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diagnostic related groups

medicare developed, a set amount of money that medicare will pay the hospital for a certain diagnosis categorizes based on diagnosis, treatment, and length of hospital stay

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steps for administering meds via a NG tube

turn off suction clamp tubing apply 60 cc syringe to NG, insert 30cc of air or aspirate gastric contents reclamp tubing prepare meds, flush before and after each med with 15-30cc of water after all meds- flush with 30-66cc of water keep suction discontinued for one hour then reconnect to suction

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abnormal lab findings patient education

understanding the results of the lab tests- meaning of lab values, terminology, causes and effects of abnormal labs interpreting MD's diagnosis- confusions about MDs suggestions/diagnosis, receiving confirmation after a diagnosis, concerns of misdiagnosis learning about lab tests as sources of info- specific test info, lab test recommendations, test comparisons, concerns about procedures consulting next steps- HCP consultation

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red blood cells

4.7-6.1 million/microliter produced in bone marrow in response to blood oxygen levels A condition that limits oxygen causes an increase in red blood cells

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hemoglobin

14-18gm/dl protein in RBC that carries oxygen, test is to evaluate oxygen carrying capacity of blood low- anemia/bleeding/surgery, overhydration, bone marrow suppression high- dehydration, polycythemia vera, pulmonary fibrisis

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hematocrit

42-52% measures the percentage of red blood cells found in whole blood low- overhydration, anemia, bleeding, bone marrow suppression high- dehydration, polycythemia vera

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WBC

4500-10,000 per microliter leukopenia (small amount of WBC) and leukocytosis (large amount of WBC

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basophils

0.5-1% allergic reaction to food/drugs, parasitic infection

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eosinophils

1-4% allergies, autoimmune issue, parasitic infection

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lymphocytes (T and B cells)

20-40% inversely related to neutrophils Increased: leukemia and lymphoma infection make antibodies and are killer cells Decreased: HIV, congenital immunodeficiency

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monocytes

2-8% viral infections, leukemia, TB infections

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neutrophils

40-60% bacterial infections give antibiotics

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platelets

150000-450000/microliter Help with clotting thrombocytopenia- gram negative infection, sepsis thrombocytosis- infection, trauma, spleen removal

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mean corpuscular volume (MCV)

80-95 fl provides info about the size of RBC to determine if the patients anemic and what kind of anemia they have high MCV= RBC are too large and indicates macrocytic anemia Low MCV= RBC are too small indicating microcytic anemia

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prothrombin time

11-12.5 seconds to clot coumadin and heparin therapy causes a prolonged clotting time

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international normalized ratio (INR)

0.8-1.2, 2-3 on coumadin standardize the results of PT no matter the resting method

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partial thromboplastin time

60-70 s, 1.5-2.5x longer in heparin therapy how long it takes to form fibrin using the intrinsic pathway

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sodium

135-145 mEq/L cation, chief electrolyte of the ECF maintains water balance throughout the body, participates in the generation of and transmission of nerve impulses

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hyponatremia

<135 causes- medications, inadequate sodium intake, water gain, sodium loss s/s- abdominal cramps, headaches, nausea, seizures, muscle twitching, tremors, weakness, altered LOC, lethargy, confusion nursing- hx of diet, meds, behavioral changes, weight, I/O, vitals, sodium levels, replace sodium with diet, restrict fluids, NS or LR

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hypernatremia

>145 causes- water deficit, excessive Na intake s/s- polyuria, anorexia, vomiting, weakness, agitation and restlessness, confusion, dry and dlushed skin, intense thirst, lethargy, tachycardia, low grade fever from dehydration nursing- VS, sodium levels, correct underlying problem, fluid replacement, hypotonic NS (0.45%), NS or D5W, go slow

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chloride

98-106 mEq/L extracellular anion with Na follows sodium losses and accompanies sodium excess in an attempt to maintain electrical neutrality, affects water balance, serves as a buffer to assist in acid-base balance

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potassium

3.5-5 mEq/L ICF cation serum level depends on aldosterone, sodium reabsorption, acid-base balance role in transmission of electrical impulses (nerve, skeletal, intestinal, lung tissue), protein and carb metabolism, cellular building

