Milestone Exam 1b - hesi

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Medical-Surgical Nursing I Family history questioning‐ pre test‐ item not graded Ask about family health issues, family history of diseases, conditions to gather information on what pt ... may be already genetically disposed to. History ‐ mental illness pre test‐ item not graded Med admin client‐ ID NSG122.07.02.04: Identify the client by checking the name or arm brand.First identification is the patient's name and second one is date of birth. The patient's full name is used. The middle name or initial should be included to avoid confusion with other patients. In facilities using paper records, the patient's full name, secondary identification number, and the primary care provider's name are labeled on all sheets on the patient's chart, including the medical order sheet. Be extremely careful when administering medications when there is more than one patient on the unit with the same last name. Not only can the nurse give the wrong patient the wrong medication, but a provider may enter an order in the wrong patient's medical record. A secondary identifier is used when verifying the patient's identity. Rights of administration- patient, drug, time, dose, route, documentation, reason, assessment, response, education, right to refuse Occluded IV NSG122.13.02.04 : The main reason for IV occlusion is blood reflux. Or when blood backs up into the catheter. It forms a thrombus. IV flow may cease if the clot obstructs the needle. Symptoms are local acute tenderness, redness, edema of vein above the insertion site. Discontinue the infusion immediately, apply warm compression , and avoid further use of the vein. Restart the infusion in another vein. Vital signs NSG121.04.03.02 B/P, pulse, temperature, pulse oximeter (sp02), pain level Normal values of adult B/P: 120/80 HR: 60-100 SP02: 95-100% Temperature: 97 F - 99 F Normal values of child B/P: 95/57 HR: 70-115 SP02: 95-100% Hypertension, one of the most common health problems, is blood pressure that is above normal for a sustained period. A diagnosis of hypertension is made when the systolic pressure is 130 mm Hg or higher or the diastolic pressure is 80 mm Hg or higher, The prevalence of hypertension is greater in African American and Hispanic adults than in White adults Hypotension is below normal blood pressure. Hypotension is blood pressure that is lower than 90/60 mm Hg. Hypotension occurs primarily as a result of the inability of the body's control mechanisms to maintain or return blood pressure back to normal or the inability to do it quickly enough. Can result from a disease process which might result from vasodilation of the arterioles, failure of the heart to function as an effective pump, or loss of blood volume (such as with a hemorrhage). A consistently low blood pressure is normal in some adults, with no signs or symptoms. Hypotension is a medical concern if it causes signs or symptoms or is linked to a disease or health process. The nurse should immediately report assessments of hypotension and associated symptoms of dizziness, tachycardia, pallor, increased sweating, blurred vision, nausea, and confusion Orthostatic hypotension (postural hypotension) is a decrease in systolic blood pressure of ≥1520 mm Hg or a decrease in diastolic blood pressure of ≥10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position Pulse decreases as person ages due to decreased metabolic rate Digoxin toxicity S&S‐ NSG124.09.05.03 : S/S- altered heart rate or rhythm, visual or GI disturbances, notify healthcare provider if these occur Elevated levels- dysrhythmias, visual disturbances (blurred vision, yellow tinge to vision, appearance of halos around dark objects), nausea, vomiting and anorexia Narrow therapeutic range- 0.5 to 0.8 ng/mL KCl must be kept therapeutic at 3.5-5 mEq/L Digoxin [Lanoxin] belongs to a family of drugs known as cardiac glycosides. Digoxin is indicated for HF and for control of dysrhythmias. When used for HF, digoxin can reduce symptoms, increase exercise tolerance, and decrease hospitalizations. However, the drug does not prolong life. Furthermore, when used by women, it may actually shorten life . Because benefits are limited to symptomatic relief and because the risk of toxicity is substantial, digoxin is now considered a second-line drug for treating HF. MS Contin Chronic‐ pain NSG124.02.03.01 In patients with chronic and increasing pain, such as occurs in some cases of cancer, pain management requires a judicious choice of drugs used in a stepwise fashion to maximize the reduction of pain. Usually tolerance to narcotic drugs develops in time, requiring an increase in dosage to be effective. Eventually a new drug may be required Non pharmaceutical interventions for chronic pain may include stress reduction and relaxation therapy, distraction, applications of heat and cold, massage, physiotherapy modalities, exercise, therapeutic touch, hypnosis imaging, and acupuncture .These measures may act in the spinal cord at the “gate” or may modify pain perception and response in the brain. Many of these strategies are believed to increase the levels of circulating endorphins that elevate the pain tolerance. Also, maintenance of basic nutrition and activity levels as well as adequate rest assists people in coping with pain. Specialized clinics deal with certain types of pain such as chronic back pain or temporal mandibular joint pain MS long acting- morphine sulfate controlled release (MS contin)- extended release Mimics endogenous opioid peptides at mu receptors of CNS Respiratory depression, constipation, orthostatic hypotension, urine retention, sedation, tolerance and dependence, pinpoint pupils Taper [Show More]

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