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116 Cards in this Set
- Front
- Back
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IV fluid requirements for a child
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0-10 kg = 100 mL/kg
11-20 kg = 50 mL/kg 21 and over kg = 20 mL/kg |
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Respiratory Distress
Early S/S |
PLB
tripoding increased RR (3-4 above baseline) increased HR increased BP restlessness |
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Conversions
1 tsp = __ mL 1 tbsp = __ mL __kg = __lbs 1 fl oz = ___ mL 1 cup = ___mL = ___oz |
1 tsp = 5 mL
1 tbsp = 15 mL 1 kg = 2.2lbs 1 fl oz = 30 mL 1 cup = 240mL = 8oz |
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IV fluid requirements for a child
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0-10 kg = 100 mL/kg
11-20 kg = 50 mL/kg 21 and over kg = 20 mL/kg |
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Lab values
Hemoglobin (HGB): RBC: Hematocrit (HCT): WBC: |
Hemoglobin (HGB): 14 to 18 g/dl
RBC: 4.2-5.6 mill/mcl Hematocrit (HCT): 40-54% WBC: 3.8-10.8 thous/mcl |
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Lab values
-Calcium: -Potassium: -Sodium: |
-Calcium: 8.5-10.3 mEq/dl
-Potassium: 3.5-5.5 mEq/L -Sodium: 135-146 mEq/L |
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Lab values
Hemoglobin (HGB): RBC: Hematocrit (HCT): WBC: |
Hemoglobin (HGB): 14 to 18 g/dl
RBC: 4.2-5.6 mill/mcl Hematocrit (HCT): 40-54% WBC: 3.8-10.8 thous/mcl |
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Respiratory distress
late s/s |
nasal flaring (adults only)
use of accessory muscles depth of breathing increases high RR (greater than 24) high HR (greater than 120) low BP (less than 90/50) intercostal retractions |
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respiratory distress
children: early s/s |
restlessness 1st and then nasal flaring
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TB
-how is the organism transmitted? |
via aerosolization (airborne route) by droplet nuclei. So when a person with active TB coughs, laughs, sneezes, whistles or sings, droplets become airborne and may be inhaled by others and deposited in the lungs
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Lab values
-Calcium: -Potassium: -Sodium: |
-Calcium: 8.5-10.3 mEq/dl
-Potassium: 3.5-5.5 mEq/L -Sodium: 135-146 mEq/L |
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respiratory distress
children: early s/s |
restlessness 1st and then nasal flaring
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respiratory distress
children: late s/s |
intercostal retraction & grunting
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TB:
the patient with TB will be in airborne isolation, what special equipment must health care works wear? what if they don't have this equipment available? |
N95 or high-efficiency particulate air (HEPA) respirator when caring for the patient.
-if no mask, stay 3 feet away |
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a pt who is hypoxemic and has chronic hypercapnia, they would require what oxygen system? why?
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a low O2 delivery (1-2l/min) because a low arterial oxygen level is the primary drive for breathing
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TB
-what kind of room will this patient be in? |
-they will be in a negative pressure room w/ outside air (6 times per house) and hand washing before and after care is a must.
-UV light in clinical and homeless shelters |
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a pt who is hypoxemic and has chronic hypercapnia, they would require what oxygen system? why?
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a low O2 delivery (1-2l/min) because a low arterial oxygen level is the primary drive for breathing
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Respiratory distress
late s/s |
nasal flaring (adults only)
use of accessory muscles depth of breathing increases high RR (greater than 24) high HR (greater than 120) low BP (less than 90/50) intercostal retractions |
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TB
-what organism is it caused by? -viral or bacterial? |
mycobacterium tuberculosis.
It is the most common bacterial infection |
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a pt who is hypoxemic and has chronic hypercapnia, they would require what oxygen system? why?
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a low O2 delivery (1-2l/min) because a low arterial oxygen level is the primary drive for breathing
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Pneumonia
what should you instruct the pt see their doctor? |
-teach the pt who has a cold or the flu with a fever lasting more than 24 hours or a cold lasting longer than a week
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TB
-what do you have to do with any specimen from a patient with TB? |
-Specimens must be labeled acid fast bacilli so anyone handling them will know to take precaution
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TB:
the patient with TB will be in airborne isolation, what special equipment must health care works wear? what if they don't have this equipment available? |
N95 or high-efficiency particulate air (HEPA) respirator when caring for the patient.
