Prophylactic DVT Care - ANSWER -Assess and compare peripheral pulses
-Caused by dehydreation, obesity, trauma, malignacy, Hx of thrombosis, hormones, and
... [Show More] use of indwelling cath
-Nursing actions: prevention, avaoid dangling pt for long periods, anticoagulants, provide adequate hydration
Cardiac cath postoperative care - ANSWER -Apply an initial dressing of gauze and replace with transparent dressing w/i 24 hr.
-x ray to ensure placement
-assess q8hr
- Use 10mL or < syringe to flush
-Clean port for 3 seconds and allow to dry
-flush before, between, and after meds
- no BP on arm with PICC
Ventricular fibrillation - ANSWER -can cause cardiogenic shock
-Dx- ECG, Ech, CT, Cardiac cath, chest x ray
-Tx- Cardiac cath, Anticoagulants, defib shock to fix rythem
Assessing arterial line - ANSWER -check placement
-keep pressure
-flush before between and after meds
-watch for clotting
Eval. pt understanding of digoxin administration - ANSWER -Hold if apical HR is <60bpm per min
-Watch for N&V
-Monitor ECG, BP
-Take same time each day
-take 2 hr before or after antacids
- If you miss dose take it as soon as you remember
Expected findings following administering Narcan - ANSWER -Increase Resp.
-Pain returns
-increase HR
-increase BP
Allergic blood transfusion reactions - ANSWER Mild- Itching, urticaria, flushing- Administer benadryl
Anaphylactic- wheezing, dyspnea, chest tightness, cyanosis, hypotension
-maintain airway, admin. 02, IV fluids, antihistamines, corticosteroids, and vasopressors
Acute and Chromic Kidney: Planning Dietary Restrictions - ANSWER - Possible fluid restrictions
-Restrict K+, phosphate, & magnesium
- Potassium and sodium regulated
-High pretine and possible TPN
Acute and chronic kidney: Evaluating pt understanding - ANSWER -Encourage pt to drink 2-3L daily
-Promote smoking cessation, weight loss, and use of NSAIDs
-Instruct pt to take ALL perscribed meds and ATB
-Decreased dietary potass, phosphate, and mag.
-Increase protein, possible TPN
Cardio: ECG abnormalities following myocardial infarction - ANSWER Q waves and ST elevation
Inflammatory Bowel: Dietary recommendations - ANSWER low fiber
increased protein
decreased calories
Pt. teaching about Dilantin - ANSWER -If one med doesn't work dose is increased or another med is added
-Therapeutic lvl determined by blood test
-Med taken same time each day
-No oral contraception or warfarin
Acute and Chronic kidney: Med Adverse effects - ANSWER -Avoid antimicrobial, NSAIDs, ACE inhibitors, IV contrast dye
-Monitor Digoxin lvl & administer post dialysis
-kayexalate to increase elemination of serum potassium
-epogen, procrit, to increase RBS stimulation
-Iron supplement
-Lasix
-Amphojel- taken to stop phsophate absorption
-take 2 hr before or after digoxin
Preventing complications following a transurethral resection of the prostate - ANSWER -Urine should be light pink. If red increase irrigation
-If cath becomes obstructed turn of CBI and irrigate with 50mL
-Record amt. of irrigation and sub. from total to get true output
-Instruct pt not to urinate around cath-it will cause bladder spasem
-Monitor vitals and bleeding
Teaching colostomy care - ANSWER Cause odor-fish, eggs, asparagus, garlic, beans, greeen leafy veggie
cause gas- green leafy veggies, beer, pop, dairy, corn
-Avoid incresed fiber for 2 months post op, drink lots H2O and watch for obstruction when adding fiber
- proper appliance fit and maintenance prevent odor
-refer to counseling if needed
Head injury: Monitor. for CSF leakage - ANSWER -CSF leakage from ears or nose
-"halo" sign- yellow stain surrounded by blood on a paper towel, fluid tests positive for glucose
-report to dr.
Resp. manage. & Mechanical ventilation: Need for suctioning - ANSWER Suction secretions to maintain airway and tube patency
Monitoring initial does of lisinopril (Zestril) - ANSWER -may make pt feel dizzy
-Monitor BP, HR, and keep on falls precautions
-Remind pt top ask for assistance to get up and to move slowly
Self-administering enoxaparin (lovenox) - ANSWER -Injection given in R or L abdomen
-Take only as directed
-may inhibit blood clotting
Safer sex practices - ANSWER -Abstienence is best
-Use condoms
-Get tested regularly
Complications following extubation - ANSWER -RR > 30/min or <8/min
-BP or HR changes >20% baseline
-SaO2 <90%
-Dysrhythmias, increased ST segment
-Sig. decrease in tidal volume
-Labored resp. and increased use of accessory muscles
-Restlessness, anxiety, decreased LOC
-Monitor for resp. destress or airway obstruction such as ineffective cough, dyspnea, and stridor
DM: Pt education regarding medications - ANSWER -Take even if can't eat.
