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153 Cards in this Set
- Front
- Back
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How would you provide care and support for client with gambling dependency?
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1) Provide emotional support and reassurance to the client and family
2) Begin to educate the client about addition and the initial treatment goal of abstinence 3)Begin to develop motivation and commitment for abstinence and recovery 4)Encourage self-responsibility 5) help the client develop an emergency plan |
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what is an emergency plan?
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a list of things the client would do and people he would contact if he felt like using or actually use.
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What are the example of individual psychotherapies?
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1) CBT
2) psychodynamic therapies |
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Individual psychotherapies are used for------
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relapse prevention therapy.
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How do individual psychotherapies help clients?
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1) teach the client to recognize s/s of relapse and factors that contribute to relapse.
2) helps the client develop strategies such as meditating, exercising to create feelings of pleasure from activities other than using substances or from process addictions. |
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What is group therapy?
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Group of clients with similar dx may meet in an outpt setting and within mental health residential facilities.
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What family therapy does?
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1) teaches families about abuse of substances
2) educates the family regarding such issues as family coping, problem solving, relapse signs, and availability of support groups |
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What is self-help groups?
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12-step programs including AA, NA, Gambler's anonymous teach that abstinence is necessary for recovery and use the belief in a higher power to assist in recovery.
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What are the interventions in crisis management?
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1) provide for client safety
2) Use strategies to decrease anxiety 3)teach relaxation techniques 4) use problem solving to anticipate the client's needs (anticipatory guidance); identify and teach coping skills 5) assist the client with the development of an action plan 6) identify and coordinate with support agencies and other resources 7) plan and provide for follow up care |
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How would you provide for client safety in crisis management?
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1) ensure that external controls such as hospitalization are applied for protection of the person in crisis if the individual has suicidal or homicidal thoughts
2) organize interventions so tangible threats are addressed first |
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What are the strategies you use to decrease anxiety in crisis?
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1) develop a therapeutic nurse-client relationship
2)listen, observe, and ask questions 3) make eye contact 4) ask questions r/t the client's feelings 5) ask questions related to the event |
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how an action plan should be in crisis intervention?
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1) short term no longer than 24-72 hours
2) focused on the crisis 3) realistic and manageable |
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What are advance directives?
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Advance directives are legal documents for medical treatment per the client's wishes.
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What is durable power of attorney for health care?
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An agent appointed by the client or the courts to make medical decisions when the client is no longer able to do so.
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How to provide support to the family, whose loved one are dying, regarding decision making?
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The nurse must consider the desires of the client and the family.
Any decisions must be shared with other HCP for smooth transition during this time of stress, grief, and bereavement. |
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What are the substances that can lead to an episodes of mania?
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1) alcohol
2) drugs of abuse 3) caffeine |
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What is the s/s of relapse for bipolar disorder patient?
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Sleep disturbances may come before, be associated with, or brought on by an episodes of mania.
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recognizing s/s of impaired cognition
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S/S: impairment in memory, judgment, ability to focus, and ability to calculate.restless, agitation are common. Sundowning may occur.
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S/s of delirium
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1) cognition impairments may fluctuate throughout the day
2) LOC may be altered. 3) behaviors may increase or decrease daily |
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S/s of dementia
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1) impairments not change throughout the day
2) LOC unchanged 3) behaviors remain stable |
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What are the effects of amnestic disorder?
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1) decreased awareness of surroundings
2) inability to learn new info despite normal attention 3) possible disorientation to place and time 4) typically there is no personality change or impairment in abstract thinking |
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Describe client teaching point for those taking Lithium
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1) Client must maintain adequate sodium and fluid intake while taking lithium (lithium takes the place of sodium in body)
2) Advise the clients that effects of lithium begin within 5-7 days and that it may take 2-3 weeks to achieve full benefits 3) Advise the client to report signs of toxicity and to take the med as prescribed 4) Encourage the client to comply with follow up appts to mnitor thyroid and renal function |
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Teach client how to take Methylphenidate (Ritalin) correctly
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1) Advise client to swallow sustained release tablets whole and to avoid chewing or crushing tablets
2) it is important to administer the med on a regular schedule and take the med exactly as prescribed 3) Take the morning (or daily) dose after breakfast and the last dose in the early afternoon to minimize wt lose and insomnia. The med schedule should be taken at least 6 hrs before bedtime. |
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What are signs of Methylphenidate (Ritalin) mild overdose?
