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128 Cards in this Set

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falls
#1 safety issue,
adults, impaired mobiity
complete falls risk assessment
put near a room next to nurse's station
no throw rugs
restraints
current client safety standards focus on reducing the need for client restraints, least restrictive, implement distraction, review mfrs directions, notify dr when they are put on, assess q2hrs, retraints should never interfere w/tx, convenience
seizures
monitor activity, hx, freq, auras, sequence of events, place rescue eq next to bed, inspect environment, ease to floor protect the headk raise side rails, roll the client to the side with this head flexed slightly forward, nothing in mouth, loosen clothing
fire
race, remove, alarm, confine, extinguish
extinguishers
class a-paper
class b-flammable
class c-electrical
pass
pull, aim, squeeze, sweep
equipment
must be grounded, dont overcrowd outlets, no extension cords,
chemical agents and radiation
"caution radioactive material"
wear badge, never handle any type of radioactive agent with bare hands
lifting and transfer of clients
safe care using proper body mechanics, assess their strength and mobility, mechanical lift, avoid twisting or bending at waist, use major muscle groups and tighten abd muscles
transferring from bed to chair or chair to bed
1. instruct client to assist
2. lower the bed
3. position the bed/chair so that the client is moving toward the strong side
4. assist the client to stand, then pivot
repositioning clients in bed
1. raise the bed
2. lower side rails
3. use slide boards/draw sheets
4. smooth movement
5. ask for help
how to use crutches with non-weight bearing
1. tripod position, keep wt on the "unaffected side" leg
2. advance both crutches and the "affected" leg
3. move the "unaffected" wt bearing foot/leg forward (beyond the crutches)
4. advance both crutches, and then the "affected" leg
how to use crutches with wt bearing
1. move crutches forward about one step's length
2. move "affected" leg forward, level with the crutch tips
3. move the "unaffected" leg forward
walking up stairs with crutches
1. one hand on rail, one hand on crutches
2. push down on the rail and the crutches and step up with the "unaffected" leg
3. if not allowed to place wt on the "affected" leg, hop up with the "unaffected" leg
4. bring the "affected" leg and the crutches up beside the "unaffected" leg
5. remember the "unaffected" leg goes up first and the crutches move with the "affected" leg
5.
walking down the stairs with crutches
1. place the "affected" leg and the crutches down on the step below, support wt by leaning on the crutches and the stair rail
2. bring the "unaffected" leg down
3. remember the "affected" leg goes down first and the crutches move with the "affected" leg
walking with a cane
1. for correct size wear shoes, measure from wrist to the floor.
2. cane is used on the "unaffected" side to provide suport to the opposite lower limb
3. advance the cane simultaneously with the opposite affected lower limb
4. the "unaffected" lower limb should assume the first full wt bearing step on level surfaces
walking with a walker
1. for correct size have the client wear shoes. the client's wrists are even with the handgrips on the walker when arms are dangling downward
2. advance the walker approx 12 inches
3. advance with the "affected" lower limb
4. move "unaffected" limb forward
medical asepsis (clean technique)
precise practices to reduce the number, growth, and spread of germs
steps in medical asepsis (clean technique) to reduce
1. perform handwashing
2. use ppe as indicated
3. do not place items on floor
4. do not shake linens
5. clean least soiled area first
6. place moist items in plastic bags
surgical asepsis (sterile technique) to eliminate all
1. avoid coughing, sneezing, talking over sterile field
2. only dry touch the field leaving a 1 inch boarder
3. keep above the waist
4. don sterile gloves to perform procedure
5. dont take your eyes off your sterile field
standard precautions
applies to all:
body fluids
non-intact skin
mucous membranes
standard precautions ppe:
1. gloves
2. prn mask, gown, goggles
use gloves for all clients
report to cdc
standard ppe:
gloves
gown
touching blood, body fluids
non-intact skin
mucous membranes
contaminated materials
standard ppe:
gloves
mask
face/goggles
when anticipating splashing of body fluids
transmission based precautions, used in addition to standard precautions, known or suspected individuals to be infected
airborne
droplet
airborne precautions
transmitted by air
smaller than 5mcg, (measles, varicella, tb)
airborne precautions ppe:
gloves
mask
n95 respiratior for known or suspected tb
negative air flow
door closed
nurse must be fit for n95
droplet precautions,
protect against droplets larger than 5mcg, strept, pneumonia, scarlet fever, rubella, pertussis, mumps, plague
droplet precautions ppe
gloves
mask
private room
door closed
mask is required within 3 ft of client
contact precautions ppe
gloves
gown
prn: mask and goggles
order of ppe application
1. gown
2. mask
3. goggles/face shield
4. gloves
order of ppe removal
1. gloves
2. goggles/face shield
3. gown
4. mask
protective isolation
used to protect clients who
1. have inc susceptibility to infections
2. receiving chemo
3. immunocomprimised or neutropenic
protective isolation ppe
1. follow standard precautions
2. sterile linens, food, supplies
3. no fresh flowers, fruits, vegetables
4. wear sterile gloves and gown/mask when in contact with client
5. ventilated/positive pressure room
aids / hiv precautions duration of illness
standard-
1. gloves
2. prn mask, gown, goggles
contact-
1. gloves, gown
2. prn: mask/goggles
chicken pox
varicella
standard/airborne/contact
primary prevention
focus is on promoting health and prevention of dz.
