predictor test 1

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  • 7/30/2019 Predictor Test 1

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    Oxytocin is used to stimulate an active labor pattern; nursing care includes

    administering with infusion pump, closely monitoring mother and fetus; if

    contractions occur less than 2 min apart, last longer than 60 to 90s, or if there is

    significant change in fetal heart rate, stop infusion and turn client to left side.

    Osteomyelitis-infection of the bone caused by staph aureus, carried by blood fromprimary site of infection ( upper respiratory, otitis media and tonsillitis

    acyclovir- to treat genital herpes, herpes zoster and varicella)

    Cholecytectomy-surgical removal of the gallbladder,; monitor T-tube if present

    inserted to ensure drainage from bile from common bile duct until edema in area

    diminishes; check amount of drainage-usually 500-1,000 mL/day, protect area from

    the incision, position pt in semi fowlers

    Pancreatic cx-6 months to live after diagnosis

    Infectious mononucleosis- acute, self limiting infections dz caused by the herpes likeEpstein barre virus: sxs- malaise, fever, enlarged lymph nodes, sore throat, flulike

    aches; tansmission is thru direct contact with secretion- avoid contact with saliva

    ( cups & silverware) avoid aspirn, avoid strenuous exercise due to rupture of spleen

    Hypercalcemia: muscle weakness, lack of coordination, constipation, abdominal

    pain and distentsion, confusion, depressed or absent tendon reflexes,,

    dysrhythmias.

    Sleep apnea: avoid alcohol and medications that depress the upper airway, wight

    reduction diet and activity, use of cpap and bipap

    Sputum specimen: obtained to determine pathogenic organisms and to identify

    malignant cells; early morning specimen best; encourage client to clear nose and

    throat and rinse mouth, instruct patient to deep breathe , cough, and expectorate

    specimen into sterile container, deliver specimen to the lab within 2 hrs

    Lactulose- laxative administered for tx of hepatic encephalopathy, decreased blood

    ammonia by excreting it in stool; side effects: belching, cramping, distention,

    flatulence. Nursing L mixng with fruit juice, water, milk, or carbonated citrus

    beverage, admin with full glass of liquid, giving on empty stomach for more rapid

    results. Assess pts mental status throughout treatment.

    Ineffective endocarditis: infection of heart lining and valves; indications include

    fever, malaise, back and joint pain, splinter hemorrhages under fingernails and

    toenails, petechiae in conjunctive and mucous membranes, heart murmur, nursing

    care includes IV antibiotics for 4-6 weeks

    BuSpar- anti-anxiety med

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    Normal newborn: RR: 30-50; HR 120-140; bp 80/40

    Hydrocephalus- position on the unoperative side, keep flat to prevent complication

    of due to rapid reduction of intracranial fluid, assess for increased ICP & infection

    Postural drainage- a component to chest physiotherapy

    Placenta previa- abnormally implanted near or over the cervical opening; indication

    include painless bright red vaginal bleeding accompanied by soft uterus usually in

    third trimester bewee 29 & 30 weeks, caused by scarring of uterus from pregnancy,

    tumor, or treatments includes bedrest, ultrasound to locate placenta, no

    vaginal/rectal exams before fetal vviability, amniocentesis for lung maturity, daily

    hgb and hct

    Total hip replacement- complication includes: dislocation of hip prosthesis,

    excessive wound drainage, thromboembolism, and infection; nursing responsibilities

    : positioned leg in aduction, abduction splints, wedge, or 2-3 pillows used between

    the legs, hip should not b e flexed more than 45 to 60 degrees, and the head of thebed should not be elevated more than 45 degrees, to use a fracture bedpan, the pt

    should flex unoperaed hip and use a trapeze while lifting the pelvis; semi reclining

    toilet seats and wheelchairs are used to prevent hip joint flexion

    Postpartum: check lochia ( color, volume) day 1-3 rubra ( bloody with fleshy odor,

    may have clots; day 4-9 serosa ( pink/rown with fleshy odor); day 10+ alba ( yellow-

    white)Fundus should be at or 1 cm/finger breadth above the umbilicus for the first

    12 hr, then descent by one finger breadth each succeeding day;

    The first stage of labor is divided into three phases:

    - Phase one ( latent): cervix is dilated 0-3 cm, contractions 10-30 sec long. 5-

    30 min aport, mild to moderate

    - Phase two ( active); cervix is dilated t 4-7 cm, contractions 30-40 sec long, 3-

    5 min apart, moderate to strong

    - Phase three ( transition): cervix is dilated 8-10 cm, contractions are 45-90 sec

    long, 2-3 min apart, strong, impending delievery marked by increase in dark

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    red bloody show, increased urgency to bear down; Second stage: from full

    dilation of cervix to delivery of baby

    Third stage: birth of baby to expulsion of placenta

    Fourth stage: first 2 hr after the birth of the baby

    Parkinsons disease: characterized by fine, slowly spreading tremor, muscular

    rigidity, and altered gate; nursing care include encouraging finger exercises, e.g

    typing, piano-playing, rom,

    Ambulation: goose stepping walk, walk with wider base, concentrate on swinging

    arms while walking, turn around slowly using small steps. Intellect not impaired,

    sight and hearing are intact. Meds: cogentitn, L-dopa, sinemet, symmetrel

    Ultrasound- done as early as 5 weeks to determine pregnancy-client must drink fluid

    prior to test to have full bladder to assist in clarity

    Defense mechanisms: denial-failure to acknowledge intolerable thoughts, feelings,

    experience , or reality

    Displacement- redirection of emotions or feelings to a subject that is more

    acceptable

    Or less threatening.

    Projections: attributing to others ones feelings, impulses, thoughts, or wishes

    Undoing : : an attempt to earse an act, thought , or desire

    Compensation: attempt to overcome a real or imagined shortcoming

    Repression: unacceptable thoughts kept from awaremness

    Suppression : consciously putting a disturbing thought or incident out of

    Awareness

    iM- vastus lateralis is preferred for infants;

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    Rice- rest ice compression and elevation