-Clear-cloudy-cloudy- clear pull in short acting first then long acting
-Rotate injection sites
-Must eat after injection or will have hypoglycemia
Interventions for Boood transfusion reaction - ANSWER Stop infusion
Change tubing
start IV of 0,9% sodium chloride.
Keep tubing, bags to send back to lab
Cardio DX: Complications of IV therapy - ANSWER fluid overload
Hypersensitivity to morphine - ANSWER Narcan- antagonist
Older pt do not metabolize as well
If Resp. rate falls below 8/min stop opioid and give narcan
Cancer tx: Dietary consierations for a client who has stomatitis - ANSWER - Discourage consumption of salty, acidic, or spicy foods
-Avoid glycerin-based mouthwashes. Nonalcoholic and aneseptic mouthwashes recommended
-Offer oral hygiene before and after each meal
Peptic ulcer Disease: Comlications - ANSWER -Heartburn, bloating, N&V
-Pain, bloddy emisis or stools
-weight loss, med. side effects
-Perforation/hemorrhage-pain, rigid abd, rebound tenderness
-pernicious anemia
dumping syndrom
Burns: Prioritizing emergency interventions - ANSWER -Airway
-fluid and electrolyte
-thermoregulation
-infection
Cardio Dx: Accessing implanted port - ANSWER -x ray to confirn placement
-document cath placement @ beg. and end of shift (and any time py is moved)
-check readings for hemodynamic cath
-use 0.9% sodium chloride of flushing no heparin
-Avoid air embolisim
-risk for pneumothorax
-Risk for dysrhythmias with insertion/movement of line
Dietary restricions for Renal Calculi - ANSWER -Limit food high in animal protine
-reduce calcium intake
Evaluating therapeutic response to blood transfusion - ANSWER Monitor Vitals I&O and Labs
Evaluating epoetin alfa (Epogen) effectiveness - ANSWER Monitor hematocrit lab values
Calculating protine intake - ANSWER 0.8-1.8gm/kg
Adverse effects of Garlic therapy - ANSWER -Effect blood clotting
Laryngeal Cancer and Body Image Disturbance - ANSWER -Consult speech language path. for clients who have difficulty speaking
-Provide comfort to pt who have permenant loss of voice or disfigurment
-Refer to counseling servcies as needed
Complications of hemodialysis - ANSWER -Clotting/Infection of access site
-Disequilibrium syndrome
-use slow exchange rate
- Administer anticonvulsant/barbituates if needed
-Hypotensoin
-IV fluids
-Decreased HOB
-Anemia
-Monitor labs and provide blood products as needed
-Infectious Diseases
Clinical manifestations of thoracic outlet syndrome - ANSWER -Neck, shoulder, and arm pain, numbness
-Impaired circulation and flushed sensations to the extremities
-Symptoms are reproduced when arm is positioned above the shoulder or extended
Prevention of Dumping syndrome - ANSWER -Instruct pt to avoid foods that cause distress
-Monitor for orthostatic changes in v/s and tachycardia at these findings are suggestive of gastrointestinal bleeding
-Have pt lie supine after eating
Evaluating pt understanding of TPN - ANSWER -Must monitor glucose lvls closely durring TPN infusion
-Given through PICC or Central Line
Infusion of autologous salvaged blood - ANSWER -Pt blood is collected in anticipation of future transfusions. This blood is designated for and can only be used by pt.
-Pt may donate blood 5wks-72 hrs before surgery
-Must have Rx from Dr.
Fluid imbalances: prioritizing assessment findings - ANSWER Safety, A, B, C
Evaluation of potassium chloride therapy - ANSWER Normal lvl 3.5-5.0mEq/L
Hypokalemia
-VS- weak, irregular pulse, hypotension, resp. distress
-neuromuscular- weakness to point of collapse
- ECG- PVC, bradycardia
Hyperkalemia
-VS- slow, irregular pulse, hypotension
-neuromuscular- restlessness, irritablility, weakness
-ECG- PVC, V Fib.