ex: shots, car seat edu, nutrition/fitness activities, health edu
secondary prevention:
focus on early id of illness, providing tx, coducting activities geared to prevent a worsening health status
ex: communicable dz screening, early detection tx of htn, exercise programs of geriatrics who are frail
tertiary prevention:
focus is on preventing long term consequences of chronic illness or disability and supporting optimal functioning
ex: prevention of pressure ulcers as a result of spinal injury, promoting independence following a stroke
1 kg =
1 liter
early s/s of fvd
wt loss, poor skin tugor, dry mucous membranes, inc pulse and RR, hyperthermia, cap refill >3sec, wkns, fatigue
late s/s of fvd
oliguria, dec cvp, flat neck veins, elevated hct, elevated spec grav/osmolarity
early s/s of fve
cough, dyspnea, crackles inc bp, p, amplitude, rr, ha, wt gain, hemodilution of hct
late s/s of fve
jvd, tachycardia, pitting edema, inc cvp
Na+
135-145
ca++
8.5-10
Cl-
85-115
HCO3-
22-26
K+
3.5-5.0
PO4
2.5-4.5
Mg+
1.8-3.0
function of electrolytes
1. homeostasis
2. promote neuromuscular exciteability
3. fluid volume
4. water between fluid compartments
5. cardiac stability
6. acid base balance
interventions of hypokalemia
never give K+ iv bolus, must dilute
note: no P=NO K
ecg monitor
administer K+
teach dietary sources
interventions of hyperkalamia
kayexalate
note: blood sugar assessment with kayexalate
ecg,
50% glucose w/insulin
calcium gluconate
loop diuretics
dialysis
interventions with hyponatremia
daily wts, assess cns changes, i/o
admisinster:hypertonic: acuteisotonic: restore volume
if etiology is fve, restrict fluids
note: risk with hypertonic solutions: cerebral edema
teach sodium rich food
hypernatremia interventions
daily wt, assess cns changes, i/o
administer ivf: isotoic (restore volume)
seizure precautions
teach food sources
hypocalcemia interventions
seizure precautions
iv calcium replacement
daily calcium supplements
note: calcium has inverse relationship with phosphorus
hypercalcemia interventions
increase mobility,
isotonic ivf
furosemide, calcitonin, glucocorticoids, biosphosphonates
NOTE: increase risk of fractures
hypomagnesemia interventions
seizure precautions, assess for difficulty swallowing, correct underlying cause, iv magnesium, teach food sources
NOTE: monitor for s/s of magnesium toxicity w/iv replacment and treat with calcium
hypermagnesemia interventions
decrease intake, iv calcium gluconate, mechanical ventilation, temporary pacemakeer
hypophosphatemia interventions
correct etiology, oral phosphate replacement, vitamin d, decrease calcium level
hyperphosphatemia interventions
aluminum hydroxide with meals, decrease dialysis (RF),
note: phosphorus has inverse relationship with calcium
acid base balance
normal value
ph 7.35-7.45
pco2 35-45
hco3 22-26
metabolic acidosis
ph -7.35
pco2 35-45
hco3 -22
metabolic alkalosis
ph 7.45+
pco2 35-45
hco3 26+
respiratory acidosis
ph -7.35
pco2 45+
hco3 22-26
respiratory alkalosis
ph 7.45+
pco2 -22
hco3 22-26
rome
respiratory
opposite
metabolic
equal
regulation of acid base balance is primarily controlled by:
1. lungs--regulate carbonic acid through respiration
2. kidneys--regulate bicarb by retention or excretion
nursing interventions for asthma
1. remain w/client during attack
2. high fowlers
3. monitor lung sounds/sats
4. administer o2
5. maintain iv access
NI: on chosen alternative therapies
1. assist w/chosen therapy
2. teach safety/contraindications
3. do not endorse therapies
NI: on herbal medications
1. not regulated by FDA
2. cause interactions use w/doctor supervision
3. discourge in preg, nursing, infants, children, older adults w/cardio/liver problems
NI: for spirtually sensitive care
1. remain sensitive to beliefs, provide proper diet, privacy, allow visits, allow rituals
NI: for culturally competent care
1. remain sensitive, provide translator, diet, family to provide care, respect personal space, respect the meaning of EYE CONTACT, ck on herbals
