More shit Flashcards
This deck was created by combining two or more decks
What are some activities done during assessment ?
Obtain a nursing health history Conduct a physical assessment Review client records Review nursing literature Consult supper persons Consult health care professionals
What to watch for with opioid use
Watch patient for Respiratory Depression, hold med if respiratory rate is less than 10.
Constipation is a main side effect of Opioids along with urinary retention and puritis (itching).
Internet
Information may be incomplete, misleading, or inaccurate.
Natural disasters
Tornadoes, hurricanes, earthquake, flood, storm, epidemic
PRN medications
Pain medication that is given on an as needed basis after doing a pain assessment on the patient. Can only be given every few hours depending on the drug.
Government responses to disaster
FEMA-federal emergency management agency
SEMA-state emergency management agency
CERT-community emergency response team
NDRM-National disaster medical systems(homeland security)
Red cross-volunteers
Activities of diagnosing
Interpret and analyze data
-compare data against standards
-cluster or group data
-identify gaps and inconsistencies
Determine strengths, rushed and problems
Formulate nursing diagnosis and collaborative problem statements
Affective domain of learning
Feelings related to values, attitudes, and opinions. Ex) asking them to change what they may value more.
Partially compensatory
Nurse agency supplements clients limited self-care ability.
Non-disaster stage
Preplan when vulnerable to disaster. Threat of disasters and there is time to prepare.
Demonstration/return demonstration
Perform motor skill for client then have them perform it back to you. Needs practice.
Teaching nanda with deficient knowledge as etiology
Risk for impaired parenting related to deficient knowledge(skills in infant care and feeding)
Risk for injection related to deficient knowledge (stds and their prevention)
Anxiety related to deficient knowledge (bone marrow aspiration)
Others that can be used: risk for injury, ineffective breast feeding, coping, or health maintenance
Group teaching
Support groups
Teaching strategy: lecture
Short, but never short enough to really learn.
Analgesics in elderly
Metabolize drugs slower Start low and go slow NSAIDS – High incidence of GI bleed Nephrotoxicity Avoid using Demerol/Codeine (causes constipation) Increased cognitive impairment Slow GFR (glomerular filtration rate) Decreased GI motility and absorption
Emergency stage
Help arrives, recovery begins
Analogs
Verbal instruction with familiar images.
Teaching nandas
Deficient knowledge ex-(low-cal diet)
Readiness for enhanced knowledge ex-(exercise and activity)
Noncompliance ex-(with medication plan)
What must a goal statement include?
A time frame, be realistic, mutually developed, observable or measurable.
PCA
Patient controlled analgesia. Can improve pain relief and increase patient satisfaction. Reduces anxiety which helps relieve pain.
Cognitive domain of learning
Intellectual behavior understanding. Ex) alert and orientated and able to listen and interact
Antagonist/antidote for opioids
Narcan (Nalaxone)
Reconstruction stage
Restore, rebuild mitigation (minimizes the effects or prevents future disasters and makes them right)
SE titration
- You want to give the minimal dose that will give the maximum affect w/minimal side effects. (Start low & go
slow)
What’s an actual diagnosis
A client problem that is present at the time of the nursing assessment.
Ex) inefffective airway clearance and anxiety.
Purpose of assessment is
To establish a database about the clients response to health concerns or illness and the ability to manage health care needs.
Supportive educative
Nurse agency provides support counseling and teaching.
Nursing preparation to disaster
Know facilities plan Know your role Be supportive to patients Carry out plan as best you can Be available if off duty
Lecture-discussion
Allows for questions, better way to learn.
Printed material
Must fit reading level, use information in language used by client. 12th grade reading level is national average.
What’s a risk diagnosis ?
A clinical judgement that a problem does not exis, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
Ex) risk for injection risk for falls.
Purpose of nursing diagnosis is
To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions.
Psychomotor domain of learning
Integration of mental and motors abilities. Ex) ability to use motor skills for activity, giving injection.
