Flashcards in Kaplan Study Guide Deck (119):
What is Ulcerative Colitis?
Inflammatory condition of the colon characterized by eroded areas of mucous membrane and tissues beneath it;
What are the indications of Ulcerative Colitis?
indications include rectal bleeding, blood, pus, mucous in the stool, abdominal pain occurs pre-defication, may have 20-30 diarrhea stools a day, nutritional deficit, weight loss, anemia, dehydration common
What is the treatment for Ulcerative Colitis?
treatment includes high protein, high calorie, low fat, low fiber diet. TPN used for bowel rest, analgesics, anticholinergics, antibiotics, corticosteroids to reduce inflammation, ileostomy;
What are the nursing considerations for Ulcerative Colitis?
nursing considerations include instruct client about mediations and diet, maintain fluid electrolyte balance, monitor electrolytes, promote rest, relieve anxiety.
What is COPD-
Group of conditions associated with obstruction of airflow entering or leaving the lungs, asthma, emphysema, chronic bronchitis, and cystic fibrosis;
What are the indications for COPD?
Indications include change in skin color, weakness, dyspnea, cough, and adventicious breath sounds
What is the nursing care for COPD?
Administering bronchodilators, mucolytics, corticosteroids, anticholinergics, and atropine sulfate, administering low flow oxygen, encouraging fluids, providing small frequent feedings, listening to breath sounds teaching the patient about breathing exercises, Instructing the patient to stop smoking.
Radiopaque catheter inserted through peripheral blood vessel into chamber of the heart, usually used with angiography, purpose is to diagonostic or can be used as intervention in some congenital heart defects;
What are the nursing considerations for cardiac catheterizations?
measure height to help determine the correct size catheter, history of allergic reactions, any infections present, assess and mark pedal pulses, age appropriate preparation for procedure.
assess for pulses, temperature, and color of affected extremity, assess heart rate every 15 min for a full minute, assess indications of hemorrhage, insure adequate hydration.
What is Epilepsy?
Chronic disorder characterized by recurrent seizure disorder, symptom of the brain or central nervous system irritation
What are the classifications of epilepsy?
Generalized seizure- tonic clonic seizure
Simple Partial Seizure
What is a tonic clonic seizure
begins with tonic phase and immediate loss of conciousness, followed by clonic phase, rhythmic jerking of all extremities
What is an absence seizure?
brief periods of loss of conciousness like day dreaming, more common in children
What is a myoclonic seizure?
brief jerking of extremities
What is a simple partial seizure?
remains conscious, often reports aura
What is a atonic seizure
sudden loss of muscle tone, client falls,
occur for no known reason
What are the nursing responsibilities for a person having a seizure?
observe and document the type and progress of seizure activity and postictal behavior
o2 and suction at bedside
after seizure- position on back with head turned to the side or position on side to prevent aspiration and promote drainage of secretions.
treatment includes medication
Unilateral facial paralysis involving the seventh cranial nerve;
What are the implications of Bells Palsy
inability to close eye
decreased corneal reflex
What are the nursing interventions for Bell's Palsy?
Protect head from cold and drafts
assist with electrical stimulation
teach isometric exercises for facial muscles and also gental massage and warm packs
prevent corneal abrasions (artificial tears)
Sunglasses in day
eye patches at night
reassure client has not had a stroke
provide emotional support for altered body image
Sickle Cell Disease
Hereditary severe chronic anemia condition in which abnormal hemoglobin distorts erythrocytes, increases their fragility, and causes them to become sickled in shape.
