Test Hightlights part 2
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
|
|
||||
|---|---|---|---|---|---|
| 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
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
Jgar2007
Popular Anatomy sets