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CH 30 MOD IV-9

Test Hightlights part 2

QuestionAnswer
True or false: Nose bleeds are common in elderly true, especially those on anti-coagulants
Immediate nursing interventions for epistaxis lean forward, apply pressure at least 5-10 mins (NCLEX says 10..book 3-5); apply cold pack/compress (NCLEX says also put cotton into nostrils)
Once epistaxis stops, what should the patient avoid doing? blowing nose for several hours
If bleeding continues, what does the physician do? name two things use topical constrictors or electric cautery.
Name a topical vasoconstritor silver nitrate
If cautery is used, the pt is given what before the procedure? local anesthetic
if bleeding is not controlled, what is the next step? Direct pressure to the nasal cavity
Name 2 methods used to apply direct pressure to the nasal cavity. nasal balloon catheter and nasal packing
Nasal ballon cath: Is passed into ____. What applies the pressure? What anchors the catheter nasal cavity; large balloon inflated against blood vessels; smaller balloons anchor
When an emergency epistaxis occurs (severe bleeding) what priority data must be taken? evidence of uncontrolled bleeding and excessive blood loss
during emergency nose bleeds, the nurse should inspect what immediate areas. What subtle behavior is indicative of more blood loss? inspect nose, back of throat; swallowing frequently
during emergency nose bleeds, monitor pt's lvl of ____, VS to detect what condition? consciousness; hypovolemia
signs and symptoms of hypovolemia: name three restlessness, tachycardia, tachypnea, hypotension
During severe nose bleeds, nasal packing was performed. When assessing pain, what areas of the body should you specifically address for pain? nose, pharynx, ears
Interventions for epistaxis: Decreased Cardiac output - name the cause. name the intervention. hypovolemia secondary to hemorrhage;monitor vital signs for hypovolemia, hemorrhage
Interventions for epistaxis:anxiety-name the cause. threat of bleeding; unpleasant procedures
Which nasal packing causes more anxiety?what intervention is needed? Posterior; mild sedative ordered
Interventions for epistaxis: risk for injury and risk for infection-name the cause injury due to packing and possible airway obstruction; infection due to presence of packing
when a patient has a nasal catheter, why must you check the respiratory status frequently? Balloon can depress soft palate and impair breathing
when catheter is used to stop nosebleeds, placement of catheter should be checked how many hours? At least every four hours
when do you deflate anchor cuffs for a nasal balloon? 10 minutes every 24 hours as ordered; be sure to deflate smaller cuff
why is frequent mouth care needed for nasal packing patients? patients must breathe through the mouth, causes dryness and infection
if packing slips out of place and blocked airway, what should be done? Strings holding anterior pad are cut; third string tape to the cheek is used to pull packing out
when packing is being removed, put patient in what position? provide what equipment to receive packing?___the patient to protect clothing. What hygiene care is given? Sitting position; emesis basin; draped; mouth care
tonsillitis is inflammation of the tonsils and what other type of tissue in the throat? lymphatic
Mrs. M. said this that tonsillitis is usually accompanied by what other inflammated condition? adenoids
tonsillitis: Which is the most common cause, bacteria or virus? bacteria; few times it is virus
tonsillitis is caused by what organism's? How is it spread? streptococci, staphylococci, H. Influenza," pneumococi: by food or airborne routes
what symptom is found with patients with chronic tonsillitis? Offensive breath order
patient w/ tonsillitis complains of pain in the ears. What does this indicate? eustachian tubes are blocked ritual and tissues
Tonsillitis signs and symptoms: Tonsils appear large or small and what color? large; red
tonsillitis signs & symptom: What type of drainage and patches will you see on the tonsils? Purulent; yellow or whitish patches
What test are ordered for tonsillitis? Think what tests are done to check for infection, help find the right antibiotic, assess respiratory complications. CBC, throat culture, test for mononucleosis, chest x-ray
Elevated WBC suggests what type of infection? bacterial
Medical treament for tonsillitis: how many days of antibiotic therapy? What is prescribed for pain and sore throats? 7 to 10 days; Tylenol; anesthetic lozenges
tonsillitis medical treatment: what 2 things may be ordered to decrease swelling and remove drainage? Warm saline gargles or irrigation.