periods of exacerbation called crisis occur
What are the indications of Sickle Cell Disease
are systemic and include chronic anemia-hemoglobin 6-9
possible growth retardation and delayed sexual maturity
pain (often especially focused on joints)
impaired renal function
altered pulmonary function
increased susceptibility to infection
What are the interventions for sickle cell disease
administer analgesia as prescribed and teach how to use PCA pump as necessary
IV fluids and electrolytes
encourage activity as tolerated while not in crisis
Immediate cast care
- avoid covering cast until dry
- Handle with palms not figertips (plaster cast)
- avoid resting cast on hard surfaces or sharp edges
- keep affected limb elevated above heart on soft surface
-Observe for blueness or paleness, pain, numbness of affective area,
Intermediate Cast Care
- encourage client to perform prescribed exercises
-report any break in cast or foul odor
- inform client not to scratch skin underneath cast
- Don't Put anything underneath cast
Inflammation of the appendix (small fingerlike appendage attached to the cecum) due to infection or obstruction
What are the indications of Appendicitis
- abdominal pain in right lower quadrant (McBurney's P. )
- Diarrhea or constipation
- Rigid Abdomen
- Increased temperature
What are the nursing interventions for appendicitis?
- no heating pads, enemas, or laxatives preop
- Maintain NPO status until blood labs received
- No analgesics until cause of pain determined
- Ice bag to abdomen to alleviate pain
- observe for signs and symptoms of peritonitis
- realize that sudden loss of pain indicates perforation and
is a medical emergency
- After appendectomy give normal postop care
- place in Flowlers position to relieve pain and ease
Application of pulling force to part the body to reduce, align, and immobilize fractures and relieve muscle spasms
Bucks traction is a skin traction, pulling force applied to skin;
What is the nursing care for someone in Buck's Traction
maintaining straight alignment of ropes and pulleys
assuring that weights hang free
frequently inspect skin for breakdown areas
if no fracture, may turn to either side
With fracture- turn to unaffected side
Elevate foot of bed for counter-traction
use trapeze for moving
DO NOT elevate knee gatch
7.35 - 7.45
pH < 7.35
pH > 7.45
80 - 100
35 - 45
Opacity of lens that is usually caused by aging;
What are the indications of Cataracts?
blurred vision and decreased visual acuity
Treatment includes surgical removal of lens and capsule
What are the nursing responsibilities for a person who has Cataracts?
antibiotic and steroid ointment instilled into eye immediately post-op
eye covered with a patch and protective shield
position on the back in semi-fowlers position or on the unoperated side
observe and report any drainage on the eye pad
Syndrome resulting from esophageal reflux, which is backflow of gastric contents into esophagus
esophageal mucosa breaks down
often associated with Hiatal hernia, but not always
What are the indications of GERD?
Odynophagia (Severe sensation of burning, squeezing pain while swallowing)
dyspepsia (gastric discomfort after eating such as fullness, heartburn, bloating, nausea)
Symptoms may mimic heart attack symptoms
What are the interventions for GERD?
Surgery if pt does not respond to medical management
What are the nursing interventions for GERD?
Administer medications as ordered to decrease reflux (antacids, histamine receptor antagonists, cholinergics, gastrointestinal stimulants, proton pump inhibitors)
Instruct about dietary changes (small frequent feedings, adequate fluids with meals, chew slowly and thoroughly, avoid irritating foods such as very hot or cold, spicy, fatty, citrus juices, coffee)
NPO for 3 hours before sleep
Instruct about lifestyle changes (elevate head 6 to 8 inches at night, lose weight if over weight, avoid tobacco, salicylates, and alcohol).
Deficiency of Adrenocortical hormones;
- surgical removal of the adrenal cortex,
- destruction of it idiopathically or by infections,
- inadequate pituitary ACTH,
- sudden stopping of exogenous adrenocortical hormone threrapy
What are the indications of Addison's Disease
Dark Pigmentation of Skin
Low Serum Sodium
Low Blood Glucose
High Serum Potassium
What is the treatment for Addison's Disease?
Hormone Replacement Therapy
What are the nursing Interventions for Addison's Disease?
Monitor balance of fluid and electrolytes
Total Hip Arthroplasty
Surgical Replacement of the head of the femur and acetabula with an artificial joint;
Used for diseased femoral joint or fracture of the head of the femur or femoral neck
What are the complications following a total hip arthroplasty?
dislocation of hip prothesis
excessive wound drainage
What are the nursing interventions for a total hip Arthroplasty?