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restlessness, insomina and nervousness
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What are signs of Methylphenidate (Ritalin) sever overdose?
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panic, hallucinations, circulatory collapse, and seizures.
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What to avoid when taking Methylphenidate (Ritalin)?
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1) Avoid other CNS stimulants such as coffee, cola, tea, and chocolate
2) Avoid alcohol or OTC meds unless approved by the PcP. Many OTC meds contain CNS stimulant properties. |
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What client needs to do to minimize mouth dry when taking Methylphenidate (Ritalin)?
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suck hard candy
chew gum take sips of water |
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What client need to know to avoid potential for abstenence syndrome when taking Methylphenidate (Ritalin)?
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Avoid abruptly stopping the med
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Client teaching point for those taking Disulfiram (Antabuse)
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1)Inform the client of the potentials dangers of drinking any alcohol
2) Advise the client to avoid any products that contain alcohol (eg cough syrups, aftershave lotion) 3) encourage client to wear medic alert bracelet |
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How to take Fluoxetine (Prozac) correctly?
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1) take the med with meals/food
2) take on a daily basis to establish therapeutic plasma levels |
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How long does it take for the Fluoxetine (Prozac) to be effective?
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1) Therapeutic effects may not be experienced to 1-3 weeks
2) it might take 2-3 months for full benefits to be achieved |
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what to do to avoid relapse when taking Fluoxetine ( Prozac)?
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1)continue therapy after improvement in symptoms. D/c of med can result in relapse.
2) continue the therapy for 6 months after resolution of sx and may continue for 1 yr or longer. |
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How to monitor older adults clients who taking Fluoxetine (Prozac) and diuretics concurrently?
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1) Older adult clients taking diuretics should be monitored for sodium levels
2) Obtain baseline sodium levels and monitor periodically |
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How to evaluate if spiritual needs have been met?
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1) Ask if the client's needs are being met
2) family and friends with whom the client seeks to have fellowship can be a useful source 3) use established expected outcomes to evaluate the client's response to care |
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When communicate with hearing impaired client, what the nurse should do?
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1) get the client's attention before speaking
2) Stand/sit facing the client in a well-lit, quiet room without distrations 3) Speak clearly and slowly to the client without shouting and without hands or other objects covering the mouth 4) arrange for communication assistance (sign language interpreter, closed caption, phone amplifiers, TTY capabilities) as needed. |
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Planning interventions for the hearing impaired client include: ----
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1) select strategies to assist the client in remaining functional in the home
2) adapt therapies depending on whether sensory deficit is short or long term 3) involve the family in helping the client adjust to limitations 4) refer to appropriate HCP and/or community agency |
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how to evaluate effectiveness of teaching regarding stress management techniques?
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by evaluating goals and expected outcomes including effective coping, family coping, caregiver emotional health, psychosocial adjustment: life change
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Give interventions involving client supportive systems in family dynamics:
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1) identify and adapt family strengths to perceived stressors
2) Set goals with family that are realistic 3) Provide information on support networks |
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What are the purposes of giving broad openings in effective communication in mental health nursing?
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1) communicates a desire to begin a meaningful interaction
2) allows the client to define the problem or issue |
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T/F: Within the therapeutic milieu of the mental health facility the client is expected to learn adaptive oping, interaction, and relationship skills that can be generalized to other aspects of life
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True
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What are the characteristics of the therapeutic and safe environment?
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- clean and orderly unit
- color scheme should be appropriate for the client's age - setting should include comfortable furniture for lounging and interacting with others - solitary spaces for reading and thinking alone, comfortable places conducive to meals, and quiet areas for sleeping - floors should be attractive, easy to clean, sage for walking -traffic flow considerations should be conducive to client and staff |
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Describe characteristics of a therapeutic environment
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-promote independence for self care and individual growth in clients
- allow choices for clients within the daily routines and within indiv tx plans - treat client as indiv - apply rules of fair tx for all clients - model good social behaior for clients, such as respect for the rights of others - work cooperatively as a team to provide care - maintain boundaries with clients - maintain professional appearance and demeanor - promote safe and satisfying peer interactions among clients - practice open communication techniques with HCP and clients -promote feelings of self-worth and hope for the future - clients should feel safe from harm - clients should feel cared about and accepted by the staff and others |
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T/F: the nurse's station and other areas should be set up for easy observation of clients by staff and access to staff by clients
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True
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How to set up the following provisions to prevent client self-harm or harm by others?
