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359 Cards in this Set
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- Back
when do you need an order for restraints
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within one hour unless serious risk to you or patient.
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are there prn orders for restraints
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no
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how often do restraint orders need to be renewed
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every 24 hours on non leathers
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can you use a physical and chemical restraint at the same time
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no only one at a time
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can you put a patient in spread eagle
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no
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how many side rails are considered a restraint
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if all 4 are up
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what are geri chairs
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restraints
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what should you document when giving a restraint
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that you tried other approaches, date and time the restraint is applied, type of restraint, and notification of patients family and physician. Include frequency of assessment, your findings, regular intervals, when the restraint is removed and nursing interventions
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what other types of approaches can you use
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diversion, low boy bed, electronic alarms, exercise, out to nurses station, get a sitter.
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when should you check for when restraints are on
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toileting-q3
circulation- q2 or more two finger check for tightness remove and do rom-q2 food and water find flow sheets use quick release knot attach to frame not side rail |
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how many stages of skin break down of pressure are there
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4 stages. later added 2 more stages (deep tissue injury and unstageable pressure ulcers)
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how are the stages pregressed
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starts as reddened, then raw, then tear/blister, then deteriorates to massive tunneling craters.
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when should you intervene on a pressure ulcer
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before you see red
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what is suspected deep tissue injury
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purple or maroon localiezed area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and or shear.
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what may a deep tissue injury be preceded by
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tissue that is painful, firm, mushy, boggy, warmer or cooler and compared to adjacent tissue.
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how might it be hard to detect a deep tissue injury in
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dark individuals
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how does a suspected deep tissue injury evolve
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may include a thin lister over a dark wound bed, the wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment
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how d you characterize stage one pressure ulcer
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intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Dig pigmented skin may not have visible blanching. May be painful, firm, soft, warmer or cooler as compared to adjacent tissue. May be difficult to detect in individuals with dark skin tones
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how do you treat stage one pressure ulcer
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use duoderm to protect skin integrity or tegaderm over duoderm if duoderm is rolling off
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what is a stage 2 pressure ulcer
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partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Partial thickness skin loss involving epidermis, dermis or both.
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how is a stage 2 pressure ulcer presented
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shiny or dry shallow ulcer without slough or bruising. This stake should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. Ulcer is superficial-presents as abrasion, blister or shallow center.
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what is a ducubitus ulcer
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stage 2 ulcer
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how do you treat a stage 2 ulcer
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use duoderm or curasol wound gel with dry dressing (if lightly draining)
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what is used in colostomy wafers
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pectin which is duoderm
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what is a stage 3 pressure ulcer
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full thickness tissue loss. subcutaneous fat may not be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling
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how deep do nose, ear occiput and malleolus tunneling go
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they do not have subcutaneous tissue and can be shallow
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what part of the body can develop extremely deep stage 3 pressure ulcers
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areas of significant adiposity but bone and tendon is no visible or directly palpable.
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how are stage 3 ulcers presented
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as a deep crater. Full thickness kin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. Bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
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what is a stage 4 pressure ulcer
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full thickness tissue loss with exposed bone, tendon ro muscle. Often include undermining and tunneling.
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where do stage 4 pressure ulcers extend to
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into muscle and or supporting structures such as fasica, tendon or joint capsule making osteomyelitis possible
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how do you document tunneling
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stick qtip in a say how far it goes in a the time
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what is an unstageable pressure ulcer
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full thickness tissue loss in which the base of the ulcer is cover by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown or black) in the wound bed.
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why is is called unstageable
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cannot stage what you cannot see
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what might be unstageable
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surgical debridement, necrosis???
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what is maceration
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ongoing contact with excessive moisture softens the skin, turns it white and causes it to breakdown. Exudate leaked from ulcers can also cause maceration, leading to larger ulcers or satellite ulcers
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how are heel ulcers treat differently than sacral area
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won't be surgically treated
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what do you do for skin tear and tape burns
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don't use tegaderm, used gentle clean, roll skin back, use petroleum gauze
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what is a pressure ulcer
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called decubius or decubiti and is caused by the pressure of the patients own body weight preventing blood flow to tissues causing
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what is decubiti
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a bedsore
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what is the amount of direct pressure on the skin to have skin necrosis
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greater than 32 mm Hg for capillary perfusion pressure for as little as 2 hours
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after short periods of immobilization how high do sacral pressure reach
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70 mm Hg
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what is the pressure under the unsupported heel averages
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45 mm Hg
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how often do you want to move someone
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atleast every 2 hours
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what does pressure depend on
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position in bed
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what is important is skin integrity
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nutritional status, hydration, proteins should be given.
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what should you do if a person is stuck in lateral position
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small position changes are helpful, skin prep, assess, first see red spongy then break down, nutrition- proteins-more later, hydration, keep pt dry as a skin barrier, draw sheets.
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what is a normal prealbumin level
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15-30 and half life is 2 days.
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what is normal albumin levels
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3.5-5.0. half life is 20 days.
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what is the difference between prealbumin and albumin
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prealbumin will show you changes in nutritional status over the last 7 days
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how do you treat pressure ulcers
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key is prevention. Assess pressure points and nutrition. Use dressing to keep ulcer moist but remember not to get surrounding tissue wet. Don't use betadine or hydrogen peroxide, use a vac.