-if no mask, stay 3 feet away |
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TB
-When are precautions discontinued? |
when the patient is no longer considered infectious.
-the disease is usually no longer contagious after drugs have been taken for 2-3 consecutive weeks and clinical improvement is seen, however, the pt must continue with the prescribed drugs for 6 months or longer as prescribed. It’s safe to go into the community after a few weeks |
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TB
-what kind of room will this patient be in? |
-they will be in a negative pressure room w/ outside air (6 times per house) and hand washing before and after care is a must.
-UV light in clinical and homeless shelters |
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Home Care for people who have TB
-tell them to open windows, why? |
Open windows so you can have air circulation (TB Doesn’t like fresh air)
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Home Care for people who have
-if a home health nurse comes to get a sputum specimen, what should the patient be instructed to do? |
-hand sputum specimen to home health nurse outside
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Respiratory Distress
Early S/S |
PLB
tripoding increased RR (3-4 above baseline) increased HR increased BP restlessness |
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TB
-what do you have to do with any specimen from a patient with TB? |
-Specimens must be labeled acid fast bacilli so anyone handling them will know to take precaution
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TB
-When are precautions discontinued? |
when the patient is no longer considered infectious.
-the disease is usually no longer contagious after drugs have been taken for 2-3 consecutive weeks and clinical improvement is seen, however, the pt must continue with the prescribed drugs for 6 months or longer as prescribed. It’s safe to go into the community after a few weeks |
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respiratory distress
children: late s/s |
intercostal retraction & grunting
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Home Care for people who have TB
-tell them to open windows, why? |
Open windows so you can have air circulation (TB Doesn’t like fresh air)
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Home Care for people who have
-if a home health nurse comes to get a sputum specimen, what should the patient be instructed to do? |
-hand sputum specimen to home health nurse outside
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chronic hypoxemia / hypoxia
s/s |
polycythemia
clubbing mental changes cor pulmonale |
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-Lung Cancer
-Surgery may be done for palliative reasons, just to shrink or remove – cure is not possible (Lobectomy & Pneumonectomy) |
•Lobectomy – removal of one lobe
•Pneumonectomy – removal of entire lung |
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TB
-what organism is it caused by? -viral or bacterial? |
mycobacterium tuberculosis.
It is the most common bacterial infection |
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TB
-how is the organism transmitted? |
via aerosolization (airborne route) by droplet nuclei. So when a person with active TB coughs, laughs, sneezes, whistles or sings, droplets become airborne and may be inhaled by others and deposited in the lungs
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Home care instructions for the client who has been hospitalized and treated for TB:
-activities? -nutrition? |
-inform the client that activities should be resumed gradually and about the need for adequate nutrition and a good diet rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection.
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Pneumonia
--get pneumonia vaccine (how often) --get flu vaccine (how often) |
every 5-7 years
yearly |
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Pneumonia
-avoid (2) substances |
tobacco and alcohol
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Pneumonia
-if pt has mobiliy issues, instruct them to do what |
learn to cough and deep breathe and turn q2h
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Pneumonia
-what precautions is the patient on? -what equipment do you wear? |
-Droplet precautions
wear mask |
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Pneumonia
-encourage what 2 populations to receive the PPV23 vaccine ? |
every one older than 65 and those who have a chronic health problem to
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-Pneumonia
-who is at risk? (2) |
- pt who has a respiratory problem,
-limited mobility and is confined to a bed or chair during waking hours |
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-Pneumonia
-how much fluids should they drink? |
-drink at least 3L f fluid each day to thin secretions
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Pneumonia
-HOB? -position to avoid? |
30 degrees
avoid supine position |
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Lung CA
prognosis = poor what is treatment aimed at? |
toward relieving symptoms (palliation) rather than cure because of the presence of metastasis
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Lung CA
prognosis = poor what is treatment aimed at? |
toward relieving symptoms (palliation) rather than cure because of the presence of metastasis
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Lung CA
-occurs as a result of |
repeated exposure to inhaled substances that cause chronic tissue irritation/inflammation
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Lung CA
-biggest risk factor? |
-cigarette smoking
-primary prevention for lung cancer is reducing tobacco smoking (starting with elementary kids to discourage them from beginning to smoke) |
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Lung CA
-what do you teach to prevent this (2)? |
-teach industrial workers to wear masks and specialized clothing
-encourage pts who are at high risk for lung cancer development to seek frequent health exams |
