PNR 120 Med-Surg Final Test Study Guide PDF

PNR 120 (Med-Surg) Final Test Study Guide **Chapter 13** - **Chronic Disease: Diabetes Mellitus (p. 317)** - Chronic diseases develop over time - Diabetes is a chronic disease - **Data Collection (Objective vs. Subjective Data) (p.315-316)** - Objective is what the nurse...

PNR 120 (Med-Surg) Final Test Study Guide **Chapter 13** - **Chronic Disease: Diabetes Mellitus (p. 317)** - Chronic diseases develop over time - Diabetes is a chronic disease - **Data Collection (Objective vs. Subjective Data) (p.315-316)** - Objective is what the nurse observes - Subjective is what the patient says - **Initial Assessment by Registered Nurse (327-328)** - Assessment must be completed within 24 hours of admission - The RN performs the initial baseline nursing assessment - **Lung Sounds: Crackles p. 332-333** - [Crackles]- produced by fluid in the bronchioles, short cracking or bubbling sound - [Sonorous]- lower pitched snoring sound that indicates mucus in the trachea - **Pitting Edema (+2) p.338** - 2+ is mild deeper pit that rebounds in 10-15 seconds - **Sonorous Wheezes** - lower pitched snoring sound that indicates mucus in the trachea - **Positioning for Assessment (Knee-Chest, Upright) p. 321** - Sitting position- assess areas of head, neck, thorax, lungs, breasts, axillae, heart, vital signs, upper extremities - Knee-chest- rectum assessment - **Constipation 318** - Difficulty passing stool - **Diarrhea** - Frequent passage of loose stools - **Jaundice** - Yellow tinge to skin (liver) - **Erythema-** - redness of the skin that looks like a mild sunburn - **Scleral Icterus**- sclera is yellow - **Sequence of Assessment: Inspection, Palpation, Auscultation, Percussion 322** - In this order: Inspection, palpation, auscultation, percussion - **Basic Nursing Assessment Tools 328** - Penlight, Stethoscope, Blood pressure cuff/nurse on stick, Thermometer, Gloves, Watch, scissors, Black pen, scissors, tongue blade - **Dehydration & Fluid Loss (Fatal Body Fluid Loss) 490** - A loss of 20% body fluid is fatal - A loss of 10% of body fluid is serious in an adult - **Osmosis 494** - Diffusion of water through a selectively permeable membrane. - Low concentration to high concentration (water concentration) - Lasix (furosemide) often prescribed for patients with edema to stimulate osmosis - **Electrolyte Measurements (mEq) 494** - Electrolytes are measured in milliequivalents. It is a measurement of chemical activity of an electrolyte compared with the chemical activity of hydrogen. - **Sodium (Extracellular Electrolyte) 494** - Most abundant, extracellular electrolyte - **Hypernatremia 495** - Concentration of sodium is greater than normal and exceeds 145 mEq/L. - It is caused by excess of sodium or decrease in body water and presents as edema - **Buffer Systems in the Body 503** - Blood buffers- bi carb and carbonic acid - Respiratory- lungs - Kidneys - **Wound Healing by Tertiary Intention 627** - Healing where the wound is left open and closed later after infection is controlled. - Healing from the inside out - **Postoperative Coughing Support (Splinting) 627** - Teach patient to use a pillow to splint themselves for coughing. - Prevents opening of incision - **Wound Irrigation Techniques 638** - Clean from least contaminated to most contaminated - Hand held shower can be used at home by holding it 12 in away from the wound - **Bowel Protrusion (Postoperative Priority) 639** - Evisceration - Medical emergency - Use sterile water moistened gauze to cover organs. - **Drainage Documentation (Jackson-Pratt Drain) 643** - exudate or drainage in quantities greater then 300 mL in the first 24 hours is abnormal. Report to provider immediately. - **Clean Wound Definition 625** - Class one - Infection risk is less than 5% - **Phases of Wound Healing (Hemostasis, Inflammation, Reconstruction, Maturation) 626** - [Hemostasis]- clotting. Fibrin holds the wound together - [Inflammation]- initial increase in the flow of blood elements and water that allows the repair of cells - [Reconstruction]- collagen formation occurs and granulation tissue fills wound - [Maturation]- skin becomes stronger and keloid may appear - **Surgical Suture Removal 640** - Removed 7-10 days - **Serous, Purulent, Sanguineous, and Serosanguineous Drainage 629** - [Serous]- watery drainage - [Purulent]- pussy, green, tan, indicates infection. - [Sanguineous]- bloody, indicates active bleed - [Serosanguineous]- pink tinged watery drainage - **Patient Assessment for Nutrition-Related Problems** - Protein is needed for wound healing. - Insufficient nutrition (patient problem) - Smoking