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how should you pack an ulcer
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loosely
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how should you ask you patient before treating ulcer
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if they want pain medicine
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what is the braden scale
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six pint assessment tool for skin breakdown. Pressure sore risk
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what are the 6 points of the braden scale
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sensory perception, moisture, activity, mobility, nutrition, friction and sheer
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how is sensory perception scored on the braden scale
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ability to respond meaningfully to pressure related discomfort.
1: completely limited: unresponsive to painful stimuli 2. very limited: resonds only to painful stimuli 3. slightly limited: responds to verbal commands but cannot always communicate discomfort 4. no impairment: responds to verbal commands and has no sensory deficit |
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how is moisture scored on the braden scale
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degree skin is exposed to moisture
1. constantly moist-skin is moist almost constantly by perspiration, urine, ect. 2. moist-skin is often but not always moist, linen changed atleast once a shift 3. occasionally moist- skin is occasionally, linen change x1 4. rarely moist-skin is usually dry, linen requires changing only at routine intervals |
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how is activity scored on the braden scale
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degree of physical activity
1. bedfast-confined to bed 2. chairfast- ability to walk severely limited or nonexistent. Cannot bear own weight 3. walks occasionally- walks occasionally during day but for very short distances, spends majority of each shift in bed or chair 4. walks frequently- walks outside the room at least twice a day and inside room at least once every two hours during waking hours |
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how is mobility scored on the braden scale
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ability to change and control body position
1. Completely immobile-does not even make slight changes in body or extremity position without assistance 2. Very limited- makes occasional slight change in body or extremity position but unable to make frequent or significant changes independently 3. slightly limited-makes frequent though slight changes in body or extremity position independently 4. no limitations |
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what can raising bed do to the skin
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cause shearing
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what is shear
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the result of skin being pulled in one direction, however supporting structures such as muscle and bone do not move, or move in the opposite direction.
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what is friction
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the result of the skin being moved one way while a surface is stationary or moves in the opposite direction
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how is friction and shear scored on the braden scale
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1. Problem- requires moderate to maximum assistance. Frequently slides down in bed or chair. Spasticity, contractures leads to almost constant friction.
2. Potential problem- moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position 3. No apparent problem: moves in bed and chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. |
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how do you move patient to head of bed
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use two people at minimum. use draw sheet. put HOB down. tell patient to cross arms and have knees bent, heels on bed and chin down.
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when should you document skin assessment
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on admission
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what should you document about skin assessment
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prevention as well as treatment and education. Document stage, length, width, depth, tunneling.
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what are the nursing diagnosis of skin
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impaired tissue integrity, ineffective tissue perfusion, pain. at risk for infection, care giver strain
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what are the hazards of bed rest beyond pressure ulcers
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loss of muscle mass and bone density, hight potential for neuro involvement, DVT. Also have impact on cardiac, pulmonary and mental systems.
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what does bed rest do to nutrition
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leads to reduced stimulation of whole-body protein synthesis by amino acid administration.
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what does recumbent position do to hydrostatic pressure
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loss of most hydrostatic pressure below heart, and reduced muscular force of all bones, and reduced total energy utilization
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how is the cardiopulmonary system effected by bed rest
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results in loss of plasma volume and CO is effected.
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how is the pulmonary system effected by bed rest
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supine reduces ventilation even more by increasing the closing volume enough to cause an additional fall in PaO2 2-8 mm Hg
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how is neuro system affected by bed rest
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sensory deprivation or overstimulation results in confusion and delirium. Developing subjective sensory distortions
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how do you prevent hazards of bedrest
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positioning, ROM, exercise in bed.
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what do you do to assess the joints
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inspect, palpate, ROM, strength
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Why do you do ROM
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to see if motion is limited by a mechanical problem within the joint, swelling of tissue around joint, spasticity of the muscles, pain or disease.
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what is a contracture
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fixed tightening of muscle tendons, ligaments, or skin. prevents normal movement of the associated body part.
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what is the best kind of ROM
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active
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if you have to do passive ROM what do you do
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extend, flex and rotate. imitate normal movements
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How often should you do passive ROM
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once per day. Each 10 times to the point of resistance.
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how do you do passive ROM
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do it slowly, watching pts face for pain, move until pt feels a slight stretch, but don't force a movement. Move only to the point of resistance, keep limbs support throughout motion.
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how do you do hip and knee flexion
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push knee toward chest.
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how do you do hip rotation
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bend the knee halfway to the chest with 90 degree angle between knee and hip, push foot away from you then pull foot toward you.
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how do you assess hip abduction
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pull straight leg toward you
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how do you ankle rotation
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turn foot inward and outward
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how do you do toe flexion
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pull toes forward and push forward
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how do you do heel cord stretching
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place forearm against the ball of the foot. Push the ball of the foot forward, bending the foot toward the knee and stretching the muscles in the back of the leg
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when should you do ROM
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before getting patient out of bed.
