Integrated Test 3

1 Pressure Ulcers „ Risk Factors

Integrated Test 3

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Immobility

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Inadequate nutrition

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Fecal & urinary incontinence

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Diminished sensation

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Excessive body heat

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Advanced age

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Chronic medical conditions

Decreased mental status

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6. Isolation Precautions Tier 1: Standard Precautions Tier 2: Transmission-based Precautions

Standard Precautions „ Designed for all clients in hospital „

Apply to… „ „ „ „

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Handwash

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Gloves, Goggles, Gown

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Handle soiled equipment & linen carefully

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Sharps precautions

except sweat

Designed to reduce risk of transmission of microorganisms from recognized & unrecognized sources

6 Standard Precautions

Blood All body fluids, secretions, excretions Non-intact (broken) skin Mucous membranes

7 „

Care of client with a sealed radiation source „

Private room with a private bath

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Place caution sign on client’s door

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Organize nursing tasks to minimize exposure

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Rotate nursing assignments to client

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A nurse should never care for more than one client with a radiation implant at one time

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7. „

Care of client with a sealed radiation source (cont.) „

Limit time to ½ hour per care provider per shift

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Wear a lead shield

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Do not allow a pregnant nurse to care for client

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Do not allow visitors who are pregnant or <16yo

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Limit visitors to ½ hour per day; visitors should be a least 6 feet from source

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Save bed linens & dressings until the source is removed

8 „

Skin Traction „

8 „

Pelvic halter/ traction „

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Pelvic girdle with extension straps attached to ropes and weights Used for low back pain to reduce muscle spasm and maintain alignment

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Usually intermittent traction

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Client on semi-Fowler’s position with knee bent

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Secure pelvic girdle around iliac crests

Play allows for therapeutic release of tension & stress; manipulation of syringe & other equipment allows control over threatening events

a.

Buck’s traction

b.

Russell traction

c.

Cervical traction

d.

Pelvic traction

11 b. Chronic alcoholism leads to enzyme induction, thus the need for increased dosage of analgesics c. Individualized pain thresholds d. Dependency behavior is reinforced more if there’s immediate, unpredictable gratification

12 „

Weights are attached to a moleskin or adhesive strip secured by elastic bandage (or foam rubber boot) used to cover the affected limb

16 S/Sx of intestinal obstruction in an infant 1. 2. 3. 4.

Absence of stools (esp. newborn) Weak, thready pulse Cyanosis Weak, grunting respirations from abdominal distention, causing diaphragm to compress lungs

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21. Concept of Death Infant/toddler

24 „

no concept of death

Preschool

death as temporary sleep

School age

death as irreversible

Stages of Dying „ „ „ „ „

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“No, not me…” “Why me?” “If only….” (Silence) “Yes, it’s me.”

Stages of Grieving Shock, numbness, disbelief „ Yearning & protest „ Identification stage „ Reorganization/ restitution „

Late school age death as final Adolescence

understands the concept of death

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(Source: Belizario & de Leon. Philippine Textbook of Medical Parasitology 2nd ed.)

Plasmodium

Incubation period

falciparum

8-15 days

vivax

12-20 days

ovale

11-16 days

malariae

18-40 days

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HTLV I causes adult T cell leukemia and tropical spastic disease HTLV II causes T-hairy cell leukemia

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45 „

SHOCK

Hypersensitivity to iodine dye following IVP „

hypovolemic

cardiogenic

obstructive

distributive

septic

neurogenic

anaphylactic

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Hives, skin rashes, nausea, swelling of parotid glands Anaphylactic (shock, dyspnea, decreased BP, convulsions)

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88 „

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Echolalia – stereotyped repetition of another person’s words or phrases Clang association – flow of thoughts are based on similar sounding words Neologism – making up new words Word salad – stringing together of words that seem to have no logical association

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