reduces the amount of function of hemoglobin which decreases oxygenation to tissues affecting the repair of tissues - **Notification of Healthcare Provider for Abnormal Lab Results 678** - The nurse notifies the prescribing health care provider when results are abnormal. - **Midstream Urine Specimen Collection** - 1\. Clean front to back - 2\. Collect urine midstream (between initial stream and final stream) - For culture sensitivity test - **Throat Culture Collection 692** - Collect at least 1 hour before meal time - 1\. Assess drainage from nasal mucosa and sinuses - 2\. Determine whether patient has experienced postnasal drip, sinus headache, nasal congestion, or sore throat - 3\. Assess condition of posterior pharynx - 4\. Assess for systemic indications of infection, including fever, chills and malaise - 5\. Do not allow culture swab to touch buccal mucosa, tongue, or teeth, because such contact contaminates the specimen. - **Electrocardiogram (ECG) Abnormalities 695** - Identify abnormalities of electrical conduction of the heart - A Fib - **Post-Barium Enema Stool Color 663** - white - **Wound Labeling and Specimen Collection 686** - [Wound labeling]- circle drainage, initial with time and date. Do not remove dressing without order - [Specimen collection]- [Patients name], [identification number (medical number)], bed and room number, date of birth, age, sex, providers name, date/time of collection, initials of person who collected specimen, test ordered. - **Solid Food Introduction in Infants 720** - Cereal/oatmeal first - Introduce solid foods one at a time to determine allergies allowing several days in between foods - **Toddler Development (Autonomy and Finger Foods) 724** - Autonomy v shame and doubt - Potty training - Egocentric - Trial and error methods - Finger foods allow autonomy/independence - **Signs and Symptoms of Menopause 736** - Irregular periods, flow changes, excess fluid retention, breast tenderness, hot flashes, night sweats, mood swings - **Stages of Family Development (Establishment, Expectant)** - [Engagement]- commitment to marry - [Establishment]- get married and establish a life together (marriage) - [Expectant]- expecting a child (pregnancy) - [Parenthood]- taking care of their child (begins at birth or adoption of first child) - [Disengagement]- when grown children depart from the home (empty nest) - [Senescence]- when individuals cope with large lifestyle changes (older adults) - **Autoimmunity Theory of Aging** - The body becomes less able to recognize and tolerate itself which results in antibodies that attack the immune system - **Disengagement Theory of Aging** - A natural withdrawal between the individual and society - **Sudden Infant Death Syndrome (SIDS) Prevention 721** - Back sleeping, avoid soft bedding or pillows - **Infant and Child Safety Guidelines 722** - Turn pot/pan handles away from edge - **Piaget's Cognitive Development (Sensorimotor & Concrete Operational Stages) 717** - [Sensorimotor- birth to 2 years] - Object permeance - Uses senses to understand the world and interact with it - [Concrete operational- 7-11 years] - Applies logical thinking to interpret experiences, more realistic views, improved memory, can focus on more than one task, cause and effect, understand basic ideas in conversation and number classification - **Young Adult Challenges (Career, Family, Intimacy) 733** - Rational decisions, consequences and relationships - Career goals, building a family, intimacy in relationships **Chapter 33** - **Social Security Act of 1935 1085** - Legislation that provides financial security for older adults - **Skin Care for Pruritic Older Adults** - [Pruritis]- dryness and itching of skin - Less frequent bathing, water based lotions - Antibacterial soap will dry out their skin - **Pressure Injury Prevention (Repositioning)** - Reposition every 2 hours - Adequate nutrition - **Incontinence Types (Stress, Urge, Overflow, Functional)** - Older adults have [nocturia] (frequent night urination) - [Stress]- pressure in abdomen that causes urination (sneezing or coughing) - [Urge]- sudden feeling of needing to urinate often caused by inflammation of the bladder, tumors, stones, CNS - **Blood Pressure Changes Due to Aging 1095** - Orthostatic hypotension - Hypertension caused by increased atherosclerosis. - Coronary artery disease - **Orthostatic Hypotension in Older Adults** - Caused by decreased elasticity of heart muscle and blood vessels - **Presbyopia & Glaucoma in Aging 1104** - [Presbyopia]- farsightedness from vision changes caused by the loss of lens elasticity - [Glaucoma]- leading cause of blindness from increase