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what muscles and how do you assess
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shoulder flexion, wrist extension, elbow extension and flexion, grip, hip flexion, knee flexion and extension, ankle plantar flexion and dorsiflexion
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which action is believed to be most useful in preventing wound infections
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performing careful hand hygiene
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what is the type of moist heat application
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a sitz bath. Aquathermia pad, hot water bag, and commercial hot packs are dry heat.
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what action would be a priority in preventing a patient form developing a pressure ulcer.
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using a mild cleansing agent when cleansing the skin
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what do you do to prevent pressure ulcers in patients in supine
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use padding, use air bed, turning, skin prep, skin barriers on, bonny boots/heel elbow protectors on.
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what are the phases of wound healing
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hemostasis, inflammatory phase, proliferation phase maturation phase.
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what are factors that affect wound healing
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local factors and systemic factors
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what are local factors that affect wound healing
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pressure, desiccation, maceration, trauma, edema, infection, necrosis
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what is desiccation
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dehydration
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what is maceration
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over hydration
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what are systemic factors that affect wound healing
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age, circulation and oxygenation, nutritional status, wound condition, medications and health status
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what is dehiscence
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partial or total separation of wound layers as a result of excessive stress on wound that are not healed but muscle is still intact.
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what is evisceration
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wound completely separates with protrusion of viscera through the incisional area. Protruding bowl ect. can occur.
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what is a fistula
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abnormal passage from an internal organ to the outside of the body or from one internal organ to another.
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what are the factors in pressure ulcer development
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external pressure the compresses blood vessels and friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin
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what is local anemia resulting from poor circulation called
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ischemia
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what should the nurse assess for wounds
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skin assessment, nursing history, pain assessment, wound assessment, pressure ulcer assessment
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what do you assess in wound assessment
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appearance, drainage, sutures and staples
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what do you assess in pressure ulcer assessment
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risk assessment, appearance, mobility, nutritional status, moisture and incontinence.
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what is a normal potassium level
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3.5-5.0
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what should you say when labs are out of safe range
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symptoms, vital signs, what meds, what IV is running, I and O per hour check EKG, allergies, LOC, pain. Have chart in front of you.
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what are factors influencing communication
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developmental level especially for transfer of information, Gender for you and patient, sociocultural gender differences, language and the culture of the hospital. Prior relationships, and hierarchy
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what is the root cause of sentinel events
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communication problems
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why are they called sentinel events
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because they signal the need for immediate investigation and response.
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why does communication break down
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different communication styles, high level of activity, frequent interruptions, no standardization in organizing essential information
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what is the result of communication break down
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loss of information
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what are nurses communication styles
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narrative and descriptive
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what are physician communication styles
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guided to be problem solvers "just the facts please"
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what is SBAR
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a framework for communication to keep patient safe. Situation, Background, Assessment, Recommendation
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what is situation
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the problem
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what is background
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brief, related, to the point
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what is assessment
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what you found, what you think
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what is recommendation
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what you want
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what do you state in situation
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Name and unit, who you are calling about, the problem.
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what do you state in background
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state the admission diagnosis and date of admission, state the pertinent medical history, a brief synopsis of the treatment to date
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what do you state in assessment
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pertinent objective and subjective information for you to decide. Can state vitals, mental status, respiratory rate and quality, blood pressure, pulse rate and quality, pain, neuro changes, skin color, rhythm changes in input and output
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what do you state in recommendation
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what you would like to see done. Can be to transfer the patient, change treatment, come to see the patient at this time, talk to the family and patient about something, ask for a consulting physician to see the patient
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what should you ask for in recommendation
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if the patient does not improve, when would you want to be called again
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when talking to a family you should never
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say anything with out a purpose
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what is intrapersonal level of communication
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talking to yourself... such as a pep talk. Often where spiritual aspects arise
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how can patients and nurses communicate
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eye contact, facial expression, posture and gait, touch, gestures, sounds, cry, hummph. Never say oops as a nurse.
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what is communication via touch
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can be used as a distracter from pain. Pain is worse when alone. Hand is often most effective to show you care, they can tell your there especially if there eyes are clossed.
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what does communicating via actions do
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actions speak louder than words. Explain your actions when they can be misconstrued. Say 'For you' a lot
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what does communicating with space do
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use space especially if patient is angry. Often evaporates in emergency.
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when should you use open questioning
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when a patient says something like i don't feel so well
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when should you use closed questioning
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when a patient says something like i am having chest pain
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what is the difference between a helping relationship vs. a friendship
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helping occurs for a specific purpose with a specific person. it is purposeful and time limited. You never know where next answer will take you such as asking about a son in pre open heart if son is dead
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what are some barriers to communication
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hearing, mental, physical, emotional state, foreign language, special needs such as coma, vents, aphasia, infant ect.
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what are reasons for patient teaching
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Illness/injury prevention such as for immunizations, health screenings, safety
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what are other reasons for patient teaching
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health restoration such as medication information, treatment implementation, the illness anatomy and physiology, signs and symptoms, significance and what to
do. Facilitating coping-stress management, grief counseling, referrals for PT, self help groups, etc |
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what should you teach all patients about falling
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it could open incision, if person is on anticoagulant
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what are the ABCS of falling
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Age, bone, coagulants, surgery-mean high risk for serious injury
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how do you teach diabetics
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start where they want, teach about measuring glucose, injections, and diet, exercise, and stress
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what should teach your patient in pre up
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will they wake in ICU of ventilator, pain control, tubes they will have, when they come out, when they are allowed to get out of bed, if they have a blood glucose monitor, teach them to practice deep breathing to prepare
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what is noncompliance associated with
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patient confusion, disappointment, misunderstanding, fear, or inadequate finances
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what are the systems associated with urinary elimination
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cardiovascular, renal, neuro.