Positioning leg in ABDUCTION using abduction splints or wedge or 2-3 pillows between the legs
hip should not be flexed more than 45 - 60 degrees
head of the bed should not be elevated more than 45 degrees
turn from back to unaffected side
use fracture bedpan by having the client flex the unoperative hip while using the trapeze to lift the pelvis or have the client ambulate to the bathroom or use the bedside commode
use over head trapeze to reposition in bed
prevent complications of immobility by early ambulation
use semi reclining or elevated toilet seats and semi reclining wheelchairs to prevent hip joint flexion.
Malignancy in the Epithelium of respiratory tract
What is the primary risk factor for lung Cancer
Is there an effective screening test for lung cancer?
No effective Screening Test
Limited treatment options
usually poor prognosis
What are the indications of Lung Cancer?
change in respiratory patterns
bloody or purulent sputum
Unexplained Weight loss
recurring pulmonary system problems
pain in arm shoulder chest or back
What are the interventions for Lung Cancer?
What are the Nursing Interventions for Lung Cancer?
preop and post op teaching (esp related to respiration)
Maintenance of chest tube drainage system
gental careful skin care
administration of antiemetics, analgesics
appealing small frequent means high in calories and protein
including coping with alopecia
balance rest with activity
25 - 35
4.6 - 6.1
4.7 - 6.1
135 - 145
3.5 - 5
7 - 18
0.6 - 1.3
8.5 - 10.5
12.2 - 16.2
43.5 - 53.7
Multiple Sclerosis (MS)
Progressive disorder of Nerve impulse Transmission characterized by demyelination of white matter throughout brain and spinal cord; periods of exacerbation and remission; intellect intact; leads to paraplegia or complete paralysis
What are the indications of MS
paresthesias or abnormal sensations in extremities
bowel and bladder dysfunction
chewing and swallowing difficulties
What are the nursing interventions for MS
include teach exercises related to relaxation, coordination, progressive resistance, range of motion
teach to balance activity and rest
provide warm baths and packs
teach wide based walk
use of cane or walker
implement bowel and bladder training
teach about self help devices
instruct in use of eye patch for diplopia
provide emotional support
refer to support groups or organizations
Systemic Lupus Erythematosus (SLE)
Chronic, systemic inflammatory autoimmune collagen vascular disease of multiple body systems
What are the indications for Systemic Lupus Erythematosus (SLE)
joint swelling, tenderness, and pain on movement
butterfly rash across bridge of nose and cheeks
What are the Nursing interventions for Systemic Lupus Erythematosus (SLE)
maintain skin integrity
monitor steroid therapy
monitor closely for infection and teach preventive measures
relieve pain and discomfort- including NSAID use,
advise lifestyle changes to decrease risk of CAD,
monitor for cognitive abilities and emotional stability
provide emotional support
Chronic Inflammatory disease of the airways caused by increased responsiveness of tracheobronchial tree to various stimuli
What are the indications for asthma
What are the nursing interventions for Asthma
assess respiratory status
administer medications as prescribed
instruct about use of peak flow meter
use of metered dose inhaler (MDI)
asthma triggers to avoid
Infection or inflammation of membranes covering brain and spinal cord
bacterial, viral, or fungal in origin
What are the indications of Meningitis
signs of meningeal irritation (Nuchal rigidity, Kernigs sign, Brudzinskis skign, opisthotonic position)
changes in level of consciousness
in infants, - refuse feedings, vomiting, diarrhea, buldging fontanelles, vacant stare, high pitched cry,
What are the nursing interventions for Meningitis
Administer antibiotics or antifungals as ordered
observe for increased intercranial pressure
maintain seizure precautions
maintain adequate fluids and electrolyte balance
Failure of the heart to pump enough blood to meet metabolic (oxygen and nutrient) demands of tissues, left and right ventricles can fail separately;
Left-sided heart failure indications:
dyspnea, orthopnea, cough, crackles, tachycardia, faigue, anxiety, restlessness, confusion,
Right sided heart failure Indicators:
JVD, dependent edema (especially in the lower extremities, and progressing up the body eventually up to the abdomen.) hepatomegaly, right upper quadrant tenderness, increasing hepatic dysfunction, ascites, anorexia, nausea, weight gain, weakness, respiratory distress, abdominal pain, altered liver function tests, GI distress,
Treatment for Heart Failure:
oxygen, digoxin, diuretics, vasodilators, potassium supplements, low sodium diets, bedrest,
Nursing Responsibilities for heart failure include:
promoting physical and emotional rest, high fowlers position, assessing vital signs, lung sounds, I&O’s, good skin care, and client education.
