Diversity, Self, Family
This Erikson's stage of development happens when a person examines attitude, values , and beliefs; establishing goals for the future.
Identity versus Role Confusion
Purpose of incentive spirometry. Who would benefit it most?
Incentive spirometry encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It is a commonly used intervention that promotes deep breathing and is thought to prevent or treat atelectasis in the postoperative patient
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purulent drainage and serous drainage
I have abdominal cramps, diarrhea, and cardiac dysrhythmias. What electrolyte imbalance am I?
hyperkalemia
Legal document that expresses patients wishes if patient is unable to communicate.
advance directives
The amount of urine a person should produce hourly
30ml/hr
The goal of family nursing
The outcome of family nursing is to help a family and its individual members reach and maintain maximum health throughout and beyond the illness experience.
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5 Risk Factors associated with a Pulmonary Embolism
•Immobility or reduced mobility
•Surgery within 3 months (especially pelvic and lower extremity)
•History of VTE
•Cancer
•Obesity
•Oral contraceptives/ hormone therapy
•Smoking
•Prolonged air travel
•Heart failure
•Pregnancy
•Clotting disorders
What is the removal of necrotic tissue from a wound called?
Debridement
A nurse takes the vital signs of a client who collapsed while working outdoors. What BP should the nurse expect to find that is associated with Fluid Volume Deficit (FVD)?
hypotension
Specifically a decreased systolic BP is a direct result of FVD
Positive actions to help others
beneficence
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Patient is experiencing a strong desire to void and is unable to easily hold without dribbling small amount of urine. What medication is needed?
Oxybutynin (Ditropan)
used for overactive bladder. Relaxes the bladders muscles to prevent urgent, or uncontrolled urination
4 Factors Influencing Self-Concept. Provide 2 examples of each that alter self-concept.
Identity Stressors.
Body Image Stressors.
Role Performance stressors
Self-Esteem Stressors.
Fig33.3
The Patient is complaining of shortness of breath. What would you include in a focused assessment?
Complete a Focused Respiratory Assessment
4 interventions the nurse can do to help prevent skin breakdown
performs thorough skin assessments
cover bony prominences with mepilex
reposition patient q 2hr
keep skin dry and clean
adequate nutrition with protein and vitamins
Your Patient's sodium lab is 126meq/L. Name 4 signs and symptoms associated with this lab value.
headache, irritability, difficulty concentrating.
confusion, vomiting, seizures, coma
The most important act affecting your nursing practice. Each state has its own rules that protects the public by broadly defining the legal scope of practice
What is the Nursing Practice Act
5 causes of Constipation
• Irregular bowel habits and ignoring the urge to defecate
• Chronic illnesses (e.g., Parkinson’s disease, multiple sclerosis, rheumatoid arthritis, chronic bowel diseases, depression, eating disorders)
• Low-fiber diet high in animal fats (e.g., meats and carbohydrates); low fluid intake
• Stress (e.g., illness of a family member, death of a loved one, divorce)
• Physical inactivity
• Medications, especially use of opiates
• Changes in life or routine, such as pregnancy, aging, and travel
• Neurological conditions that block nerve impulses to the colon (e.g., stroke, spinal cord injury, tumor)
• Chronic bowel dysfunction (e.g., colonic inertia, irritable bowel)
Box47.1
4 Factors influencing family forms and family health
Family caregivers.
Poverty.
Homelessness.
Domestic violence.
Warfarin (Coumadin)
(medication class, action, indication of use, administration routes, nursing implications, antidote)
Vitamin K Antagnoist
Warfarin inhibits activation of the vitamin K–dependent coagulation factors II, VII, IX, and X and the anticoagulant proteins C and S.
Oral anticoagulation for long-term or extended anticoagulation
Nursing Implications: INR used to monitor therapeutic levels.
Give at the same time each day.
Monitor signs of bleeding
Antidote: Vitamin K.
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What are the stages of a wound and how do you differentiate between the stages?
Stage I, II, III, IV also note deep tissue pressure injury and unstageable pressure injury.
Deep tissue- persistent non-blanchable deep red, maroon, or purple discoloration
Stage 1-non-blanachabele erythema of intact skin
Stage 2 -partial thickness skin loss with exposed dermis; involves both epidermis and dermis
Stage 3-full thickness skin loss- visible adipose tissue; some slough, some eschar present
Stage 4-full thickness skin and tissue loss with muscle, bone, ligaments, fascia or tendon exposed in the wound
unstageable - obscured, full thickness skin and tissue loss; no determination of stage because eschar or slough obscures the wound bed.