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- no access to sharp or otherwise harmful objects
- restriction of client access to out of bounds or locked areas - monitoring of visitors - restriction of alcohol and illegal drug access or use - restriction of sexual activity among clients - deterrence for elopement from facility - rapid de-escalation of disruptive and potentially violent behaviors through planned interventions by trained staff |
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T/F: Seclusion rooms and restrains should be set up for safety and used when there are harms to clients and/or staffs. When used, there should be procedures and policies to prevent any client harm
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False. used only after all less restrictive measures have been tried.
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What are the considerations of room assignments on a 24 hour inpatient unit?
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- personalities of each roommate
- the likelihood of nighttime disruptions for a roommate if one client has difficulty sleeping - medical diagnoses, such as how tow clients with severe paranoia might interact with each other |
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Structure activity may include time for ---
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- community meetings
- group activities and indiv therapy sessions - recreational activities - psychoeducational classes such as learning about medication side effects |
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Describe unstructured flexible time
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Unstructured flexible time in which the nurse and other staff are able to observe clients and ineract spontaneously within the milieu.
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What are the interventions that assist with client adaptation?
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- establish a therapeutic relationship with the client. A caring and nonjudgmental manner puts the client at ease and fosters meaningful communication
- ensure privacy and confidentiality, many sensitive issues may be discussed, and the client needs to now that these issues are safe to discuss. - identify indiv who may be at risk for body image dusturbances - acknowledge anger, depression, and denail as normal feelings when adjusting to body changes. - encourage the client to participate in the plan of care, - arrange for a visit from a volunteer who has experienced a similar image change. |
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What EEG does?
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EEG records electrical activity and identified the origin of seizure activity
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client instruction regarding EEG includes:
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- no caffeine
- wash hair before the procedure ( no oils, sprays) and after the procedure (remove electode glue) - may be asked to take deep breaths and/or be exposed to flashed of a strobe light during the test. - sleep may be withheld prior to test and possible induced during test |
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What is the purpose of maintaining normal blood glucose levels?
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to prevent development of complications like: hypoglycemia, hyperglycemia, diabetic ketoacidosis
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Describe changes of lab value in the uncompensated state
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The pH will be abnormal and either the HCO3 or PaCO2 will be abnormal
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the ph, HCO3, and PaCO2 will be abnormal
What state is it in the base-acid balance lab value? |
Partially compensated
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the pH will be normal, but the PaCO2 and HCO3 will both be abnormal
What state is it in the base-acid balance lab value? |
fully conpensated
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What is Diabetic Ketoacidosis?
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DKA is an acute, life-threatening condition characterized by hyperglycemia (> 300mg/dL) resulting in breakdown of body fat for energy and an accumulation of ketones in the blood and urine. The onset is rapid
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What are the cause of hyperglycemia?
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- lack of sufficient insulin
- increased need for insulin |
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What are the signs and symptoms of Diabetic Ketoacidosis?
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- polyura, polydipsia, polphagia (early signs)
- change in mental status - signs of dehydration ( dry mucous membrane, wt loss, sunken eyeballs, resulting from fluid loss such as polyuria - Kussmaul respiration pattern, rapid and deep respirations, "fruity" breath - N/V, abdominal pain |
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What do Hgb/Hct value look like in a dehydrated client?
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-Hgb/Hct increase
- serum osmolarity increase ( increase protein, BUN, electrolytes and glucose) - Urine Specific |
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T/F: in a dehydrated client, serum osmolarity increase ( increase protein, BUN, electrolytes and glucose)
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True
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What are expected lab finding in a dehydrated client?
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Hgb/Hct increase
- serum osmolarity increase ( increase protein, BUN, electrolytes and glucose) - Urine Specific gravity and osmolarity increase - Serum Sodium increase |
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What is the normal Hgb for males?
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13.5-18 g/dL
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What is the normal Hgb for females?
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12-16 g/dL
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What is the normal Hct for males?
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40-54%
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What is the normal Hct for females?
