Unit 2 Flashcards by Krissa Thrift

Complications from burns

CONTRACTURES, infection, shock

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When doing dressing changes for burns always remeber to use

sterile technique

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Cherry red mucosa is a tell tale sign of

Carbon monoxide posioning

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How would you propritize tx after a massive trauma?

Airway
Other injuries
Burns

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How to prevent contractures?

ROM

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Dietary considerations for Burn pts

High calorie high protein

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Herniated nucleus pulposus

herniated disc

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Pt presents with severe pain, muscle spasms, numbness/tingling, decreased reflexes, or sciatic nerve pain…What do you suspect the dx is?

Herniated disc

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tx for herniated disc

RICE 1-2 days
heat after 2 days
medications
ultrasound tx
PT for back strengthening exercises
swimming
PT
Chiropractic care
surgery
when laying on back use pillow to elevate legs to take pressur eoff back

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If a spinal cord injury is suspected to be incomplete you know what about their condition?

That it cannot be fully assessed until the swelling goes down

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Complications associated with a spinal cord injury

PRIORITY IS AIRWAY
spinal shock
neurogenic shock
muscle spasms

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What to remember when a pt is taking prednisone?

they need to be tapered off of it

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most common muscle relaxer used amongst SCI pts.

baclofen

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Used to help tx low blood pressure (think SCI pt’s

dopamine

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Nursing interventions for pts with a spinal cord injury

pt is a fall risk
assess bladder
prevent pressure ulcer

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pt presents with sudden onset of HIGH BP, has a distended bladder, has a spinal cord innjury at T6…what could be the diagnosis

Autonomic dysreflexia

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If autonomic dysreflexia is suspected what should be done FIRST

Raise the HOB

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If a spinal cord injury is suspected what is the PRIORITY action?

Do NOT move them unless they are in immediate danger. Wait for EMS to come with stabalizing equipment

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What is the usual first sign of infection in older adults

confusion

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What is a major sign of parkinsons disease

resting tremor

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A pt with parkinsons usually has trouple reading but does better writing why?

Resting tremors eases up with intentional movement

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Nursing care for pt’s with parkinsons

Fall risk
drug therapy (sinamet)
PT
A lot of emotional support
neurosurgery electrical implants to shock and block tremors

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Drug that enhances the delivery of dopamine to the brain cells. Used to tx the symptoms of parkinsons

sinemet

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A parkinsons comes into the ER and daughter states since taking her new meds the pt presents with GI complications, palpitations, urinary retention, behavioral changes, severe nausea, vomiting, increased gambling, sexual binge or compulsive eating or other intense urges what do you suspect?

Sinemet toxicity

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Why should sinement pts report leasions to their PCP

it can cause a malignant melinoma

The spontaneous separation of an incision (often abd), involved separation of the layers beneath the skin as well

Dehiscence

A pt has just experiencenced dehiscence of his abd incision. What is the first thing you do?

Cover with a wet sterile dression or cloth

Protrusion of an internal organ through the incision

evisceration

Pt presents with: ``` T: >100.4 F <96.8 F.4 F RR: > 20 HR: > 90 WBC: < 4,000 or >12,000 or > 10% bands PCO2: <32 mmHg—low bc of hyperventilation ``` What do you suspect?

SIRS

Pt presents with: ``` T: >100.4 F <96.8 F.4 F RR: > 20 HR: > 90 WBC: < 4,000 or >12,000 or > 10% bands PCO2: <32 mmHg—low bc of hyperventilation confirmed or suspected infection Change in LOC decreased platelets elevated leukocytes elevted lactate increase in pain ```

sepsis

Pt is showing signs of: ``` Change in LOC decreased urine output decreased intake or onset of N/V increased pain lab and vital sign changes ``` can be clasified as doing what?

decompensating

Pt presents with severe sepsis w/ persistent hypotension, S/S of end organ damage Lact >4

septic shock

pt presents with the following:  RUQ pain progressing to the lover back  Clay colored stool that will float because of indegested fat  N/V  Severe pain  Possible fever  Bile backs up into liver jaundice may occur What could the dx be?

Gallbladder disease

Dx testing for Galbladder disease

 Labs: increased white count  Ultrasound  HIDA scan  CT scan

If a pt that has had a recent cholecystectomy is complaining of shoulder pain what should you do?