Surgical incision made into the trachea by way of the throat; tube inserted through incision into the trachea; care should be performed every 8 hours and PRN-
Hyperoxygenate or deep breathe client,
suction tracheostomy tube,
remove the old dressings,
open sterile kit, put on sterile gloves,
remove inner cannula, clean with hydrogen peroxide,
rinse with sterile water and dry,
reinsert into outer cannula,
clean stoma with hydrogen peroxide then sterile water and then dry,
change the ties as needed,
apply new sterile dressing without cutting gauze pads,
Why would you need to suction a patients Trach?
Noisy respirations, restlessness, increased pulse, increased respirations, and presence of mucus in the airway.
Inflammation of the pancreas; may be acute or chronic;
acute reflects digestion of the organ by the enzymes that it produces (particularly trypsin).
Chronic reflects obstruction of the pancreatic ducts and destruction of the secreting cells, frequently related to alcoholism.
Indications of acute Pancreatitis-
severe abdominal pain, often radiating to the back, nausea and vomiting,
Indications of Chronic:
severe abdominal pain, often radiating to the back, nausea and vomiting,
as well as weight loss, diabetes, steatorrhea; if pain does not respond to medical management surgery may be indicated.
General Nursing Indications for pancreatitis include:
Establish and monitor NG tube with suction.
Maintain fluid and electrolyte balance,
place in semi fowlers position (or especially for pain relief, keep knees flexed when sitting in bed or lying on side with a pillow pressed to abdomen),
monitor for infection, shock, hyperglycemia, administer TPN, administer medications such as antacids, analgesics, anticholinergics, for chronic pancreatitis give medication for treatment of exocrine insufficiency.
Enlargement of prostate gland, which surrounds neck of bladder and urethra in men; results in compression and urinary retention;
Indications of BPH-
dysuria, frequency, urgency, leakage, decreased force of urinary system, hesitancy, nocturia,
Nursing interventions for BPH-
If surgery is not needed, include teaching about BPH, encourage fluids, explain medications, catheterize if ordered, monitor urine output,
Preop= promote urinary drainage, discuss concerns (including possible sexual dysfunction)
Post-op= includes assess and maintain catheter patency, if traction on catheter, keep leg straight, monitor drainage, control and treat bladder spasms, teach pelvic exercises, instruct to avoid heavy lifting and prolonged sitting, discuss sexual concerns.
lung collapse caused by accumulation of air or fluid in the pleural cavity; indications include pleuritic pain, tachypnea, diminished breath sounds, treatment includes chest tubes.
Wound Healing Diet-
Diet to support wound healing should be high in protein, fat, carbs, vitamins (ACE) and minerals (zinc)
Chronic Renal Failure-
Progressive reduction of functional renal tissue resulting in inability of kidneys to excrete wastes, concentrate urine, and conserve electrolytes; irreversible
Indications for Chronic Renal Failure-
Anemia, acidosis, azotemia, fluid retention, hypertension, hypocalcemia, anorexia, nausea and vomiting, constipation, impaired insulin action,
Interventions to slow the process of Chronic Renal Failure:
control Blood pressure and make fluid and dietary changes, dialysis or transplantation may be done when these measures are no longer effective;
Nursing interventions for Chronic Renal Failure include:
monitor fluid status, encourage nutrition by decreasing nausea, vomiting, stomatitis, and other GI symptoms, Teach appropriate diet (Low protein, low potassium, low sodium) manage cnstipation, teach to balance rest and activity, encourage rest and activity, encourage good skin care with emphasis on moisturizing, teach coping skills to client and family, teach dialysis related procedures, explain transplantation procedures, explain transplantation process and subsequent potential issues and care.