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Lung CA
cachexia: extreme body wasting and malnutrition developes from an imbalance b/w food intake and energy use -they need a diet high in what? |
a diet high in protein and carbs for weight maintenance, energy, and cellular repair
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Clinical Manifestations of Lung Cancer
Early symtpmoms are nonspecific. -Persistent pneumonitis from obstructed bronchi earliest symptom – resulting in 3 S/S |
fever, chills, cough
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Clinical Manifestations of Lung Cancer
Early symtpmoms are nonspecific. -Persistent pneumonitis from obstructed bronchi earliest symptom – resulting in 3 S/S |
fever, chills, cough
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Clinical Manifestations of Lung Cancer
Metastasis present before symptoms present |
– anorexia, fatigue, wt loss, N/V, hoarseness (late), dyspnea
-CM: sputum production, change in endurance, chest pain |
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-Lung Cancer
Surgery Thoracotomy/thorascopy -Post Op (what should you assess for?) |
incision into thorax
asses for hemorrhage, chest tube should get less over time (50-100mL per hr) -impaired gas exchange- monitor CT function, monitor RR and pattern, lungs should be expanding , are they restless? |
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-Lung Cancer
Surgery Thoracotomy/thorascopy -Post Op (what should you assess for?) |
incision into thorax
asses for hemorrhage, chest tube should get less over time (50-100mL per hr) -impaired gas exchange- monitor CT function, monitor RR and pattern, lungs should be expanding , are they restless? |
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-Lung Cancer
Surgery Thoracotomy/thorascopy -How much O2 are they on? |
-O2 (1-2L) for first couple days. warm and humidify air
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-Lung Cancer
Surgery Thoracotomy/thorascopy -How much O2 are they on? |
-O2 (1-2L) for first couple days. warm and humidify air
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-Lung Cancer
Surgery Thoracotomy/thorascopy -assist with frequent position changes, why? |
so they don’t get frozen shoulder & lose function
- splinting while coughing so CT doesn’t fall out, |
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TB – High Risk Groups
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•Immunosupressed - HIV/AIDS, malignancy, chronic diseases *high risk*
•Homeless •Inner city residents •Foreign born persons: Asia, Africa, Carribbean, Latin America Mexico, Philippines, and Vietnam *high risk* |
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TB – High Risk Groups
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•Immunosupressed - HIV/AIDS, malignancy, chronic diseases *high risk*
•Homeless •Inner city residents •Foreign born persons: Asia, Africa, Carribbean, Latin America Mexico, Philippines, and Vietnam *high risk* |
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-one of the first symptoms associated with TB is:
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a cough with the expectoration of mucoid sputum
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Home care instructions for the client who has been hospitalized and treated for TB:
-inform the client and family that respiratory isolation is not necessary (true or false) |
true
because family members already have been exposed |
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Home care instructions for the client who has been hospitalized and treated for TB:
-what do you tell them about sputum cultures and when they can go back to work? |
-inform the client that a sputum culture is needed every 2-4 weeks once medication therapy is imitated and when the results of 3 sputum cultures are negative, the client is considered no longer infectious and can return to former employment
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TB
-stay away from infected person for how long? |
until they have been on therapy for 2-3 weeks
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-TB has a slow onset. A diagnosis of TB should be considered for any pt with what CM?
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a persistent cough,
weight loss, anorexia, night sweats, hemoptysis, SOB, fever, chills |
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COPD
-cigarette smoking is the most important risk factor for COPD. why? |
(tobacco triggers the release of excessive amounts of proteases from cells in the lungs which break down elastin, the major component of alveoli). The risk is greater when exposure occurs in small, confined places.
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-one of the first symptoms associated with TB is:
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a cough with the expectoration of mucoid sputum
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Home care instructions for the client who has been hospitalized and treated for TB:
-inform the client and family that respiratory isolation is not necessary (true or false) |
true
because family members already have been exposed |
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Home care instructions for the client who has been hospitalized and treated for TB:
-what do you tell them about sputum cultures and when they can go back to work? |
-inform the client that a sputum culture is needed every 2-4 weeks once medication therapy is imitated and when the results of 3 sputum cultures are negative, the client is considered no longer infectious and can return to former employment
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COPD
-PLB: what is the purpose? |
prolongs exhalation –gets rid of CO2
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TB
-stay away from infected person for how long? |
until they have been on therapy for 2-3 weeks
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-TB has a slow onset. A diagnosis of TB should be considered for any pt with what CM?