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38-47%
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What is the normal BUN?
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10-30 mg/dL
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What is the normal potassium level?
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3.5-5.5
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What is the normal specific gravity?
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1.005-1.030 (increase = concentrated)
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What is the normal serum sodium?
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135-145 mEq/L
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In Rheumatic fever, what are expected lab findings for:
Antistreptolysin O titer? Erythrocyte sedimentation rate? C-reactive protein? Throat culture? WBC count? Red blood cell parameters? |
- Antistreptolysin O titer > 250 IU/ml
- Erythrocyte sedimentation rate > 15 mm/hr in men, > 20 mm/hr in women - C-reactive protein is Positive - Throat culture is Positive for streptococci (ussually negative) - WBC count elevated _ RBC parameters: mild to moderate degress of normocytic, normochromic anemia |
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What are expected lab findings for urine chemistry in patient with Diabetes Insipidus?
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Urine chemistry: think Dilute
=> DECREASE urine specific gravity (< 1.005), urine osmolarity (50-200 mOsm/kg), urine pH, urine Na, urine K. |
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What are expected lab findings for serum chemistry in Diabetes Insipidus patient?
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( As serum volume decreases, the serum osmolarity increases)
=> INCREASE serum osmolarity, serum Na, and serum K+ |
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What is BNP?
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BNP stands for Human B type Natriuretic peptide. It is used to differentiate dyspnea r/t CHF vs respiratory problem and to monitor the need for and effectiveness of aggressive CHF intervention
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BNP levels <100 pg/ml indicates----
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no CHF
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BNP levels 100-300 pg/,L suggest-----
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CHF is present
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BNP levels > 3000 pg. mL indicates ----
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mild CHF
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BNP levels > 600 pg/mL indicates----
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moderate CHF
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BNP levels > 900 pg/mL indicates----
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severe CHF
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In CHF patients, what are expected lab findings for:
BNP? CVP? right arterial pressure? PCWP? PAP? CO? |
BNP > 100pg/ mL
CVP (central venous pressure) increased right arterial pressure increased PCWP (pulmonary capillary wedge pressure) increased PAP (pulmonary artery pressure) increased CO decreased |
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What is conscious sedation?
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Conscious sedation is the administration and/or hypnotics to the point where the client is relaxed enough that minor procedures can be performed without comfort, yet the client can respond to verbal stimuli, retains protective reflexes (gag reflex), is easily arousable and (most importantly) independently maintains a patent airway
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What are nursing responsibilities after the conscious sedation procedure?
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record VS and LOC until the client is fully awake and all assessment criteria return to pre-sedation levels.
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What typical discharge criteria after the conscious sedation procedure?
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_ LOC as on admission
_ VS stable for 30-90 min _ Ability to cough and deep breathe _ Ability to take oral fluids _ No N/V, SOB, or dizziness |
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What are complications of peripheral venous disease?
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-Ulcer formation: typically ove malleolus, more often medially than laterally. May lead to amputaion and/or death
_ Pulmonary embolism: occurs when thrombus is dislodge, becomes emboli and lodges in the pulmonary vessels. |
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Interventions for Deep Vein Thrombosis and Thrombophlebitis: -----
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- bedrest
- elevation of extremity above the level of the heart (avoid using a knee gatch or pillow under knees) - admin intermittent or continuous warm moist compresses (to prevent thrombus from dislodging and becoming an embolus. Do not massage the affected limb) - provide thigh-high compression or antiembolism stockings to reduce venous stasis and to assist in venous return of blood to the heart. -Admin meds as prescribed -monitor aPTT to allow for adjustments of heparin dosage - monitor platelet counts for heparin-induced thrombocytopenia |
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What is antidote for heparin?
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Protamine sulfate, needed for for excessive bleeding in pt taking heparin
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give examples of Low molecular weight Heparin
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-Enoxaparin (Lovenox)
- Dalteparin (Fragmin) - Ardeparin (Normiflo) |
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When is Low molecular weight Heparin prescribed?
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to prevent and treat Deep Vein Thrombosis
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What are client criteria for taking Low molecular weight Heparin?