Acute inflammatory disease of the liver resulting in liver cell damage; hepatitis A is transmitted by infected feces via fecal oral route, shellfish from contaminated waters is a major source;
Indications of Hep A-
jaundice, anorexia, right upper quadrant pain, clay colored stools, tea colored urine, pruritis, liver function studies reveal elevated ALT and AST. Prothrombin time is prolonged.
Interventions for Hep A-
prevention by improved sanitation, gamma globulin early postexposure, Bedrest for severe symptoms, contact precautions if patient wears diapers or is incontinent, diet low in fat, high in calories, carbs, and protein. No Alcohol, use calamine lotion, antihistamines, maintain short clean nails for itching, administer medications as ordered including: Vit K, antiemetics, corticosteriods, avoid potentially hepatotoxic prescriptions over the counter. teach balance rest and activity periods, techniques to prevent spread, cannot donate blood.
caused by thrombus formation, venous insufficiency, vericose veins,
cool brown skin, edema, ulcers, pain, normal or decreased pulses, positive Homans sign,
predisposing factors for PVD-
immobility, pregnancy, heredity, obesity, surgery, heart failure, injury to vein wall, hypercoagulability,
Nursing Interventions for PVD-
monitor peripheral pulses, thombectomy, avoid extremes of temperatures, elastic stockings, TED hose, intermittent pneumatic compression devices, anticoagulants, bedrest, elevate legs.
The nurse cares for a client diagnosed with group a beta hemolytic streptococcal bacterial infection. The nurse knows that the patient is at high risk to develop:
Glomerulonephritis, inflammation of the glomeruli is a type III hypersensitivity reaction immune complex formation due to binding of the antigens and antibodies
Acute Glomerulonephritis most common, usually caused by beta hemolitic strep infection elsewhere in the body. Glomerulonephritis caused by damage to the glomerulus caused by an immunological reeaction that results in proliferattive and inflammatory changes within the glomerular structure.
Indications include fever, chills, hematuria, red cell casts, proteinuria, weakness, pallor, dyspnea, weight gain, lung rales, fluid overload, generalized and or facial and periorbital edema, moderate to severe hypertension.
Nursing care includes administer antibotics, corticosteroids, antihypertensives, restrict sodium intake, water if oliguric, daily weights, I&O's
Nutritional changes for cancer patients include anorexia, nausea, and vomiting commonly seen with chemo, malabsorption and cachexia (wasting) common
Nursing care includes making meals appealing to senses, conforming diet to client preferences and nutritional needs, providing small frequent means with additional supplements between meals (high calorie, high protein) encouraging fluids but limiting at meal times. Performing oral hygiene and providing relief of pain before meal times, administer TPN as needed.
Hypersecretion of adrenal hormones (mineralocorticoids, glucocorticoids, androgens)
Indications include fatigue, weakness, osteoporosis, muscle wasting, cramps, edema, increased blood pressure, hypernatremia, hypokalemia, hyperglycemia,
Treatment is adrenalectomy
Cushing signs and symptoms
thinning extremities with wasting
thin fragile skin
moon face and ruddy complexion
broad purple striae
impaired wound healing
Restore balance to hormones and reverse cushings syndrome
high protein and k
low calorie, carbs, sodium
Severe hyperthyroidism caused by injury, infection, thyroid surgery, insulin reaction, diabetic acidosis, pregnancy
indications include hyperpyrexia, extreme tachycardia, altered mental status,
nursing considerations include hypothermia blanket, administer o2, sodium iodine, PTU, Propranolol, hydrocortisone, tylenol