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hypokalemia

<3.5 causes- ALCOHOLISM, inadequate intake, loss of K, surgery, hyperaldosteronism, liver disease, cancer, redistribution of K s/s- muscle cramps, anorexia, abdominal distention, constipation, weakness and fatique, n/v, weak irregular pulse, abnormal EKG nursing- replace K with diet, supplement, IV, correct cause of imbalance, cardiac monitor, K levels, Mg levels

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hyperkalemia

>5 causes- acute and chronic renal failure, excessive release from cells secondary to traumatic injury, severe infection, burn, excess IV infusion or oral intake, acidosis, meds, fast growing cancers s/s- abdominal cramps, diarrhea, hypotension, irregular HR, muscle weakness, nausea, paresthesia (numbness and tingling), convulsions, cardiac arrest nursing- critically ill, restrict K, correct cause of imbalance, infuse insulin and glucose or Na bicarb, IV of calcium gluconate, kayexalate (diarrhea), dialysis, cardiac monitor, K levels

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CO2

23-30 mEg/L venous blood specimens are not highly accurate for measuring true CO2 content use as a rough guide for acid-base balance High: lung diseases, metabolic alkalosis, cushing's syndrome, kidney failure Low: addisons disease, shock, diabetic ketoacidosis, respiratory alkalosis, metabolic acidosis

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calcium

9-10.5 mg/dL 99% found in bone

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hypocalcemia

common in older adults. Vit c deficiency

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hypercalcemia

>11 common in metastatic malignancy, hyperparathyroidism, thiazide diuretic therapy

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magnesium

1.3-2.1 mEq/L 50% in bone, 49% intracellular, 1% blood most are bound to an ATP molecule, more than 300 biochemical reactions absorbed in small intestine and excreted by kidney foods- pumplin, cashews, almonds, lentils, brown rice, shitaki mushrooms, sunflower seeds

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hypomagnesemia

increase in cardiac irritability, aggravate cardiac arrhythmias

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hypermagnesemia

retards neuromuscular conduction, respiratory depression

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phosphorus

2.4-4.1 mg/dl ICF anion absorption is facilitated by vitamin D, maintains the pH of body fluids, maintains cellular osmotic pressure, important component of DNA and RNA inverse relationship with Ca levels controlled by intake and renal function kidney failure- hyperphosphatemia and hypocalemia hypocalemia- bone demineralization

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blood urea nitrogen

7-20 mg/dL formed when protein breaks down, effected by certain drugs low- liver failure, low protein diet, malnutrition, overhydration high- CHF, excessive protein levels, GI bleed, hypovolemia, kidney disease, kidney failure, UTI, shock, elderly

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creatinine

0.5-1.1 mg/dl waste product produced in muscles from the breakdown of creatinine used to diagnose impaired kidney function and to determine renal damage high- diets high in meat, heavy metal chemotherapy, cephalosporins, dehydration, elderly/renal low- older patients with decreased muscle mass, muscular dystrophy, paralysis

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glucose

60-100 formed by digesting carbs, stored in the liver as glycogen screening for diabetes mellitus, gestational diabetes, hypoglycemia

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hypoglycemia

blood sugar is too low

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hyperglycemia

blood sugar is too high

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lactic acid

5-20 mg/dl helpful to document and quantify the degree of tissue hypoxemia associated with shock or localized vascular occlusion; can also be a measurement of success in treatment causes- prolonged use of a tourniquet, vigorous exercise, meds high- shock, sepsis, tissue ischemia, carbon monoxide poisoning, severe liver disease, genetic errors of metabolism and diabetes mellitus

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HgbA1C

nondiabetic 4-5.9% diabetic- <7%

high hgba1c= high average glucose level of the last two or three months and are at risk for developing type 2 diabetes low=

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How do you measure fluid balance and how many lbs of weight gain in a day is concerning?