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-must have stable DVT or PE
- low risk for bleeding - adequate renal function - normal vital signs - willing to learn self- injection |
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T/F: aPTT is checked on an ongoing basis for client taking Low molecular weight Heparin
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False: the aPTT is not checked on an ongoing basis because the doses of LMWH are not adjusted
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What is warfarin action?
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works in the liver to inhibit synthesis of the four vitamin K dependent clotting factors
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when warfarin has a therapeutic effect?
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takes 3-4 days before it has therapeutic anticoagulation
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T/F: heparin is discontinued before the administration of warfarin
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False: heparin is continued until the warfarin effect is achieved then IV heaprin may bed d/c'd
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T/F: if client is on LMWH, warfarin cannot be administered
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False: if client is on LMWH, warfarin is added after the first dose of LMWH
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How is the therapeutic level for warfarin measured?
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measured by INR
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What is an antidote for warfarin?
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Vitamin K
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what is the nurse need to monitor in client taking warfarin?
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monitor for bleeding
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the indication of Thrombolytic therapy:
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dissolve thrombi quickly and completely
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When to administer thrombolytic therapy for it to be most effective?
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must be initiated within 5 days after onset of symptoms to be most effective
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what is the advantage of thrombolytic therapy?
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is the prevention of valvular damage and consequential venous insufficiency or postphlebitis syndrome
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Contraindications for thrombolytic therapy?
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contraindicated during pregnancy and following surgery, childbirth, trauma, a CVA, or spinal injury
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What is tissue plasminogen activator (t-PA)?
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is a thrombolytic agent and platelet inhibitors
ex: abciximab (REoPRo), tirofiban (Aggrastat), sptifibatide (Integrilin) |
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Indication for tissue plasminogen activator (t-PA)
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may be effective in dissolving a clot or preventing new clots during the first 24 hours.
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The primary complication of thrombolytic therapy is -----
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serious bleeding
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Client teaching for Venus Insufficiency:
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- elevate legs for at least 20 minutes , 4-5 times a day, above the level of the heart,
- avoid prolonged sitting or standing, constrictive clothing or crossing legs when seated. -wear elastic or compression stockings during the day and evening - on using an intermittent sequential pneumatic compression system is applied over a dressing. |
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Client teaching for elastic or compression stockings:
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- put elastic stockings on before getting our of bed after sleep
- clean the elastic stockings each day, keep the seams to the outside, and do not wear bunched up or rolled down. -replace worn our compression stockings as needed. |
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client teaching for an intermittent sequential pneumatic compression system
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- instruct the client to apply the system twice daily for 1 hour in am and evening
- advise the client with an open ulcer that the compression system is applied over a dressing. |
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client teaching for Varicose Veins:
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- emphasize the importance of antiemolism stockings as prescribed
- instruct the client to elevate the legs as much as possible - instruct the client to avoid constrictive clothing and pressure on the legs. |
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the common manifestation of sickle cell anemia is ----
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Vaso-occlusive (painful episode) usually lasting 4-6 days
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S/S of acute sickle cell anemia
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- severe pain, usually in bones, joints, and abdomen
- swollen joints, hands and feet - anorexia, vomitting, fever - hematuria - obstructive jaundice - visual disturbances |
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S/S of chronic sickle cell anemia:
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- increased risk of respiratroy infections and/or osteomyelitis
-retinal detachment and blindness -systolic murmurs - renal failure and enuresis - liver failure - seizures - deformities of the skeleton |
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What are the si/s of sickle cell anemia in the stage of sequestration?
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- excessive pooling of blood in the liver (hepatomegaly) and spleen (splenomegaly)
- tachycardia, dyspnea, weakness, pallor, and shock |
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what is aplastic anemia?
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extreme anemia as a result of decreased RBC production
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What is hyperhemolytic?
