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NCLEX > Basic Care and Comfort > Flashcards

Basic Care and Comfort Flashcards

(83 cards)

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1
Q

diabetic diet

A

decreasing serum lipid levels

accurate carbs counting

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2
Q

DASH diet

A

limit sodium to 2300 mg/day

lower DASH diet = 1500 mg/day of sodium

low in saturated fat, cholesterol and total fat

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3
Q

low tyramine

A

avoid foods high in tyramine:

  • aged cheese
  • cured, processed or smoked heats
  • beer
  • pickled or fermented foods
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4
Q

low purine diet

A

used for clients with gout

restrict
- glandular meats
- chicken
- ducks
- fowl foods
anchovies
- beer and wine
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5
Q

low calcium

A

limit to 400 mg/day

restrcits:

  • dried fruits and vegetables
  • shellfish
  • cheese
  • nuts
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6
Q

enteral nutrition

A

breast milk can be given to newborns or infants through a feeding tube

types of feeding tubes:
NG tube, oro tube
- used for short term nutirtional supports
- usually less than 4 weeks

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7
Q

enteral nutrition interventiosn

A

HOB 30-45 degreee
monitor character and frequency bowel movements
pH less than 6

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8
Q

administration of enteral nutrition feedings

A

may be continuous or intermittent

hang for 8 hours or less
change tubing every 24 hours

administer at room temp

receive “free water” or water boluses

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9
Q

gastric residual monitoring

A

evaluate gastric residual every 4-6 hours for conitnuous feeding or prior to intermittent feedings

if gastric residual is greater than volume given over 2 hours

  • may be necessary to reduce the heart rate of feeding
  • or temporarily hold the feeding

DO NOT discard the aspirated residual
- return the entire residual amount to the stomach

flush tube with approc 30 mL at room temp every 4 hours after feeding is complete and before and after meds

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10
Q

hypercalcemia causes and findgins

A

causes:
- hyperparathyroidism
- metasis of cancer
- prolonged immbolization
- Pagets disease

findings:

  • weakness
  • paralysis
  • decreased deep tendon reflexes
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11
Q

hypocalcemia causes and findings

A

causes:

  • vit D deficiency
  • renal failure
  • pancreatitis
  • hypoparathyroisim

findings:

  • mscle tingline
  • twitching
  • tetany
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12
Q

magnesium is used for

A 
normal muscle and nerve function
heart rhythm
immune system
blood sugar regulation
BP
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13
Q

hypermagenesemia causes and findings

A

causes:

  • chronic renal disease
  • overused of mangesium-containing antacids like Maalox and Mylants
  • Addison’s disease
  • uncontrolled diabetes mellitus

signs and symptoms will be the opposite of “hyper” so all the findings will be slow or low

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14
Q

hypomagnesemia causes and findgins

A

causes:
- malnutrition
- malabsorption
- alcoholism
- diabetic acidosis

signs and symptoms will be the opposite of “hypo” so all the findings will be high or erratic

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15
Q

phosphate is used for

A

aids in cellular energy absorption
combines with calcium in one

assistsin structure of genetic maternal
normal: 2.8 - 4.5

balanced by parathyroid gland, along with calcium

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16
Q

potassium is used for

A

regulated by kidneys

hyperkalemia and hypokalemia:
high or low findings can results ina fast or slow and irregular heart rhythm, changes in ECG and muscle function
- like leg cramps

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17
Q

sodium is used for

A

regulated by slat intake, aldosterone and urianry output

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18
Q

hyponatremia

A

fluid overload

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19
Q

hypernatremia

A

dehydration

hypertension
generalized edema or anasarca

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20
Q

pressure ulcers

A

turn and reposition at least every 2 hours
use heel and elbow protectors

use alternating pressure mattrees or other pressure-reducing bed surface

avoid massaging any reddned areas and potentially damaging any skin tissue

limit sitting in chair for no longer than 2-4 hours
- shift weight at least every 30-60 minutes

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21
Q

mobility for respiratory system

A

instruct client to cough and deep breathe every hour

perofrm incentive spirometry every hour
turn immobile client every 2 hours

oropharyngeal suctioning if needed

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22
Q

mobility for urinary renal system

A

ensure that client drinks at least 2000 to 3000 mL (2-3L) of water per day

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23
Q

orthostatic hypotension

A

put the client at risk for falls

instruct to change positions slowly, progressing from lying down to sitting up and then standing

