Term
| What assessments should be included for a patient with acute abdomen? |
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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. |
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Term
| Priority nursing interventions for a client with acute abdomen? |
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Definition
| Give pain meds, keep patient quiet, assess for trauma, treat if indicated. |
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Term
| Important data to report to physician when a client has acute abdomen? |
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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. |
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Term
| Orders anticipated from physician for client with acute abdomen? |
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Definition
| Pain meds, NPO, labs, IV fluids, NG suction, antiemetics, narcotics and/or analgesics, surgical consultation. |
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Term
| What information/data from labs will be important for persons with acute abdomen? |
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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. |
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Term
| What should the nursing assessment focus on for a client with CHF? |
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Definition
| Auscultating lung fields and hear sounds,blood pressure, temp, pulse, history, recent weight gain, activity limits, sleep Pattern, edema. |
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Term
| Priority nursing interventions for a client with CHF? |
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Definition
| O2, raise head of bed, IV access, cardiac monitor, pulse oximetry, antiembolism stockings |
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Term
| Data to report to physician of client with CHF? |
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Definition
| Blood pressure, respiratory status, pulse, recent weight gain, activity limits, sleep pattern, current medications, edema |
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Term
| Orders anticipated from the physician of a patient with CHF? |
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Definition
| O2, ECG, Chest X-ray, ABG's, cardiac monitor, diuretics, potassium, Labs, electrolytes, BUN and Creatinine, BNP, cardiac enzymes, echocardiograpy |
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Term
| Pertinent data/Labs for patient with CHF |
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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. |
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Term
| What should assessment for a client with DKA focus on? |
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Definition
| Dehydration, hypotension or hypertension, metabolic acidosis, tachypnea, nausea, vomiting, abcominal pain and tenderness, LOC, cardiac changes, history. |
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Term
| Priority nursing interventions for a client with DKA? |
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Definition
| Monitor I&Os, replace fluids as ordered, monitor blood glucoses, monitor cardiac monitor, NPO, provide reassurance, bed rest. |
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Term
| What should you inform the position of in a patient with DKA? |
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Definition
| Blood sugar, LOC, cardiac changes, respiratory status, pain level, location, etc, blood pressure, temperature, pulse, nausea, vomiting |
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Term
| What orders can you expect from the physician for a patient with DKA? |
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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, |
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Term
| What pertinent data may you need from labs, etc for a patient with DKA? |
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Definition
| Serum ketosis, urine ketosis, glycosuria,hyponatremia, increased BUN, metabolic acidosis, increased anion gap, meds, insulin drip, potassium fluid replacement. |
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Term
| What should the nurse focus the assessment on for a patient with acute MI? |
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Definition
| History, Chest pain, dyspnea, diaphoresis, nausea, vomiting, heart and lung sounds. |
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Term
| What are the priority nursing interventions for a patient with acute MI? |
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Definition
| O2, monitor patient, morphine, Nitro, ECG, bed rest. |
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Term
| What data should be communicated to the physician of a patient with acute MI? |
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Definition
| Blood pressure, respiratory status, pulse, LOC, chest pain, and heart and lung sounds. |
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Term
| What orders should be anticipated from the physician of a patient with acute MI? |
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Definition
| O2, ECG, chest x-ray, ABGs, cardiac monitor, serum troponin, CBC, electrolytes, coagulations tudies, cardiac enzymes, cardiac cauterization, IB access, morphine, aspirin |
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Term
| What pertinent data from labs may be useful in a patient with acute MI? |
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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. |
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Term
| What areas of focus should be included for a patient with pulmonary emboli? |
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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. |
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Term
| What are the priority nursing interventions for a client with a pulmonary emboli? |
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Definition
| Monitor respiratory rate, ECG, response to fluids, monitor SaO2, bed rest, ambulate when patient is stable. |
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Term
| What data should be reported to the physician of a patient with pulmonary emboli? |
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Definition
| History of DVT, present heart and lung sounds, temperature, blood pressure, respiratory status |
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Term
| What orders should be anticipated by the physician for a patient with pulmonary emboli? |
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Definition
| IV access, IV heparin, warfarin, vasopressors if hypotensive, chest x-ray, VQ scan. |
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Term
| What meds would you anticipate for a client with pulmonary emboli? |
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Definition
| Heparin, warfarin, morphine |
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Term
| What would the nurse focus the assessment on for aspiration pneumonia? |
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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. |
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Term
| What are the priority nursing interventions for clients with aspiration pneumonia? |
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Definition
| SaO2, O2, clear airway if indicated, monitor patient, elevate head of bed. |
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Term
| What data must be communicated to a physician for a patient with aspiration pneumonia. |
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Definition
| Blood pressure, respiratory status, pulse, LOC, heart and lung sounds, history, SaO2, smell and color of sputum. |
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Term
| What orders can the nurse anticipate for a patient with aspiration Pneumonia? |
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Definition
Labs: WBC may be normal to elevated.
Meds: Ribavirin, albuterol nebulizer, antibiotics |
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Term
| What are the priority nursing interventions for patients with sepsis? |
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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. |
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Term
| What are the priority nursing interventions for a client with sepsis? |
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Definition
| Minimize handling, decrease environmental stimuli, bed rest, position to prevent aspiration |
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Term
| What information should be communicated to the physician of a patient with sepsis? |
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Definition
| SaO2, LOC, temperature, heart rate, respiratory status, blood pressure, perfusion, urine output, pain scale, heart and lung sounds, nausea, vomiting, rash and erythema |
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Term
| What pertinent data can the nurse caring for a patient with sepsis anticipate? |
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Definition
Labs: Positive blood cultures, positive cultures from other sites, elevated WBC, ventilator if respiratory failure
Meds: antibiotics, vasopressors if hypotensive |
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Term
| What assessments should the nurse caring for a client with acute renal failure include? |
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Definition
| Assess for anorexia, back pain, delirium, diarrhea, dyspnea, ecchymosis, edema, headache, hypertension, nausea, vomiting, rales, tachycardia, history of CHF. |
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