NUR 2356/MDC 1 Final Exam Review_ LATEST 2021/2022
Managing open fractures, how to prevent infection
Frequent dressing changes with aseptic technique,
... [Show More] monitor temperature and heart rate, administer broad spectrum antibiotics as ordered (Clindamycin and Gentamycin), irrigate open wound (clean to dirty)
Managing ambulation with client who has cancer
➤Ask the patient to wear nonskid footwear.
> Place the bed in low position and lock the wheels.
> Assist the patient to dangle at the side of the bed
> If two nurses are available, each nurse should stand facing the patient on opposite sides of the patient.
> Brace your feet and knees against the patient. Bend your hips at the knees and hold onto the transfer belt. Pay attention to any known weakness.
> Instruct the patient to place her arms around you between your shoulders and waist (the location depends on the height of the patient and the nurses).Ask the patient to stand as you move to an upright position by straightening your legs and hips.
> Allow the patient to steady herself for a moment.
> One nurse: Stand at the patient’s side, placing both hands on the transfer belt. If the patient has weakness on one side, position yourself on the weaker side
Slowly guide the patient forward. Observe for signs of fatigue or dizziness.
> If the patient must transport an IV pole, allow the patient to hold onto the pole on the side where you are standing. Assist the patient to advance the pole as you ambulate
OA/RA
OA: Degenerative condition. Wear and tear. Loss/wear down of articular cartilage in the joint which causes pain, stiffness, and crepitus (cracking/popping sound). Aggravates with weight- bearing joint use (weight loss, physical exercise, ice)
RA: Chronic, inflammatory, autoimmune disorder that causes bone erosion, joint deformity, and painful swelling. Aggravates with weight-bearing joint use. Inflammation and pain with no activity. Ice and heat. Adequate rest. NSAID’s. Stretching.
Knee pain assessment
Client history, knee inspection for joint effusion/swelling/warmth/deformity, palpate for point tenderness, AROM/PROM, neurovascular assessment
Discharge instructions for osteomyelitis
Importance of medication adherence and taking full-course, signs/symptoms/re-infection detection, importance of hand hygiene, proper irrigation techniques, assistive device use, assistance with ADL’s
Total knee repair management
DVT/PE prevention/monitoring (TED hoses, anti-embolic/anti-thrombotic stockings) , surgical
dressing changes and monitoring of incision site for infection, observation of mobility and sensation, ABC’s, no excessive blood/fluid loss, monitor tissue perfusion
90 degree ROM- elbow
Assessment for patient on bedrest w/pain in leg
PROM, neurovascular assessment for DVT/PE, pain assessment
Importance of ROM
Improves joint function, balance and muscle strength, flexibility, reduces pain and stiffness, improves circulation, reduces injury potential
Abduction/adduction
AB: away from
ADD: towards the body
Type of order from provider for acute flank pain
Possible reasons for pain: dehydration, kidney problems (kidney stones), UTI
Orders: WILDA assessment, blood tests, ultrasound, x-ray, abdominal CT scan, urinalysis/culture, cystoscopy, IV fluids, pain medication
ADL limitations for client with limited motion of hands
Eating, toileting, bathing, dressing, personal hygiene, weight-bearing activities, medication adherence
Priorities for immobility
Perform PROM, reposition every 2 hours, encourage independent activity as possible even in bed rest/AROM, provide assistance devices as needed
Potential impacts of stress on arthritis
Exacerbates symptoms, increases pain and muscle tension, increases risk for development of inflammatory arthritis
Response to client reporting fatigue and joint pain
Encourage rest, complete pain assessment (WILDA), complete assessment/inspection/medical history, assess ROM
Halo traction: pin site red and inflamed
Treat with daily pin care, increase dressing changes, culture as needed if pus presents, determine pain level
Response to confused client climbing out of bed
Move client to room closer to nurses station, implement use of bed alarm, refrain from raising bed rails
First action when client falls: check vital signs and for any injuries sustained
Priorities for new femur fracture
BKA symptoms: phantom pain, decreased ROM, localized swelling
Colors of drainage and meaning Serous: watery consistency, clear Sanguineous: bloody drainage, red
Serosanguineous: combination of blood and clear serum, pink/blood tinged Purulent: thick, malodorous, pus, yellow, green
Priorities for homeless client
Physiologic needs and safety needs met, case management/social worker collaboration
How to avoid shearing injuries