highest risk of falling is while moving from supine to standing position

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24
Q

increased cardiac workload

A

avoid bearing down when exhaling and to minimize coughing

allow limited sitting in high fowlers position from 1-2 hours

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25
venous thromboembolism formation
apply thigh or knee-high anti embolic stockings and/or intermittent pneumatic compression tunr every 2 hours administer anticoagulation therapy initate ambulation or assist with dorsiflexion and plantar flexion of the foot limit client sitting with feet in dependent position to 1-2 hours at one time
26
full weight bearing
healthy person can carry their own weight without any type of assistive device upper extremities are also considered full weight bearing when lifting and moving objects without assistance
27
partial weight bearing
limitation that is greater than non-weight bearing assistive device such as: - walker - cane - crutches - CAM walker boot imagine that there is a raw egg underneath their foot and cannot crak it
28
toe touch weight bearing
client toes may lightly rest on ground while sitting, stnaidng or transferring to maintain balance but no actual weight should be place on affected leg
29
non weight bearing
stricted limitation no weight whatsoever, not even for a moemtn or 2 whether standing, walking or sitting for an upper extremity: - should wear sling or similar device to prevent client from placing weights on affected limb
30
stress incontinence
sudden increase in intra-abdominal pressure like sneezing or coughing or anything that puts pressure on the bladder causes urine to leak from bladder
31
overflow incontinence
bladder empties incompletely so urine dribbles constantly often due to an obstruction exmaple: enlarge prostate in men
32
urge incontinence
overactive bladder uncontrolled contraction of bladder results in urine leakage beofre one reaches the bathroom
33
functional incontinence
incontinence that is not due to organic reasons impaired mobility may prevent client from reaching the bathroom in time
34
treatment in incontinence
structed peeing schedule kegel exercises protect skin integrity surgery
35
ileostomy
opening created ti bring the small intestine to surface of abdomen, specifically the ileum always have liquid stool poses the highest risk of skin breakdown after surgery, stool will be dark green, then turns yellow when pt starts to eat NO enteric coating medications because they dont dissolve
36
colostomy
opening created to rbing large intestine to surface of abdomen descending ascending transverse sigmoid descending and sigmoid: similar to normal consistency of regular stool ascending: liquid stool transverse: loose to partly formed stool after surgery: may pass mucous stool at first - will be liquid at first then progress to what it should look like depending on the location
37
colostomy and ileostomy diet teaching
start out slow for first 6 weeks low fiber small meals throughout the day monitor hydration and electrolyte status eat slowly and chew thoroughly, then advance as tolerated with ileostomy, need to stay hydrated and consume fluid and electrolyte solutions like Gatorade use caution and eat small amount of completely avoid foods that are not completely digestible: - conr - celery - peas - coleslaw - popcorn - nuts and seeds - raisins - skin of fruits - raw mushroom - pineapple
38
colostomy and ileostomy pouch care
colostomy: put petroleum gauze over stoma to keep it moist - then a sterile dressing until pouching system is in place empty pouch when 1/3 to 1/2 full change pouch when gut less active - morning before breakfast keep stoma and skin around stoma clean watch for burning around skin or leaking be familiar with various pouching system when applying, be sure to measure the stoma and cut the opening of the skin barrier to be 1/8" larger than stoma stoma irrigation may be ordered by the doctor
39
colostomy and ileostomy pre-operation
educate what to expect, what it will look like, where it will be on abdomen start teaching pouching system MD may prescribe oral antibiotics 2-3 days before surgery soft or semi-liquid diet cleansing solution and laxative may be ordered NPO on day of surgery
40
colostomy and ileostomy post operation
monitor signs of electrolytes and dehydration after surgery, stoma will be swollen and large for 48-72 hours, but after couple months it'll shrink down should always look pink or red and be moist/shiny if client has a blockage or notices a significant decrease of stool in pouch, the client should call their HCP immediately
41
loop stoma
usually temporary proximal end of loop stoma is functioning end while distal end drains mucus
42
double barrel
forms 2 stomas similar to a loop stoma, but the bowel is surgically severed
43
sleep and SIDs
infants should be place on their back for sleep cribs should be clear of pillows, toys and blankets
44
risk factors of SIDs
``` co-sleeping history of SIDs low birth weights male age under a year prematurity exposure to second hand smoke twin births poverty ```
45
infant play
tend to play alone or with caregivers toys: - music boxes - teething toys - mobiles or large blocks
46
toddlers play
alongside other childrenwithout interacting together ``` toys: push-pull oys - blocks - thick crayons - finger paints - puzzles - dolls - trucks and dress up ``` play should be active and screen time should be limited to 1 hour a day
47
preschool play
enjoy group play without rigid rules toys: - tricycles - wagons - paints - crayons - puzzles - books - balls play may be imaginative and dramatic media time should be limited to 2 hours a day
48
school age play
cooperative play toys: - board games - jump ropes - books - bicycles - crafts or sports
49
adolescent play
participating with peers during play toys: - music, sports - career - training programs - books - movies
50
blood administration
