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56 Cards in this Set

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Cuffed Tracheostomy

*Tube inserted through surgical incision made into trachea by way of throat


*Nsg care: should be inflated during and after eating, 1 h after tube feeding, when client is unable to handle oral secretion


*Cuff pressure should not exceed 20 cm H20



Chronic Bronchitis

Type of COPD; caused by inflammation of the bronchi


*Nsg responsibilities: listening to breath sounds, administering low-flow oxygen, encouraging fluids, providing small, frequent feedings, bronchodilators, antibiotics, corticosteroids

Fetal Lie

(Position is described relative to the mother's pelvis and its four quadrants)


*LOA is the most common fetal presentation and FHT is heard on the left side

Adolescent pregnancy

< 15, girls still see parents as authority figures; age 15-17, look to peer group for authority and decision making; 17 and older, are more comfortable with themselves and the ability to make decisions



Growth and Devolopment: Toddler

Age 12-36 months; time of slowed growth, profound activity, curiosity, and negativism, builds 2-7 block towers, vocabularly increases from 10-200 words

Agitation

Indicated by increased motor activity, decreased ability to relate to others, distorted perceptions, and loss of rational thought; when interacting with an agitated client, it is important for the nurse to be supportive and protective

Orchitis

Acute inflammation of the testes caused by trauma or infection; indications include scrotal pain and edema


*Treatment: bedrest with scrotal elevation, ice, analgesics, and antibiotics

Suicidal Behavior

*Highest priority: protecting clients from inflicting harm on themselves; clues for impending suicide include any sudden change in behaviro, becoming energetic after a period of severe depression, improved mood for 10-14 days after taking an antidepressant, finalizing business or personal affairs

IV infiltration

(occurs when the IV needle or catheter becomes dislodged from the vein and is in the subcutaenous tissue)


*Nsg intvns: frequent, at least hourly, monitor IV insertion site; stop fluid flow, DC site if med/fluid is not a vesicant and apply a sterile dressing and pressure until bleeding stops



Total Hip Arthroplasty

Surgical replacement of the head of the femur


*Nsg responsibilities: position leg in abduction using abduction splints or wedge or 2-3 pillows between the leg; do not flex hip more than 90 degrees



CPR

Step 1) Establish unresponsiveness, breathing, pulse

Step 2) activate EMS


Step 3) Start compressions


Step 4) Establish airway using head-tilt chin lift


Step 5) begin breathing 8-10 breaths per minute

Buck's Traction

(application of pulling force to part of the body to reduce, aligh, and immobilize fractures and relieve muscle spasms)


*Nsg care: frequently inspecting for skin breakdown, turn to unaffected side; elevate foot of bed for counetrtraction, use trapeze for moving

Alzheimer's Disease

Nsg responsibilities: reorienting as needed, speaking slowly, providing clocks and calendars in patient's room, promote sleep

Anorexia Nervosa

(Eating disorder common in females 8-18 years)


*Promote individual, group, family therapy, and behavior modification; monitor weight, intake, VS, encourage responsibility for self

Change of shift report

*Nurse receiving report should learn individual client's symptoms, discomforts, what has been done, what remains to be done, how client has responded to treatments and activities so changes can be made to meet client needs

CVA

(sudden disruption in blood supply to brain resulting in a sudden loss of brain function that may be temporary or permanent)


*Encourage the client to attain maximum independence, facing the client and speaking clearly and slowly, give the client time to respond



Nitroglycerin

(Nitrate, vasodilator)


*Teach pt possible side effects: throbbing headache, flushing, hypotension, tachycardia, proper storage

Blood Pressure Cuff

*Primary cause of falsely elevated reading is a blood pressure cuff that is too narrow; bladder width of blood pressure cuff should be approximately 40% of the arm circumference midway between the olecranon and the acromion.

Head Injury

(trauma to the scalp, skull, and/or brain)


*Nsg care: close observation, possible surgery, maintenance of head and neck alighnment with body axis, and lower ICP; prevent seizures with anticonvulsants, maintain fluid and electrolyte balance

Late Deceleration

(Begins after a contraction has been established, and continues after the contraction is over)


Tx: positioning client on left side, elevating the client's legs, oxygen, and contact MD



COPD

Nsg care: administering bronchodilators, mucolytics, corticosteroids, anticholinergics, and atropine sulfate, encourage fluids, provide small, frequent feedings

Mantoux Test

Results:


-Induration of 5 or more mm is considered positive in HIV patients, recent contact with a person with TB, or immunosuppressed pts; induration of 10mm is considered positive in recent immigrants, injection drug users, or high risk pts; induration of 15 or more is considered positive in any person with no known risk factors

Pain management

5th vital sign, whatever the patient says it is


*Nsg interventions: establish a 24-h profile, reduce anxiety and fears, provide comfort measures, administer pain relief

Amitriptyline

(Tricyclic antidepressant)


Monitor VS for client with cardiac disease, check for urinary retention and constipation; may take 3-4 weeks to achieve a therapeutic level, suicide risk high after 10-14 days; sunblock required, take dose at bedtime

Cocaine Abuse

Symptoms: dilated pupils, tachcardia, increased BP, and NV


Care: maintain airway, start IV, monitor cardiac rhythm, check LOC and VS

Tamoxifen

(Hormonal drug)


Administer analgesics for increase in bone pain, monitor serum calcium and CBC; client education: wear sunscreen and sun protective clothing

