Kaplan Diagnostic Review
Study online at https://quizlet.com/_5flgx3
Largest speculum that fits into ear canal
tilt head slightly away and toward oppo-
site shoulder to view eardrum
pull pinna up and back for adult or older
Inspect Tympanic Membrane
child
pull pinna downa nd back for infant or
child under 3 years
hold otoscope "upside down"
assesses bone conduction
vibreatrinng tuning for placed in middle
Weber test of foorehead
noirmal finding: hear sound equally in
both ears
compares bone conduiction with air con-
duction
determines if hearing loss is sne-
sorineural or conductive
vibrating tuning fork placed on mastoid
Rinne test
process- when client no longer hears
sound, fork is positioned in front of ear
canal- still should hear sound
air conduction is heard longer than bone
conduction by 2 to 1
Romberg test assesses balance
balloon encircles trachea tube to form
se34al between outer cannula and tra-
chea
used to permit mechanical ventilation
and protect lower airways
should be inflated: during and after eat-
Tracheostomy - Cuffed
ing, 1 hour after tube feeding, when client
unable toi handle oral secretions, during
mechanical venitlation, respiratory treat-
mentes
cuff pressure should not exceed 20 cm of
wttrer
Tracheostomy- Fenestrated
, Kaplan Diagnostic Review
Study online at https://quizlet.com/_5flgx3
tube with hole or window in bend of tube
permits air to flow around and through
tube to upper airway
*permits talking
*Tube can be removed if spontaneous
ventilation is adequate, pharyngeal and
laryngeal gag reflexes are active, client
cna swallow, move jaww, or clench teeth,
voluntary cough is effective in remov-
ing secretions without suctiuoning, care
should be performed every 8 hours and
PRN
*hyperoxygenate or deep breathe client
*insert suction catheter length of trach
tube without suction
*apply sduction for 10 seconds
*remove suction catheter
Nursing considerations for suctioning
*oxygenate client between suctioning
passes
*observer for signs of distress such as
decrease in heart rate
*document
*explain procedure, elevate head of bed,
suction inner cannula
*remove old dressings
*open sterile kit, put on sterile gloves
*remove inner cannula
*clean with hydrogen peroxide
*rinse with sterile water and dry
*reinsert into outer cannula
Cleaning a tracheostomy
*clean stoma with HP then sterile water,
dry
*chage ties as needed
*apply new sterile dressing without cut-
ting gauze pads (airway hazard)
*every 8 hours or as needed- if ties are
loose aor have secretions, excess secre-
tions, etc.
Cast Care
, Kaplan Diagnostic Review
Study online at https://quizlet.com/_5flgx3
Assess for signs and symptoms of com-
partment syndrome (increased pain, de-
creased pulses in extermity, paresthesia,
paralysis, and pale or discolored skin
fat embolism commonly seen with long
bone factures, deep vein thrombosis
(DVT), infection (pneumonia and urinary
tract infection), and breakdown of skin
Maintain tissue perfusion to affected
extremity along with management of
client's pain. Prevnt skin breakdown
around cast and prevent possible oinfec-
tions.
regular rhythm of the heart cycle stim-
ulated by the SA node (average rate of
60-100 beats/minute)
normal sinus rhythm (NSR)
*P Wave followed by a QRS complex
* PR Interval: 0.12-0.20 seconds
* QRS Complex: <0.12 seconds
*each small box is 0.04 seconds
*25 small squares = 1second
*tachy or bradycardia
normal sinus rhythm
rapid irregular atrial contractions leading
to ineffective atrial emptying of blood into
the ventricles
Atrial Fibrillation (A-Fib) blood pools in atria possibly forming clots
Causes: hypoxia, hypercarbia, cardiac
structural abnormalities
atrial fibrillation indications and treat-
ment
Study online at https://quizlet.com/_5flgx3
Largest speculum that fits into ear canal
tilt head slightly away and toward oppo-
site shoulder to view eardrum
pull pinna up and back for adult or older
Inspect Tympanic Membrane
child
pull pinna downa nd back for infant or
child under 3 years
hold otoscope "upside down"
assesses bone conduction
vibreatrinng tuning for placed in middle
Weber test of foorehead
noirmal finding: hear sound equally in
both ears
compares bone conduiction with air con-
duction
determines if hearing loss is sne-
sorineural or conductive
vibrating tuning fork placed on mastoid
Rinne test
process- when client no longer hears
sound, fork is positioned in front of ear
canal- still should hear sound
air conduction is heard longer than bone
conduction by 2 to 1
Romberg test assesses balance
balloon encircles trachea tube to form
se34al between outer cannula and tra-
chea
used to permit mechanical ventilation
and protect lower airways
should be inflated: during and after eat-
Tracheostomy - Cuffed
ing, 1 hour after tube feeding, when client
unable toi handle oral secretions, during
mechanical venitlation, respiratory treat-
mentes
cuff pressure should not exceed 20 cm of
wttrer
Tracheostomy- Fenestrated
, Kaplan Diagnostic Review
Study online at https://quizlet.com/_5flgx3
tube with hole or window in bend of tube
permits air to flow around and through
tube to upper airway
*permits talking
*Tube can be removed if spontaneous
ventilation is adequate, pharyngeal and
laryngeal gag reflexes are active, client
cna swallow, move jaww, or clench teeth,
voluntary cough is effective in remov-
ing secretions without suctiuoning, care
should be performed every 8 hours and
PRN
*hyperoxygenate or deep breathe client
*insert suction catheter length of trach
tube without suction
*apply sduction for 10 seconds
*remove suction catheter
Nursing considerations for suctioning
*oxygenate client between suctioning
passes
*observer for signs of distress such as
decrease in heart rate
*document
*explain procedure, elevate head of bed,
suction inner cannula
*remove old dressings
*open sterile kit, put on sterile gloves
*remove inner cannula
*clean with hydrogen peroxide
*rinse with sterile water and dry
*reinsert into outer cannula
Cleaning a tracheostomy
*clean stoma with HP then sterile water,
dry
*chage ties as needed
*apply new sterile dressing without cut-
ting gauze pads (airway hazard)
*every 8 hours or as needed- if ties are
loose aor have secretions, excess secre-
tions, etc.
Cast Care
, Kaplan Diagnostic Review
Study online at https://quizlet.com/_5flgx3
Assess for signs and symptoms of com-
partment syndrome (increased pain, de-
creased pulses in extermity, paresthesia,
paralysis, and pale or discolored skin
fat embolism commonly seen with long
bone factures, deep vein thrombosis
(DVT), infection (pneumonia and urinary
tract infection), and breakdown of skin
Maintain tissue perfusion to affected
extremity along with management of
client's pain. Prevnt skin breakdown
around cast and prevent possible oinfec-
tions.
regular rhythm of the heart cycle stim-
ulated by the SA node (average rate of
60-100 beats/minute)
normal sinus rhythm (NSR)
*P Wave followed by a QRS complex
* PR Interval: 0.12-0.20 seconds
* QRS Complex: <0.12 seconds
*each small box is 0.04 seconds
*25 small squares = 1second
*tachy or bradycardia
normal sinus rhythm
rapid irregular atrial contractions leading
to ineffective atrial emptying of blood into
the ventricles
Atrial Fibrillation (A-Fib) blood pools in atria possibly forming clots
Causes: hypoxia, hypercarbia, cardiac
structural abnormalities
atrial fibrillation indications and treat-
ment