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increase rate of RBC destruction leading to anemia, jaundice, and/or reticulocytosis
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Sickle Cell Crisis prevention
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- avoid high altitude
- maintain adequate fluid intake - treat infection promotly - pneumovax, influenza, and hepatitis immunizations should be administered -treat chronic leg ulcers during physical activities (minimize tissue deoxygenation) - avoid contact sports if spleen is enlarged - edequate nutrition, freq medical supervision, proper hand wahsing and isolation from known sources of infection |
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Assess for hemorrhage after a thyroidectiomy:
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- assess surgical dressing and incision site for excessive drainage or bleeding during the postop period,
- inspect the surgical dressing for bleeding especially at the back of the neck. |
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Nursing care to prevention hemorrhage after a thyroidectomy:
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- avoid pressure on the suture line
- encourage the client to avoid neck flexion or extension - support the head and neck with pillow or sandbags. If client needs to be transferred from stercher to bed, support the head and neck in good body alignment. |
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Assess for thyroid storm after a thyroidectmy:
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- monitor for signs of thyrotoxicosis, a hypermetabolism state that is a result form elevated thyroid hormone level, ( tachycardia, diaphoresis, increasd BPs, anxiety)
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Assess for airway obstruction after a thyroidectomy:
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- a trach tray should be kept near the client at all times during the immediate recovery period.
- maintain the bed in high-fowler's position to decrease edema and swelling of the neck. - if the client reports the dressing feels tight, the surgeon needs to be alerted immedately. |
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Assess for hypocalccemia and tetany after a thyroidectomy due to damage to the parathyroid glands
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- monitor for s/s of hypocalcemia (tingling of the fingers and toes, carpodedal spasms, and convulsions)
- have calcium gluconate available - maintain seizure precaution |
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Nursing intervention to prevent aspiration in CVA client
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- maintain patent airway
- monitor for changes in client's LOC ( increased ICP sign) - elevate client's head to reduce ICP and to promote venous drainage. Avoid extreme flexion or extension, maintain head in midline neutral position and elevate to 30 degrees. - institute seizure precautions -maintain non-stimulating environment -assist with communication skills if client's speech is impaired. |
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nursing interventions for safe feeding for a client with CVA
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- assess swallowing reflexes: swallowing, gag, and cough before feeding
- liquid may need to be thickened to avoid aspiration - have client eat in an upright position and swallow with the head and neck flexed slightly forward - place food in the back of the mouth on the unaffected side -suction on standby |
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Prevention and Monitoring for thromboemolism during postop period (especially following abdominal and pelvic surgeries)
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- apply pneumatic compression stockings and.or elastic stockings
-reposition the client every 2 hr and ambulate early and regularly -administer low-level anticoagulant as prescribed -monitor extremities for calf pain, warmth, erythema, and edema |
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client positioning during postop period
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- position client supine with head flat (prevent hypotension)
- do not elevate the legs higher than placement on a pillow if the client has received spinal anesthesia - do put pillows under knees or use a knee gatch (decrease venous return) |
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S/S of Cardiac Tamponade, a complication of Angiography
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- hypotension
- JVD - muffled heart sound - paradoxical pulse (variation of 10 mmHg or more in systolic blood pressure between expiration and inspiration) -hemodynamic monitoring will reaveal intracardiac and pulmonary artery pressures similar and elevated (plateau pressure) |
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Nursing intervention for Cardiac Tamponade
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- notify the PCP immediately
-admin IV fluids to combat hypertension as ordered. - obtain a chest xray or echocardiogran to confirm dx -prepare the client for pericardiocentesis (informed consent, gather materials, admin meds as appropriate) |
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Nursing intervention after a pericardiocentesis
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- monitor hemodynamic pressures as they normalize
- monitor hear trhythm, changes indicate improper positioning of the needle - monitor for reoccurrence of signs after the procedure |
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S/S of Cardiac Tamponade, a complication of Angiography
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- hypotension
- JVD - muffled heart sound - paradoxical pulse (variation of 10 mmHg or more in systolic blood pressure between expiration and inspiration) -hemodynamic monitoring will reaveal intracardiac and pulmonary artery pressures similar and elevated (plateau pressure) |
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Nursing intervention for Cardiac Tamponade
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- notify the PCP immediately
-admin IV fluids to combat hypertension as ordered. - obtain a chest xray or echocardiogran to confirm dx -prepare the client for pericardiocentesis (informed consent, gather materials, admin meds as appropriate) |
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Nursing intervention after a pericardiocentesis
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- monitor hemodynamic pressures as they normalize
- monitor hear trhythm, changes indicate improper positioning of the needle - monitor for reoccurrence of signs after the procedure |
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Nursing interventions for Hematoma Formation, a complication of Angiography
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- assess the groin at prescribed intervals and as needed
-hold pressure for uncontrolled oozing/bleeding -monitor peripheral circulation -notify PCP |
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NUrsing interventions for Restenosis (of treatd vessels)
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- assess ECG patterns and for occurrence of CP
- notify PCP immediately - prepare the client for return to the cath lab |
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Nursing intervention for retroperitoneal bleeding, a complication of Angiography
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- assess for flank pain and hypotension
- notify the PCP - admin IV fluids and blood products as ordered |
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Measures to prevent aspiration
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- assess for gag reflex. Place tongue blad in client's mouth, touching uvula to induce a gag response.