Situational Crisis

*Stages include denial, increased tension/anxiety, disorganization, attempt escape from problem/pretent problem doesn't exist, blame other, general reorginization

Crutch Walking

*Keep crutches 8-10 inches out to side; ensure safety: remove throw rugs, make sure that crutches won't bump furniture causing client to trip, instruct client not ot walk on wet or slippery floors or sidewalks

Hypoglycemia

Nsg care: if conscious offer 15g of carbs, if unconscious adminster dextrose 50%, follow with an additional carbohydrate or dextrose in 15 minutes if blood glucose not within normal range

Altered Body Image

Stages: 1) Psychological shock, 2) Withdrawal, 3) Acknowledgement, 4) Integration


Show acceptance of the person as they are, don't show any emotion when looking at the person, offer support group if appropiate

Normal Newborn

RR: 30-50; pulse: 120-140; normal BP: 60 to 80/40 to 50; temp < 97.6 may be caused by prematurity, infection, or low environmental temperature

Alcohol Withdrawal

(happens 4-6 hours after last drink)


*Nsg responsibilities: administer sedation as needed, monitor VS, sz precautions, providing quite, well-lighted environment

Epilepsy

Observing and documenting type and progress of sz activity and postictal behavior, O2 and suction at the bedside; post-seizure, position on back with head turned to the side

Preterm Labor

Labor that occurs between 20-38 weeks gestation; Promote bedrest inside-lying position, uterine monitoring, daily weights, good nutrition

Wound Irriagation

*Warm irrigating solution to 90-95 degrees F; remove soiled dressing and discard in a plastic trash bag together with the gloves, position client to allow for gravity drainage, establish a sterile fluid and pour irrigatin solution into sterile container

Postpartum

Check loch every 15 minutes, follow protocol until stable, check fundus every 15 minutes

Prolapsed Umbilical Cord

Treatment includes examiner putting direct finger pressure on presenting part, relieving pressure on cord, placing in Trendelenburg or modified Sims' position with pillows under the right hip

Growth & Development: 4 year old

Climbs and jumps well, laces shoes, brushes teeth, 1500 word vocab, skips and hops on one foot, throws overhead; age-appropiate toys include playground materials, housekeeping toys, coloring books, tricylces with helmet

Addison's Disease

(deficiency of adrenocortical hormones)


*Monitor balance of fluid and electrolytes, VS, weight, pt education: diet, meds, activity level

Osteoporosis

(degenerative disease characterized by generalized loss of bone density and tensile strength)


Encourage diet high in calcium, protein, and vit D, encourage weight-bearing on long bones, instructing about safety precautions to prevent pathologic fractures

Shock

****In any emergency situation, shock should be anticipated before it develops


Ensure patent airway, maintaining breathing and circulation, restoring circulating blood volume, inserting dwelling catheter, determine cause of shock

Advance Directives

(written statemtnt by competent person that states decisions about individual's treatment in the event of a serious illness or injury; designates person authorized to make decisions on individual's behalf if that individual is unable to make and/or communicate decisions

Hyperventilation

Pt breathes very rapidly over prolonged period of time, which causes an O2/Co2 imbalance


Tx: breathing into paper bag to rebreathe CO2

Percutaneous Liver Biopsy

(needle biopsy of the liver under local anesthesia)


*After biopsy: take VS hourly for 8-12 hours, poisitioning in the right lateral position for approx 1-2 hrs after procedure, check CBC

Diversity

Nurses should be aware that nurses from diverse cultures may have different learning styles; charge nurse should provide extra time for questions and restate concepts and ideas until they are understood by all the nurses attending the meeting

Hyperglycemic, hyperosmolar, nonketotic syndrome

(Occurs in type 2 diabetics over 50); indications include glucose levels greater than 800, hypotension, dry mucous membranes, poor skin turgor)


Care: administration of normal saline, regular insulin, assess VS, blood glucose, CVP, and LOC

Confusion

(Pts having difficulty with orientation need clear messages and instructions; simple direct statements are the best)

Heart Failure

(Failure of the heart ot pump enough blood to meet metabolic demands of tissue)


Nsg responsibilities: promoting physical and emotional rest, high Fowler's position, assessing VS, lungs sounds, and I&O

Physical Assessment

Order: Inspection, palpatation, percussion, auscultation, smell; only variation is physical assessment of abdomen-order: inspection, auscultation, percussion, palpation; includes head to toe exam, all body systems, ht, wt, and VS

Delegation

Steps include: defining task to be delegated, determining who should receive the task, identifying what the task involves, providing clear communication about expectations regarding the task

Immunizations

*Discuss with parents the importance of immunizing children on prescribed schedule


*Obtain detailed list of any allergic responses to antibiotics or past vaccinations


*Remind parents to report any reaction other than local swelling and pain and a mild temperature

Pancreatic Enzyme Replacement

Educate client to not use with antacids, avoid inhaling powder, take with meals

Mastectomy

Common tx for breast cancer


All breast tissue is removed together with axillary lymph nodes, chest muscles are left intact

Chain of command

Nurse reports to this person and is responsible to the person above the nurse; nurse reports variances, problems, and concerns to the next person with authority in direct line in his/her area

Cyclophosphamide

(Alkylating agent); Report hematuria, force fluids, monitor for infection, administer antibiotics, should be administered by a nurse who is not pregnant

Confidentiality

Code of ethics safeguards client's right to privacy; client has a right of records; information about the client can be used only for purposes of diagnosis and treatment