing water
What is Neupogen (filgrastim)?
Drug used to treat neutropenia; monitor WBCs
If a client has had a mastectomy, can you do a blood pressure on the affected side?
No IV or BP on affected side
Post mastectomy patient education
Elevate affected extremity
No initial exercise
Encourage discussion of positive self image
What are signs of cataracts?
Milky/ white lens painless, blurred vision
How are cataracts treated?
No treatment until vision is severely impaired
During cataract surgery what is done?
The cataracts are removed, a new lens may be implanted
After surgery will vision be corrected?
Only if a new lens is placed, if no new lens then client will need glasses
After cataract surgery what is main concern?
Check for hemorrhage of the eye. Semi-Fowlers position
Cataracts: what do you tell clients to avoid
Coughing sneezing bending over at the waist straining rubbing Eye no lifting greater than 5 pounds
Cataracts: how should the post up quiet sleep
Sleep on unaffected side or if surgery on both eyes sleep sleep on back. Use eye shield at night
In Celiacs disease malabsorption of ________occurs?
Fats
Celiacs disease:
Foods containing ________ must not be eaten.
Gluten
What foods contain gluten?
B.R.O.W.
( barley, rye, oats, wheat)
Celiacs disease: what does the clients abdomen feel like?
Distended
Celiacs disease: what does the clients stool look like?
Smelly, pale, bulky expect lots of gas w/some diarrhea
Define the term CVA
Cerebrovascular accident;
Reduction of cerebral blood flow and oxygen causing brain cell damage
Three most common causes of CVA are _______?
Embolism, Hemorrhage, Thrombus
What is the difference between CVA and Transient Ischemic Attack (TIA)?
TIA is a temporary period Neurological deficit. It has similar signs of a CVA but the symptoms will all resolve.
What is agnosia?
Inability to use an object correctly
Expressive aphasia occurs when _________?
Client cannot communicate properly. Can be expressive or receptive
CVA: remember to place clients belongings on the ____________ side.
Unaffected
CVA: What are the nursing assessments?
Monitor vital signs, neurochecks , watch for seizures, monitor for increased in intracranial pressure, check ability to swallow
What complication of the eyes can a client with CVA have?
Corneal abrasions b/c lacrimal glands will not produce secretions.
What is the activity level for this CVA client?
Strict bed rest
How do you position the CVA client?
Turn q 2hrs on unaffected side, 20 mins on affected side, make sure to elevate affected extremities
Why would a thrombolytic be given to the CVA client?
To dissolve clots
Do not give thrombolytic sir the cause is ___________?
Hemorrhage
What other medications may be prescribed to treat a CVA?
Anti-hypertensive, Anti-coagulants(not for hemorrhage), Anti-convulsants
Do anti-coagulants like Coumadin and aspirin dissolve clots?
NO. They only thin the blood not dissolve clots.
What are the 3 disorders that make up COPD?
Asthma, Brochitis, Emphysema
What are the S/S of COPD?
SOB w/activity, wheezing, productive cough, cyanosis
What would the ABG of a client w/ COPD show?
Hypoxemia
What does the chest of a COPD client look like?
Barrel chest
What would the fingers of a client with COPD look like?
Clubbed
Due to SOB w/activity clients may experience _____ _________ because of difficulty eating?
Weight loss
Why must you assess the amount of O2 to your COPD client receives?
COPD'ers keep a high level of CO2 in their blood
A client with with COPD should not receive O2by nasal cannula greater than _________.
2 LPM
To control SOB the _________ ________ __________________ technique should be taught.
Pursed lip breathing
Chronic renal failure is progressive and irreversible.
True or False
True
What are possible causes of chronic renal failure?
Hypertension, Diabetes Mellitus II, frequent infections, renal or urinary obstructions
S/S of chronic renal failure
Decreased urine output, hypertension, decreased urine specific gravity, fluid overload
What is uremic frost?
Urea crystals that come through the skin with perspiration
Where would you see uremic frost?
Face, underarms, groin; teach client to wash skin with plain water
What are the nursing interventions for chronic renal failure?
Modification of diet
Give diuretics, anti-hypertensives, monitor BUN and creatinine, daily weights
Clients may need ___________ to assist with wast removal.
Dialysis
What is the best diet for chronic renal failure?
High carb, low protein.
Goal of this diet is to provide energy while decreasing protein metabolism
Prochlorperazine , belongs to which class of antipsychotics?
Phenothiazines
Prochlorperazine:
This drug in smaller doses can be used as an antiemetic, which means it suppresses _________ and ___________.
Nausea & Vomiting
Prochlorperazine:
It will make you ________ so avoid driving and operating heavy machinery.
