Final BNAT Exam

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.

Cause of pressure sores

Unrelieved pressure that results in damage to the underlying tissues

Prevention of pressure sores

-Changing positions (q 2 hours)

-Using pillows

-Padding

-Keep skin clean and dry

-Promote hydration

Treatment

-Wound care products

-Drugs

-Treatments

-Special equipment to promote healing

Positioning techniques

Complications

-Infection

-Osteomyelitis (Inflamation of bone)

Persons at risk

-Bedfast or chair fast

-Need some or total help moving

-Have loss of bowel or bladder control

-Are exposed to moisture

-Lowered mental awareness

-Problem sensing pain or pleasure

-Circulatory problems

-Older, obese, or very thin

Osteomyelitis

Inflammation of the bones

Shear

Injury that will not be seen at the skin level because it happens beneath the skin

Bony prominence

Areas where bones are close to the surface

Key points for caregivers in preventing pressure injuries

-Inspect daily for signs of pressure injuries and report if spotted.

-Promote proper nutrition

-Change a persons position q 2 hours

-Keep the skin clean and dry

-Promote movement

Skin Tears

A break or rip in the skin

Circulatory Ulcers

Caused by decreased blood flow through the arteries or veins

Venous Ulcers

-Open sores on the lower legs or feet

-Caused by poor blood flow through the veins

-Are commonly found on heels and inner aspect of ankles

Arterial Ulcers

-Are open wounds o legs or feet Caused by poor arterial blood flow

-Are found between toes, on top of toes, an the outer side of the ankle

Diabetic Foot Ulcer

Open wound on the foot caused by complications from diabetes

-Check the persons legs and feet everyday

Purpose of Heat Applications

Increases blood circulation

Purpose of Cold Applications

Reduce pain, prevent swelling, and decrease circulation and bleeding

Types of Heat Applications

-Moist heat has faster and greater effects than dry heat

-Includes hot compresses, hot soaks, sitz baths, and hot packs

Dry heat applications stay at desired temp longer

-Some hot packs and the aquathermia pad are dry heat applications

Types of Cold Applications

Moist cold applications penetrate deeper than dry ones (cold compress)

Dry cold applications include ie bags, ice collars, ice gloves

-Cold packs can be moist d dry

Complications of Heat & Cold Applications

Heat

-High temp can cause burns

-When heat is applied too long, blood vessels constrict (flow of blood decreases)

Cold

-Pain, burns, blisters, and poor circulation

-When cold is longer than 20 minutes, the blood vessels dialate (flow of blood increases)

Length of Treatment for Heat & Cold

15-20 minutes

Binders

Montgomery ties

Montgomery ties are a type of tie that can be used to secure a bandage and change it without having to replace the tape each time. Can be used to facilitate frequent dressing changes and help prevent skin trauma.

Key points for caregivers

Friction and shearing

Friction occurs when two surfaces rub against each other, causing resistance. Shearing happens when layers of skin slide over each other. For bedbound individuals, friction and shearing can lead to pressure ulcers.

Thrombus

Blood clot.

A clump of blood that has changed from a liquid to a gel and forms in blood vessel. They can form in areas of slow blood flow.

Elastic stockings

Improve blood flow in the veins of your legs.

Aquathermia pad

An electrical device that produces dry heat to treat muscle sprains, mild inflammations, and pain.

Active ROM

The ability to move your body parts without the assistance of another person.

Passive ROM

the range of motion that a joint can achieve when an outside force, like a therapist or machine, causes movement.

Orthostatic Hypotension

A condition that causes a sudden drop in blood pressure when standing up from a sitting or lying position.

Dorsiflexion

Movement of the foot towards the body

Plantar Flexion

Movement of the foot away from the body

Ambulation

Act of walking or moving

Purpose of bedrest orders

• Bed rest orders are prescribed to reduce physical activity and promote healing in patients with certain medical conditions or injuries.

Types of supportive devices for bedrest

Types of Supportive Devices for Bedrest:

1. Pillows for elevation and support.

2. Overbed tables for meals and activities.

3. Bedside commodes for toileting.

4. Footboards to prevent foot drop.

5. Bedpans for toileting needs.

WHy are supportive devices used?

To prevent pressure injuries, promote comfort, and enabling movement.