I/O daily weight- most accurate >3 lb/day is concerning

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ventilation

the process of moving gases into and out of the lungs. it requires the muscular and elastic properties of the lungs and thorax to be coordinated

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perfusion

the cardiovascular system must have the ability to pump oxygenated blood to the tissues and then return it to the lungs

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diffusion

the movement of respiratory gases from one area to another by concentration gradients

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atelectasis

normal exchange of oxygen and carbon dioxide is altered by a collapse of alveoli; not a disease but a condition or sign that results from disease causes- infection, blockage of airways, compression, scarring from radiation, pneumothorax, immature lungs

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pneumonia

inflammation of the lung parenchyma (alveolar spaces) creating a buildup of fluid and excrement in the alveoli; decreasing gas exchange

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pulmonary embolism

a blockage of one or more pulmonary arteries by fat or thrombus, amniotic fluid or tumor tissue presents as cardiac arrest, fatalities after 1-2 hours obstruction causes- bronchoconstriction, impaired gas exchange, loss of surfactant V/Q mismatch, RVF, pulmonary HTN, tricuspid regurgitation, compression of RCA, elevated BNP and troponins,

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chronic obstructive pulmonary disease

chronic bronchitis causes hypersecretion of mucus and chronic productive cough, emphysema causes airflow limitations due to loss of elastic recoil in airways

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what are ways to avoid drug-drug interactions in the elderly?

identify indication of each medication ask if the indication is still present any duplications in drug therapy, any meds prescribed for an adverse drug reaction therapeutic doses significant drug-drug or drug-food interactions exploration of non-pharmacologic interventions review med reconciliation form

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6 rights of medication administration

patient, medication, dose, time, route and documentation

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50

normal vital signs

96.8-100.4, avg is 98.6 or 37 c 60-100 bpm 12-20 rr 100-120/60-80 mmHg greater than 95%

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51

What are the different pain scales and what is the gold standard in reporting pain?

self reporting pain is the gold standard OPQRSTU visual analog scale (scale with words or numbers or both), word descriptor (0= no pain 1=mild pain etc.), graphic scale(images), verbal scale (on a scale of 1-10 how much pain are you feeling?), functional pain scale (0=no pain 5= intolerable and pain prevents verbal communication. scale of 1-5 with descriptors like the word descriptor scale but references pain and activity to determine pain)

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how do you asses pain in a nonverbal patient patient?

consider painful conditions and procedures observe for behaviors recognized as pain related, get info from caregivers/family members attempt an analgesic trial physiologic- increased HR, RR, BP, fluid overload, immune cell suppression, arrhythmias

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nociceptive pain- somatic

orginates in the skin, connective tissue, joints, muscles. Usually localized at the site of injury and gets worse with movement ie. broken bones, sprains, cuts, bruises

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nociceptive pain- visceral

originates in organs tends to not be clearly localized, could be referred pain, aching, pressure, cramping, nausea, diaphoresis ie. labor pain, appendicitis, bowel obstruction

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neuropathic pain- peripheral

pain between spinal cord and extremities. Burning, shooting, electric shock feeling. Ie. diabetic peripheral neuropathy, neuralgia (shingles) and phantom limb pain

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neuropathic pain- central

Within the spinal cord and brain. Described as tingling, pins and needles. Ie. spinal cord injury, post stroke pain

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what is central sensitization? Hyperalgesia? Allodynia? what do these types of pain have in common?

CNS becomes sensitized resulting in patient becomes more sensitive to pain so person will respond hyperalgesia- increased response to a stimulus that is ordinary painful allodynia- pain when no painful stimulus less responsive to opioid analgesia and often result in escalation of opioid dosing with a higher risk of side effects These types of pain are less responsive to opioid analgesia

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acute pain

short duration from a known cause, recent onset, limited, predictable course of healing identifiable temporal and causal relationship to an injury or disease objective indicators- tachycardia, elevated BP, sweating/pallor, dilated pupils, anxiety, expression

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chronic pain

longer than expected duration or more than 6 months not always clearly identifiable or flare from recurrent chronic illness adaptation- normal HR, blood pressure, pupils, no sweating/pallor, depression

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acute-on-chronic pain

acute pain from trauma or exacerbation of a disease in a patient with a chronic pain condition

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nonpharmacologic pain interventions

positioning, relaxation, ice/heat, distraction, talking, increase patient's knowledge about pain, increase patient's sense of control over pain, address pain-related factors (n/v, anxiety, fear, lack of sleep)

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pain evaluation and documentation

frequent reassessment, monitor for side effects, monitor for pain related symptoms (anxiety, depression, withdrawing)