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what is the renal function
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filter blood/waste products, excrete urine, maintain fluid, electrolyte, acid base balance
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what is the process you should to for functional status of GI and GU
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ADPIE
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what is the fluid balance affected by or have an impact on
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GI, GU, cardiact, pulmonary, renal, skin integrity, meantal satus.
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How closely you look at I and O depends on what
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Patient condition such as ESRD, liver failure, fresh MI, CHF, fresh post op and tools.
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I and O gives you a rough assessment of balance and kidney G/U function only if
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there is no other drainage, no internal fluid shifts, no obstruction or no inability to void.
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what are some reasons to catheterize a patient
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monitoring of critically ill patients for accurate I and O, urinary retention especially post op and epidural for pain, obtaining a sterile urine specimen, surgery. Dont use for incontinent patient unless in extreme case it is delaying healing of a wound
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on a foley cath what tells you how much water to put in and take out
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the balloon port
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what is a coude catheter
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designed with a curved tip that makes it easier to thread the catheter past the prostate or obstructions in the urethral canal. Hockey stick up to umbilicus
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what is a urinary diversion ileal conduit
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diversion of rueters to the ileum, ileum brough to abdominal wall. Stoma opening is urostomy
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what are the GU assessment labs
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BUN, Cr, Na, GFR or eGFR
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what is a normal BUN level
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5-20
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what is a normal Cr level
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.5-1.5
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what is a normal Na level
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135-145
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what does BUN levels indicate
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renal and liver function
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what does an increase in BUN mean
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Renal disease, GI bleed, shock, dehydration, CHF, MI
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what does a low BUN signify
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liver failure, malnutrition, over hydration
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what is creatinine
|
breakdown of creatine, an important component of muscle
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what can creatinine be converted to
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the ATP molecule, which is a high energy source
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what is the significance of creatinine
|
creatinine is excreted form the body entirely by the kidneys and with normal renal excretory function, serum creatinine level remains normal
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what can cause changes in creatinine
|
acute tubular necrosis, dehydration, preeclampsia, hypertension, glomerulonephritis, pyelonephritis, reduced renal blood flow from shock and congestive heart failure, renal failure, rhabdomyolysis, diabetic nephropathy, urinary tract obstruction
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how is sodium related to the GU system
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it is the main extracellular cation. Related to blood pressure by its working of nerves and muscles
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what are the causes of hyponatremia
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cirrhosis, vomiting, kidney disease, diarrhea, SIADH (syndrome of inappropriate antidiuretic hormone)
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what are the causes of hypernatremia
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diabetes insipidus, hyperaldosteronism, cushings syndrome or salt or sodium bicarbonate ingestion.
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what is the GFR of stages of kidney failure
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130-90, 90-60, 60-30, 30-15, 15-0 (renal failure)
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when do you need a kidney transplant
|
stages 1 through 5
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when do you need dialysis
|
stage 5
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what questions should you ask for urinary elimination assessment
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any problems, frequency, urgency, burning, retention, color, clear cloudy sediment clots, amount if measured.
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what makes urine output low
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obstruction or retention, light on fluids
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what is the bladder is not palpable
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it is empty
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what if the bladder is moderately full
|
palpation above pubis
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what if the bladder is full
|
palpation may be close to umbilicus
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what is anuria
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no or less than 100cc in 24 hours
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what is oliguria
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decrease production of urine. 100-400 cc's in 24 hours
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what is nocturia
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increased frequency in the night
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what is hematuria
|
blood in urine
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what is the minimum assessment of the abdomen
|
inspection and palpation
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what do you check for with inspection and palpation of abdomen
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if it is round, flat, distended, symmetric, tender, soft
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what is an inguinal hernia
|
occurs when part of an organ (usually the intestines) sticks
through a weak point or tear in the thin muscular wall that holds the abdominal organs in place. Seen near bladder |
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what is lymphogranuloma venereum
|
enlarged inguinal and femoral lymph nodes separated by a groove made by the inguinal ligament
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what is a caput medusae
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the appearance of distended and engorged paraumbilical veins, which are seen radiating from the umbilicus across the abdomen to join systemic veins.
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what can happen in portal hypertension
|
dilated veins are draining towards the superior vena cava, gynaecomastia and dilated surface veins, and dilated veins drain away from the umbilicus to the caval circulation
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what is ascites
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central protuberance with a stretched umbilicus. Abdomen symetrically distended secondary to fluid buildup in peritoneal cavity. Note bulging flanks as fluid distributes to most dependent areas of abdomen. Skin also yellow due to hyperbuilirubinemia
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have causes ascites
|
alcohol
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what are the cage questions
|
questions to assess alcoholism
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what is C is cage questions
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have you ever felt that you should cut down on your drinking
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what is the A cage question
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have people annoyed you by criticizing your drinking
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what is the G cage question
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have you ever felt bad or guilty or drinking
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what is the E cage question
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have you ever had a drink first thing in the morning to stead your nerves or get rid of a hangover
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what is an incarcerated umbilical hernia
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note reddened umbilical area resulting from entrapment of intra abdominal contents in hernia. When is occurred the patient developed acute pain in this region
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what is rectus diastasis
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separation of rectus abdominus muscles, occurs in older patients and or those with weakening of the abdominal musculature. The hernia can be made more apparent by increasing intra abdominal pressure. Have head up.
