Final Care Of Complex Flashcards

1
Q

The transfer of heat from the body to moving liquid or air is called what

A

Convection

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2
Q

The transfer of heat via electromagnetic waves is called what

A

Radiation

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3
Q

The transfer of heat from the body to a cooler surface by direct contact is called what

A

Conduction

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4
Q

Clinical manifestations of hyperthermia

A

Flushing warm skin increased MBR, increased need for fluids.
Skin rash, loss of appetite, confusion, dizziness, fatigue, vomiting, diarrhea.

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5
Q

What heat related injury occurs because of loss of body fluid volume cause by loss of body fluid and salts. Due to heat

A

Heat exhaustion.

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6
Q

What heat related injury occurs due to high environmental temperatures accompanied by high humidity leading to a dysfunction in the brains thermoregulation center resulting in loss of ability to cool itself

A

Heatstroke
Treatment is urgent cooling

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7
Q

Symptoms of malignant hyperthermia

A

Dangerously high body temperature, rigid muscles/spasms, dysrhythmia, tachycardia, hypotension, cyanosis.

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8
Q

Cardiac arrest algorithm.

A

Start cpr, give o2, attach to defibrillator

If in pulse less vtach or vfib- admin shock

Return to cpr, ensure IV access, (epi Q3-5min eventually)

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9
Q

If PCO2 levels are increase what does it suggest. What if they are decreased

A

Increased = respiratory acidosis
Decreased = respiratory alkalosis

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10
Q

If HCO3 levels increase what does it suggest? What about if they decrease

A

Increase= metabolic alkalosis
Decrease =metabolic acidosis

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11
Q

What is a never event

A

A surgical procedural error that should never have occurred.

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12
Q

What type of assessment does a nurse do pre operatively

A

Full head to toe

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13
Q

What is the nurses role with informed consent

A

Ensuring that consent is obtained, witnessing the signed consent, and making sure all questions have been answered by appropriate persons (by notifying surgeon if questions arise)

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14
Q

What is the earliest sign of increased intracranial pressure

A

Change in LOC

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15
Q

What is Cushing triad

A

Bradycardia
Respiratory rhythm change
Widened pulse pressure.

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16
Q

what clinical manifestations would you expect with heatstroke

A

dizziness
fatigue
nausea/vomiting
hypotension
muscle cramps
late signs: irritability, confusion, stupor, coma

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17
Q

what happens to a patients electrolytes with hyperthermia? what will we do?

A

there will be a loss of fluids and electrolytes with hyperthermia.
we treat the underlying cause. Asess I/Os, provide fluid replacement
be alert for signs of dehydration or electrolyte imbalance.

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18
Q

what clinical manifestations would you expect with a fever?

A

flushing
warm skin
increased metabolic rate
tachycardia/ tachypnea
increased need for fluids
fatigue. malaise, weakness
mental status changes, decreased responsiveness

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19
Q

what interventions will the nurse implement with frostbite?

A

rewarm the affected areas in circulating warm water.
do not rub or massage
bedrest
elevate affected limb
analgesics and anti-inflammatory agents
whirlpool therapy to clean skin, debride necrotic tissue, necrotic tissue may require amputation.

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20
Q

systemic responses to cold

A

decreased metabolic rate
hypotension, bradycardia/irregular rhythm, bradypnea/irregular respiration,
shivering
decreased urinary output
increased blood viscosity.

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21
Q

what are some examples of interventions to prevent venous thromboembolism (VTE)

A

SCDs
antiembolism/compression stockings
early ambulation
anticoagulant meds (heparin, lovenox…)

22
Q

list these post op findings inpriority order by most concerning :
copious oral secretions, hoarseness, sore throat, stridor.

A

stridor
copious oral secretions
sore throat
hoarseness

23
Q

what are some benefits of administering opioids to post op patients?