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acetaminophen

max dose less than 4000mg in 24 hrs avoid in patients with liver disease beware of hybrid drugs like vicodin and percocet

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NSAIDs

mediate the inflammatory response use cautiously in patients with renal insufficiency

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adjuvants and what are adjuvants

Help with pain but aren't designed for pain antidepressants (tricyclic) alpha adrenergic blockers (BP meds, withdrawal) anticonvulsants NMDA inhibitors corticosteroids muscle relaxants

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opioid analgesics

morphine- 5-10 min, 20 min, 1.5-4.5 hours hydromorphone (dilaudid)- 15 min, 20 min, 4-5 hours fentanyl- immediate, 5-10 min, 30-60 min demorol-lowers seizure threshold oxycodone methadone- withdrawal and pain adverse effects- respiratory depression, constipation, n/v, pruritus (itching skin), urinary retention, sedation

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fentanyl patches

for chronic pain only, change every 3 days, transdermal delivery systemic effects so rotate shoulders

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lidocaine patches

topical, place where the pain is

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at risk for uncontrolled pain

elderly, pediatric, confused, non-english speaking, different ethnicity, hx of substance abuse, chronic pain with acute pain

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gastrostomy types and placements and care

PEG- local anesthesia and placed with an endoscope mic-key- long term use, more discrete ^both are passed through the abdominal wall into the stomach g-j tube- bypasses the stomach for those with recurrent aspiration, pneumonia, severe GERD, gastric outlet obstruction, gastric emptying Placed through existing hole (gastrostomy) into the small bowel (jejunum) care- keep clean and dry, use soap and water, avoid dressings, avoid ointments, no pulling on tube, child can bath, law, swim one week after

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71

what are the signs and symptoms of acute viral nasopharyngitis (common cold) in infants and children

s/s- fever, poor feeding, vomiting, diarrhea, abdominal pain, nasal blockage/discharge, cough, respiratory sounds, sore throat, headache, neck pain care- prevention and protection, comfort, symptom management, hydration, managing secretions, family support

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72

what are the signs of influenza?

s/s- dry throat, hoarseness, lack of energy, sudden onset of fever and cells complications- viral pneumonia, bacterial infections

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what are symptoms of croup?

dx- inflammation of larynx, trachea, bronchi s/s- epiglottitis, laryngitis, laryngotracheobronchitis (LTB), tracheitis (severe effects on the voice and breathing)

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what is acute epiglottitis and signs of epiglottitis?

medical emergency serious obstructive inflammatory process, quickly progresses to severe respiratory distress s/s- absense of cough, drooling, agitation (anxiety increases as respiratory distress increases), dysphagia, high fever, toxic apperance

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what are the signs of acute laryngotracheobronchitis (LTB)?

most common croup syndrome (6mo-3years) cause- viruses, rarely bacterial s/s- preceded by URI which descends to other structures, barky cough, retractions, nasal flaring, stridor

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what are the symptoms of bronchitis?

inflammation of the large airways frequently associated with URI s/s- dry hacking non-productive cough worsen at night

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respiratory syncytial virus (RSV)

s/s- increased secretions, sneezing, wheezing, tachypnea, apnea, poor air exchange, coughing, pharyngitis, rhinorrhea, cyanosis

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what are the symptoms of pneumonia in children?

s/s- fever, malaise, non-productive to productive cough, chest pain

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respiratory infections in infants/small children

etiology and course of infection is influenced by infectious agent, age of child (children have more generalized and localized s/s, <3 react more severely to acute respiratory infections), size of child, resistance, season, living conditions, preexisting conditions

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80

what is a home care for child with asthma and symptoms of asthma?

create a school action pain, breathing exercises, yoga, acupuncture, diet, herbal remedies teach how to use an inhaler avoid triggers s/s- prolonged expiratory phase, wheezing, chest tightness, cough, tachypnea, accessory muscle use, retractions, nasal flaring, agitation, altered muscle state, hyperinflation, increased AP diameters meds- MDI (albuterol), inhaled corticosteroids, prednisone

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81

what are the signs of cystic fibrosis and it's impact on the pulmonary and gastrointestinal system? Treatment and diagnosis?