Drowsy
Prochlorperazine:
The routes of administration are IV,IM, PO Which route lasts the longest?
IM (decorate form)
Prochlorperazine:
As with all anti-psychotic drugs clients must be monitored for __________ reactions.
Extra-pyramidal
What are extra- pyramidal reactions?
Dystonia, tardive dyskinesia, akathisia.
What class of medications can be given to decrease extra- pyramidal reactions?
Anti-Parkinson's
ex. Benzotropine
What herbal medication is contraindicated with prochlorperazine?
Kava Kava
Most corticosteroids end in _____.
-ONE
What are some examples of corticosteroids?
Dexamethasone, Cortisone, Prednisone
What are the primary functions of of corticosteroids?
To decrease inflammation and hormone replacement
What should you teach clients about stopping corticosteroids therapy?
To gradually decrease use; don't stop abruptly
What must be monitored while client is taking corticosteroids?
Potassium level, glucose level, and I&Os
Corticosteroids may cause symptoms of _____________ syndrome.
Cushing's
Corticosteroids will also delay __________ healing.
Wound
If the client is NPO for surgery should you still give the steroids?
Yes , during surgery , stress and illness in the body increases the needs for corticosteroids. In all other situations do not take steroids on an empty stomach.
Crohn's disease is an ______________ of the bowels.
Inflammation
Can Crohn's disease be cured w/ surgery ?
No, symptoms frequently reoccur
Crohn's disease affects the digestive tract from the mouth to the anus?
True or False
True
S/S of Crohn's disease
Abdominal pain, diarrhea, weight loss
Excessive diarrhea will cause what electrolyte imbalance?
Hypokalemia
Crohn's disease:
What foods should be avoided and why?
Dairy products and high fiber meals, which may worsen the diarrhea
Crohn's disease can lead to what kind of cancer?
Colon
Crohn's disease:
What are the treatment goals?
Drugs and Nutrition to reduce inflammation
In cystic fibrosis the ____________ _______________ or exocrine glands are affected.
Mucous producing
How does cystic fibrosis change mucous secretions abnormally?
Mucous glands become thick and sticky which causes obstructions in the body
What are the two systems most affected by cystic fibrosis?
RESPIRATORY: mucous gets trapped in the lungs
DIGESTIVE: mucous blocks the pancreas and digestive enzymes making absorbing nutrients very difficult
What is the most accurate test for cystic fibrosis?
Sweat test- the chloride level will be > 60 mEq/L
What are other ways to diagnose cystic fibrosis?
Chest x-Ray, stool analysis, pulmonary function tests
How does poor absorption of fat in the digestive change the appearance of stool?
Steatorrhea
(Greasy, foul smelling, pale)
______________ ________________ are given with each meal to help with absorption of nutrients in clients with cystic fibrosis
Pancreatic enzymes
What is the most appropriate diet with cystic fibrosis ?
High calorie high protein
______________ ___________________ is a common technique used to clear thick mucous from the lungs. This is important to prevent respiratory infections.
Postural drainage
What should parents who already have a child's with cystic fibrosis do before having another child?
They should get genetic counseling because cystic fibrosis is hereditary
Which type of diabetes is mostly controlled by diet and exercise?
Type 2 diabetes Mellitus
Which type of diabetes will be controlled mostly by insulin?
Type 1 diabetes Mellitus
What should you teach diabetics about footcare?
Have MD cut toe nails, cut toe nails straight across, inspe feet daily for sores, keep skin clean and dry
If a diabetic vomits after taking PO insulin what should they do?
Monitor blood glucose, do NOT repeat dose
How often should a diabetic get an eye exam?
Yearly; diabetes can cause retinopathy
What is insulin lipodystrophy?
It is the fault of not rotating SQ insulin injection sites. Fatty masses will appear decreasing insulin absorption in that area. Teach injection site rotation.
Do you need to aspirated if injecting insulin SQ?
No
Exubera is an ________ insulin.
Inhaled
Exercising __________ blood glucose.
Lowers
Alcohol, oral contraceptives, aspirin, MAOI ___________ blood glucose.
Lowers
Infection, dehydration, stress, surgery ___________ blood glucose
Raise
What do you give whenever you client is hypoglycemic and unconscious?
Glucagon (IV or IM)
Why is digoxin prescribed?
To treat heart failure and arrhythmias
Digoxin is a __________ _________.
Cardiac glycoside
Always hold digoxin if heart rate sis less than______.
60
What is the therapeutic range for digoxin?
1-2
Greater than 2 = toxic
What are the signs of digoxin toxicity?
Seeing yellow spots, nausea, vomiting, abdominal pain
How is digoxin toxicity treated?
