Unit 2 Flashcards
(84 cards)
1
Q
an injury to the tissue of the body caused by heat chemical, electrical, Radtion ?
A
Burns
2
Q
what are the 5 type of burns?
A
Thermal burns Chemical burns Smoke inhalation injury Electrical burns Cold Thermal injury
3
Q
what is the most common type of burn?
A
Thermal
4
Q
what are some complications associated with burns
A
shock
infection
5
Q
headache, fatigue, SOB, dizziness, N/V, confusion, Loss of muscle, passing out, cherry lips and mouth are symptoms of what ?
A
Carbon Monoxide Poisonings
6
Q
Cherry red lips and Mouth
A
Cherry Mucosa
7
Q
what is the main priority with carbon monoxide poisoning’s/ Inhalant Injury?
A
AIRWAY
8
Q
what are some nursing interventions for Burns?
A
Monitor airway Circulation fluid replacement comfort management Thermoregulation infection prevention feeding needs (ex NG) psychological support restoration for mobility
9
Q
what are some dietary consideration for burn clients?
A
prevent protein loss
1.5-2 grams of protein a day
supplement mineral and vitamins
prevent infection by meeting metabolic needs
10
Q
what are some ways to prevent Burn injuries’ ?
A
smoke alarms water regulation kitchen safety close lids chemicals out of reach label containers check bath water by submitting forearm.
11
Q
Nucleus pulposus bugles and herniates and squeezes into spinal cord putting pressure on spinal cord and nerve ?
A
Herniated Nucleus Pulposus
HNP
12
Q
Severe pain, muscle spasms, numbness and tingling, decreased reflexes, and sciatic nerve are symptoms of what
A
HNP
13
Q
what are some treatments for HNP ?
A
bedrest 1-2 days walking ice/heat meds physical therapy back strengthen exercises (swimming) surgery.
14
Q
all sensory, motor, and sympathetic functions of the nervous system are lost below the level of injury, damaged & undamaged nerves unable to send msg to brain?
A
Spinal Cord Injury
15
Q
what are some expected findings of SCI (Spinal Cord Injury) ?
A
Paralysis paresthesia Loss of reflex Spinal shock (1st) risk for autonomic Dysreflexia
16
Q
complications of SCI ?
A
Infections DVT Orthostatic hypotension' skin breakdown Renal Complications Depression Substance abuse Autonomic dysreflexia bladder distention
17
Q
what are some medications for SCI?
A
Prednisone
Baclofen
Dopamine
18
Q
what is an emergency intervention with SCI?
A
Autonomic Dysreflexia
19
Q
Autonomic Dysreflexia?
A
is a syndrome in which there is a sudden onset of excessively high blood pressure.
resulting to seizure’s
20
Q
spinal cord injury to the T6 or above thoracic nerve is commonly known to cause what?
A
Autonomic Dysreflexia
21
Q
A degeneration of neurons in the brain affecting the motor structure control causing involuntary movements is what?
A
Parkinson’s disease
22
Q
what are s/s of Parkinson’s disease ?
A
RESTING tremors decreased with movement Bradykinesia (slow movement ) poor body balance stiff movements flat affect speech issues drooling constipation incontinences sweating heat tolerance decrease sexual ability
23
Q
what medication is given for Parkinson’s disease?
A
Sentiment
24
Q
give w/food antacids and stool softeners
may upset stomach
delivery of Dopamine to brain cells
A
Sentiment
25
what are nursing cares for Parkinson's disease
obtain motility
ability to ambulate
self care needs
safety to pt
26
a splitting open of an incision?
Dehiscence
27
Extrusion of viscera outside the body especially through a surgical excision ?
Evisceration
28
inflammation in organs remote from the initial damage?
SIRS
29
SIRS/SEPSIS/SEPTIC SHOCK are most commonly associated with what?
bacterial infections.
30
s/s of Sirs/Sepsis/septic shock?
```
elevated leukocytes
elevated lactate
decreased platelets
elevated temp
Hypotension
swelling
edema
```
31
what are some nursing interventions for Sirs/sepsis/septic shock?
maintain skin integrity
rest
broad spectrum antibiotics
monitor I&O's
32
gallstones and inflammation of the gallbladder and common bile duct ?
Gallbladder disease
33
what are some S/s of gallbladder disease
```
fever
elevated pulse, rr
vomiting
positive murphy sign
Pain in RUQ
pain after meal w/in 1-3 hrs
jaundice
heartburn
```
34
inability to take a deep breath when pressed below the liver is what ?
Positive Murphy
35
Dx testing for Gallbladder disease?
```
Ultrasounds
endoscopy
ct
HIDA SCAN
WBC count
```
36
A surgical removal of the gallbladder via Laparoscopy is called what?
Cholecystectomy
37
Glomerulonephritis
Several renal diseases affecting both kidneys.
38
S/s of Glomerulonephritis
```
Oliguria
Hypertension
Electrolyte imbalances
Edema
edema beginning in the eyes and face
Flank pain
```
39
nursing interventions for Glomerulonephritis include?
```
reduce edema
monitor vitals
fluid restriction
limit protein intake
low sodium
```
40
Low protein is recommended for Glomerulonephritis clients why?
reduces nitrogenous waste by-products.
41
most commonly associated with group a beta-hemolytic streptococcal infection following infection of the throat and skin ?
etiology of Glomerulonephritis
42
an inflammatory disease of the glomerulus
Pathophysiology of Glomerulonephritis
43
serious infectious disease that mainly affects the lungs.
Tuberculosis
44
test reading for TB?
