Section 1
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Obese BMI
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Last updated
6 years ago
Date created
Mar 1, 2020
Cards (142)
Section 1
(50 cards)
Obese BMI
30 - 39.9
ideal rate of weight loss
losing 1-2 lbs per week
droplet precautions
Appropriate for diphtheria Strep Pneumonia Influenza
to have a bowel elimination, the patient should?
increase dietary bulk
primary reason that elderly adults have constipation
less peristalsis decreased muscle tone in GI tract reduced activity
aspirin/ salicylates prolonged usage
GI bleeding, blood dyscrasia, and acid- base disturbances
Physical decline decreased independence fear of death fear of nursing home placement
largest fear for elderly presurgery
mutilation
largest fear for preschool age presurgery
If client received less than 3 doses of Td
Administer both Td and tetanus immune globulin (TIG)
contact precautions
appropriate for: wound infections C. Diff Multi resistant strains respiratory syncytial virus
protein electrophoresis
differentiates between protein fractions
prothrombin time
used to measure therapeutic level of warfarin
Neutropenic precautions
Used for clients at increased risk for infection ie immunosuppressed Absolute neutrophil count < 1000 mm3 No fresh fruit or flowers meticulous body hygiene no staff or visitors with cold or sore throat
heparin
anticoagulant used for short term therapy given IV or subQ inactivates thrombin dosage is adjusted according to PTT
Heart failure
failure of the cardiac muscle to pump sufficient blood to meet the body's metabolic needs manifestations dyspnea orthopnea pleural effusion dependent edema bounding pulses
loss of control
largest fear for school age presurgery
ADT
measures damage to liver and heart normal is 10- 40 u/L
If client received at least 3 doses of Td
administer tetanus toxoid booster
normal BMI
18.5-24.9
5th vital sign
Pain
bleeding time
measures the duration of bleeding after standardized skin incising
airborne precautions
Appropriate for: measles Tuberculosis Varicella Disseminated zoster
risk factors for pressure ulcer
impaired sensory perception (diabetic, paraplegic) impaired mobility altered LOC Shear Friction moisture anemia
High fowlers
Best position to deep breathe and cough
underweight BMI
< 18.5
Change in pattern of urine elimination as usually associated with aging d/t
decreased sphincter reflexes
albumin
protein formed in liver contributes to osmotic pressure transports enzymes, drugs, hormones indicates liver and nutritional status will be increased if dehydrated
Serum creatinine level
Normal = 0.5 0 1.5 mg/ dL measures renal function elevated in acute kidney injury and chronic kidney disease
Chronic pain
episode of pain that lasts for 3 months or more Serves no useful function characterized by weight loss or gain, fatigue
morbid obese BMI
> 40
midazolam
provides anxiety reduction, sedation preop medicine given
Partial thromboplastin time
lab test used to monitor the effectiveness of heparin must be measured at least once a week
atelectasis
probable cause for crackles secretions block the bronchioles and the alveoli collapse --> hypoventilation
serum albumin
indicator for malnutrition important part of nutritional assessment
Overweight BMI
25- 29.9
vitamin C
necessary for formation of cartilage in CT maintain integrity of intracellular cement (ie capillary walls)
Thrombophlebitis
unilateral edema warmth tenderness firmness of muscle of Lower extremity swelling localized redness over a vein with IV catheter
eczema
itchy red skin rash may ooze serum and form a crust often associated with allergic rxn onset usually in infancy around 2-3 mo; outgrown by 2-3 y administer topical steroids and antihistamines
Warfarin
anticoagulant interferes with synthesis of vitamin K dependent clotting factors has prolonged action; duration is 2-5 days
pulmonary embolism
dyspnea tachypnea pleuritic chest pain
separation
largest fear for toddler age presurgery
Normal range of wbc
5,000 - 10, 000/ mm3 if elevated = infection
Wound diet
high in vitamin C high in protein (tissue growth) high in carbohydrates (used for energy so the protein is properly utilized for repair of tissue
Purpose of a drain
keep the tissues close together so healing can occur provide exit route (gravity or vacuum) for air, blood, and other material following surgery
Effects of morphine
Depresses CNS, especially respiratory center would cause decreasing or fluctuating of consciousness
To make sure NG tube is reliably in correct position?