Dose will be lowered; in severe cases give activated charcoal or Digiband.
What are the three ways a diuretic can be given?
PO, IV, IM
Why are diuretics prescribed?
Chronic heart failure, fluid overload, renal failure
When should clients take diuretics?
In the AM
Why should clients take diuretics in the AM?
If take in the evening clients will be going to the bathroom all night
Diuretics:
What should clients be monitored for?
Dehydration, low potassium, hyponatremia, weight changes
Loop and thiazide diuretics inhibit what electrolytes?
Potassium, sodium, chloride
Furosemide (Lasix) is a ________ diuretic.
Loop
Thiazide diuretics are contraindicated in clients allergic to ?
Sulfa drugs
_____________ is an osmotic diuretic used to reduce ICP.
Mannitol (Osmitrol)
Because Mannitol decreases ICP it can also be used to treat _________.
Glaucoma
Mannitol crystallizes at room temperature, you will need a __________ needle to draw it up.
Filter
Spironolactone (Aldactone) is a ___________ sparing diuretic.
Potassium
Because Spironolactone helps the body retain potassium the client is at risk for?
Hyperkalemia
If your client's K+ is 3.0 and Lasix and Spironolactone are both ordered, how would you proceed?
Only give the Spironolactone, the potassium is low and the Lasix will only create more K+ loss
In order to accurately measure urine output a patient may be given a ___________ ___________.
Indwelling (foley) catheter
What is the epiglottis and what does it do?
It is a lap of skin that is at the base of the tongue
it opens and closes during breathing
What is the cause of epiglottis?
Haemophilus influenza ( bacteria)
What is the usual age of children who get epiglottis?
2-5 years old
What are the signs of epiglottis?
3D's DROOLING, DYSPHAGIA, DYSPHONIA( no voice)
What will the child look like during an episode of of epiglottis ?
Sitting upright, tongue protruding drooling, shallow rapid breathing
Can epiglottis be treated home?
No child must go to hospital immediately
When assessing the airway, can you use a tongue depressor or tongue blade?
No never put anything in the mouth to assess
If child cannot breathe what might be done?
Intubation
What medication will be given to treat epiglottis?
Antibiotic therapy
How can epiglottis be avoided?
By getting the H. Influenzae vaccine
What is the treatment for genital herpes?
Acycovir
Genital Herpes:
If lesions are present in a pregnant woman how would you deliver the baby's?
C-section
What is the vision like with glaucoma?
Blurry, tunnel vision, halos around light
This condition can be chronic or acute due to
Increased intraocular pressure
____________ is the most simple painless procedure used to measure intraocular pressure.
Tonometry
What are the two types of glaucoma?
Open angle or closed angle
Which type of glaucoma is painful?
Closed angle is painful and most common
Give this class of drug to constrict the pupil and let aqueous humor flow?
Miotics
Give an example of a miotic
Timoptic or pilocarpine
Why might diuretics be given to clients with glaucoma?
To decrease aqueous humor production
What diuretic is usually prescribed with glaucoma?
Mannitol because it is an osmotic diuretic
Never give ________ because they dilate the pupil. (Glaucoma)
Mydriatics
If surgery is required, what should you monitor for? ( glaucoma)
Hemorrhage
What post-op teaching should be done ?( glaucoma)
No straining , lifting, crying or rubbing eyes
Tetanus and diphtheria are optional vaccinations, what is the earliest age they may be given?
2 months old
What is a booster shot?
An additional dose of vaccination , increases effectiveness
What are the side effects of immunizations?
Low grade fever, tenderness, swelling at the site, child may be irritable
What medication should be given for side effects of immunizations?
Tylenol ( Acetaminophen)
Never give _________ for children experiencing side effects of immunizations.
Aspirin
If an older woman receives an MMR shot what should you teach her?
Wait 3 months before pregnancy
How soon can a child get the influenza vaccination?
Not until 6 months
Do not give MMR if client is allergic to _________ or ____________.
Eggs or neomycin
Do not give the influenza vaccination if the client is allergic to ________.
Eggs
Incentive spirometers is a method of ________ ______ which helps maximin lung inflation.
Deep breathing
Incentive spirometry:
Instruct the client to place ______ tightly around mouth piece.
Lips
Incentive spirometry is used after surgery to prevent __________.
Atelectasis
What is the normal intracranial pressure range?
5-15 mm Hg
What are the common causes of ICP?
Trauma, hemorrhage, edema, tumors
ICP:
Assess _________ ___________ ___________.
Level of conscious, it'll decreases as ICP decreases
Earliest sign of ICP?
Decreased level of consciousness
What are the signs of epiglottis?
...
Why would a thrombolytic be given to the CVA client?
...
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