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Terms in this set (59)
What is the range of potassium?
What are the clinical manifestations of hypokalemia?
Fatigue, dysrhythmias, muscle weakness (leg cramps/paresthesia, glucose intolerance, decreased muscle strength, cardiac output, polyuria/altered renal function.
What are the clinical manifestations of hyperkalemia?
Cardiac changes, dysrhythmias, possible cardiac arrest, potential respiratory impairment, muscle weakness, paresthesia, tremors, twitching, anxiety, GI manifestations
What is the range of sodium?
What are the clinical manifestations of hyponatremia?
Poor skin turgor, dry mucosa, headache, decreased salivation and BP, nausea, abdominal cramping, neuro changes, muscle weakness.
What are the clinical manifestations of hypernatremia?
Thirst, elevated temperature, dry and swollen tongue, sticky mucosa, neuro symptoms, restlessness, weakness, seizures or coma.
What is the range of calcium?
What is the clinical manifestation of hypocalcemia?
Tetany (spasms), circumoral numbness, paresthesia, hyperactive DTR's, Troussau's sign, Chvostek's sign, seizures, respiratory symptoms, dyspnea
What is the clinical manifestations of hypercalemia?
Anorexia, Constipation, Abdominal/bone pain, excessive urination, severe thirst, confusion, impaired memory, slurred speech, lethargy, acute psychotic behavior or coma.
What is the range of magnesium?
What are the clinical manifestations of hypomagnesemia?
Mood changes, neuromuscular irritability, muscle weakness, tremors, EKG changes, dysrhythmias, HTN, tachycardia, positive babinski, chovostek and trousseau
What are the clinical manifestations of hypermagnesemia?
Flushing, decrease BP, diminished DTRs, Drowsiness, muscle weakness, depressed respirations, EKG changes, dysrhythmias, coma/cardiac arrest
What is the trade name of lisinopril?
Prinivill, Qbrelis, Zestril
What is the classification of medication lisinopril?
What is the action of drug of lisinopril?
Angiotensin-converting enzyme (ACE) inhibitors block the conversion of angiotensin I to the vasoconstrictor angiotensin II, ACE inhibitors also prevent the degradation of bradykinin and other vasodilatory prostaglandins. ACE inhibitors also increase plasma renin levels and lower aldosterone levels. Net results is systemic vasodilation.
What are the contraindications of lisinopril?
Hypersensitivity, history of angioedema with previous use of ACE inhibitors, and concurrent use with aliskiren in patient with diabetes or moderate to several renal impairment.
What are the toxic/side effects of lisinopril?
Dizziness, cough, hypotension, and angioedema
What are the nursing interventions of lisinopril?
monitor BP and pulse frequently during initial dose adjustment and periodically during therapy. Notify health care professional of significant changes. Monitor frequency of prescriptions to determine compliance. Assess patient for signs of angioedema.
What are the safe dosage of lisinopril?
10 mg once daily, can be increased up to 20-40 mg/day (initial therapy at 5 mg/day in patients receiving diuretics).
What do you do prior to all procedures?
Handwashing, check MD orders, check allergies, gather equipment, identify client, check client's ID band, assess client and explain procedure to client.
What is the first nursing task you do for a post op client?
Auscultates breath sounds observing for the development of atelectasis.
What do you do after auscultating a post op client?
monitor vital signs, including temperature, pulse, blood pressure, oxygen saturation, pain level
What do you do after monitoring vitals with a post op client?
Assists/instructs in coughing and deep breathing exercises with splinting techniques
What is the fourth step in helping with a post op client?
Observe for the development of fluid volume imbalance
What do you do after observing for fluid volume imbalance with a post op client?
Assists/instructs in ankle circles and calf pumps
What is the sixth step in caring for a post op client?
Assists with early ambulation. Assists client in getting out of bed (OOB), protecting incision and IV site.
What happens after the sixth step of caring with a post op client?
Reinforces surgical dressing. Changes dressing using sterile technique as ordered
What do you do after assisting with early ambulation?