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a persistent cough,
weight loss, anorexia, night sweats, hemoptysis, SOB, fever, chills |
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COPD
-PLB: what is the purpose? |
prolongs exhalation –gets rid of CO2
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Laryngectomy
-what happens to their speech? -do they have a temporary or permanetn trach? |
-lose normal speech (speech rehab)
-permanent trachea -no voice box |
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Laryngectomy
-what happens to their speech? -do they have a temporary or permanetn trach? |
-lose normal speech (speech rehab)
-permanent trachea -no voice box |
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Care of Trach
-suctioning can cause: |
hypoxia, tissue trauma, infection, bronchospasm and cardiac dysrthymias
-tell the pt that the sensations such as shortness of breath and coughing are to be expected but that any discomfort will be very brief |
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Laryngectomy
-what should you say if you can’t understand someone who doesn’t have an alternate means of communication? |
it is your problem and it is not his problem.. so you need to say “I’m sorry I’m having a difficult time understanding you, if you could repeat it and talk slower I will get it”. just remember it is not their fault. they might not mind writing but that can get old too. so saying you write it out is not that answer.
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Laryngectomy
-what should you say if you can’t understand someone who doesn’t have an alternate means of communication? |
it is your problem and it is not his problem.. so you need to say “I’m sorry I’m having a difficult time understanding you, if you could repeat it and talk slower I will get it”. just remember it is not their fault. they might not mind writing but that can get old too. so saying you write it out is not that answer.
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Care of Trach
-suctioning how can you prevent hypoxia? |
by hyperoxygenating the pt with 100% oxygen for 30 seconds to 3 minutes (at least three hyperinflations)
until the pts HR and O2 status are WNL |
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Laryngectomy and there senses?
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-airflow is altered so some people may lose their taste/smell
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Care of Trach
-suctioning lubcriation? what do you apply suction? |
-lubricate the catheter with sterile water or saline before insertion.
apply suction only during the withdrawal of the catheter |
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Laryngectomy and there senses?
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-airflow is altered so some people may lose their taste/smell
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Laryngectomy
-body image disturbance: how do you know if they are coping? |
as long as they are going out in the public and interacting, they are getting involved in the care of the trach – they are accepting the body image change (if someone says you do it, or have home health keep coming that is a problem) help pt set realistic goals, starting with involvement in self care
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Care of Trach
-suctioning withdraw the catheter and begin to apply suction. what kind of suction do you use? what motion do you do? |
use intermittent suction and a twirling motion of the catheter during withdrawal to prevent grabbing of the mucosa
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Laryngectomy
-body image disturbance: how do you know if they are coping? |
as long as they are going out in the public and interacting, they are getting involved in the care of the trach – they are accepting the body image change (if someone says you do it, or have home health keep coming that is a problem) help pt set realistic goals, starting with involvement in self care
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Laryngectomy
-airway maintenance (suction secretions) ___seconds in an adult, ___ seconds in an infant |
10-15 seconds in an adult,
5-8 seconds in an infant |
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Care of Trach
-suctioning how many suction passes are allowed? |
-repeat as needed for up to 3 total suction passes
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Laryngectomy
-airway maintenance (suction secretions) ___seconds in an adult, ___ seconds in an infant |
10-15 seconds in an adult,
5-8 seconds in an infant |
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technique when suctioning?
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-in the hospital, use sterile technique. at home, use clean technique when suctioning because the number of organisms in the home envt is lower than in the hospital
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Laryngectomy
-tell me about their nutrition |
-nutrition : loss of taste and smell (they are breathing through the trach so they lose
their senses. sometimes the smell can come back (they need a smoke detector) |
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Laryngectomy
-tell me about their nutrition |
-nutrition : loss of taste and smell (they are breathing through the trach so they lose
their senses. sometimes the smell can come back (they need a smoke detector) |
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total laryngectomy
-aspiration is a big concern true or false |
false
-aspiration cannot occur after because the airway and esophagus have been completely separated |
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total laryngectomy
-aspiration is a big concern true or false |
false
-aspiration cannot occur after because the airway and esophagus have been completely separated |
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Trachea
--can cover it with gauze, trach covers, light scarfs... cover the airway with what material to protect it during the day? -what does covering the permanent opening do? |
- cotton or foam
- filters the air entering the stoma, keeps humidity in the air, and enhances appearance. |
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Care of Trach
-suctioning can cause: |
hypoxia, tissue trauma, infection, bronchospasm and cardiac dysrthymias
-tell the pt that the sensations such as shortness of breath and coughing are to be expected but that any discomfort will be very brief |
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-they need to keep water out of their trach (showering is ok but they need to have a trach bib –
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hard plastic bib that prevents water from getting in – or they can use a shower shield to prevent water from entering the airway)
-they shouldn’t go swimming |
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Care of Trach
-suctioning how can you prevent hypoxia? |
by hyperoxygenating the pt with 100% oxygen for 30 seconds to 3 minutes (at least three hyperinflations)
until the pts HR and O2 status are WNL |
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Care of Trach
-suctioning lubcriation? what do you apply suction? |
-lubricate the catheter with sterile water or saline before insertion.