Position bed to 30 degrees or below, use assistive devices when repositioning
Narcolepsy management
Regular sleep schedule, planned short naps, sleep-inducing environment/hygiene, wake promoting medications, antidepressants
Wound healing stages
Hemostasis: clotting
Inflammatory phase: cleaning/phagocytosis
Proliferative phase: granulation/regeneration/fibroblasts form collagen
Maturation phase: epithelialization/remodeling/scar tissue/collagen broken down into organized structures/healing
Potential harms from low platelet count: thrombocytopenia
Cannot form clots, delayed wound healing, severe bleeding, higher risk for infections
How to prevent heel skin breakdown
Elevate heels using pillows, pressure redistributing devices, reposition every 2 hours
Extensive burn assessment
ABC’s, inspection (wound drainage, depth of burn injury, wound complications) culture/biopsy/wood’s light exam/diascopy, pain, wound care
FRO M H EAD TO
TO E
CO LO R,
TEM PER ATU RE,
M O ISTU RE
LESIO N S ED EM A VASC U LAR
CH A N G ES
CLEA N LIN ESS M ED ICATIO N S LIFESTYLE
Priority action for oozing wound
Inspect/assess wound, get culture if needed, apply pressure and cover wound, implement contact precautions
Potential skin outcomes of continuous high-fowler position
Increases sacral pressure, increases risk for pressure ulcers and venous stasis in lower extremities, increases risk for skin tears due to shearing forces
Role malnourishment plays in skin integrity: disturbs/delays cell metabolism and wound healing, increases infection rate, proteins/fat/water promote tissue integrity and prevent breakdown
How to document coccyx wound w/ eschar
Stage IV pressure ulcer
Priority action for well approximated wound w/ blood tinged drainage
D EB R ID EM E N T
IN FEC TIO N PA C K D EA D
SPA C E
A B SO R B E X U D ATE
M A IN TA IN M O IST
E N V IRO N M E N T
O P E N O R C LO SE D W O U N D E D G ES
(E P IB O LY )
P RO T EC T FR O M
TR A U M A
IN SU LAT E
Management of abdominal incision with bowel protrusion
Immediately cover bowel protrusion with sterile towels/dressings soaked in sterile saline solution, notify surgeon, prepare client for surgery
When to culture wounds: prior to cleaning wound
Characteristics of client at risk for skin breakdown
Advanced age, radiation history, malnourished, immobile, impaired sensation/circulation, long- term steroid use, obese, dermatitis/skin condition history
Priority for blanching erythema (reddened skin area that becomes white/pale) in child client ABC’s, determining pulse, relieving pressure to area (repositioning client/increasing activity level), pain level, establishing/maintaining fluid balance
Types of activities to delegate to unlicensed assistive personnel relating to client w/ recent tympanoplasty
Positioning bed to flat position, taking and recording vital signs, assistance with ADL’s, maintaining a safe environment for the client
Glaucoma types, irreversibility education
Increased intraocular pressure and progressive/gradual vision loss Risk factors: over age 40, diabetes, hypertension, family history
Primary open-angle glaucoma: gradual loss of peripheral vision (tunnel vision), painless, decreased visual acuity, eventual blindness
Secondary: related to another eye problem Associated: related to another disease process
Meniere’s disease
Dizziness/Vertigo/Tinnitus/Hearing Loss
Results from abnormal fluid and ion homeostasis in the inner ear Managed with diuretics and salt restriction
Fire safety
R.A.C.E
Which ophthalmology client would be seen first?
Primary angle-closure glaucoma, acute onset: MEDICAL EMERGENCY
Fibromyalgia symptom reduction
Setting sleep schedule, frequent rest, regular exercise (walking, swimming, stretching, yoga), massage therapy, warm moist heat, OTC pain relievers (aspirin, ibuprofen, naproxen sodium), antidepressants, anticonvulsants (Lyrica), vitamin D
Impact of ice on oral temperature: lowers/inaccurate reading, wait at least 15-30 minutes to take
Lupus
Systemic lupus erythematosus: progressive inflammatory connective tissue disorder that causes major body organs and systems to fail, remissions and exacerbations, alopecia, mouth ulcers, polyarthritis
Discoid lupus erythematosus: affects only the skin
Infant safety
Lay on back in crib with nothing else in crib, do not microwave bottles, car seat should be rear facing
Dirty needle exposure priorities
Hand hygiene, take precautions/complete lab tests, complete incident report
Scleroderma assessment findings and education for client w/ scleroderma and recent lung transplant
Scleroderma: chronic hardening of skin and connective tissues as a result of excess collagen production. Can affect internal organs including: lungs, GI tract, heart, and kidneys. Symptoms include: tightening of skin, joint pain, Raynaud’s disease (exaggerated response to cold), and heartburn.
