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Exam3 Review Prep - Fundamentals of Nursing
Fundamentals of Nursing (165)
University of California Los Angeles
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Review ASSESSMENT of -
GI/GU – contore, shape, the 4 quadrents (RL,RU,LU,LL) ALWAYS START RL = because of pendics and Illam Secral Valve (bowl sounds there bowl sounds everywhere) Berneys Point (tender there infalmatory process apperitinitous, appendisistus) Pain start away work towards end at pain in RL gentally push down palpate not deep and asses Rebound Tenderness (assess face and abdominal) assess for 5 MINUTES before you can call NO bowl sounds (if not sound then call Dr) palpate superpubic area and pressure (or use bladder scanner) shows bladder is full (then you can straight cath if ORDER and its ASEPTIC (STARIL) watch urine output, shock = organs that shut down is the kidneys and skin and GI tract as far as blood flow, sunts all blood to the heart to the brain, 30cc per hour is normal urnine output, hypervolemia shock = watch urnine output, Nasal Gastric tube = in nose to stomach, Oral = mouth, Nasal = nose Tube to decompression somach or feed. Dysphasia = peg tube don’t wanna leave the other tube in long, neg nitrogen balance and contabolism state = muscle loss and WEIGHT LOSS due to not eating for long time (DETERMIES NUTRION = weight) also ALBUMIN determines NUTRION NG tube cannot be left in long because it will adhere the GI tract, TUBE feed protical = check every 4 hours for residue (pH strip when checked should be acidic) placement, BIG COMPLICATION OF TUBE FEEDING = liquid and osmilatity are different from GI tract causing DUMPING SYNDROM (diahrra, sking break down, stomach feeling bad) NG TUBE = abdominal assessment, contoure destended (Destend = percouse and it will sound tympania if its destended) Continuous or Intermitent LOW sucktion, TUBE DECOMPRESSION = KNOW DRAINAGE AND HOW MUCH, GASTRIC JUICES = Yellow, Dulanum = Green, GI Bleed = Coffee ground, STOOL (FOBT positive) = upper GI bleed (gastric ulcer) shows TARRY color, low GI bleed = FRANK/bright BLOOD/BLOODY, URINE = organ green all due to medication (MADE KNOW THE MEDS), FOLY Insertion = ASEPTIC TECHNEQUE (parry care, where the urethria SCOT AREA), is it an analysis or culture
Neuro – brain hates hypxiamia, hyperprofussion, they loss the LOC watch LOC, brain needs blood and oxygen, common tools we use GLASGOW COMA SCALE – three things you asses Verbal Eye opening and Motor movement Give command and see if they will follow, Upper motor strength = squeeze my hands, stuper and utundent = ask them to talk stupper = verbeg comments to you understandable Utundent = not understandable, CN3-CN12 – PERLA size and reactive to light accommodation (not always done but if done chart) 346 is perla, trigeminal touch face facal = smile symmetrical, 8 hearing chemo cancer pt problem toxic (fumoseride high dose can cause hearing loss 160mg or IV ) get auditory before and watch, 9 and 10 swallowing vagus never, general anasetia, anything affecting the throat, GAGE REFLEX test before they can eat/drink, 11 spinal shrug, 12 stick tounge out look under tongue due to ORAL CANCER there, HEAD = Normalsephalic,
MS – atrophy loss of motor strength peraliisis, peralisis secondary to stroke that side losses strength and lossees muscle on that strength LOSS MUSCLE = LOSS MOTOR STRENGTH, brain computer, Neuro goes with MS, hazard of immobility, ablitly to move, if neuro and ms don’t work together
IMMOBILITY is a problem, ALWAYS ASSESS PT CAPABLITY HOW MUCH HELP THEY NEED (assistance x 1,2 etc) tetraprolegic = huyer lift ASSESS ASSESS ASSESS every body system is effected by immobility depression low HR shallow Repersation Orthostatic phnemia, GI tract constipation, weakness, atrophy, strength depleats,
Integ – look at skin, intactness, asses skin injuries, ebqudious ulcers, hospital pays for it (same as GI) if new infection picked up at hosptile, 4 STAGES – KNOW THESE 4 STAGES WOUNDS = REEDA
= Fresh wound (Redness Erathema Edema redness (hyperaemia), oedema,
ecchymosis, discharge and approximation of the wound edges
(coaptation).) don’t want a wound to DEHIS = pressure build up and wound opens up again.
TYPES of Drainage = serous sanguinous serosanguinous and purulent (know what these type of liquid they are blood puss sero plasma etc) HemoVac/Jackson prat (press down compress drain and cap again, cause suction SUTURED IN) Penrostrain (nothing holding the penrostain in can dislog easy) CULTURE = wound infected, know arobic (superficial w O2) or anaerobic (deep wo O2) culture (KNOW THE DIFFERECNE) truly culturing wound bag (A LOT OF DRAINAGE = IRRIGATE WOUND<, get old drainage away, don’t wanna culuter drainage but the wound BED itself) 3 DEMNSION OF A WOUND MEASURE = WIDTH DEETH AND LENGTH, pressure ulce check for TUNNLING, ulcer eating away under good skin, INDERATION (hardness) needs check with wounds aswell (redness and warm = INFLIMATION) INFECTION = drainage FEVER/TEMP WBC INCRESAED in addition to redness and warmth, INFLIMATION = REDNESS and WAMRTH
MED ADMIN - perental oral topical TYPES OF ADMIN OF MED, ASK TWO IDENTIFIER (NAME AND DATE OF BIRTH (AVIOD “CAN You”)
MUSCLE – know location of muscle, HEPRIN = Admin abdominal, two inches or more away of embolicous area because its vascular, and it needs admin SUBCUTANIOUS not intro vascular, EAR = UP AND BACK and KID = DOWN AND BACK for drops, DO NOT admin drops is Tempanic membrane is NOT intact (look at ear drum DRAINAGE) to much SURUMEN (order to irrigate ear conal because drops wont get to area needed) EYES = make sure you know what the drops are for, LOL = beta blockers if given through eyes and goes in lacromal duct could decrease BP (watch with glycoma DOUBLE DOES) BLOCK LACOMAL DUCT FOR A MINUTE OR SO WITH BETA BLOCKERS, admin = look at ceiling, eye away then close in lower conguntive, pull lower conguntive down and drop in it, TROPCIAL = nitroglycerin, nicotine patch WEAR GLOVES, TIME AND DATE and ALTERNATE patch to avoid irritation (SAME WITH heparin and insulin ROTATE SIDES due to hardness of skin where you inject an stops absorbing) IV = usually used for PUMP not GRAVITY, assess for complication = INFILTRATION FLABITOUS AND ETRAVASION (extreme infilitration) FLABITOUS = red hard and warm, Infiltration = hard pale and cool, Extravasation = tissue destroys, med that are harsh when they infiltrate CHEMO breaks down and destroys skin,
Electrolyte/fluid - fluid def and fluid excess, EXCESS = weight increase or DEF = decrease, if its a lot its severe, Heart Failure couple pounds, 1L = 1Kg, NUTRITION IMBALANCE mainly. DEF = weight, heart rate
Exam3 Review Prep - Fundamentals of Nursing
Course: Fundamentals of Nursing (165)
University: University of California Los Angeles