A construction worker has been diagnosed with extracellular volume depletion due to dehydration after working in extremely high temperatures. Name 6 clinical manifestations the patient may have presented with?
sudden weight loss(overnight), postural hypotension, tachycardia, thready pulse, dry mucous membranes, poor skin turgor, flat neck veins, dark yellow urine, restlessness, confusion, Increased Hemoglobin, creatinine and BUN.
Loss of 2.2lb (1kg) or more in 24 hours for adults
Provide a scenario of a nurse advocating for their patient
patient advocacy includes: protecting patients, acting as their voice, providing high-quality care, building interpersonal relationships, and educating patients about their conditions and the care they are receiving.
What would a patient need a urinary analgesic?
Provide Example, indication, patient education
Pyridium (phenazopyridine)
used to help relieve symptoms associated with UTIs, usually pain and burning during urination.
Turns urine orange, if noted it is normal and there is no need call the provider
List 5 types of Family Forms. Provide examples of each
Box10.1
Nuclear family-A nuclear family consists of two adults (and sometimes one or more children).
Extended family-An extended family includes relatives (aunts, uncles, grandparents, and cousins) in addition to the nuclear family.
Single-parent family-A single-parent family is formed when one parent leaves the nuclear family because of death, divorce, or desertion or when a single person decides to have or adopt a child.
Blended family-A blended family is formed when parents bring children from previous marriages or other parenting relationships into a new joint-living situation.
Alternative family-Relationships include multiadult households, grand families (grandparents caring for grandchildren), communal groups with children, “nonfamilies” (adults living alone), and cohabiting partners.
Unfractionated Heparin (Heparin Sodium)
(medication class, action, indication of use, administration routes, nursing implications, antidote)
Anticoagulant
Indirect Thrombin Inhibitor
Heparin affects both the intrinsic and common pathways of blood coagulation by way of the plasma antithrombin. Antithrombin inhibits thrombin-mediated conversion of fibrinogen to fibrin by affecting factors II (prothrombin), IX, X, XI, and XII
Heparin can be given subcutaneously for VTE prevention or by continuous IV infusion for VTE treatment.
Therapeutic effects measured at regular intervals by the aPTT.
Monitor CBC counts at regular intervals and titrate according to parameters.
IV given as an adjunct for existing blood clots.
SQ given prophylactically to prevent the development of clots.
Antidote: Protamine reverses the effect of UH.
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What areas are measured on the Braden Scale and What score is of most concern to the nurse?
Sensory Perception, Moisture, activity, mobility, nutrition, friction & shear
16 or less pt at risk
the lower the score , the higher the risk
What is special/unique about D5W compared to other IV solutions?
The Key Elements of informed consent (6)
1. The patient receives an explanation of the procedure or treatment.
2. The patient receives the names and qualifications of people performing and assisting in the procedure.
3. The patient receives a description of the serious harm, including death, that may occur as a result of the procedure and anticipated pain and/or discomfort.
4. The patient receives an explanation of alternative therapies to the proposed procedure or treatment and the risks of doing nothing.
5. The patient knows of the right to refuse the procedure or treatment without discontinuing other supportive care.
6. The patient knows of the right to refuse the procedure or treatment even after the procedure has begun.
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Stimulant Cathartics
(example of medication, action, indication of use, nursing implications)
table 47.2
example of medications: Bisacodyl (Dulcolax), Castor oil, Casanthranol (Peri-Colace), Correctol, Senna (Ex-Lax, Senokot)
Action:Agents cause local irritation to the intestinal mucosa, increase intestinal motility, and inhibit resorption of water in the large intestine. The rapid movement of feces causes retention of water in the stool. The drugs cause formation of a soft-to-liquid stool in 6 to 8 hours and usually contain bisacodyl or senna. These laxatives should be used occasionally because regular use of a stimulant laxative can lead to dependence on the stimulus for defecation.
Indication of use: Agents prepare bowel for diagnostic procedures or may be needed for those with constipation from frequent opioid use
Nursing Implications: Agents cause severe cramping. Agents are not for long-term use. Chronic use could cause fluid and electrolyte imbalances.