Mantoux test
xray
Sputum
Radiographic exams
45
injecting 0.1 ml of tuberculin purified protein derivative (PPD) into the inner surface of the forearm.
Mantoux Test
46
when is a Mantoux test read?
48-72 hrs
47
swelling at site of more than 5mm is what kind of reading?
Positive Reading of TB Mantoux test
48
induration less than 5mm or no induration is what kind of reading?
Negative reading of Mantoux test
49
what are some nursing interventions for Tb?
```
wear n95
negative air pressure rooms
medications
no alcohol
observe meds are being taken.
```
50
what are the four medications prescribed for TB ?
Pyrazinamide
Ethambutol
Isoniazid (INH)
Rifampin (Rifadin)
51
how long is the course of medications with a positive Tb patient?
4-7 months
52
edema and inflammation primarily in the rectum and the rectosigmoid colon, ulcers in the colon is what ?
Ulcerative colitis
53
```
diarrhea w/blood or pus,
5-10 liquid stools per day
abdominal pain
rectal pain
rectal bleeding
fecal urgency
fever
weight loss
vomiting
fatigue
dehydration
cramping
are s/s of what?
```
Ulcerative Colitis
54
treatments for ulcerative colitis ?
colostomy
proctocolectomy w/wo ileostomy
diet
med
55
Nursing interventions for Ulcerative Colitis?
```
monitor potassium levels
monitor I&O's
limit foods w/lactose, fat and fiber
encourage high calorie and protein
nsaids for inflammation
antidiarrheal
steroids
Surgical procedures - . Anastomosis and or a colostomy may be needed
```
56
A colostomy can be reversed sometimes, the stoma will be reattached with anastomosis to the remaining intestine inside the body is known as what?
Take-down
57
what are some complications of Ulcerative Colitis
Bleeding
fluid and electrolyte imbalance
peritonitis
58
inflammation of the bowel mucosa is what?
Diverticulosis
59
what are some treatments for diverticulosis?
includes a high-fiber diet, increased fluids, and the use of stool softeners as needed
60
leading cause of permanent impairment of close-up vision or reading in residents over 64
Macular Degeneration
| AMD
61
s/s of Macular degeneration
```
depth perception
objects appear distorted, blurred, o double vision
loss of central vision
blindness
progressive blindness color appear dull
```
62
Wet macular degeneration ?
Less common form
| caused by new growth of blood vessels that have thin walls leaking blood and fluid
63
Dry Macular degeneration?
MOST Common
| caused by gradual in retinal capillary arteries, macula becomes ischemic and necrotic. due to lack of retina cell
64
opacity in the lens of an eye that impairs vision
Cataracts
65
risk factors of cataracts?
```
age related
diabetes
hereditary
smoking
eye trauma
sun exposure
alcohol disorder
chronic use of corticosteroids, Beta blockers and mitotic meds
```
66
s/s of cataract ?
decreased visual activity, blurred vision, diplopia, visible opacity
absent red reflex
67
what disorder in which vascular changes occur in the retinal blood vessels. common in clients with diabetes ?
retinopathy
68
risk factors for retinopathy ?
```
diabetes
poor blood glucose control
smoking
pregnancy
hyperlipidemia
```
69
s/s for retinopathy ?
visual acuity
color vision discrimination
vision loss at last stage!
70
what disorder is associated with disturbances of optic nerve? IOP is between 10-21 mm
Glaucoma
71
this disorder is MOST common, the angle between iris and sclera, aqueous humor is decreased due to blockage ?
Open angled Glaucoma
72
the angle between iris and sclera suddenly closes, causing increase of IOP
Closed Angled Glaucoma
73
aching of the eyes, headache, Halos, visual changes not corrected with glasses are expected findings of what?
Glaucoma
74
what are some complication of glaucoma?
blindness
| regular glaucoma checks
75
s/s of Open angled Glaucoma?
```
SEEK HELP IMMEDIATLY
headache
mild eye pain
loss of peripheral vision
halos around light
elevated IOP of more than 21 mm
```
76
s/s of Closed Angled Glaucoma ?
```
rapid onset of elveated IOP 30 mm or higher
decreased vision
blurred vision
colored halos
non perrla
severe pain
nausea
photophobia
```
77
an IOP of more than 21MM indicates what?
open angled glaucoma.
78
an IOP of 30mm or higher indicates what?
closed angled glaucoma
79
what are some treatments for glaucoma?
surgery
eye drop medication
cholinergic agents (miotics)
80
what are some nursing interventions for Glaucoma clients ?
```
inform patient of disease
adhere to medication
treat pain
low sodium diet
no caffeine
prevent constipation
Monitor IOP
monitor visual sensitivity
```
81
**Butterfly rash** , painful swollen joints, muscle pain, extreme fatigue, unexplained fever, loss of hair, sensitivity to sun. mouth ulcers, poor appetite, abnormal menses, swollen are s/s of what glands
SLE
| Systemic lupus erythematosus.
82
```
Tachycardia
Hypotension
increased troubled breathing
Tachypnea
Dyspnea
Cough stridor
Wheezing
angioedema
warm dry flush skin
Low urine output.
are symptom's of what ?
```
Anaphylactic Shock
83
what the the priority concern in a anaphylactic shock client ?
AIRWAY
84
what are some Gerontological considerationds with elderly patients ?
```
Blood pressure control
Abnormalities in carbohydrate and lipid metabolism related to immobilization Cardiovascular disease
Respiratory complications
Osteoporosis
Bladder infections
Skin injuries
Chronic pain
```