aspirate for gastric contents and check pH pH of gastric aspirate is 4 or less
most important when caring for a client in pain
establish a trusting relationship with the client
Lockjaw
1st sign of generalized tetanus
tetanus
fatal disease caused by bacterium that can live for a long time in soil and dirt can enter blood via wounds after a dirty wound, the tetanus toxoid booster is given to ensure protection against tetanus
Loss of independence; being different from peers
largest fear for teenagers presurgery
Section 2
(50 cards)
spinal anesthesia
injected into lumbar intervertebral space beyond dura mater into subarachnoid space blocks pain sensation and movements causes anesthesia of lower extremities, lower abdomen hypotensive possible
hyperextension
excessively increase angle of joint Ex: bending head backwards
vital signs for patient in pain
Increase BP increase HR Rapid, irregular respirations Decreased skin temperature
lumbar lordosis
exaggerated concavity in the lumbar region
exercise
maintain joint mobility and function promotes muscle strength stimulates circulation promotes optimum ventilation stimulates appetite promotes elimination enhances metabolic rate
Preventive approach to pain
If pain is expected to occur throughout most of a 24 hour period, a regular schedule is better than prn
Prevent pressure ulcers
frequent turning skin care; keep skin dry esp. incontinent pt. Ambulate as feasible Use draw sheet Balanced diet with adequate protein Use air mattress, flotation pads, elbow and heel pads, sheepskin
Isometric exercise
performed by client alternate contraction and relaxation of muscle without moving joint maintains muscle strength when joint is immobilized
Pain definition
"whatever the person says it is, and it exists whenever the person says it does"
eversion
rotate ankle and sole of foot outward
Morphine sulfate side effects
Liver damage Dizziness and weakness Sedation or paradoxic excitement Nausea Sweating Respiratory depression Decreased cough reflex Constipation Hypotension
aspirin/ salicylates side effects
Short term GI bleeding Heartburn Nausea Long term Salicylism Metabolic acidosis Respiratory alkalosis Dehydration Tinnitus
inversion
rotate ankle and sole of foot inward
activity
maintains muscle tone and posture serves as outlet for tension and anxiety
radial flexion
rotate the hand inward at the wrist
pronation
turn wrist so palm is down
Prevent negative nitrogen balance
give high protein and easily digestible diet in small, frequent feedings
abduction
move body part away from midline of body
psoriasis
lifelong scaling skin disorder inflammation recurrent itchy, erythematous papules/ plaques covered with silvery white scales chronic autoimmune reaction noninfectious elevated sedimentation rate with negative rheumatoid factor
scoliosis
lateral curvature in a portion of the vertebral column
PCA/ Patient controlled analgesia pump
portable device that delivers predetermined dosage of IV pain med
supination
turn wrist so palm is up
rest
basic physiologic need allows body to repair its own damaged cells enhances removal of waste products from the body restores tissue to maximum functional ability before another activity is begun
flexion
decrease angle of joint Ex: bending elbow
side
allows drainage of oral secretions
flat/ supine
minimizes hip flexion
24 Pain Profile = COLDERR
C- Character and intensity- acute/ chronic; mild vs. severe O- onset- sudden or insidious L- Location D- Duration E- Exacerbation R- Radiation R- Relief
prone
promotes extension of hip joint
Prevent stasis of respiratory secretions
turning coughing deep breathing High fowler position Administer postural drainage as appropriate Use incentive spirometer
ulnar flexion
rotate the hand outward at the wrist
Acetaminophen/ Tylenol side effects
Overdosage may be fatal Liver toxicity Rare GI side effects
chronic pain
episode that lasts 6 mo or longer may cause depression, weight gain, fatigue, immobility
Phases of Pain experience
Anticipatory (fear, anxiety about impending pain) Sensation of pain (mild, moderate, severe) Pain aftermath (weakness, nausea, sweating)
passive ROM
performed by nurse without assistance from client
kyphosis
exaggerated convexity in thoracic region
responses to pain stimuli
Increased BP and HR (allow increased blood flow to brain and muscles) Rapid, irregular RR (increased O2 to brain and muscles) Increased papillary diameter = increased eye accommodation to light Increased perspiration = decreased temperature Increased muscle tension, leads to neuromuscular responsiveness Aroused apprehension, anxiety, irritability Verbalized pain
extension
increase angle of joint Ex: straightening elbow
Modified Trendelenburg
feet elevated 20 degrees head slightly elevated Increased venous return increased blood supply to brain
plantar flexion
point the toes away from the head
ASSESS BEFORE IMPLEMENTING
ASSESS BEFORE IMPLEMENTING
adduction
move body part toward the midline of the body
Fowlers
head elevated Increased venous return = maximal lung expansion
acute pain
episode that lasts from a split second - 6 mo may cause decreased healing, vital sign changes, diaphoresis
Codeine side effects
Same as morphine Constipation High dosage = restlessness and excitement less potent than morphine
prevent constipation
ambulate as appropriate increase fluid intake administer stool softeners ie Colace
Sims
side with legs bent allows drainage of oral secretions (ab. tension)
Prevent thrombus formation
leg exercises- flexion and extension of toes and feet for 5 min q hr. Ambulate as appropriate Frequent change of position Use TEDs
rotation
move joint around central access
dorsiflexion
point the toes toward the head
how often should restraints should be checked
every 1-2 hours
Section 3
(42 cards)