dysfunction of the exocrine glands that produce thick tenacious mucous thick mucous obstructs the respiratory passages, causing trapped air and over inflation of the lungs, thick mucous obstructs the secretory ducts of the pancreas, liver, and reproductive organs

Pulmonary system impact: causes hypoxia that results in barrel chest and clubbing

Gastrointestinal system: decreased absorption of vitamins and enzymes, abdominal distention, decreased enzymes, rectal prolapse, fatty stinky stool (steatorrhea) meconium ileus in newborns s/s-fatigue, chronic cough, recurrent URTs, thick mucous,

Diagnosis: elevated sweat electrolytes -gold standard abnormal chloride and sodium movement stool analysis

Treatment: CFTR breathing exercises Chest pulmonary therapy (CPT) pancreatic enzymes and vitamins with meals high calorie and fat diet

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nasal cannula low flow

1/8-6 lpm 25-45% humidification, lubrication, extension tubing

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nasal cannula high flow

5-8 lpm 25-45% humidification, lubrication, extension tubing

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simple face mask

low flow 6-12 lpm, 35-50% co2 retention, humidification, snug fit, short term use

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partial rebreather mask

low flow 10-15 lpm, 60-90% has reservoir bag 1/3 to 1/2 full on inspiration co2 retention

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venturi mask

high flow 4-12 lpm, 24-60% has exhalation port and flow control attacked for specific rate and fio2 may depress respiratory drive

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nonrebreather mask

low flow 10-15 lpm, 60-90% has reservoir bag 1/3 to 1/2 full on inspiration no co2 retention bc of one way valve

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safety measures for o2

-suction in the room -oxygen flow meter with age appropriate devices -ambu bag appropriate for infant, pediatric, adult -masks -intubated- have intubation supplies at the bedside and know the size of ET tubes alarm limits set of cardiac monitors airway, breathing, circulation drugs no smoking, can cause retina and lung damage with toxicity

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89

measuring nonverbal children pain

FLACC scale face, legs, activity, cry, consolability children less than 4 or developmentally delayed observational/behavioral tool

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90

physiologic and behavioral pain scales

NIPS, CRIES, NPASS, PIPP vital signs, oxygen, color muscle tone, facial expression, body movements, cry, changes in state consider infants maturity, behavioral state, energy resources available to respond, risk factors for pain

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older children and verbal pain scale

FACES children over 4 years old that understand and point or verbalize numeric pain scale for kindergarten age (5-6) PQRSTU

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nonpharm pain management for peds

NNS, kangaroo care, swaddling, guided imagery, parent involvement, heat, distraction, sucrose, pet therapy, art therapy, deep breathing CAM- herbal remedies, aromatherapy, acupuncture, Reiki, massage

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what acute illness causes the highest morbidity in children and what children have an increased morbidity

respiratory illnesses- 50% of illnesses, 11% caused by infection and paracites, 15% by injury groups of children with increased morbidity- low birth weight, homeless, living in poverty, in day care centers, chronic illness and foreign born adopted

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96

what are childhood health problems and health promotion?

nutrition- obesity and diabetes type II- 30% of children are overweight and 17% are obese injuries are the most common cause of death and injury in children in the us injuries, suicide, MVA, falls, mechanical suffocation, violence, mental health issues, car crashes Health promotion: promote development (survey for delays, anticipatory guidance) nutrition (essential for growth and development) Oral health firearm safety

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97

infant development stages

birth to 1 year high increases by a foot weight doubles at 6 months, triples at a year head circumference equals chest circumference by a year able to use large muscle groups to maintain balance and for locomotion able to coordinate hand to eye movement in an orderly manner (holding bottle and putting in mouth) rolling over, sitting up, crawling

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toddler development stages

1-3 years walking and jumping feeds self, builds towers, grasps small objects decreased appetite potty training temper tantrums negativism "no" toddlers often say can undress self and walk alone

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preschooler developmental stages

3-6 years riding tricycles, skipping and hoping physical growth slows, body systems mature increased eye-hand coordination, improved muscle coordination development of fine motor skills set limits diversion of aggressive behavior dental visits at 3

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100

school age developmental stages

6-12 years weight and height increases heart rate and RR slows looses baby teeth ugly duckling phase peers are important

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