Audiovisual material
Use of visual and auditory stimulation, films.
Opioid analgesics
Mainstay in the management of all types of pain. Block the release of neurotransmitters in the spinal cord.
Ex) morphine, fentanyl, hydrocodone, meperidine, methadone, codeine
Impact stage
Disaster has happened, assess damage, death , loss of propert, injury
Discussion
Exchange points of view, correct information, requires more time.
Wholly compensatory
Nurse agency totally compensates for client self-care deficits.
hypoalbuminemia
low protein, caused by dehydration, malnutrition, dehydration, starving, dieting, burns liver disease, chronic infection
hypothyroidism
under active thyroid gland due to thyroidectomy, atrophy of the gland, autoimmune disorders, there is an increased TSH and a decreased t3 and t4, people have slow metabolism, happens to women more than men, they also have cardiomegaly, activity intolerance, high cholesterol, slurred slow speech, altered LOC, and are overweight, treat with synthroid and if they had a thyroidectomy make sure they take this med all their life. put them on a low calorie diet
calcium
when calcium is up, phosphate is down, when calcium is low, the pt can have trousseaus and chvoteks, nerve impulses, skeletal, muscle contractions, if pt had thyroid or neck surgery they can also have low calcium,
hyperthyroidism
sustained release of thyroid hormone (over active) increased level of t3 and t4 and a decreased level of TSH, causes are autoimmune (graves) or goiters, everything speeds up so tachycardia, increased metabolism, increased systolic BP, frequent bowel movements, fast RR, warm moist skin, muscle weakness, restlessness, increased temperature give an anti thyroid med PTU, a b-blocker to manage their hypertension and tachycardia(propranolol, inderal) an iodine solution SSKI, Lugol) and tapazole
normal ABG levels
pH- 7.35-7.45
HCO3- 21-28
pCo2- 35-45
02- 80-100
hypernaturemia
sodium over 145- caused by steroids, sweating, cushings pt, over infusing IV, infection, fever pt will have a decreased LOC, muscle twitching, full bounding pulse, pad the side rails because they can seize, give a loop, hypotonic IV, eat low sodium less than 2 gram, stop smoking, exercise, fresh fruits and veggies
metabolic acidosis
HCO3 below 21 pH below 7.35, caused by renal disease, uncontrolled diabetic, DKA, seizures, diarhhea(out your ass) k-sparings, your gonna see and increases RR, kussmauls respirations, give k-exelate to get rid of k, also give d50 w/ insulin
cushings syndrome
excessive secretion of cortisol from the adrenal glands, excess glucocorticoids, excess secretion of ACTH and aldosterone, pt’s will have weight gain, pinpoint pupils, low potassium and high sodium, high blood glucose, delayed wound healing and poor nutrition, do strict i&O’s and a low sodium diet, and restrict fluid, highest risk is a patient on long term steroids, if they have an adrenalectomy it’s to remove the adrenal glands due to hyperfunction, if they can’t operate on pt due to cancer of adrenal cortex, MITOTANE is given
thyroidectomy
removal of all ( total) or part of the thyroid gland (subtotal) women who are of child bearing age usually have a subtotal thyroidectomy and before either surgery is done the client must have a normal (euthroid) state with iodine if they have a total then they must take synthroid lifelong and if they have a partial they may still produce some thyroid hormone. teach them how to support their head and neck while turning before surgery also teach them how to cough and deep breathe before surgery, and after surgery have calcium gluconate at the bed side because the surgery will cause hypocalcemia and look for chvoteks and trousseaus and stridor can be the first sign of hypocalcemia. check the front and back of their dressings to make sure they are not bleeding have a crash cart, calcium and a trach kit at the bedside also, the parathyroid glands may accidently be removed so this is a risk of doing the surgery
addisons disease