If tonsillectomy is indicated, it is usually delayed until the patient's___returns to normal. Temperature
why are adenoids usually removed during a tonsillectomy? adenoids are almost always infected and the councils
Care for Tonsillectomy (handout): what two positions should the patient be in? Name if position is done before or after they are awake. sidelying = before fully awake; mid-Fowler's = awake
after undergoing a tonsillectomy, the patient is frequently swallowing. What is the first nursing intervention that should be done? And what disrepair swallowing indicate? Inspect throat; hemorrhage
other symptoms of hemorrhage after tonsillectomy are___vomitus, rapid___, and restleness. bright red; pulse
tonsillectomy comfort measures: give how many percent of cool mist via collar? what can be applied to the neck? Do you give aspirin? 30%; ice collar; no give Tylenol instead
during the initial period of recovery from tonsillectomy, what type of food and fluids are appropriate? Ice cold fluids, bland foods: none sutures and noncarbonated fluids
after tonsillectomy, avoid what to colors when giving liquids? Why? Red purple; colors appear like blood
after tonsillectomy why is milk not given? Increases mucous and cause the patient to clear throat
after tonsillectomy, patients should avoid coughing, sneezing,nose blowing, and vigorous exercise for how many weeks 1 to 2 weeks
patient is recovering from tonsillectomy. She wants to clear her throat despite being told not to. What can a nurse teach her as to why she should avoid clearing her throat after surgery? Clearing the throat may initiate reading
Care for Tonsillectomy (handout): drink how many fluids a day until what disapprears? 2 to 3 L a day until mouth odor disappears
is toast appropriate after the initial period of tonsillectomy care? Why? no; patient must avoid hard scratchy foods
Care for Tonsillectomy (handout): after a tonsillectomy the patient reports more throat discomfort between the fourth and eighth day. What is the explanation for this? Is an expected outcome because membranes are separating at this time/scab (she said something about a scab lol)
Care for Tonsillectomy (handout): patient is recovering from a tonsillectomy and is worried when he saw his stool was black. What what explanation can you give to the patient? Black or dark stool is expected for a few days because of swallowed blood.
Care for Tonsillectomy (handout): patient asks when they can resume normal activity after a tonsillectomy. What is the appropriate answer? You may resume activity that is not stressful or straining
after a tonsillectomy the patient wanted to take a sip of water through a straw. What can you tell the patient to make him understand that sipping a glass is better than using a straw. straws are sharp objects and should be avoided along w/ forks etc.
after undergoing a console that to me, the patient is a risk for ineffective airway. What equipment should be in the room? suction equipment
What did Mrs. M say is a main symptom/sign of Laryngitis? hoasrness/aphonia (losing voice)
what may be a permanent effect after long periods of chronic laryngitis? Change and the voice
What did Mrs. M say in regards to laryngitis lasting as long as two weeks? Cancer is suspected
what is the best care for patients have acute laryngitis? resting of your voice
what is in a portrait aspect of treatment for chronic laryngitis? Removal of the irritant
patient is hospitalized for laryngitis. What must be put over the bed? a sign advising staff and visitors that patient should not speak
a nurse complains that Mr.L is not answering back when she talks w/ the intercom. Because she just started, she was unaware that the pt has laryngitis. What can you do to avoid this in the future? put a notice at the intercom that the pt cannot talk
why is it important for laryngitis pts to know that they should keep the temperature constant? setting changes in temperature can to aggravate learned earnings
cancer of the larynx is most common in men ages 50 to 65 years. What is thought to be the related factors causing this condition to be higher in men? Alcohol, combined with tobacco or smoking
with chronic illness of the throat can cause cancer of the larynx? chronic laryngitis
most malignancies of the larynx are what type of cells? squamous cell carcinoma
what did Mrs. M. say are the large factors causing cancer the larynx? EBV (virus), smoking combined w/ alcohol
the cure rate for cancer in the larynx is highest when it is confined in what area of the respiratory tract? Confined to the vocal cords
cancer of the larynx tend to spread fairly early. What is the most common site of metathesis? lungs
what did Mrs. M. say is the best intervention for cancer of the larynx? Why? education, patient understanding of early signs and symptoms, stop smoking and drinking; cancer is hard to treat/better to prevent
early symptoms of cancer of the letter include persistent___, sore___, and___pain. hoarseness, throat, ear
a patient comes to you and says that he feels there's a lump in his throat. This may be a sign of what condition? Cancer of the larynx
later signs and symptoms of laryngeal cancer are blood in ____, difficulty___, or difficulty___. Sputum, swallowing, breathing