POINT TO REMEMBER
regarding information systems and technology
A nurse should not share computer passwords with another person, including coworkers and family members
POINT TO REMEMBER
regarding LEGAL ISSUES
One of the most vital and basic functions of a professional nurse is the duty to intervene when the safety or well-being of a client or another person is obviously at risk
NI: on legal matters
Nurses who are able to recognize the rights and responsibilities in legal matters are better able to protect themselves against liability or loss of licensure
NI: on advance directives
it is important for a nurse to identify clients who do not have advance directives, to inform them of their rights, and to ensure that clients who have advance directives have copies placed in their charts
NI: on organ donation
nurses have an ethical responsibility to participate in the donation process by presenting the option of organ donation to all suitable clients and families.
five rights of delegation
1. right person
2. right task
3. right circumstances
4. right direction and communication
5. right supervision and evaluation
the RN cannot delegate:::
1. nursing process
2. client education
3. tasks that require nursing judgement (including care of unstable clients)
NI: on referral
the processes of consulatation and referrel are integral for effetive use of services along the continuum, and they establish collaboration with the health team. the nurse should support the client/family with appropriate consultation and referral to contacts in the community
NI: on consultation
notify the doctor of the clients needs, provide the consultatn with pertinent information, include the consul info into the plan of care, and facilitate coordination with other providers in order to protect teh client from conflicting and potentially dangerous RX's
NI on case management
a nurse's role in case management is to coordinate services that respond tot he hierarchy of the client's individual's needs. This system provides care that minimizes fragmentation and maximizes holistic indiviualized client care
NI on resource management
the nurse must identify essential needs for material and equipment needed for client care. In addition, the nurse reviews effective use of client care supplies by assistive personel.
NI on variance, incidence, occurrence reports
the nurse should report identified concerns to appropriate personnel and to document the facts. DO NOT PUT IN CLIENTS CHART
NI on team building
1. foster a culture that values collaboration and cooperation
2. communicate that teamwork is expected
3. publicity celebrate team success
4. bring a sense of play and fun to the team
NI on influence
the power of influence is aimed at accomplishing well defined goals, preferably as a cohesive team
SBAR
1. situation
2. background
3. assessment
4. recommendation
types of conflicting managment to create a win win situation
1. avoiding
2. cooperating, accomodating
3. compromising
4. competing
5. collaborating
6. smoothing
NI on effective communication
effective communication requires committment, effort, focus and cooperation, especially when deaing with complex clinical issues and people who have diverse backgrounds and perspectives. It is essential to understand and use effective communication skills to successfully manage others.
NI on managment styles
nurses should learn mgmt skills and identify their own personal leadership style. nurses should know the differences between being an autocratic and democratic leader. Most effective is the DEMOCRATIC leader who uses an interdisciplinary approach to encourage open communication and collaboration, which will promote individual autonomy and accountability
NI on concepts of mgmt
all nurses will need leadership skills to manage other nurses, AP and clients. it is essential to the nursing role to identify and implement effective leadership practices.