Walk them around. It's probably trapped gas

Pt presents with the following: High BP edema periorbital edema (puffy around the eyes) What can the nurse suspect the pts dx to be?

Glomerulpnephritis

What kind of diet do glomerulonephritis pts need to be on?

low protein; low sodium

A TB test with swelling at the site more than 5mm

Positive

A TB test with an induration less than 5mm

negative

WHen transporting a pt with TB what should you always make sure the pt is wearing?

a surgical mask

A home health nurse is dispatched to collect what kind of culture to ensure the tx is working and the pt is compliant

Sputum culture

Pt presents with the following:  5-10 diarrhea/blood stools a day, abd pain, rectal pain, rectal bleeding, fecal urgency, fever, weight loss, vomiting, fatigue, dehydration, cramping What can the nurse suspect the pts dx to be?

Ulcerative colitis

Nursing interventions for ulcerative colitis

 Pain control, monitor potassium, I&O’s, low fat and fiber diet, high calorie and protein encouraged, small amounts of food with lactose (dairy)

Treatment for ulcerative colitis

 No medical cure; surgical cure which required the section of bowel to be removed

How to tx diverticulitis

High fiber diet, increased fluids, stool softener, surgical removal of affected part of the colon, anastomosis, colostomy, take-down

Center eye blindness

maclar degeneration

What kind of shock can you anticipate from a burn?

hypovolemic shock

What kinf of electrolyre imbalances can you anticipate from a severe burn?

hyponatremia | hyperkalemia

Best method of looking for carbonmonixide poisoning?

ABG

If burn is smoldering what do you put on it?

Tepid water

Dietary considerations for burn patients

High calorie | high protein

S/S associated with a lumbar injury

sciatic nerve pain, decreased nerve reflexes below the waste. No S/S in hands and arms.

pt presents with sciatic nerve pain, decreased nerve reflexes below the waste. No S/S in hands and arms. what do you suspect is the dx?

lumbar injury

S/S associated with a cervical injury

difficulty breathing depending on how high the injury is. Numbness and tingling in the hands and arms.

Main S/S of parkinsons

``` Resting tremor shuffling gait slow movement poor balance muscle rigidity ```

Diet for a glucomephritis pt

low protein low sodium restrict fluids

TB results should be read within

48-72 hrs

What test is used to check for remission of tb?

Sputum culture

If a pt who has TB has any sort of mental impairment, a previous dx that is untreated, or is confused, anticipate what?

Going into the home to ensure they are compliant with their medications

Diet for patient with unlcerative colitis

Low fat and low fiber diet, high calorie and high protein Small amounts of lactose If NPO for a long period of time expect TPN

Ulcerative colitis puts pt at risk for what kind of cancer?

Colon

If a ulcerative colitis pt has a lot of bleeding what should you suspect?

anemia

Nursing interventions for ulcerative colitis

``` Fluid resusitation pain control monitor potassium Strict I&O Diet ```

tx for diverticulosis

High fiber diet, increased fluids, stool softener, surgical removal of affected part of the colon, anastomosis, colostomy, take-down

What kind of macular degeneration is more common with age?

dry

Risk factors for cateracts

smoke, excessive alcohol use, eye surgery, eye trauma, poor nutrition

S/S of cataracts

blurry vision, colors will appear less vivid, halos, inability to read small print

pt presents with: blurry vision, colors will appear less vivid, halos, inability to read small print What do you suspect the dx is?

cataracts

risk factors of retinopathy

underlying conditions; hypertension, diabetes, hereditary, smoking

S/S of Open angle glaucoma

more common, angle between iris and sclera, aquoes humor outflow is decreased due to blockage. Seek help immediately, headache, mild eye pain, loss of peripheral vision, decrease accomadation, halos around light, elevated IOP of more that 21mm. No. 1 risk factor is age. Onset is more gradual

S/S of closed angle glaucoma

angle between iris and sclera suddenly closes causing IOP 30mm or higher, decreased/blurry vision, colored halos around lights, pupils nonreactive to light, severe pain and nausea, photophobia. Onset is more sudden

S/S of open angle glaucoma

S/S of glaucoma

aching of eyes, head ache, halos, visual changes, nor corrected with glasses

Pt presents with: aching of eyes, head ache, halos, visual changes, nor corrected with glasses What do you expect the dx to be?

glaucoma

What medication should you avoid if you have closed angle glacoma?

antihistamines

Unit 2 Flashcards

(75 cards)