A

pain relief
wound care
early ambulation
cough, deep breathing, incentive spirometry
sleep

24
Q

what are some recommendations to prevent aspiration perioperatively

A

NPO prior to procedure
Advance diet appropriately post op

25
what are some clinical manifestations of hypovolemia
decreased fluid volume= decreased BP increased HR increased RR decreased urinary output
26
what is the priority nursing action if a hemolytic reaction occurs?
STOP the infusion immediately no matter how mild. symptoms may include: decreased BP, tachycardia, tachypnea, nausea, fever, chills, lower back pain.
27
what clinical manifestations would you expect with increased ICP?
nausea, vomiting HA fatigue light sensitivity decreased LOC, restlessness, irritability. irregular respirations, bradypnea hypertension
28
what nursing interventions might you implement for a patient with IICP
elevate HOB fluid restriction/management reduce environmental stimuli pharmacological seizure precautions
29
what pharmacological nursing interventions might you expect to administer with IICP
diuretics (mannitol) to decrease edema IV fluids (MAP and electrolyte management) anticonvulsants (seizure management) vasoavtive medication (MAP management: (epi, dobutamine, vasopressors). antibiotics (infection prevention.)
30
what is the difference between decorticate and decebrate posturing?
Decorticate= flexor= C, arms are like Cs moves in towards the "cord". indicates problems with cervical spinal tract or cerebral hemisphere. Decerbrate= extensor= E, arms are like e's and outwards. indicates problems with midbrain or pons.
31
what changes with a patient diagnosed with IICP would prompt you to notify the MD?
change in LOC CHange in GCS clear fluid drainage from ear or nose change in hemodynamics (abnormal vitals)
32
what number range is considered mild on the GCS
-13-15=mild 9-12= moderate 3-8= severe
33
a patient presents to the ED after a trauma. WHat is the priority action?
maintain a patent airway
34
pH lower than 7.35 and pCO2 higher than 45= what
respiratory acidosis. caused commonly by respiratory depression COPD, pneumonia.
35
pH higher than 7.45 and pCO2 lower than 35= what
respiratory alkalosis. caused commonly by hyperventilation (emptions/pain).
36
contraindications to oral contraceptives
pregnancy heavy smoking acute or chronic liver disease history of thromboembolism hypertension
37
what are some signs the nurse needs to massage the fundus 2hrs postpartum
patient appears ashen soaked perineal pad patient reports weakness/lightheadedness fundus boggy
38
a nurse suspects anaphylaxis. what is the priority action?
Assess ABCS
39
what diet recommendations would you provide to a patient with iron deficiency anemia
iron rich foods= beef, chicken, eggyolk, clam,pork, turkey, veal bran, brown rice, whole grain, beans, dried fruit, leafy greens
40
what are potential complications for newborns with small gestational age (SGA)?
polycythemia (elevated RBC count) cold stress asphyxia hypothermia hypobilirubinemia
41
a newborn has both nose and mouth secretions. which do you suction first and why>
mouth because aspiration
42
what clinical manifestations would you expect with SLE
dry scaly raised rash on face unexplained fever malaise muscle atrophy, arthralgias loss of appetite
43
what early clinical manifestations would you expect with HIV/AIDS
flulike symptoms general malaise and fatigue night sweats fever opportunistic infections
44
what is immune thrombocytopenic purpura and what priority assessment would the nurse monitor
rare autoimmune (cytotoxic) disorder wher blood doesnt clot properly. thrombocytopenia= low platelets purpura= petechiae monitor and assess for BLEEDING
45
what will the nurse include with droplet precautions
hand hygiene basic isolation face mask possibly gown gloves goggles if coming into contact with secretions
46
what are education points for patients with neutropenia (leukopenia)
eat cooked foods avoid large crowds wash hands frequently monitor for infections
47
who should get a colonoscopy
45-75 every ten years
48
what clinical manifestations would you expect with hypoxia
tachypnea (rapid and shallow breathing) restlessness agitation cyanosis tachycardia
49
what does coffee ground emesis indicate?
bleeding in the GI tract
50
what is DIC
a cascade of abnormal coagulation that involves multiple small clots that use up all the clotting factors and then the person cannot clot and can bleed out.
51
indications for omeprazole
duodenal and gastric ulcers prolonged dyspepsia GERD Esophagitis
52