NI on Rhogam
Rhogam is injected after any event where fetal cells can mix with maternal blood incl: miscarriage, ectopic preg, induced abortion, amniocentesis, chorionic villus sampling, abdominal trauma
NI on ante-natal steroids that stimulate production of surfactant in fetus between 24-34 weeks gestation, promoting lung maturity
administer 2 doses (usually IM) 24 hr apart (repeat doses not recommended)
provide emotional support to family
NI on mag sulfate
STOPS PRETERM LABOR
monitor vs, dtr's, mag levels 4-8, administer infusion pump in diluted form, use indwelling cath to monitor urine elimination, admin calcium gluconate 10% if s/s of toxicity
NI on nifedipine (procardia)
STOPS PRETERM LABOR
monitor bp, avoid concurrent use with mag sulfate, motnitor contractions and FHT, prevent complication with hypotension
NI on terbutaline sulfate (brethine) Yutopar)
STOPS PRETERM LABOR
monitor contractions, fht, vs, do not admin if pulse rate is over 140 or if client has chest pain, administer beta blocker agent as antidote
methylergonovine (methegine)
stimulates forceful contractions, post partum hemorrage
continuously monitor blood pressure, assess uterine bleeding and uterine tone
NI on oxytocin (pitocin)
stumulates uterine contractions for induction of labor
administer 2nd infusion via infusion pump, montior uterine contractions, fht, d/c oxytocin with any s/s of uterine hyperstimulation, administer o2 facemask 10L s/s hyperstimulation, when used in postpartum monitor for uterine bleeding
oxytocic (cervical ripening)
causes cervical softening
put client on bedrest for 1-2 hr after insertion, monitor and record maternal vs and fht, uterine contractions, remove by gently pulling the netted string and discard, oxytocin augmentation may be initiated as needed, assess bishops score for 6 and greater to begin induction
NI for contraception
discuss conception, and contraception with client to include reliability, benefits, and risks, maintain reg health visits, prevent PID, stds, reinforce unreliable forms of b/c coitus interuptus, withdrawl, douching and breast feeding
NI on opiod analgesics
monitor vs, respiratory depression, reinforce client instruction on PCA pump, administer narcan for clients with respiratory depression
NI on NSAIDS
monitor liver function, renal function, do not exceed adult 4,000mg/24 hrs, recognize s/s of hepatotoxicity, admin to children do not exceed 5 doses per day, treat overdose with mucomist, acetylcysteine
NI on ophthalmologic medications
anti-glacoma
levobunolol (betagan), pilocarpine (pilocar)
timolol (timoptic)
use sterile technique when handling applicator, hold gentle pressure on the nasolacrimal duct (inner)for 30-60 sec after drops, monitor pulse/rhythm after taking oral beta or calcium channel blockers
NI on anti-seizure
carbamazepine (tegretol)
gabapentin (neurontin)
phenobarbital (luminal)
phenytoin (dilantin)
valproic acid (depakote)
monitor for therapeutic effects, monitor phenyton for toxic effects 10-20), importance of compliance, not a cure, individualize tx regimen, teach se/adverse effects, drug therapy for status epilepticus: iv phenytoin and valium
anti-parkinsons
increase dopamine to minimize tremors and rigidity
benztropine (congentin)
carbidopa/levodopa (sinemet)
levodopa (dopar)
family to assist w/med regimen, notify dr if different effects of med happens, 4-6 wks to reach maximum effect, monitor for s/s effects, avoid high protein meals, keep med away from heat, sun, may lost potency need new RX
chronic neurologic disorders
cholinesterase inhibitors
medications
neostigmine (prostigmin)
ambenonium (mytelase)
edrophonium (tensilon)
therapeutic use: myasthenia gravis, dont use if sbp <90
NI dose is individualized
keep diary to record side effects
wear medic alert bracelet
monitor for cholinergic crisis
NI on methadone (dolophine)
prevents withdrawl s/s in pts who were addicted to opiates
1. monitor for s/e drug tolerance and dependence
2. ck pancreatic enzymes, may cause biliary spasms
3. methodone must be slowly reduced to produce detox
4. monitored thru tx center
disulfiram (antabuse)
maintain sobriety of alcohol
do not give within 14 days of ingestion of any alcohol