never use dextrose or LR to prime blood and administer blood products - avoid giving any medications through same IV line used for transfusions do not discard blood product and blood tubing - send tubing and product to blood bank O negative = universal red cell donor AB blood = universal plasma donor if transfusion cannot be started within 30 minutes from when product was released from blood bank, then nurse must return to blood bank should never be stored on nursing unit, even if its refrigerated
51
blood administration reaction
if reaction occurs: disconnect blood product and blood tubing - do not discard maintain patent IV line with saline obtain vital and monitor closely notify blood bank and HCP imediately send saved blood product and tubing to blookd bank monitor urine output
52
pediatrics: giving med orally
for meds with unpleasant taste, nurse may mix small amount of meds with - syrup - applesauce - sherbet with younger children, use a small syringe or nipple giving time for swallowing - place liquid medication at side of of mouth rather than to the back of the throat to avoid aspiration
53
pediatrics: IM med
vastus lateralist: preferred location for infants and toddlers - with infants give 0.5mL/leg - older children may have up to 2 mL ventrogluteal: route may less reactions or pain than vastus lateralist - administer 0.5 mL for infants - up to 2mL for older children deltoid: faster absorption than other routes - should not use this site for infants and small children - administer 0.5 - 1mL/arm
54
infiltration sxs
edema pain coolness around insertion site infusion pump alarm
55
infiltration nursing care
``` discontinue IV apply warm compress apply sterile dressing elevate arm monitor for compartment syndrome evaluate neruovascular status ```
56
phlebitis sxs
reddened, warm are a around insertion site or path of vein tenderness swelling
57
phlebitis nursing care
discontiue IV | apply warm, moist compress
58
thrombphlebitis sxs
``` pain swelling redness and warmth around insertion site or path of vein fever leukocytosis ```
59
thrombophlebitis nursing care
discontinue IV apply warm compress elevate extremity
60
hematoma sxs
ecchymosis immediate swelling at site leakage of blood at site
61
hematoma nursing care
discontinue IV apply pressure with sterile dressing aply cool compress intermittently for 24 hours to site, followed by warm compress
62
clotting sxs
decrease IV flow rate or infusion pump alarming | back flow of blood into tubing
63
clotting nursing care
disconitnue IV do not attempty to flush or irrigate the IV do not aspirate clot from cannula
64
circulatory overload sxs
``` crackles dyspnea increased BP, HR restlessness anxiety confusion seizures ```
65
circulatory overload nursing care
reduce IV rate to keep vein open monitor vitals notify HCP immediately
66
central venous access device nursing care
strict hand hygiene aseptic technique close monitoring for sxs of complications changing of administration sets, dressings and add-on devices at recommended intervals CHG bathing consulting with HCP for removal monitor for resp distress, diminishe or absent breath sounds monitor for chest pain or tracheal deviation from midline - should not be accessed or used until correct placement has been confirmed via chest x-ray
67
complications of CVA device
``` catheter occlusion local catheter infection systemic catheter infection embolism catheter migration ```
68
catheter occlusion sxs
inability to infused and/or aspirate from lumen
69
catheter occlusion treatment
reposition client "gently" flush client with 10mL NS instill thrombolytic agent
70
local catheter infections sxs
``` redness tenderness warmth edema purulent drainage ```
71
local catheter infection treatment
``` change dressing chlorhexidine biopatch aspetic technique "closed" system wit IV tubing remove catheter if necessary ```
72
systemic catheter infection treatment
remove catheter culture tip of catheter obtain blood cultures start antibiotic therapy
73
embolism sxs
sudden onset of resp distress hypotension tachycardia chest pain
74
embolism treatment
immediately place on their left side with head lower than heart administer oxygen notify HCP
75
catheter migration sxs
``` "gurgling" sound in ear edema of chest or neck inability to infused and/or aspirate blood from catheter dysrhythmias change in catheter length ```
76
catheter migration treatment
stop any infusions perform fluoroscopy or chest x-ray remove catheter if needed
77
interventions when caring for a client with CVAD
``` hand hygeiene bathe chlorhexidine on daily basis scrub access port or hub with friction sterile device replace dressings that are wet, soiled, or dislodged perform routine dressing changes - with clean or sterile gloves ``` daily audits to see if CVAD is still needed
78
parenteral nutrition or TPN preparation
prepared by or under the supervision of a pharmacist aseptic technique under a laminar airflow hood nothign should be added after it has been prepared good for 24 hours - mut be refrigerated until 30 minutes before use
79
parenteral nutrition or TPN administration
0. 22 micron filter with TPN without lipids 1. 2 micron filter with TPN with lipids always use infusion pump use dedicated line for TPN - do not infused other solutions with TPN or administer intermittent IV meds - including IV push meds through the same line with TPN before starting TPN infusion, nurse must verify that the ingredients in the solution match what the HCP ordered
80
parenteral nutrition or TPN complications
hypoglycemia - can occur when TPN runs out before a new bag is available - should hang dextrose-containing IV solutions like (D5, D10, or D20%) until new TPn bag is available hyperglycemia - blood sugar should be checked fluid/circulatory overload
81
parenteral nutrition or TPN interventions
daily weights accurate intake and output blood sugar regular lab tests
82
teratogenic drug categories
category A: no risk to fetus; controlled studies in humans B: animals studies show no risk to fetus C: no controlled studies in animals or humans D: evidence of human risks to the fetus X: fetal abnormalities in both animals and humans
83
high alert medications
``` potassium insuline narcotics chemotherapy heparin ```

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