apply suction only during the withdrawal of the catheter |
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Trach and seasonal changes
-what do you tell them to do if it is the middle of winter and really dry out (2) |
use a humidifier (keep air moist) and drink lots of water. the normal airway goes through the mouth and nose and that humidifies it. with a trach, we have a direct route from the outside down the trach into the lungs, so think about the protection. drink a lot of fluids to keep airways moist.
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Care of Trach
-suctioning withdraw the catheter and begin to apply suction. what kind of suction do you use? what motion do you do? |
use intermittent suction and a twirling motion of the catheter during withdrawal to prevent grabbing of the mucosa
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- the tracheostomy tube bypasses the nose and mouth, which normally humidify, warm, and filter air before it reaches the lower respiratory tract. if humidification and warming are not adequate, tracheal damage can occur. thick, dried secretions can occlude the airways
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hydrate!
-if a person is sick, push fluids so the airways don’t become dry. |
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Care of Trach
-suctioning how many suction passes are allowed? |
-repeat as needed for up to 3 total suction passes
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technique when suctioning?
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-in the hospital, use sterile technique. at home, use clean technique when suctioning because the number of organisms in the home envt is lower than in the hospital
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Trachea
--can cover it with gauze, trach covers, light scarfs... cover the airway with what material to protect it during the day? -what does covering the permanent opening do? |
- cotton or foam
- filters the air entering the stoma, keeps humidity in the air, and enhances appearance. |
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-they need to keep water out of their trach (showering is ok but they need to have a trach bib –
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hard plastic bib that prevents water from getting in – or they can use a shower shield to prevent water from entering the airway)
-they shouldn’t go swimming |
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Trach and seasonal changes
-what do you tell them to do if it is the middle of winter and really dry out (2) |
use a humidifier (keep air moist) and drink lots of water. the normal airway goes through the mouth and nose and that humidifies it. with a trach, we have a direct route from the outside down the trach into the lungs, so think about the protection. drink a lot of fluids to keep airways moist.
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- the tracheostomy tube bypasses the nose and mouth, which normally humidify, warm, and filter air before it reaches the lower respiratory tract. if humidification and warming are not adequate, tracheal damage can occur. thick, dried secretions can occlude the airways
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hydrate!
-if a person is sick, push fluids so the airways don’t become dry. |
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-Lung Cancer
-Surgery may be done for palliative reasons, just to shrink or remove – cure is not possible (Lobectomy & Pneumonectomy) |
•Lobectomy – removal of one lobe
•Pneumonectomy – removal of entire lung |
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TB – High Risk Groups
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•Institutionalized persons (long term care, prisons) the immune system becomes compromised and there is a lot of close proximity
•IV drug users or ETOH •Socioeconomically disadvantaged: homeless, inner city •Medically underserved |
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when someone is on an immunosuppressant drug, they should do a TB skin test, why?
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because once the immune system becomes compromised, and if you have TB, your immune system can not fight TB anymore and the disease can become active
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TB
-(fast or slow) growing and most commonly grows where in the body? |
slow
in the lungs |
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Home care instructions for the client who has been hospitalized and treated for TB:
-activities? -nutrition? |
-inform the client that activities should be resumed gradually and about the need for adequate nutrition and a good diet rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection.
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Croup
-what do you teach them to do to prevent this? what do you teach about humdification? |
-good hygiene, teach hand washing
-go out in the cold, give popsicle (helps decrease thickness of secretions) |
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Group A Beta Hemolytic Streptococci
-what 2 diseases can result if not treated? |
-acute glomerulonephritis (kidney disease in which part of your kidneys that help filter waste and fluids from the blood is damaged) can occur 7-10 days after
-rheumatic fever carditis may occur 3-5 weeks after |
