NR 304 Final Exam Review (VERIFIED)

- - Hypovolemic Shock NR 304 Final Exam Review • Volume depletion; plasma of the blood is too low • S/s- a. Dehydration b. Dizziness c. Fainting d. Fatigue e. Thirst f. Weakness g. Nausea h. Vomiting i. Tachycardia j. Insufficient urine production k. Mental confusion l. Pallor m. Sleepiness - Deep Vein Thrombosis • Deep vein occluded by a thrombus • Inflammation, blocked venous return, cyanosis, edema • Virchow triad- stasis, hypercoagulability, endothelial dysfxn • Causes- prolonged rest, history of varicose veins, trauma, infection, cancer, obesity, immobility, heart failure, estrogen hormone use, smoking • S/s- intense, sharp, deep calf pain; warmth, swelling, redness, dependent cyanosis, tender to palpation • Wells criteria - Vitals on Infants and Toddlers • Respirations pulse temperature • Rectal temperature w/ infants • Tympanic or temporal w/ toddlers • Pulse- palpate or auscultate an apical rate • Respirations- watch infants abdomen for diaphragmatic respirations; sleeping rate most accurate a. Neonate = 30-40 bpm b. 1 y/o = 20-40 bpm c. 2 y/o = 25-32 bpm • Blood Pressure- annual BP 3 y/o and up; most common error is wrong size cuff; crying stopped for 5-10 mins before measuring - Peripheral Artery Disease • Affects noncoronary arteries supplying the limbs; usually caused by atherosclerosis • More men have PAD than women • S/s- coolness in skin, weak thready pulse • Ankle-Brachial Index of 0.9 or lower = PAD • Beginning vs end stage? - COPD • Obstruction of air flow • S/s- barrel chest, wheezing, decreased breath sounds, accessory muscle use, clubbing, paradoxical pulse • A-P diameter = transverse - Contact Dermatitis • Local inflammatory reaction to an irritant in the environment or an allergy • S/s- erythema, swelling, wheals (urticaria), maculopapular vesicles, scales, intense pruritus • Can be caused by poison ivy • Vaginal- a. Red, swollen vesicles