do not use mouthwash or anything containing alcohol. will cause n/v, flushing, respiratory distress
NI on sedative, hypnotic meds
eszopiclone (lunesta)
temazepam (restoril)
zolpidem tarate (ambien)
for short term insomnia
1. take right before bedtime
2. avoid alcohol
3. potential for sleep activities w/o recall, notify doctor asap
NI for ADHD meds
stimulants
dextroamphetamine and amphetamine (adderall)
1. give in the am
2. do not d/c abruptly
3. ck for s/s of abuse
4. ck for agitation
NI for ADHD med
non-stimulants
atomoxetine (strattera)
guanfacine (intuiv) may also be for aspergers syndrome
1. take med daily
2. do not crush or chew
3. report anxiety, agitation
4. do not take with maio's
NI on anti-psychotic meds
conventional
chlorpromazine (thorazine)
fluphenazine (prolixin)
haloperidol (haldol)
thiothixene (navane)
1. monitor for s/e within 5hr-5days of administration
2. advise of s/e
3. ck cbc, encourage fluids
4. stop med for s/s of neuroleptic malignant syndrome
NI of anti-psychotic meds
atypical (less s/e and adverse)
aripiprazole (abilify)
clozapine (clozaril)
olanzapine (zyprexa)
paliperidone (invega)
quetiapine (seroquel)
ziprasidone (geodon)
1. monitor for s/e within 5hr-5days of administration
2. advise of s/e
3. ck cbc, encourage fluids
4. stop med for s/s of neuroleptic malignant syndrome
bipolar disorder meds
lithium (eskalith, lithobid)
provide nutritional counseling with sodium and take with food
NI on bipolar meds
1. monitor levels (0.4-1.0)
2. monitor sodium 135-145
3. therapeutic effects 7-14 d
4. doses 2-3 times a day
5. provide nutritional counseling for sodium
6. administer with food
NI on SSRI's (inhibits serotonin uptake)
duloxetine (cymbalta), fluoxetine (prozac), escitalopram (lexapro), fluvoxamine (luvox), paroxetine (paxil, sertraline (zoloft)
1. risk for suicide, take daily, do not miss a dose, do not d/c abruptly, take ssri in the morning, do not take other meds w/o consulting doctor
NI on tricyclic antidepressants
amitriptyline (elavil), clomipramine (anafranil), doxepin (sinequan), imipramine (tofranil)
risk for suicide, take daily, do not miss a dose, do not d/c abruptly, do not take other meds w/o talking to doctor first
NI on anti-gout meds for chronic gouty arthritis
allopurinol (zyloprim)
avoid foods high in purines to reduce uric acid, monitor cbc and uric acid levels, avoid aspirin, administer with meals
NI on anti-gout meds for acute gouty arthritis
colchicine (colcrys)
avoid foods high in purines to reduce uric acid, monitor cbc and uric acid levels, avoid aspirin, administer with meals
NI on NSAIDS
ibuprofen, advil, motrin, voltaren, indomethacin, indocin, naproxen, naprosyn, celecoxib, celebrex
administer with food and full glass of water, avoid laying down for 30 min after taking med, use only prn for s/s to reduce risk of GI ulceration, use sunscreen
NI on glucocorticoids
prednisone (deltasone), prednisolone (prelone)
do not skip doses, ck bp, ck fluid/electrolyte balance and wt, s/s of bleeding, gi discomforts, take calcium and vit d, give with food, do not d/c abruptly, provide immunoprotection
NI on anti-rheumatics dmards
methotrexate (theumatrex), hydroxychloroquine (plaquenil), etanercept (enbrel), infliximab, remicade, adalimumab, humira
prevent infection, ck liver function tests, use contraception, effect may take 3-6 wks, take with food, when taking hydroxychloroquine have retinal exam every 6 months
cpr guidelines for children
use AED asap, use child pads or a chld system for children 1-8, if available, if child pads are not available, use adult AED and pads
cpr guidelines for infants
AED is not recommended for infants less than 1 yr of age
cpr guideline for infants
obstructed airway
use a combination of back blows and chest thrusts
cpr guideline for children
obstructed airway
use abdominal thrusts and hemilich maneuver, remove lg debris in oral cavity, do not reach into mouth, place recovered child in recovery position, use calm approach, administer o2 as prescribed
NI on hodgkins lymphoma-CA of the lymphatic system for adolescents/young adults, starts in lymphoids, metastasis may incl spleen, liver, bone marrow, lungs
vs, ht, wt, i/o, nutritional status, developmental delays,