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what do you ask in your GI assessment
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when was your last BM, formed, color, soft? Do you take anything to have a BM? What is your norm at home, any nausea or vomiting, and you passing any flatus
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who should be especially considered when asking about flatus
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post op patients
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what should you use to assess for vascular bruits
|
bell
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what can cause diarrhea
|
infectious agents, malabsorption, inflammatory processes, structural changes, side effects of medication, laxative/enema abuse
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what can cause constipation
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diet, dehydration, diverticular disease, neuropathy, immobility, medication, gynecological problems
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what causes fecal incontinence
|
anal sphincter dysfunction, compromised rectal function, anatomical defects
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what are some nursing diagsosis associated with GI
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bowel incontinence, constipation, diarrhea, fluid volume deficit, electrolyte imbalance, disturbed self esteem image, caregiver role stain, toileting self care deficit, impaired skin integrity
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what is the nursing process on bowel elimination
|
platn: restore patients regular elimination patterns, prevent complications through patient education.
Implementation: Increased fluid intake, high fiber diet, decrease smoking and alcohol, decrease stress, environmental modification, bowel regiment/stimulation, rectal bad/tube |
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what does caffeine do to the bladder
|
it irritates the bladder mucosa
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what happens to urine if the patient has a fever or diaphoresis
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the urine output will be decreased and highly concentrated
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what are kegal exercises
|
exercises that target the inner muscles that lie under and support the bladder and can help a patient regain control of the micturition precess
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what is enuresis
|
bed wetting
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what is maturational enuresis
|
child bed wetting at night
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what is an enema
|
he procedure of introducing liquids into the rectum and colon via the anus. The increasing volume of the liquid causes rapid expansion of the lower intestinal tract, often resulting in very uncomfortable bloating, cramping, powerful peristalsis, a feeling of extreme urgency and complete evacuation of the lower intestinal tract.
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does alcohol a laxative or constipation effect
|
laxative
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what is a fecal impaction
|
a solid, immobile bulk of stool that can develop in the rectum as a result of chronic constipation.
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what is an ileostomy
|
s a surgical opening constructed by bringing the end or loop of small intestine (the ileum) out onto the surface of the skin. Intestinal waste passes out of the ileostomy and is collected in an external pouching system stuck to the skin.
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what do emollients do
|
lubricate the stool
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what do lubricant laxatives do
|
soften the stool making it easier to pass
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what do stimulant laxatives do
|
promote peristalsis by irritating the intestinal mucosa or simulating nerve endings in the intestinal wall
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what do bulk forming laxatives do
|
causes the stool to absorb water and swell
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what does barium enema do
|
radiographic examination of the large intestine
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what does habitual use of laxatives do
|
cause chronic constipation
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what can happen in removing a fecal impaction manually
|
stimulation of the vagal nerve and resulting bradycardia
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what position facilitates the passage of flatus
|
knee chest
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what is congenital analgesia
|
lack of ability to experience pain and causes multiple health problems
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|
what is pain
|
an unpleasant sensory and emotional experience associated with actual or potential tissue damage
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is pain proportional to issue damage
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no
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is pain objective or subjective
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subjective
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what does pain do
|
inhibits the immune system and can enhance tumor growth, gastric and bowel motility goes down, have bed rest hazards, adds decrease in fluids, constipation. endocrine problems, respiratory problems, cardiovascular problems, sleeplessness, anxiety, hopelessness, thoughts of suicide
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WHAT ARE RESPIRATORY CONSEQUENCE OF UNRELIEVED PAIN
|
flow and volume go down, atelectasis, shunting goes up, cough goes down, sputum retention goes up.