hypo function of the adrenal cortex, due to surgery, autoimmune disease, trauma, tumors, atrophy of the gland, they are going to have a bronzy appearance due to an increases MSH and have increased potassium and low sodium, give them d50 w/ insulin, and a loop diuretic, they are going to have hypoglycemia, weight loss, nausea, anorexia, diarrhea, the goal is to replace glucocorticoids and mineralcorticoids by giving a synthetic aldosterone (cortisone, Florinef) make sure they take this med with meals to prevent to GI upset or bleed. pt may have addisonian crisis (hypovolemic shock due to lack of aldosterone
respiratory acidosis
co2 above 45, pH below 7.35, they are hypo ventilating, also caused by narcotics, COPD, head/neck trauma, obesity, cushings, asthma, smoking. give them pain meds, tell them to cough and deep breathe, mechanically ventilate, steroids, low flow o2, give narcan for opioid overdose, make sure their LOC is WNL (earliest sign of hypoxia)
loop diuretics
examples (lasix,bumex) they lose k+, calcium and sodium, given for SIADH and FVE, know BP, k level, creatinine, BUN before you give also STOP them when a pt has FVD or is dehydrated or metabolic alkalosis K low)
hyperkalemia
potassium above 5- caused by excessive intake, too much IV, k sparing diuretics(aldactalone,spiractalone) can cause muscle weakness, arrythmias, cardiac arrest, GI upset, give k-exelate, give a loop, give insulin d50
hypokalemia
potassium less than 3.5- caused by loops, steroids, ng tubes vomiting, diarhhea, metabolic alkalosis, these pts have arrhythmia, shallow respirations, low BP, altered LOC, hypoactive bowel sounds, distended abdomen, leg cramps give IV at 10 an hour ONLY on a pump never IV push, monitor site for phlebitis because k is a vesicant and is very irritating to skin, increase potassium intake, give supplements STOP digoxin because of possible dig toxicity
metabolic alkalosis
HCO3 above 28 pH above 7.45, k is low, caused by antacid use (tums) TPN therapy, they are going to complain of muscle weakness, vomiting, you want to give antiemetics
hyponaturemia
less than 136 low sodium caused by diuertics, ace inhibitors, addisons patient, diarrhea and vomitting, drowning, renal failure, diabetic, may have altered LOC, cerebral edema, anxious, hyper, muscle weakness, twitching, orthostatic hypotension, tachycardia treat the cause, increase intake, give normal saline or lactated ringers (isotonic) or a hypertonic IV solution, restrict fluids to people with water intoxication (dilutional hyponaturemia) (low na but over hydrated)
respiratory alkalosis
co2 below 35, pH above 7.45, caused mostly by fear and anxiety, also aspirin toxicity, they are hyperventilating (give a mask or paper bag) give mucomyst for aspirin tox
Normal electrolyte levels
k- 3.5-5.0 (potassium) na- 136-145 (sodium) ca- 9.0-10.5 ( calcium) mg- 1.3-2.1 (magnesium) phosphorous- 3.0-4.5 cl- 98-106 (chloride) albumin- 3.4-5 hemoglobin 12-16 female 14-18 male hematocrit 36-47 female 42-52 male
WORKS should be cleaned with——-?
flush used needle And syringe with clean water
fill syringe with bleach shake 30-60seconds
Is
the vaginal area is more susceptible to HIV?
True the vaginal area has more mucus membrane then the penis thus HIV like otherSTDs are more easily transmitted
penis in rectalarea same idea for the rectal mucus a
HIV to AIDS takes years T/F?
false it could be months to years depending on the more times the HIV was encountered. more encounters the more likely the process will bested up to AIDS
fungal infections include?
food may taste funny because the Candidia stomactitis or esophagus is out of control. swallowing may be painful also
retrsternal pain-pain behind the ribs
woman withHIV may have persistent itching ,perineal irritation and a thick white discharge
Highly Active Antiretrviral Threapy HAART reduces the risk of transmission
False risk is always presenting HIV patients to transmit
newly made cells and compatible blood transfusions are not deemed safe by the immune system Tru or False
False it is the job of the immune system to recognize them and to monitor for foreign or non self substances
what are safer sex practices?
latex condom for genital anal sex
a condom or dental dam latex for or genital or oral/anal sex contact
latex gloves for finger or hand contact with vagina or rectum
HIV is transmitted by casual contact?T/F
False also not by mosquitoes or other insects
Intergrase is what?