Reinforcing surgical dressing. Changes dressing using sterile technique as ordered.
What is the eighth step in caring in post op client?
observe for incisional line complications (dehiscence, evisceration)
What does a nurse do after observing an incisional line complication in a post op patient?
Secure tubing/drains to client's down to prevent dislodgement
What is the 10th step in caring for post op patient?
Auscultates for the return of bowel sounds. Progresses diet from clear liquids when bowel sounds return and within physician orders.
What is the 11th step in caring for post op patient?
Maintains patency of urinary catheter; once discontinues, observes for development of urinary retention and urinary tract infection
What is the 12th step in caring for a post op client?
Assures client comfort at all times and proper positioning/alignment
What is the 13th step in caring for a post op client?
Listens to feelings and concerns
What is the last step in caring for a post op client?
provides discharge instruction on activity restrictions, diet, incisional care, and signs and symptoms of infection.
What does a nurse do at the end of the procedure?
Dispose of equipment appropriately and document
What does the first thing a nurse does with a TPN patient?
Verify TPN components with current physician orders (new orders required daily) and medical administration record (MAR)
What does a nurse do after verifying the TPN components?
Correlate dosage change with serum lab values and client assessment.
What does the nurse do after correlating dosage change?
Inspect TPN/Lipid solution. If TPN/Lipid solution is unavailable, hand D10 and notify pharmacy (hypoglycemia may result from abruptly stopping TPN)
After inspecting the solution, what do you do to the solution?
Warm solution to room temperature prior to hanging
What do you do after warming the solution for a TPN patient?
Provide client instruction on purpose of TPN
What do you do after providing client instruction on purpose of TPN?
Assess central line insertion site; only solutions containing <10% Dextrose may be administered peripherally.
What do you do after assessing central line insertion site? (TPN)
Hang solution according to hospital policy.
What are the following possibilities are expected to hang solution? (TPN)
Usually between hours of 1800-2100, with new tubing and micron filter every 24 hours, via pump and separate from other solutions, no medicaitons to be administered via the TPN line, accc-checks regularly to assess for hyper/hypoglycemia
What do you do after hanging the solution? (TPN)
Maintain ordered flow rate: initial infusion rate is slow (50 mL/hr) as ordered, increase rate by 25 mL/hr until desired rate achieved, monitor accuracy of volume delivered at least every 4 hours, decrease rate in increments to wean if discontinuing.
After maintaining ordered flow rate, what do you do next? (TPN)
Monitor client's response to TPN and nutritional status: weigh as ordered, maintain accurate intake and output, blood sugar every six hours is nothing per os (NPO) or before meals and bedtime if taking oral foods. Monitor laboratory values and communicate with MD/pharmacist. Vital signs every four hours and prn.
What is the next step after monitoring client's response to TPN and nutritional status?
Assess for TPN complications: infection, hypoglycemia/hyperglycemia, fluid volume excess/deficit electrolyte imbalance, allergic reaction, pneumothorax, bleeding from insertion site, air embolism, infiltration, phlebitis
What is the final step in caring for a TPN patient?
Document aspects of care provided and client's response to treatment.
What should the student nurse be familiar with when it comes to a diabetic patient?
The student nurse is familiar with the diabetic medications the client is taking and can state the onset, peak and duration of the mediations
When should an assessment be done on a client with diabetes?
immediately upon assuming care for the client
What assessments are performed on a client with diabetes?
Vital signs, blood sugar level, and LOC are priority assessments performed
What should be monitored in a diabetic patient?
hypo and hyperglycemia
What signs should be understood and assessed for throughout the shift?
micro and macro diabetic complications
When should medications be done for a diabetic patient?
Timely and accurately
When should the diabetic patients diet be administered and when should I and O be done?
Diet is administered timely; intake and output are assessed
What happens when the diabetic client is NPO?
The student assesses for caloric intake necessary to counterbalance medication given.
What should the student do if an imbalance exists?
The student takes action to remedy the situation (discusses with instructor, RN, and MD if necessary)
Should a student participates in client teaching?
When should the student document?
Student documents appropriately
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