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21 terms

Nursing interventions/priorities

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First-level priority problems
Airway problems; breathing problems; cardiac and circulation problems; Signs (vital signs concerns)
Second-level priority problems
Mental status change; Acute pain; acute urinary elimination problems; untreated medical problems requiring immediate attention (e.g. a diabetic who hasn't had insulin); abnormal lab values; risks of infection, safety, or security (for the patient or for others)
Third-level priority problems (later priorities)
health problems that don't fit into the above categories (e.g. problems with lack of knowledge, activity, rest, family coping)
The nursing process is:
Assessing, diagnosing, planning, implementing, and evaluting
Assessing includes
gathering data
diagnosing includes
identifying the problem and formulating a nursing diagnosis
planning includes
writing a care plan to meet the goals
implementing includes
carrying out your written care plan
evaluating includes
collecting objective data to determine the extent that goals were met or not met. Revise the plan, as needed.
Contraindications for NSAIDS (NSAIDS)
Nursing and pregnancy; Serious bleeding; Allergy/Asthma/Angioedema; Impaired renal function; Drug (anticoagulant)
syncope treatment
if the face is red, Raise the Head;
if the face is pale; Raise the Tail
healthy lifestyle modification (DRAINS)
Diet; Reduce weight; Alcohol reduced; Improve circulation (exercise); No other disease; Smoking stopped
Influenza clinical manifestations (Having Flu Symptoms Can Make Moaning Children A Nightmare)
Headache; Fever; Sore throat; Chills; Myalgias; Malaise; Cough; Anorexia; Nasal congestion
jaundice is best assessed in
sclera, nail beds, and mucous membranes
patients with Emphysema should have oxygen rates of
no more than 2 liters per minute because of longstanding hypercapnia--they are used to hypoxic drive
for patients on seizure precautions, what should be present/available?
an airway, O2, suction equipment available, rails padded, bed in low position, IV access in place
what is impetigo
a highly contagious bacterial infection of the skin.
how long are patients contagious with impetigo?
until 48 hours after initiation of antibiotic thera py
What should the nurse avoid in patients with a Wilms tumor?
excessive manipulation of the abdomen that can cause seeding of the tumor
what is the antidote to heparin?
Protamine sulfate
What is the antidote to Coumadin
Vitamin K