Allows the viral ds viralDNA to be inserted into the host DNA
Intergrase inhibitors is a drug used to prevent viral DNA from integrating
what is the most common bacterial infection for -AIDS
MAC or my robacterium Adium complex it infects the respiratory and GI tract and is a systemic infection
culture from lymph nodes bone arrow, and blood to diagnose
look for weight loss mailse swollen lymph glands or organ disease
during assessment what should the nurse inquire about witha HIVpatient?
when diagnoses clinical symptoms chronological infection hx blood transfusion before1978-85 sexual practices STD Any TB or HEP hemophilia or clotting issues their overall knowledge of disease
AIDS is the most common secondary immune defiecny disease in the world and is caused by a virus
True
ElISA test may accurately test for HIV antibodies before 3weeks?
no the antibody is usually made anywhere from 3 weeks to 3 months and may not be detected up to 36 months after initial infection
Health are workers are not at risk of contacting HIV T/F
False. needle sticks and sharps are main means of occupational related HIVExposure
What is the first sign a woman may have for a HIV infection?
vaginal candidiasis
along with herpes,PID, cervical dysphasia, or cancer
NANDAS for aAIDS
risk for infection related to I mine deficiency
impAired gas exchange related to anemia, respiratory infection PCP,Karposi sarcoma, CMV,anemia, fatigue, pain
Acute pain or chronic pain r/t neuropathy,myelopathy, cancer or infection
Imbalanced nutrition less than body requirements r/t high metabolic need, nausea, and vomiting
Diarrhea r/t infection,food intolerance, or drugs
Impaired skin integrity r/t KS , infection, altered nutritional state, incontininance, immobility, hyperthermia, or cancer
Disturbed thought process r/t to AIDS dementia complex, enteral nervous system infection, or cancer
Chronic low self esteem r/t,, infection,changes in body, decreased self esteem or helplessness
Social isolation r/t stigma,virus transmittability infection control practices,or fear
additional. NDiagnosis
Activity intolerance r/t fatigue discomfort, cons defect, weakness, or anemia
Risk for injury r/t cons defect, mental status change, depression, or thrombocytopenia
Disturbed sensory preception(visual) r/t to CMV
retinitis or blindness
Sleep deprevation r/t pain discomfort, anxiety, or depression
Ineffective coping r/t the diagnosis of AIDS
Disabled family coping r/t the diagnosis of AIDS
Greiving r/t anticipated loss of role and function or impending death
HIV belongs to the group of viruses called———-.
Retrovirouses single stranded RNA and converts double stranded DNA
HIV protease is?
Chemical scissors that cut one long protein strand into functional pieces. These pieces bud off to infect other CD4cells
protease inhibitors work here to inhibit HIV protease
cryptocococsis widely spread with AIDS what are its symptoms
fever headache, blurred vision, nausea, vomiting, nuchal rigidity-neck pain, mild concussion, and other mental status changes
The drug that prevents single stranded HIV RNA to converting to double stranded DNAis
Nucleoside analog reverse transcriptase inhibitors NARTIS
only one infection. an be present at a time T/F
False the infection may be protozoan, fungal, bacterial, or viral and must be treAted immediately due to they may progress and cause death
cryptospordiosis may result in what fatal syndrome
severe wasting syndrome, with electrolyte imbalances
what is a protozoan infection common to HIV
PCP pneumocystis jroveci pneumonia is the most common
asses for dyspepsia on exertion, tachycardia, a persistent dry cough, and fever
may have weight loss and fatigue listen for crackles
Normal healthy adult has how manyCD4 cells?
800-1000 cells/mm3