What is the medical term for blood in sputum? hemoptysis
what did Mrs. M. say are very late signs of laryngeal cancer? Pain and anorexia leading to weight loss
Name two categories of laryngectomy total and partial
name two types of partial laryngectomy (handout) Hemilaryngectomy; supraglottic partial laryngectomy
hemilaryngectomy: what is the voice result (handout) hoarse voice
Hemilaryngectomy: what is the intervention regarding swallowing ability after the procedure? swallowing therapy (speech therapist) to learn how to swallow w/o aspiration
surpraglottic partial laryngectomy: voice result normal voice
surpraglottic partial laryngectomy: swallowing ability same as hemilaryngectomy
Total laryngectomy voice result and swallowing ability no voice; no swallowing problem
Total Laryngecomty teaching: Before teaching a pt. what should you do? Find out which specific procedure is done for individualized care
Total Laryngecomty teaching: A pt. can lose the ability to speak. You should provide ____ about alternative means of communication, refer to ___ therapist, provide ____ support, ___ pts feelings of anger and despair. information; speech; emotional; accept
Total Laryngecomty teaching: some patients benefit from meeting a volunteer from an organization for people who have had laryngectomies. What should you do before inviting a volunteer to meet the patient? Consult the patient
Total Laryngecomty teaching: patients undergoing laryngectomies go to the ICU for several days. ____ the pt that this is routine. inform
Total Laryngecomty teaching: inform the patient to expect 4 other things. IV lines, feeding tubes, wound drains, ventilator
Total Laryngecomty teaching: A pt. who had a laryngectomy is still worried that he is in ICU. What can you tell him is the purpose of being in the ICU to help him understand. routine procedure; allows close monitoring and maintenance of airway
a total laryngectomty involves removal of what 4 things? what is closed? A ____ is created by bringing the trachea to the opening of the neck entire larynx, vocal cords, epiglottis, supporting tissues; opening of pharnyx to trachea is closed; tracheostomy
Before undergoing a laryngectomy a pt. asks why a radical dissection of the neck is going to be done as well. What information can you tell him? a radical neck dissection is often done because of the high risk of metastatsis to the neck
Name 3 complications of total laryngectomy w/ a radical neck dissection salivary fitula, carotid artery blowout, and tracheal stenosis
a drainage pathway that forms when saliva leaks through a defect in the suture line salivary fistula
when a salivary fistula is formed, the patient must be fed through____ NG tube
what type of patient is at highest risk for carotid artery blowout? had radiation therapy before surgery and had a salivary fistula after surgery
A narrowing of the trachea that develops weeks or months after surgery is called tracheal stenosis
Total Laryngectomy assessment: Assessment focuses on what three things Airway (oxygenation), circulation, and comfort
Total Laryngectomy assessment: Document pt's lvl of ____, ask about ___, observe for signs of ___. consciousness; pain; discomfort
Total Laryngectomy assessment: what two things are used to assess oxygenation in circulation continuous EKG, pulse ox
Total Laryngectomy assessment: Is pt put on I&O yes
Total Laryngectomy Ineffective airway: wife of a pt. who just had a total laryngectomy asks how long will he be on a ventilator. The correct answer is: ventilators are usually dced w/in a day after surgery
Total Laryngectomy Ineffective airway: What data indicates need for suctioning increase pulse, restleness, visible mucus
Total Laryngectomy Ineffective airway: What position helps lungs expand? What prevents pooling of secretions in the lungs semi-Fowler's or high-Fowler's; TC&DB
Total Laryngectomy Ineffective airway: What two things help w/ hydration and nutrition? IV fluids and entera feedings
Total Laryngectomy Anxiety: What did Mrs. M say is important to do? Why? Talk to the pt because people assume one who cannot speak cannot hear
Total Laryngectomy Decreased Cardiac output: Pt. is at risk for? What can be done to detect this? hemorrhage; vital signs frequently and inspecting secretions for excessive bleeding
Total Laryngectomy Decreased Cardiac output: over the first few postoperative days, the color of drainage should change from what 3 color/characteristics. From bright red to pink to clear or straw colored. amount should decrease steadily
Total Laryngectomy risk for injury: Pts are often ___ of moving head. Help by placing a ____ behind pt's head when getting OOB fearful; hand
Total Laryngectomy risk for injury: tracheostomy is open to the environment, so you must teach the pt. to avoid ___places and ___ tracheostomy when shaving or having haircuts dusty places, cover LOOSELY
Total Laryngectomy risk for injury: What can you teach regarding baths? Do not submerge neck or allow water into trach because it goes into the airway.
Mrs. M primary concern/care for Laryngectomy pt. airway
Mrs. M: what do you do before teaching a pt. assess tools needed to communicate
Created by: Jgar2007