Download Nursing professionalism study guide 4 and more Study Guides, Projects, Research Nursing in PDF only on Docsity!
Nursing professionalism study guide 4
1. nursing interventions for client receiving o via nasal canula (treat- ing supplemental oxy- **gen as a med)
- nursing interventions** to promote circulation **in hospitalized clients
- interventions to pro-** mote oxygenation in **hospitalized patients
- priority nursing actions** for a client exhibiting s/s of impaired oxygenation
Nursing professionalism study guide 4
-make sure pt is receiving right rate of o -assist pt in applying nasal cannula -record pt's pulse & respiratory rate -asses patency of nostrils -Ensure that prongs are in the nares properly. A poorly fitting nasal cannula leads to hypoxemia and skin breakdown. -Provide emotional support to the patient who feels claustrophobic. Emotional support decreas- es anxiety, which contributes to a claustrophobic feeling. -Assess the patient for changes in respiratory rate and depth. The respiratory pattern affects the amount of oxygen delivered. A different delivery system may be needed. -maintain ideal body weight -decrease fat, decrease salt in diet -reg. exercise program -decrease stress -monitor cholesterol & triglycerides -B/P checked manually -no smoking -manage oxygen therapy and equipment (nasal cannula, face masks, CPAP) -raise HOB to high fowler's position -use tripod positioning -provide suctioning if needed -maintain airway patency -breathing & coughing exercises (pursed lip breathing, cough & DB, incentive spirometry) -monitor VS -monitor pt's anxiety -prevent or treat hypoxia -optimize oxygen delivery -monitor oxygen saturation levels -administer oxygen therapy
Nursing professionalism study guide 4
-decreased or absent breath sounds -shallow breathing; inspiratory crackles -it should be given in controlled amts & only if a SaO2 of 88-92% is aimed for -high levels of O2 can lead to respiratory failure & suppress the resipiratory drive
Nursing professionalism study guide 4
What is incentive spirometry?
12. purpose of incentive **spirometry
- client teaching needs** **for incentive spirometry
- meds that can increase** risk of impaired oxy- **genation
- application of clini-** cal reasoning/judgment process in care of pt **with fluid imbalance
- main organs/body sys-** tems involved in flu- id/electrolyte imbalance Used to measure air that moves into and out of the lungs. -encourages deep breathing helps pt take a deep breath -improves pulmonary ventilation -hold the device upright, take a deep breath in & exhale normally (breathe through mouth rather than nose) -frequency: -Opioid pain relievers and anesthetics that can cause slow, shallow breathing -Amiodarone, a drug used to treat irregular heart- beats -NSAIDs, anti-inflammatory drugs that can wors- en asthma or heart failure -Beta blockers, drugs that lower blood pressure and heart rate (morphine) -benzodiazepines (xanax) -narcotics -illicit drugs (heroin) -sleeping pills -barbiturates -assessment, analysis, planning, implementation, evaluation of outcomes -notice the signs & symptoms of fluid imbalance -interpret the data you collected & compare it with normal values & clinical guidelines -respond by planning & implementing appropriate interventions to correct or prevent fluid imbalance -reflect on your actions & outcomes -kidneys
Nursing professionalism study guide 4
17. why r the elderly at in- creased risk of fluid im- **balances?
- what factors place a** client of any age at risk of fluid **imbalance?
- hyperkalemia priority** nursing assessments -thirst mechanism is less effective & w/ some meds increase risk of dehydration -medication effects -decreased kidney function -changes in functional & mental status -impaired physical mobility -inability to eat or drink -age related physiological changes -women: more fat tissue than males, so r @ higher risk for dehydration -proportion of body water decreases w/ age -women/elderly decrease water r/t decreased muscle mass/increased fat tissue -ECF in infants>adults; however, more easily lost, therefore increased risk for fluid deficits assess for heart arrhythmias and flaccid muscle paralysis -monitor Urine &output -assess level of consciousness & neuromuscular function -monitor respiratory rate & depth -ID cause of hyperkalemia (excessive intake of K+ or decreased excretion)
- excess fluid volume s/s -5% wt gain -NVD -peripheral edema -rales -dyspnea/SOB -polyuria -bounding, full pulse -HTN -irritability; confusion 21. excess fluid volume pri- ority nursing interven- tions
Nursing professionalism study guide 4
-fluid restriction -low Na+ diet -monitor daily wt -bedrest
-malabsorption -renal failure (kidneys fail to excrete phosphate; increase phosphate w/ decrease calcium; inver- slety proportional)
- hypercalcemia s/s -muscle weakness; tiredness -lethargy; decrease memory -renal stones -cardiac arrest
- hypocalcemia s/s -tetany; numbness; tingling fingers -muscle cramps in extremities -mental status changes; convulsions 29. Hypercalcemia **nursing interventions
- hypocalcemia nursing** interventions -provide adequate hydration -administer diuretics or phosphate or both as pre- scribed by physician -ambulate (replacement of calcium; seizure precautions) -Closely monitor respiratory and cardiovascular status. -Take precautions to protect a confused client. -Administer oral or parenteral calcium supple- ments as ordered. When administering intra- venously, closely monitor cardiac status and ECG during infusion. -Teach clients at high risk for osteoporosis about: -Dietary sources rich in calcium. -Recommendation for 1,000-1,500 mg of calcium per day. -Calcium supplements. -Regular exercise. -Estrogen replacement therapy for post- menopausal women.