- assist client to high fowler's position unless contaraindicated helps reduce risk of aspiration and promotes effective swallowing |
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Aspiration of stomach contents into the respiratory tract (immediate response) evidenced by -----
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coughing, dyspnea, cyanosis, auscultation of crackles and wheezes.
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Nursing intervention for aspiration for client w/ immediate response
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- position client on side
- suction nasotracheally and oral tracheally - consult PCP to order chest x-ray exam |
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Aspiration of stomach contents into respiratory tract (delayed response) evidenced by -----
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- dyspnea
- fever - auscultation of crackles - wheezes |
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Nursing intervention for aspiration in client with a delayed response
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- consult PCP to obtain order for chest x-ray
- prepare for possible initiation of abx |
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Assessing/monitoring neurological status in head injury
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- respiratory status
- changes in LOC - LOC and length - Cushing reflex - Posturing - Cranial nerve function - Pupillary changes - Signs of infection (nuchal rigidity with meningitis) - CSF leakage from nose and ears |
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T/F: Respiratory status is the priority assessment for neurological assessment in head injury
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True
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T/F: changes in LOC is the latest indication of neurological deterioration
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False: it is the earliest sign
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S/S of Cushing Ref;ex
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- severe HTN w/ a widened pulse pressure and bradycardia
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What are the 3 posturings indicate neirological deterioration
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- decorticate
- decerebrate - flaccid |
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T/F: Cushing reflex is the early signs of ICP
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False: the late sign
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What are you looking when performing pupillary assessment?
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_ PERRLA
- pinpoint - fixed/nonrepsonsive -dilated |
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How do you tell there is CSF leakage?
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yellow stain surrounded by blood, a test positive for glucose
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GCS rating: normal? deep coma?
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15 = normal
3 = deep coma |
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Risks factors/ causes of UTI
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- femal gender
-indwelling urinary catheters - stool incontinence - bladder distention - urinary conditions (abomalies, stasis, calculi, and residual urine) -possible genetic links - disease (DM) |
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reasons female are prone to UTIs: ----
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- short urethra
- close prosimity of the urethra to the rectum - decreased estrogen in aging women promotes atrophy of the urethral opening toward the rectum -sexual intercourse - freq use of feminine hygiene sprays, tampons, sanitary napkins, spermicidal jellies - pregnancy - women who are fitted poorly for diaphragms - hormonal influences within the vaginal flora -synthetic underwear and pantyhose - wet bathing suits -freq submersion into baths or hottubs |
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nursing intervention post op hip replacement surgery regarding activity limits
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- early ambulation
- transfer out of bed from unaffected side - wt bearing status is determined by the orthopedic surgeon and by the choice of cemented vs non cemented protheses |
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client teaching post op hip replacement surgery regarding activity limits
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- use assisted devices
-Client position: supine with head slightly elevated with affectd led in neutral position and a pillow or abduction device between legs to prevent abduction which could cause hip dislocation - arrange for raised toilet seats, extended handle items (shoehorn, dressing sticks) |
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What are the dos for cliet post op hip replacement regarding activity limits:
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-use elevated seating raised toilet seat
- use straight chairs with arms - use and abduction between legs while in bed (and with turning) -externally rotate toes |
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What are the don'ts for a client post op hip replacement surgery?
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- avoid flexion of hip > 90 degrees
- avoid low chairs - do not cross legs - don not internally rotate toes |
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client teaching for the client post op knee replavement surgery regarding activity limits
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- positions of flexion of the knee are limited to avoid flezion contractures.
- avoid knee gatch andn pillows placed behind the knee - knee immobilize may be used while in bed - goal is to be able to straight leg raise - kneeling and deep knee bends are limited indefinitely -CPM is used to promote motion in the knee and prevent scar tissue formation. |
