PN3 Final Exam Study Guide

PN3 Final Exam Study Guide What is a high risk for hip fractures? Osteoarthritis What are signs of a fat embolism? dyspnea, tachypnea, petechial rash, swelling over the affected area-will see in neck or trunk if it is in hip what is RICE Rest, Ice, Compression, Elevation What is compartment syndrome? Swelling and pressure that can cause necrosis what to monitor for in osteomylitis Elevated temperature and elevated WBC 11,000 What is a faciotomy? When the cast is removed, reduces swelling, if not completed muscle death may occur what is the number 1 nursing intervention for amputee ROM exercises what do you monitor for with Buck's traction Never allow weights to rest on the floor do not cross legs always use an abductor pillow when re positioning what do you monitor when someone has a cast? Cap refill sensation motor function Most common cause for cirrhosis alcoholism second is hepatitis C What lab tests do you monitor in cirrhosis ALT, AST, and LDH What are physical s/s of cirrhosis changes in skin color or sclera-icertus-yellowing of the sclera what do you monitor following a liver biopsy Bleeding and bruising Interventions for Steatosis or fatty liver weight loss glucose control lipid-lowering agents Which organ is in the right upper quadrant liver Which organ is in the left upper quadrant pancreas Portal shunt nursing interventions low sodium diet diuretics trans jugular intrahepatic portosystemic shunt what is the number one cause for gallbladder problems obesity what is a non-surgical management intervention for pancreatitis NPO while acute attack pancreatic abscess is always fatal if left untreated Cancer Pathophysiology -mutation of cellular genes -abnormal cell growth -no cell division limit -lack of contact inhibition o Features: loose adherence, anaplasia(loss of differentiation), large nuclear ration, migration(metastasis), rapid cell division, abnormal chromosomes (aneuploidy) o Benign: harmless: does not require and intervention o Malignment: indicates cancer, serious and can lead to death Primary prevention examples avoidance of known carcinogens vaccinations avoidance of known carcinogens, modifying factors(diet, high fat), removal of at risk tissues, chemo prevention, vaccination (HPV) Secondary prevention examples Screenings and early treatment Tertiary prevention examples Treatment of major depression, reducing disruption of family processes, and suicide prevention, rehabilitation prevention (testing) for reoccurrence Radiation precautions for internal radiation private room, radioactive material sign, nurse's fil badge must be worn, pregnant or less than 18 do not enter room, visitors for 30 mins a day, visitors stay 6ft away, bed linens and all dressings stay in room until after implant is removed, have lead container in room 7 warning signs of cancer C-hange in bowel or bladder habits. A- sore that does not heal U-nusual bleeding or discharge. T-hickening or lump in the breast, testicles, or elsewhere. I-ndigestion or difficulty swallowing. O-bvious change in the size, color, shape, or thickness of a wart, mole, or mouth sore. N-agging cough or hoarseness. Patient Education for (internal radiation) not radioactive Brain Tumor- s/s specific to this condition headache in the morning Chemo Therapy complications- anemia (decrease in RBC and hemoglobin), thrombocytopenia (platelet count less than 85,000), neutropenia (neutrophil count less than 450), mucositis (mouth sores), alopecia, extravasation (chemo has leaked and makes large sore) Thrombocytopenia -platelet count less than 85,000 -private room, handwashing, vitals q4h, limit visitors, dedicated supplies, inspect skin q8h, daily wound dressing changes daily, avoid crowds, do not share food or liquids -meds to increase WBC-neulasta, neupogen, leuxine, prokine Severe anemia nursing interventions medications to increase RBC production: epoetin alfa and erythropoietin -prevention of bleeding (electric razor, etc) and injuries brachytherapy radiation therapy in which the source of radiation is implanted in the tissue to be treated -private room, radioactive material sign, nurse's fil badge must be worn, pregnant or less than 18 do not enter room, visitors for 30 mins a day, visitors stay 6ft away, bed linens and all dressings stay in room until after implant is removed, have lead container in room mucositis interventions sores in mucous membranes - Nursing Interventions: use soft-bristle toothbrush, avoid mouthwashes with alcohol, 2 or more liters of water a day, room temperature salt water to swish in mouth, avoid spicy foods, avoid using tobacco Hospice vs. Palliative Care -hospice: (quality care) team oriented, holistic, peaceful death, for patients who are actively dying -palliative care: (quantity care): by physician, NP and team of providers, deliver care to relieve care for life-threatening disease, given the quality of life no matter what stage s/s of airway emergency in burn victims -s/s of airway emergency: deep brassy cough, drool, difficulty swallowing, black mouth, wheezes, crowing, stridor, cyanosis when to apply oxygen and prepare for intubation -black mouth, burns in mouth, swelling interventions for TBSA burns 40%partial thickness burns -oxygen, pain management Initial nursing interventions for burns 50% burns -lactated ringers -oxygen -potential for shock -potential for ARDS Parkland formula -4ml x kg x % of total body burned= fluids given in the first 24 hours -then divide by 2: half given in first 8 hours, other half given in next 16 hours -head: anterior: 4.5% posterior: 4.5% -arms: anterior:4.5% posterior: 4.5% -legs: anterior 9% posterior: 9% -front: 18% -back: 18% -groin: 1%