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PBDS study guide
Study guide for PBDS assessment for registered nurses
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Medical
04/06/2010

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Term
What assessments should be included for a patient with acute abdomen?
Definition
History-type of pain, nature and onset of pain, location, quality (dull, sharp, crampy), changes in bowel habits, Hx of trauma, gynocological history, anorexia, malaise tachycardia, hypertension, fever, nausea, vomiting. . .look, listen and feel abdomen.
Term
Priority nursing interventions for a client with acute abdomen?
Definition
Give pain meds, keep patient quiet, assess for trauma, treat if indicated.
Term
Important data to report to physician when a client has acute abdomen?
Definition
Pain (location, type, duration, when it started), bowel habits, blood pressure, temperature, resipiratory status, pulse, nausea, vomiting, last menstrual period, trauma findings if indicated.
Term
Orders anticipated from physician for client with acute abdomen?
Definition
Pain meds, NPO, labs, IV fluids, NG suction, antiemetics, narcotics and/or analgesics, surgical consultation.
Term
What information/data from labs will be important for persons with acute abdomen?
Definition
CBC, urinalysis, pyuria, hematuria, glucosuria, ketones, serum lipase, serum HCG, serum electrolytes & glucose, gonorrhea & chlamydia, if over 40 EKG, KUB, chest X-ray, abdominal CT, guaic.
Term
What should the nursing assessment focus on for a client with CHF?
Definition
Auscultating lung fields and hear sounds,blood pressure, temp, pulse, history, recent weight gain, activity limits, sleep Pattern, edema.
Term
Priority nursing interventions for a client with CHF?
Definition
O2, raise head of bed, IV access, cardiac monitor, pulse oximetry, antiembolism stockings
Term
Data to report to physician of client with CHF?
Definition
Blood pressure, respiratory status, pulse, recent weight gain, activity limits, sleep pattern, current medications, edema
Term
Orders anticipated from the physician of a patient with CHF?
Definition
O2, ECG, Chest X-ray, ABG's, cardiac monitor, diuretics, potassium, Labs, electrolytes, BUN and Creatinine, BNP, cardiac enzymes, echocardiograpy
Term
Pertinent data/Labs for patient with CHF
Definition
Respiratory alkalosis, increased creatinine if severe, changes in pulm artery wedge pressure, meds: diuretics, digoxin to improve contractility, ACE inhibitor to decrease afterload, beta blockers, vasodilators to decrease preload, afterload, and systemic resistance.
Term
What should assessment for a client with DKA focus on?
Definition
Dehydration, hypotension or hypertension, metabolic acidosis, tachypnea, nausea, vomiting, abcominal pain and tenderness, LOC, cardiac changes, history.
Term
Priority nursing interventions for a client with DKA?
Definition
Monitor I&Os, replace fluids as ordered, monitor blood glucoses, monitor cardiac monitor, NPO, provide reassurance, bed rest.
Term
What should you inform the position of in a patient with DKA?
Definition
Blood sugar, LOC, cardiac changes, respiratory status, pain level, location, etc, blood pressure, temperature, pulse, nausea, vomiting
Term
What orders can you expect from the physician for a patient with DKA?
Definition
Labs, serum glucose, electrolytes, BUN, urinalysis, CBC, Ketones, serum osmolarity, ABG's, CT-head if mental status is altered, intubation if comatose, IV normal saline,
Term
What pertinent data may you need from labs, etc for a patient with DKA?
Definition
Serum ketosis, urine ketosis, glycosuria,hyponatremia, increased BUN, metabolic acidosis, increased anion gap, meds, insulin drip, potassium fluid replacement.
Term
What should the nurse focus the assessment on for a patient with acute MI?
Definition
History, Chest pain, dyspnea, diaphoresis, nausea, vomiting, heart and lung sounds.
Term
What are the priority nursing interventions for a patient with acute MI?