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what do you give for pain
|
opioids
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why are opioids feared
|
they can be addictive and respiratory depression
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|
what are the 3 types of pain
|
acute, cancer, chronic nonmalignant
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what is nociceptive pain
|
stimulus from somatic and visceral structures
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what is neuropathic pain
|
stimulus abnormally processed by the nervous system
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|
what are nociceptors
|
free nerve ending responding to noxious or innocuous stimuli. specialized nerve ending responding to normal pain (thermal, chemical, mechanical)
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what is nociception
|
term used to describe how pain becomes conscious
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what are the four processes that must work for pain to become conscious
|
transduction, transmission, perception, modulation
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what is transduction
|
nocieptors receive sufficient stimuli from tumor, incision, crushing injury, or burn, tissue damage occus and the trauma causes release of histamine, bradykinin, serotonin, and protaglandins
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what interferes with prostaglandins
|
NSAIDs and corticosteriods
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what is transmission
|
the pain stimuli has to become an impulse to move from periphery to the cord, noxious stimuli cause the membrane to become permeable and action potential occurs
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what do you use to block Na and K from moving in and out of the cell
|
anticonvulsants block Na channels and local anesthetics block Na completely
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how can you modify pain perception
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use imagery, relaxation, distraction
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what is modulation
|
now on the descending pain system, neurons release neurotensin, GABA, serotonin, endogenous opioid
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what do antidepressants do for pain
|
interfere with the bodys uptake of serotonin that increases its availability to inhibit noxious stimuli
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what is adjuvant
|
a drug that has a primary indication other than pain but is a useful analgestic such as muscle relaxant (steroids)
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|
what do you use Ca and beta blockers and lithium for
|
migraines and cluster headaches
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|
what do you use clonidine for
|
hypertension and pain
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what is a mu agonist
|
a type of opioid like morphine that relieves pain by binding to the Mu receptor sites in the nervous system
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what are opioids
|
codeine, morphine, fentynl and other drugs relieving pain by binding to multiple types of opioid receptors in the nervous system. have cns and periphery effects
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|
what do genetic differences (polymorphisms) result in pain
|
a wide range of analgestic responses
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when should you start thinking it is time to treat pain
|
when patient says pain is a 4
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what is on the pain assessment score
|
facial expression, cry, breathing patterns, arms, legs, state of arousal
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how is the pain assessment scored
|
all categories are 0 or 1 except crying is 0-2
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|
what is the hierarchy of pain assessment
|
patient self report then patient behavior, the reports of family, then physiologic.
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what should you check in patients taking opioids
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count the respirations
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|
what is the LOC scale
|
1. sleeping
2. alert or easy to arouse 3. occasionally drowsy easy to arouse 4. frequently drowsy 5. somnolent-difficult to arouse |
|
what do you use clonidine for
|
hypertension and pain
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|
what is a mu agonist
|
a type of opioid like morphine that relieves pain by binding to the Mu receptor sites in the nervous system
|
|
what are opioids
|
codeine, morphine, fentynl and other drugs relieving pain by binding to multiple types of opioid receptors in the nervous system. have cns and periphery effects
|
|
what do genetic differences (polymorphisms) result in pain
|
a wide range of analgestic responses
|
|
when should you start thinking it is time to treat pain
|
when patient says pain is a 4
|
|
what is on the pain assessment score
|
facial expression, cry, breathing patterns, arms, legs, state of arousal
|
|
how is the pain assessment scored
|
all categories are 0 or 1 except crying is 0-2
|
|
what is the hierarchy of pain assessment
|
patient self report then patient behavior, the reports of family, then physiologic.
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|
what should you check in patients taking opioids
|
count the respirations
|
|
what is the LOC scale
|
1. sleeping
2. alert or easy to arouse 3. occasionally drowsy easy to arouse 4. frequently drowsy 5. somnolent-difficult to arouse |
|
what are the meds levels
|
first rung-non opiods (tylenol), NSAIDS (ibuprofen, adjuvants)
2nd rung- opioids in combination 3rd rung-morphine dilaudid fentanyl. opioids not in combination |
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what do you assess in pain
|
intensity, quality, onset, duration, relived by, increased by,
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|
what is the neuropathy scale
|
measure pain, if it is intense pain, sharp, hot, dull, cold, sensitive, itcy
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|
what is an intrathecal drug pump
|
pump/reservoir implanted between the muscle and skin of abdomen. catheter carries pain medication from the pump to the spinal cord and nerves
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|
what should you do if you put a limb down
|
hold it for a brief moment
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|
what is sleep regulated by
|
sleep/wake restorative process and circadian biological clock
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|
what the the mechanism that underlies endogenous circadian rhythms
|
earths rotation on its axis
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|
what are the similarities of REM and NREM sleep
|
posture, unresponsiveness, reversibility, lack of conscious awareness
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|
what are the differences between REM and NREM sleep
|
brain blood flow, glucose utilization, neurotransmitters, thalamic function
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|
what happens to heart rate, respiratory rate, blood pressure, alveolar ventilation and skeletal muscle tone in stages 1-4 of sleeping
|
goes down
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|
what is the respiratory rate in rem sleep
|
irregular
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|
what is the skeletal muscle tone in rem sleep
|
atonia
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|
what are factors affecting sleep
|
age, motivation, sleep hygiene, activity, caffeine, beverages, food, alcohol, smoking, sleep environment, illness, and medications
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|
what is the cause of sleep apnea in children
|
enlarged tonsil and adenoids, childhood obesity associated with poor school performance and impaired growth
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|
what are some sleep problems in children and young adults
|
enuresis, somnambulism, bruxism, delayed sleep phase.
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|
what are the effects of caffeine on sleep
|
competes for adenosine receptors (inhibitory neurotransmitter that induces sleep)
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|
what are the effects of alcohol on sleep
|
sympathetic arousal with decline in blood level
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|
what is somnambulism
|
sleep walking
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|
what is bruxism
|
grinding of teeth
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|
what are the problems in sleeping in adults
|
narcolepsy, restless legs syndrome, obstructive and central sleep apnea
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|
what is the sleep assessment
|
bedtime, excessive daytime sleepiness, awakenings: night waking and early morning waking, regularity and duration of sleep, snoring
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|
what are the sleep quality self assessment instruments
|
Pittsburgh sleep quality index, epworth sleepiness scale
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|
what is the epworth sleepiness scale
|
gives 8 situations and has a 0-3 chance of dozing
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|
what are the physiological measures of sleep
|
polysomnography, multiple sleep latency test.