Pulmonary arterial hypertension (PAH), which sometimes results from scleroderma, is usually treated with medications; however, if not responding to medical therapy lung transplant may be done.
Education: aspiration prevention (speech therapist), observation for transplant rejection, lifestyle modifications including eating at least 3 hours prior to sleep and sleeping on medi- wedge, medication adherence (proton-pump inhibitors)
Safest position for client at risk for falls: lowest possible position
Lab tests ordered for systemic lupus
Same as RA: rheumatoid factor, ANA, serum complement, erythrocyte sedimentation rate, SPEP, globulin (alpha 1, alpha 2, beta, gamma), HLA testing, CBC, Anti (ss-a, ss-b, smith, DNA)
Raynaud’s disease
Rare disorder of the blood vessels, usually in the fingers and toes. It causes the blood vessels to narrow when you are cold or feeling stressed. When this happens, blood can't get to the surface of the skin and the affected areas turn white/blue
Proper transferring of client from bed to wheelchair/vice versa
Explain the steps to the patient. Park the wheelchair next to the bed, close to you. Put the brakes on and move the footrests out of the way.
To get the patient into a seated position, roll the patient onto the same side as the wheelchair. Put one of your arms under the patient's shoulders and one behind the knees. Bend your knees. Swing the patient's feet off the edge of the bed and use the momentum to help the patient into a sitting position. Move the patient to the edge of the bed and lower the bed so the patient's feet are touching the ground.
Place the patient's outside leg (the one farthest from the wheelchair) between your knees for support. Bend your knees and keep your back straight. Count to three and slowly stand up. Use your legs to lift. At the same time, the patient should place their hands by their sides and help push off the bed. The patient should help support their weight on their good leg during the transfer. Pivot towards the wheelchair, moving your feet so your back is aligned with your hips.
Once the patient's legs are touching the seat of the wheelchair, bend your knees to lower the patient into the seat. At the same time, ask the patient to reach for the wheelchair armrest.
Hospital acquired pneumonia known as: Nosocomial pneumonia, ventilator-associated pneumonia
Christian scientist beliefs: use proper nutrition, alcohol/tobacco/caffeine avoidance, and adequate rest/sleep to prevent illness, typically refrain from using western medicine, typically do not vaccinate/immunize/accept blood transfusions unless required by law
Infection control process for TB
Airborne precautions, N95 respirator, negative-pressure room
Meaning of virulent: power/ability of agent to cause disease
PCP meaning and diagnosis
Pneumocystis pneumonia: causes inflammation and fluid build-up in the lungs, often associated with a weakened immune system/HIV, diagnosed through sputum sample or bronchoalveolar lavage collection sample, lung tissue biopsy, blood test to detect PCR
Infant immunity
Does not fully develop for 2-3 months, breastmilk: passive immunity, vaccines: active immunity
Precautions for kidney transplant client
Isolation precautions, positive air pressure room, N95 mask when leaving room with construction in area
Education for client with HIV
Pain management, important of nutrition to prevent malnutrition, drug therapy adherence, infection prevention and being aware of signs/symptoms (avoid crowds, bathe daily with antimicrobial soap, avoid raw fruits/veggies, avoid gardening, hand hygiene), encourage coughing/deep breathing/suctioning, skin integrity promotion/lesion prevention, no alcohol/caffeine/spicy/fatty/sweet foods to prevent diarrhea, seizure precautions, psychosocial distress prevention, interventions to maintain quality of life
Catholic beliefs: last rites
Hindu beliefs: self-care, showering as opposed to bathing, vegetarians
Jehovah Witness: no blood transfusions
MRSA protection/precautions/proper PPE: contact precaution, gown and gloves
Limited English speaking clients and how to deliver effective care: interpreter service [Show Less]