PN3 Final Exam Study Guide
What is a high risk for hip fractures? Osteoarthritis
What are signs of a fat embolism?
dyspnea, tachypnea, petechial
... [Show More] rash, swelling over the affected area-will see in neck or trunk if it is in hip
what is RICE
Rest, Ice, Compression, Elevation
What is compartment syndrome?
Swelling and pressure that can cause necrosis
what to monitor for in osteomylitis
Elevated temperature and elevated WBC >11,000
What is a faciotomy?
When the cast is removed, reduces swelling, if not completed muscle death may occur
what is the number 1 nursing intervention for amputee ROM exercises
what do you monitor for with Buck's traction Never allow weights to rest on the floor
do not cross legs
always use an abductor pillow when re positioning
what do you monitor when someone has a cast?
Cap refill sensation motor function
Most common cause for cirrhosis alcoholism
second is hepatitis C
What lab tests do you monitor in cirrhosis ALT, AST, and LDH
What are physical s/s of cirrhosis
changes in skin color or sclera-icertus-yellowing of the sclera
what do you monitor following a liver biopsy Bleeding and bruising
Interventions for Steatosis or fatty liver weight loss
glucose control
lipid-lowering agents
Which organ is in the right upper quadrant liver
Which organ is in the left upper quadrant pancreas
Portal shunt nursing interventions low sodium diet
diuretics
trans jugular intrahepatic portosystemic shunt
what is the number one cause for gallbladder problems obesity
what is a non-surgical management intervention for pancreatitis NPO while acute attack
pancreatic abscess
is always fatal if left untreated
Cancer Pathophysiology
-mutation of cellular genes
-abnormal cell growth
-no cell division limit
-lack of contact inhibition
o Features: loose adherence, anaplasia(loss of differentiation), large nuclear ration, migration(metastasis), rapid cell division, abnormal chromosomes (aneuploidy)
o Benign: harmless: does not require and intervention
o Malignment: indicates cancer, serious and can lead to death
Primary prevention examples avoidance of known carcinogens vaccinations
avoidance of known carcinogens, modifying factors(diet, high fat), removal of at risk tissues, chemo prevention, vaccination (HPV)
Secondary prevention examples Screenings and early treatment
Tertiary prevention examples
Treatment of major depression, reducing disruption of family processes, and suicide prevention, rehabilitation
prevention (testing) for reoccurrence
Radiation precautions for internal radiation
private room, radioactive material sign, nurse's fil badge must be worn, pregnant or less than 18 do not enter room, visitors for 30 mins a day, visitors stay 6ft away, bed linens and all dressings stay in room until after implant is removed, have lead container in room
7 warning signs of cancer
C-hange in bowel or bladder habits. A- sore that does not heal
U-nusual bleeding or discharge.
T-hickening or lump in the breast, testicles, or elsewhere. I-ndigestion or difficulty swallowing.
O-bvious change in the size, color, shape, or thickness of a wart, mole, or mouth sore. N-agging cough or hoarseness.
Patient Education for (internal radiation) not radioactive
Brain Tumor- s/s specific to this condition headache in the morning
Chemo Therapy complications-
anemia (decrease in RBC and hemoglobin), thrombocytopenia (platelet count less than 85,000), neutropenia (neutrophil count less than 450), mucositis (mouth sores), alopecia, extravasation (chemo has leaked and makes large sore)
Thrombocytopenia
-platelet count less than 85,000
-private room, handwashing, vitals q4h, limit visitors, dedicated supplies, inspect skin q8h, daily wound dressing changes daily, avoid crowds, do not share food or liquids
-meds to increase WBC-neulasta, neupogen, leuxine, prokine
Severe anemia nursing interventions
medications to increase RBC production: epoetin alfa and erythropoietin
-prevention of bleeding (electric razor, etc) and injuries
brachytherapy
radiation therapy in which the source of radiation is implanted in the tissue to be treated
-private room, radioactive material sign, nurse's fil badge must be worn, pregnant or less than 18 do not enter room, visitors for 30 mins a day, visitors stay 6ft away, bed
linens and all dressings stay in room until after implant is removed, have lead container in room
mucositis interventions sores in mucous membranes
- Nursing Interventions: use soft-bristle toothbrush, avoid mouthwashes with alcohol, 2 or more liters of water a day, room temperature salt water to swish in mouth, avoid spicy foods, avoid using tobacco
Hospice vs. Palliative Care
-hospice: (quality care) team oriented, holistic, peaceful death, for patients who are actively dying
-palliative care: (quantity care): by physician, NP and team of providers, deliver care to relieve care for life-threatening disease, given the quality of life no matter what stage
s/s of airway emergency in burn victims
-s/s of airway emergency: deep brassy cough, drool, difficulty swallowing, black mouth, wheezes, crowing, stridor, cyanosis
when to apply oxygen and prepare for intubation
-black mouth, burns in mouth, swelling
interventions for TBSA burns >40%partial thickness burns
-oxygen, pain management
Initial nursing interventions for burns >50% burns
-lactated ringers
-oxygen
-potential for shock
-potential for ARDS
Parkland formula
-4ml x kg x % of total body burned= fluids given in the first 24 hours
-then divide by 2: half given in first 8 hours, other half given in next 16 hours
-head: anterior: 4.5% posterior: 4.5%
-arms: anterior:4.5% posterior: 4.5%
-legs: anterior 9% posterior: 9%
-front: 18%
-back: 18%
-groin: 1% [Show Less]