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|
when should you give a polysomnography
|
during the day, usually at 2- hour intervals to estimate time to fall asleep. assesses severity of daytime sleepiness what are common circadian disruptions
|
|
what is effected by sleep deprivation
|
cognitive abilities and mood such as memory, paying attention to and completing tasks, hard to concentrate, solve problems and make decisions.
|
|
what are health consequences of inadequate sleep
|
OSAH in patients with diabetes in hypertensive men. obesity
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|
what are possible nursing diagnosis
|
disturbed sleep pattern, sleep deprivation
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|
how do you get better sleep hygiene
|
make bedroom good to sleep in, exercise during the day, have adequate time in bed, relax, avoid caffeine, alcohol, eat healthy, sleep during the dark of night.
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|
when should you refer to sleep center
|
longer than 30 minutes to fall asleep on 3 or more nights/week. Multiple awakenings during the night more than 2 nights/week. Falling asleep during the day without deliberate effort, patient or partner reports of excessive limb movements, loud snoring or cessation of breathing
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|
how can lifestyle affect sexuality
|
stress can affect sexual expression
|
|
what are factors affecting sexuality
|
developmental considerations, culture, religion, ethics, lifestyle, childbearing, STD or STI, heath state
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|
what are health states affecting sexuality
|
chronic pain, diabetes mellitus, cardiovascular disease, diseases of the joint and mobility, surgery and body image, spinal cord injuries, mental illness, medications
|
|
what are some male sexual dysfunctions
|
erectile failure, premature ejaculation, retarded ejaculation
|
|
what causes retarded ejaculation
|
interpersonal problems
|
|
what are some female sexual dysfunctions
|
inhibited sexual desire (orgasmic dysfunction), dysparenia, vaginismus, vuvlodynia
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|
what causes inhibited sexual desire
|
anxiety, negative emotions, fear, physical factors
|
|
what is dysparenia
|
painful intercourse
|
|
what is vaginismus
|
vaginal opening is closed tightly and prevents penitration. Secondary to involuntary spastic muscle contractions at and around the vaginal opening and the levator ani muscles
|
|
what is vuvlodynia
|
a chronic vulvar discomfort characterized by burning, stinging, irritation, or rawness of the female genitalia that interferes with sexual intercourse
|
|
what are categories of patients requiring sexual history
|
patients seeking care for pregnancy, STDs, infertility, contraception, patients experiencing sexual dysfunction, patients whose illness will affect sexual function
|
|
what is level 1 of watts general levels of sexual history
|
part of comprehensive health history, obtained by a nurse
|
|
what is level 2 of watts general levels of sexual history
|
sexual history
|
|
what is level 3 of watts general levels of sexual history
|
sexual problem history
|
|
what is level 4 of watts general levels of sexual history
|
psychiatric/psychosocial history, obtained by a psychiatric nurse clinician
|
|
how do you obtain sexual information
|
description of the problem, onset and cause of the problem, past attempts at resolution, goals of the patient
|
|
what are patient outcomes regarding sexuality
|
define individual sexuality, establish open patterns of communication with significant others, develop self-awareness and body awareness, describe responsible sexual health self care practices, practice responsible expression
|
|
what are basic charting methods to predict ovulation
|
temperature method, cervical mucus method, calendar method
|
|
what is aspiration
|
something other than air is inhaled into the lungs or trachea
|
|
what are causes of aspiration
|
cranial nerves 5, 7, 9, 10 and 12, 9 and 10 for speech, physical abnormalities, tubes ect.
|
|
what do you assess for aspiration
|
loc, gag, speech, lungs
|
|
how do you help with aspiration
|
put hob up to 60 for 2 hours, get swallowing evaluation
|
|
what is the semisolid swallowing trial
|
thicken water with a thickener to make it pudding like and assess for deglutition, coughing, drooling, and voice change
|
|
what is the liquid swallowing trial
|
check liquid swallowing starting with 3mL and then increase if possible
|
|
what is the solid swallowing trial
|
small bread is used
|
|
what is the first tier of swallowing
|
patient does not have a cervical or tracheostomy, no previous history of swallowing disorder, patient is able to understand what you are saying, can sit at a 90 degree angle or not less than 60 degrees, patients chin is able to be parallel to the floor, can remain alert, body is or can be midline to the bed
|
|
what d you do if all items of first tier are not checked
|
reassess bid, obtain speech therapy consult
|
|
what is the second tier
|
patient is not experiencing respiratory distress, patient is not experiencing poor secretion managemetn requiring NT or oral suction, normal voice quality without wetness, gurgling, weakness or whispering, able to produce effective cough
|
|
what is superficial spreading melanoma
|
generally the most common form of melanoma
|
|
what is horners syndrome
|
loss of sympathetic nervous system input to eyes. Pupil is smaller and eyelid covers a great portion of the eye.