of ocular pressure behind eyes - **Parkinson's Disease Effects 1110** - [Akinesia]- abnormal state of motor and psychic hypoactivity - Progressive degenerative disease that does not impair intelligence. - **Anatomical Directions (Medial, Proximal, Distal, etc.) 1245** - [Medial]- towards middle - [Proximal]- near - [Distal]- far/distant - **Visceral Muscle Function (smooth muscles) 1254** - Involuntary movement of substances along respective tracts (kidneys, heart, digestive system, etc.) - **Adipose and mucous membranes** - Adipose tissue (fat)- helps regulate temperature. - Mucous membranes- secrete mucous that keeps membranes lubricated and protects against infection. - **Life span considerations for older adults** - the patient's physiological status and coexisting conditions should be evaluated carefully - **Preoperative Checklist Responsibilities 1282** - Medication list including herbals and vitamins - Witness informed consent - Allergies - Surgical checklist - Nurse is responsible for pre-op checklist - **Preoperative Teaching Timing 1266** - Should be done a few days before the procedure - Pre-op teaching helps reduce anxiety and fear of the unknown - **Electrolyte Imbalance in Surgery (Potassium Levels) 1293** - Abnormal serum potassium levels can lead to cardiac dysrhythmias during and after surgery. - **Surgical Incision Support and Pain Relief 1272** - [Surgical incision support] - Adequate nutrition with protein to wound healing - Monitor for dehiscence - Monitor drainage - Teach splinting to cough - [Pain relief] - Analgesics, decrease in external stimuli, reduce interruptions, eliminate odors, reposition, allow rest times. - **Bowel Sounds (Normal vs. Absent)** - Auscultate bowel sounds in all 4 quadrants - 5-30 gurgles per minutes is normal - Absence of bowel sounds is determined by listening for 3-5 minutes in each quadrant with no gurgles - **Postoperative Instructions** - Monitor airway, breathing, consciousness, circulation and system review - Evaluate wound for drainage - Vitals every 15 minutes times 4, 30 minutes times 4, 1 hour times 4 and then every 4 hours - Pain management - Ambulate- prevent blood clots and pneumonia, wake up body systems - Deep breathe and cough - **Hypovolemia Indicators and Management 1287** - restlessness - Tachycardia and hypotension - Reduced urine output - **Phagocytosis** - The process of cells eating or engulfing other cells or particles - Neutrophils use this process - **Types of Anemia (Pernicious) 1516** - [Pernicious anemia] - B12 vitamin cannot absorb because there is a lack of intrinsic factor. - **Chemotherapy and Bone Marrow Transplantation 1523** - Chemotherapy must fail before a bone marrow transplant is considered. - **Child Communication through Drawing** - Drawings can communicate perceptions and emotions about death and dying. - Helps a dying child maintain autonomy, choice, and control. - Therapeutic communication should be used when talking with the child about their drawing. - **Leukemia Vaccines and Care 1525** - Annual flu vaccine and pneumococcal vaccine (when diagnosed and then every 5 years) - Neutropenic precautions - Increased risk for infections - **Bone Pain Relief in multiple myeloma 1533** - be careful when moving and ambulating patient due to potential for bone fractures - **COPD and Cor Pulmonale** - [COPD] is chronic obstructive pulmonary disease that is progressive and irreversible and characterized by diminished inspiratory and expiratory capacity of the lungs (obstructs the air flow to/from the bronchioles) - [Cor pulmonale] is an abnormal cardiac condition characterized by hypertrophy of the right ventricle of the heart as a result of hypertension of the pulmonary circulation. - Results in edema in lower extremities, distended neck veins, enlargement of liver - A late complication of emphysema - COPD can lead to cor pulmonale - **Bronchoscopy Post-Care (Gag Reflex)** - Keep pt NPO until the gag reflex returns. - **Pursed Lip Breathing for COPD 1667** - A breathing technique for effective breathing - Used for patients who have barrel chest from COPD - **Chest Tube Maintenance 1659** - Keep below chest and keep tubing free of kinks - **Asthma Pathophysiology (Mast Cells & Histamine)** - Acute asthma attack can be caused by an antigen-antibody reaction in which histamine is released by mast cells - Inflammatory response by the mast cells caused by asthma trigger - **Chest Tube Function and Maintenance 1655** - Chest tubes is a closed drainage system used to remove fluid and connect to a pleural drainage system with a water seal to reestablish negative pressure in the thoracic cavity