-
skin impairment CV compromised
increased risk elder immobility.
-
limited mobility r/t skin
increase risk pressure ulcers
-
change position carefully
r/t decreased circularity effectiveness
-
decreased liver enzymes
decreases metabolizations of meds
-
dehydration alters vital signs
less water =dehydration=increase heart rate 100beats above
-
incontinence
A&O x3= change intake, start continence program
-
hearing loss
r/t increase serum leads to decrease conduction
-
sex
schedule private time
-
sleeplessness=irritability
irritability sign of sleeplessness
-
sleep needs
unchanged needs; patterns change
-
cultural considerations
which foods are usually consumed?
-
loose teeth
not normal, should last life time, potential airway obstruction
-
UGI prep
upper gastrointestinal series test
NPO 6-8hrs
-
EGD
esophagogastroduodenoscopy
can Dx ulcers
-
NGT suction
nasogastric tube
none vented must be low intermittent
-
NGT
nasogastric tube irrigation trouble shooting
irrigate
-
NGT to suction not draining
nasogastric tube
verify placement then irrigate
-
NGT irrigation
nasogastric tube
normal saline preferred
-
NGT residual
nasogastric tube
greater than 100mg/hold feeding
-
post Op bypass diet
clear liquids
-
symptomatic hiatal hernia
worst when lying down
-
Barret's esophagus
complications with GERD (reflux disease)
-
systematic GIB
Gastricintestinal bleed
GI bleed trends Vital signs watch for shock.
-
Zantac
decreases gastric acid production
-
GIB
GI bleed
evidence=Melina, a black tarry stool.
-
dumping syndrome
small frequent meals no liquids
-
prevent dumping syndrome
- no liquids w/meals
- no liquids 1hr before & 2hrs after meals
-
valsalva maneuver (straining BM)
straining may lead to rupture of heart after MI (myocardial infarction)
-
exercise for constipation
increase activity is moving.
-
apply post Op diet
clear liquids, apple juice, broth, sprite, coffee w/o cream
-
avoid caffeine & high fiber diets
= inflammatory bowel disease-protect tissue
-
celiac disease
avoid gluten, barley, rye,oats, wheat (B.R.O.W)
-
intussupception
telescoping of bowels leads to obstruction
-
stoma assessment
healthy perfused, moist & pink
-
new stoma assessment frequency
check 8q x3 days
-
safety with chronic liver failure
bleeding precaution use soft tooth brush
-
delegate care with fulminant liver failure
assess to determine care to delegate
-
bleeding varices
history of sclerosis, blood streak emesis
-
pancreatitis avoids ETOH
estrogen/thiazide diuretic/opioid/hyperparathyroidism
no alcohol
-
cholesterol in gallstones
components from bile
-
fat post chol
adjust dietary fat to individual tolerance
-
fat disturbance post chole
thru out the day
-
smooth muscle of the prostate
contributes to the contraction of ejaculation
-
hypospadias
meatus on under side
-
obstruction
unable to void greater than 24hrs needs Foley
-
prostatitis
empty bladder frequently
-
peyronie's disease
curved penis
-
epididymitis
elevate, ice, give meds
-
antihypertensives ED
erectile dysfunction
contribute to erectile dysfunction
-
male infertility
maybe pretesticular r/t endocrine
-
infertile after 1 yrs
medically document attempted conception x1 yrs
-
aging MS cartilage
muscleskeletal
joint stiffness r/t rough cartilage
-
cmst+pain pulse
color/movemnt/sensation/temperature
ortho trauma
-
elevated Alkaline phosphatase
bone tumor
-
CK-MM
my muscle, skeletal muscle injury r/t trauma, injury, crush.
-
MRI
best 3D non invasive image
-
bone biopsy complications
hemorrhage, unrelieved pain.
-
post bone biopsy
immobilize area for 12hrs
-
complication of bone biopsy
report uncontrolled pain
-
fracture management
maintain immobilization
-
fracture pain management
meds as ordered PRN
-
RICE for cast managment
raise/ice/compress/elevate
elevate to decrease edema
-
fracture assessment w treatment-DVT
report to Rn positive homans sign
-
gout dietary avoids
organ meats
-
rheumatoid arthritis & functional assessment
able to do ADL's dressing, hygiene
-
rheumatoid arthritis & NSAIDs
use for pain control
-
CPM
continuous passive movement
to restore joint function
-
myelin sheath insulation
electrically isolates neurons from one another
-
neurotransmitter
carries impulses across synapse
-
pans neurotransmitter
parasympathetic
ACH=acetylcholine
-
abnormal extension or decerebrate
brainstem poor prognosis
-
anisocoria
normal unequal pupils born that way
-
post Lp
lumbar puncture
lay flat 6-8hrs head of bed down
-
consensual
both pupil constrict w/light in one eye
-
EEG prep
hair should be clean & dry before test
-
improved meningitis
able to touch chin to chest/no nuchal rigidity
-
prevent iicp
increase intracranial pressure
quiet, dark room, head of bed up, stool softener
-
seizures
maintain airways abc 123
-
seizure airway compromise
check airway adequate o2, intervene as needed
-
epidural hematoma
emergent arterial bleed may lead to death rapid intervention
-
diabetes insipidus
polyuria/frequent urination
-
C spine precaution
don't move neck, no flexion, or rotation.
-
Parkinson ADLs
increase Independence support ADL's (Velcro)
-
Alzheimer's environment
keep environment familiar, non stimulating
-
Alzheimer's distress
may cause anxiety & dysfunction
-
TIA
transient ischemic attack
temporary impairment of cerebral circulation/brain o2 deprived
-
3hr window
onset of symptoms to treatment w/thrombolitics
-
antiplatelet aggregate
stared in first 24hrs example- plavix, aspirin,aggrenox.
-
contralateral
opposite side
-
flaccidity
soft paralyzed w/o movement
-
receptive aphasia
don't understand verbal, must gesture
-
CVA rehab
stroke
maintain physical therapy/ortho therapy till transferred
-
MS
multiple sclerosis
chronic progressive degenerative disease/demylination destruction of nerve fibers
-
MG S/S
myasthenia gravis
great muscle weakness, ptosis (eye droop) fatigue
-
MG tensilon test
temporary improvement of ptosis
-
myasthenia gravis thymectomy
remove thymus to decrease symptoms...decreases symptoms in most ppl.
-
myasthenia gravis scheduled meds
adjust timing for activities & school
-
ALS S/S
amyotrophic lateral sclerosis
Lou Gehrig disease
weakness fatigue, decrease coordination of extremities
-
monitor ABG's w/guillain barre syndrome
respiratory involvement increase need to check ABG's..arterial blood gases
-
eye & bell's palsy
protect eye...patch
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