|
|
what is lcterus
|
yellow discoloration of the sclera caused by hyperbilirubinema
|
|
what is conjunctivis
|
marked bilateral inflammation involving conjunctive that covers sclera and under surface of eyelid
|
|
what are manifestations of ocular graves' disease
|
hyperthyroidism, weight loss, increased appetite, nervousness, palpitations, tacycardia, hypertension, hyperrelexia,
|
|
what does macular degeneration do
|
induces image distortion and dark areas
|
|
what is retinitis pigmentosa
|
small flashes of light or a twinkling, shimmering sensation in the midperipheral or peripheral field from aberrant electrical impulses from the degeneration retina. presence of dark pigmented spots in the retina
|
|
what is a parotid gland
|
enlarged right parotid gland secondary to lymphoma
|
|
what is angioedema
|
acute selling of the lips from an allergic response to medication
|
|
what is cellulitis
|
redness and swelling form bacterial skin infection
|
|
what should you look for in the vomit
|
color, amount, onset duration, frequency, severity, projectile, precipitating factor
|
|
what should you assess in nausea and vomiting patient
|
bowel perforation, soft, distended bowl sounds, dehydration, lyte imbalance, changes in CO, renal function, bleeding, K, Na, H and H.
|
|
what are the causes of early morning vomiting
|
pregnancy, uremia, alcohol, increased intercranial pressure
|
|
what are the causes of vomiting
|
dehydration, aberrant motion, pregnancy, medications such as opioids and chemotherapy drugs
|
|
what should you assess in nausea
|
onset, duration, frequency, color, amount, accompanying diarrhea, associations, such as environment, and anesthesia and narcotics, auscultate bowel sounds, passing flatus, monitor I and O, monitor vital signs, electrolytes, hematocrit,
|
|
what should you do for patient who is nausea
|
give an emesis basin, give call light, lower lights, give cool cloth, rid room of strong odors or food smells, give zofran, reglan, or compazine, give ice chips not water, give IV for hydration, give flat ginger ale, coke, crackers, no diet soda
|
|
what should you do if patient vomits
|
water to rinse, brush teeth, moist cloth for cleaning, remove emesis immediately
|
|
when should you use on NG
|
if bowel is not functioning is the cause of vomiting
|
|
what is noise
|
acoustic signals which can negatively affect the physiological or psychological well being of an individual
|
|
how many decibles can cause harm
|
100 should not be more than 15 minutes, 110 for 1 minute can risk permanent hearing loss
|
|
what causes hearing loss
|
hair cells in cochlea are damaged and cant transmit sounds. it is damage to the delicate mechanosensory apparatus of the hair cell stereocilia
|
|
what do loud sounds cause
|
cardiovascular effects such as hypertension and arrthymias, incrases breathing rate, distrubs digestion, can cause an upset stomach or ulcer, negatively disrupts fetus, premature birth, makes it difficult to sleep, fatigue, and reduced work output
|
|
what is tinnitus
|
the perception of sound within the human ear in the absence of corresponding external sound.'ringing'
|
|
what should your priorities be in a fire in the hospital
|
RACE-
Rescue patients in area Alert other personnel Contain the fire Extinguish and or evacuate |
|
what is a class A fire
|
ordinary combustibles or fibrous material such as wood, paper, cloth, rubber and some plastics.
|
|
what is a class B fire
|
flammable or combustible liquids such as gasoline, kerosene, paint, paint thinners and propane
|
|
what is a class C fire
|
energized electrical equipment such as appliances, switches, panel boxes and power tools
|
|
what is a class D fire
|
certain combustible metals, such as magnesium, titanium, potassium and sodium.
|
|
what does a ground fault circuit interrupter do
|
detects an insulation failure by comparing the amount of current flowing to electrical equipment with the amount of current returning from the equipment
|
|
what are early on symptoms of being struck by lightning
|
intense headaches, ringing in the ears, dizziness, nausea, vomiting and other post concussion types of symptoms. May also experience difficult sleeping, develop seizure like activity several weeks to months after the injury, personality changes due to frontal lobe damage, they are irritable and easy to anger.
|
|
what are the four components of the precautionary principle
|
1. taking preventive action in the face of uncertainty
2. shifting the burden of proof to the proponents of an activity 3. exploring a wide range of alternatives to possibly harmful actions 4. increasing public participation in decision making |
|
what are the effects of DDT
|
endocrine disrupting properties, disruption in semen quality, menstruation, gestational length, duration of lactation.
|
|
what is the half life of DDT
|
11 years
|
|
what can a pesticide cause
|
solid tumors, brain, prostate, kidney, and pancreatic cancer, leukemia, non hodgkin lymphoma, birth defects, fetal death, infertility, neurological problems
|
|
what happens in prenatal phthalate exposure
|
decrease in anogenital distance in male infants
|
|
what are advance directives
|
the legal documents such as the living will, durable power of attorney and health care proxy.
|
|
what does reave mean
|
forcible taken away
|
|
what do we see in nursing for grieving
|
the initial part, usually pain is blocked because of disbelief or too much to process.
|
|
what is a living will
|
document that allows individuals t record specific instructions about the type of healthcare they would like to reveive in particular endo of lif situations
|
|
what is the durable power of attorney
|
appointing someone to make decisions on healthcare
|