- calcium normal range 8.5-10.5 mg/dL 32. hyponatremia caused by -loss of GI fluids -diuretics
- hyponatremia s/s -muscle cramps -twitching -seizures -confusion -coma (severe) 34. hyponatremia nursing **actions
- hypernatremia** caused by
- Seizure precautions
- Increase sodium intake orally
- Administer iso/hypertonic saline IV fluid as or- dered
- Restrict hypotonic fluid if indicated
- Monitor for postural hypotension -water deprivation -hypertonic tube feedings -heat stroke -excess water loss
- hypernatremia s/s -thirst -increase temp -dry swollen tongue -sticky mucous membranes -severe disorientation 37. hypernatremia nursing actions infuse hypotonic solution, offer fluids, monitor fluid I/O, monitor behavior changes, monitor lab find- ings, monitor diet (NAS, restricted Na)
- Sodium normal range 135-145 mEq/L
- potassium normal range 3.5-5.5 mEq/L 40. hyperkalemia is caused by Renal failure Potassium-sparing diuretics Hypoaldosteronism High potassium intake coupled with renal insuffi- ciency
A c i d o s i s M a j o r t r a u m a
-history of stroke, heart attack
- effects of diuretics -hypokalemia -dizziness -headaches
-dehydration -muscle cramps -heart palpitation -irritability -weakness 50 . best food sources of fruits and veggies potassium -bananas; peaches; figs; white beans -potatoes & sweet potatoes -beets -avocados -watermelon -spinach 51 . lungs -eliminate hydrogen ions -regulate pH through CO2 levels in ECF -lose approx 300-400 ml H20 daily through exha- lation 52 . adrenals -regulate blood vol, Na+, K+ through aldosterone 53 . cardiovascular circulate blood through kidneys under sufficient pressure to form urine 54 . kidneys -primary regulator of ECF vol. thru selective reten- tion/excretion of body flds -reg. electrolyte levels; selective retention of what is needed/excretes the unneeded -regulate pH of ECF 55 . thyroid -increase cardiac output regulates calcium levels -secretes calcitonin: lowers Ca blood level by pre- venting calcium release from bone
must excrete at least to eliminate body wastes
- hypoglycemia low blood sugar (<70 mg/dL)
- hypoglycemia s/s -shakiness -confusion -diaphoresis -palpitations -headache -lack of coordination -blurred vision -seizures -coma
- hyperglycemia s/s -excessive thirst (polydyspia) -Fruity odor -headache -N/V -abd. pain -Rapid Pulse -excessive urination (polyuria) -blurry vision -fatigue -recurrent infections -polyphagia (excessive hunger) -paresthesia (tingling, numbness) -Cardiovascular symptoms (chest pain, extremity pain, neurological deficts) 60. magnesium normal range 1.3-2.1 mEq/L
- therapeutic diets -treat dz -prep for diagnostic exam, surgery -promote health -provide written instructions -provide family teaching
62. reasons client might **be placed on the diet
- nursing actions to** stim- ulate/promote a **client's appetite
- priority actions if** client does not comply with their ordered **therapeu- tic diet
- factors affecting a** client's nutritional **sta- tus
- considerations with** client who has a hx of alcohol misuse -obesity -CVD -food intolerance -certain diseases (Crohn's dz, diabetes, HTN, gastrointestinal disorders) -allergies -investigate reason for loss of appetite -include food preferences -comfort measures -small portions; snacks -clean env -remove foul odors -serve food @ temp intended -provide oral hygiene -reduce stress -determine perception of diet (determine why they're refusing) -educate them on why it's important to follow the diet -if pt doesn't accept, inform Dr & respect pt's decision -ethnicity; culture -age -religion -economic status -peer grps -personal pref; lifestyle -beliefs abt health effects of nutrition -alcohol misuse: adds calories, fat; used for ener- gy so fat is stored; decreases nutrient absorption -psychol factors: anxiety; comfort foods -meds: decrease (antibiotics) or increase appetite (steroids) (it adds calories/fat; it is used for energy so fat is stored; decreases nutrient
