Exam 6

Stroke –common effects

• Loss of face, hand, arm, leg, or body control

• Hemiplegia

• Changing emotions

• Difficulty swallowing (dysphagia)

• Aphasia or slowed slurred speech

• Changes in sight, touch, movement, and thought

• Impaired memory

• Urinary Issues, loss of bowel control, constipation

• Depression and frustration

Hypertension

a long-term condition where blood pressure in the arteries is consistently high. Blood pressure is usually diagnosed when it's 130/80 mm Hg or higher

Fractures-cast care/traction

Closed Fracture- Bone is broken, skin is intact

Open fracture- Broken bone has come through the skin

Movement of the bone ends is prevented with a cast, traction, etc.

Cast Care- Keep the cast dry, clean, avoiding putting weight on it. Elevate the cast.

HIV/How are they spread/precautions

Spread through body fluids

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Angina & Myocardial Infarction – what occurs

Angina is chest discomfort caused by insufficient blood flow to the heart muscle.

Myocardial infarction- blood clot stops blood flow to the heart.

Heart Failure (CHF) – what is it; nursing interventions

Occurs when a heart is weakened and cannot pump normally

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Diabetes – what is it/interventions/treatments

Type 1- Mostly in children, teens, young adults

Type 2- Any age

Risk factors are being over 45, being over weight, lack of activity, hypertension.

Treatment:

Type 1- Daily insulin therapy, healthy eating, and activity

Type 2- Healthy eating and activity, oral drugs, some need insulin, loss of weight.

Tuberculosis (TB) - how is it spread/precaution level

Bacterial infection in the lungs

Spread by airborne droplets with coughing, sneezing, speaking, singing, or laughing.

Risk factors:

• Close, frequent contact

• being close, crowded areas

• age

• poor nutrition

• HIV

Standard precautions and isolation precautions (airborne)

• Mouth and nose should be covered when sneezing, coughing, or producing sputum

• Tissues are flushed down the toilet, placed in a biohazard bag, or placed in a paper bag and burned

Stroke- Care

A stroke is caused by a blocked artery in the brain

Therapy and help with day to day life.

The goal is to help them regain independence.

Hepatitis B/How are they spread/precautions

Inflammation of the liver

Follow standard precautions and the Bloodborne Pathogen Standard

Isolation precautions ordered as necessary

Hepatitis B

• Is present in the blood and body fluids of infected persons

It is spread by:

• IV drug use and sharing needles

• Accidental needle sticks

• Sex without a condom

• Contaminated tools used for tattoos or body piercings

• Sharing a toothbrush, razor, and nail clippers.

Care for persons with hearing aids and hearing loss

• Take off and turn off before sleep

• Keep away from heat, cold, and moisture

• Make sure they are off before showers

• Keep hearing aids clean

• Speak slowly and clearly

Care for persons with vision loss

• Provide adequate lighting

• Provide access to their glasses

• Keep the environment uncluttered, arrange things consistently

• Communicate giving clear directions and using their preferred method

• Nurse should be one step ahead in stairs and steep areas

Blindness- Key points for caregivers

• Identify Oneself

• Position items: Use an imaginary clock face to help position items

• Provide verbal cues

• Maintain safety

• Keep the room well-lit

• Communicate directly: Use the patient's preferred method

• Support independence

• Use the clock method: For example, describe meat as 12 o'clock, peas as 6 o'clock, and potatoes as 9 o'clock

• Cut food into small portions: This can be useful for children

• Avoid overfilling cups

• Indicate liquid level

Cataract surgery post-surgery points

• no bending

• no carrying too much weight or participating in demanding activity

• no swimming or getting wet

• Shield your eyes

• Don’t rub eyes

• Avoid possibly infectious substances (such as makeup)

Restorative Nursing Care – what does it do

Helps persons regain health, strength, and independence

• Helps maintain the highest level of function

• Prevents decline in function

  Restorative Nursing may involve:

• Self-care

• elimination

• positioning

• mobility

• communication

• cognitive function

Key points for caregivers re: Rehabilitation

• Promote the person’s independence

• Preventing decline

Receptive Aphasia

Difficulty understanding spoken language

Expressive Aphasia

Difficulty speaking language

Stroke patients

Physical, occupational, and speech therapy. The goal of stroke rehabilitation is to help patients regain lost abilities

Some general components of stroke rehabilitation programs include:

• Treating the disease:

• Improving function

• Providing adaptive tools

Characteristics of normal respirations

12-20 per minute 

Hypoxia- Definition and signs of

Cells do not have enough oxygen  

Early signs include restlessness, dizziness, and disorientation  

Deep breathing and coughing

purpose of- Remove mucus and bring air into most parts of the lungs

How it is done-Breathe in through their nose, hold for 2-3 seconds, release until ribs fall.

How often- 4 times or as requested every 1-2 hours.

Orthopneic position

Sitting position, head over a bedside table.

Oxygen sources and devices

• Wall Outlet

• Oxygen Tank

• Oxygen Concentrator

• Liquid Oxygen system

Pulse oximetry- normal range

Measures the amount of oxygen in your blood

95%-100%

Repositioning

• Usually easier in Fowler’s and Semi-Flowler’s position

• Persons often prefer orthopneic position

• Positioning changes at least every 2 hours

O2 therapy

Oxygen therapy is used for persons with lung failure, problems, or difficulty breathing.

Flow rate

Flow rate is set by the nurse or respiratory therapist

Monitor the flow rate to make sure it is what it’s supposed to be.

If the flow rate is too high or too low, report to the nurse at once.