Definition
O2, monitor patient, morphine, Nitro, ECG, bed rest.
Term
What data should be communicated to the physician of a patient with acute MI?
Definition
Blood pressure, respiratory status, pulse, LOC, chest pain, and heart and lung sounds.
Term
What orders should be anticipated from the physician of a patient with acute MI?
Definition
O2, ECG, chest x-ray, ABGs, cardiac monitor, serum troponin, CBC, electrolytes, coagulations tudies, cardiac enzymes, cardiac cauterization, IB access, morphine, aspirin
Term
What pertinent data from labs may be useful in a patient with acute MI?
Definition
Increase in troponin and creatine kinase, LDH, ESR leukocyte levels depending on time since MI, MEDS: O2, aspirin, heparin, nitrates, sedatives, morphine, lopressor, stool softeners if ventricular arrhythmias.
Term
What areas of focus should be included for a patient with pulmonary emboli?
Definition
History, assess legs for swelling and pain, percuss lungs for flatness, ausculatate for friction rub, wheezing, auscultate heart for splitting of 2nd heart sound, headache, stabbing right sided chest pain and tachypnea.
Term
What are the priority nursing interventions for a client with a pulmonary emboli?
Definition
Monitor respiratory rate, ECG, response to fluids, monitor SaO2, bed rest, ambulate when patient is stable.
Term
What data should be reported to the physician of a patient with pulmonary emboli?
Definition
History of DVT, present heart and lung sounds, temperature, blood pressure, respiratory status
Term
What orders should be anticipated by the physician for a patient with pulmonary emboli?
Definition
IV access, IV heparin, warfarin, vasopressors if hypotensive, chest x-ray, VQ scan.
Term
What meds would you anticipate for a client with pulmonary emboli?
Definition
Heparin, warfarin, morphine
Term
What would the nurse focus the assessment on for aspiration pneumonia?
Definition
History, assess for airway obstruction, fever, foul smelling sputum and congestion, tachycardia, dyspnea, cough, cyanosis, swallowing difficulty, blood pressure, respiratory rate LOC, chest pain, heart and lung sounds.
Term
What are the priority nursing interventions for clients with aspiration pneumonia?
Definition
SaO2, O2, clear airway if indicated, monitor patient, elevate head of bed.
Term
What data must be communicated to a physician for a patient with aspiration pneumonia.
Definition
Blood pressure, respiratory status, pulse, LOC, heart and lung sounds, history, SaO2, smell and color of sputum.
Term
What orders can the nurse anticipate for a patient with aspiration Pneumonia?
Definition
Labs: WBC may be normal to elevated.
Meds: Ribavirin, albuterol nebulizer, antibiotics
Term
What are the priority nursing interventions for patients with sepsis?
Definition
History, SaO2, fever, SOB, tachycardia, LOC, tachypnea, hyperthermia, blood pressure, hypotension, perfusion, reduced urine output, abdominal pain, nausea, vomiting, diarrhea, flank pain, heart and lung sounds, rash, erythemia.
Term
What are the priority nursing interventions for a client with sepsis?
Definition
Minimize handling, decrease environmental stimuli, bed rest, position to prevent aspiration
Term
What information should be communicated to the physician of a patient with sepsis?
Definition
SaO2, LOC, temperature, heart rate, respiratory status, blood pressure, perfusion, urine output, pain scale, heart and lung sounds, nausea, vomiting, rash and erythema
Term
What pertinent data can the nurse caring for a patient with sepsis anticipate?
Definition
Labs: Positive blood cultures, positive cultures from other sites, elevated WBC, ventilator if respiratory failure
Meds: antibiotics, vasopressors if hypotensive
Term
What assessments should the nurse caring for a client with acute renal failure include?
Definition
Assess for anorexia, back pain, delirium, diarrhea, dyspnea, ecchymosis, edema, headache, hypertension, nausea, vomiting, rales, tachycardia, history of CHF.