-GI- N&V
-oliguria
Verifying tip placement of PICC line - ANSWER x ray verification prior to use
Use 10mL or < syringe
Tape cath hub to minimize manipulation
Remove dressing from distal to proximal
note length to help detect cath. migration
Plan of care for pt who has diabetes insipidus - ANSWER -monitor Vitals and labs
-weigh daily
-IV therapy
-Fall precautions
-Add bulk foods and fruit juices
-Assess skin turgor and mucous membranes
-provide skin and mouth care
-encourage pt to drink in response to thirst
Quad cane use with hemiplegia - ANSWER -Use cane on uneffected side
-Advance cane at same time as affected limb
-Stairs-
-Up with the good and down with the bad
Hemoglobin - ANSWER Female 12-16
Male 14-18
Hematocrit - ANSWER Female 35-45
Male 42-52
RBC - ANSWER 4.5-5 million
Erythrocyte sedimentation rate - ANSWER Male up to 15 mm
Platelets - ANSWER 150,000-400,000
Albumin - ANSWER 3.5-5
Total protine - ANSWER 6.2-8.1
Total Lipids - ANSWER 400-1000
Triglycerides - ANSWER 40-50
Total cholesterol - ANSWER 130-200
CK-MB - ANSWER 50-170
Troponin - ANSWER >0.03
Alkaline Phosphate - ANSWER 30-120
Bilirubin - ANSWER <1
Amonia - ANSWER 15-110
Serum Amylase - ANSWER 56-90
Serum Lipase - ANSWER 0-110
Carcinoembryonic antigen (CEA) - ANSWER non smoker- <2.5
Smoker 0-5
T3 - ANSWER 70-205
T4 - ANSWER 4-12
Parathyroid hormone - ANSWER 50-330
HbA1c - ANSWER 4%-6%
Urine Specific Gravity - ANSWER 1.01-1.03
Digoxin Therapeutic lvl - ANSWER 0.5-2.0
Lithium Therapeutic lvl - ANSWER 0.8-1.5
Dilantin Therapeutic Lvl - ANSWER 10-20
Calcium - ANSWER 8.5-10.9
Chloride - ANSWER 95-105
Magnesium - ANSWER 1.5-2.5
Phosphorus - ANSWER 2.5-4.5
Potassium - ANSWER 3.5-5.5
Sodium - ANSWER 135-145
ph (Blood) - ANSWER 7.35-7.34
PaO2 - ANSWER 80-100
PaCO2 - ANSWER 35-45
HCO3 - ANSWER 22-26
Lactate - ANSWER 3-7
Glucose - ANSWER 70-110
Creatinine - ANSWER 0.6-1.3
BUN - ANSWER 7-22
PT - ANSWER 10-12
INR - ANSWER 1-2
aPTT - ANSWER 30-45 seconds
WBC - ANSWER 5,000-10,000
Planning care for a pt undergoing Brachytherapy - ANSWER If it falls out put in lead lined container and return to radiology
Precautions for pt who is immunocopromised - ANSWER -Avoid crowds
-Take Temp daily
-Avoid food that could contain bacteria
-Avoid yard work
-Avoid FLuids that have set out
-Was dishes in hot soapy water
-Wash toothbrush in dish washer or with bleach
-Do not share toiletry
Seizures and Epilepsy: Recognizing at risk pt - ANSWER -Genetic predisposition
-Acute febrile state
-Head trauma
-Cerebral edema
-Abrupt cessation of antiepileptic drugs
-Infection
-Metabolic disorder
-Brain tumor
-Hypoxia
-Acute drug & alcohol withdrawl
-Fluid and electrolyte imbalances
Choosing appropriate )2 equipment - ANSWER Nasal Canula
Partial rebreather
nonrebreather
Aerosol mask
T piece
Assessment of a pt who has a cervical injury - ANSWER C4 or above poses risk for impaired spontaneous ventilation because of the involvement of the phrenic nerve
Preoperative: recognizing deviations in lab values - ANSWER CBC
Hgb
Hct
Serum electrolyte
Serum creatinine
BUN
ABGs
Assessing an Arteriovenous graft - ANSWER Check for thrill or buit: could mean blockage (full or partial)
Thrombocytopenia - ANSWER ITP- Autoimmune where lifespan of platelets is decreased can result in severe hemorrhage
Unusual spontaneous bleeding from gums & nose
Chest tube: Observe the mater seal chamber for an air leak - ANSWER Continuous bubbling means there is an air leak
Pt teaching about paracentesis - ANSWER -Explain procedure and purpose
-Local anesthetics
-Pressure or pain when needle is inserted
Angina & MI: Monitoring for complications - ANSWER Acute MI- Decresed cardiac output
Cardiogenic shock
Ventricular aneurysm/rupture d/t necrotic tissue result of MI
Dysrythmia
Ischemic mitral regurgitation
Diabetes Mellitus: Evaluating Pt teaching regarding foot care - ANSWER Keep feet clean and dry
Wear shoes always
Acute kidney injury & Chronic kidney disease: Recognizing priority lab valuse - ANSWER Seerum creatinine gradual increases 1-2mL/dL q 24-48 hr or 1-6 in ine week
BUN increased to 80-100 w/i week
Urine specific gravity >1-1.01
Priority analysis of an ECG strip - ANSWER MI (chest pain and ST depression or elevation)
Monitoring a pt @ risk for pulmonary embolisim - ANSWER -Caused by dysrythmia
-dyspnea, chest pain, air hunger, decreased o2
Interpreting montoux skin test - ANSWER Red spot- no reaction
Raised red bump- reaction
48-72 hours after injection
Recognizing risk factors for atelectasis - ANSWER Snoring, Stridor
Monitor Blood o2 lvl
Cancer screening:Assessing the need for intervention - ANSWER CEA
PSA
AFP
Diabetes Mellitus: Glycosylated HGB Test (HgbA1c) - ANSWER 4-6% normal
target <7%
Indicates Blood sugar for last 120 days
Hyperthyroidisim: monitoring lab results - ANSWER -Serum THS test- decreased
-FTI and T3 increased
-Thyroid-releasing hormone- failure of expected rise
Arthoplasty: Post op care following a knee arthoplasty - ANSWER Prevent complication- DVT, anemia,
-Older adults @ higher risk
CPM
Prevent pressure ulcers [Show Less]