{"id":114389,"date":"2023-08-22T07:08:57","date_gmt":"2023-08-22T07:08:57","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=114389"},"modified":"2023-08-22T07:09:01","modified_gmt":"2023-08-22T07:09:01","slug":"mark-klimek-lectures-1-to-12-the-guide-latest-100-bestgraded-a","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2023\/08\/22\/mark-klimek-lectures-1-to-12-the-guide-latest-100-bestgraded-a\/","title":{"rendered":"Mark Klimek Lectures 1 to 12: The Guide.Latest (100% Best,Graded A)"},"content":{"rendered":"\n

GOLD 1 Nothing is impossible- the word itself says \u201cI\u2019m Possible\u201d NCLEX TIPS 1) Do not read into the question\ue601- never assume anything that has not been specifically mentioned (in the question) and do not add extra meaning or history to the question\u2014do not make up a story to validate choosing an answer 2) NCLEX land is set at \ue601Utopia General Hospital\ue601- you have all the time, all the resources, and all the staff you need! 3) Least invasive to most invasive \u2013 least restrictive to most restrictive (restraints are rarely a good choice) 4) Avoid using absolutes\ue601- always, never, must, etc. 5) Assess the client first before implementing a treatment or action\u2014if there\u2019s a choice that pertains to assessment of the patient\u2014it is \ue601usually\ue601 the answer \u2013 \ue601assess unless in distress 6) Priority goes to assessments and answers that deal with the patient (\ue601patient-focused\ue601) directly and not with machines\/monitors\/equipment (unless the question is specifically asking about them) a. Ex: Auscultate fetal heart rate before checking the monitor 7) If it is the \ue601FIRST\ue601 time doing something for or with the patient (such as vital signs upon admission to the floor\/unit, or when a transfer is involved), the \ue601NURSE\ue601 must complete the assessment- including vital signs 8) If patient is an adult, answers with family options can be ruled out (unless patient is not competent to make own decisions) 9) In emergency situations (mass casualty), patients with greater chance to live are treated first 10) If you are asked about the \ue601FIRST\ue601 action you would take in a prioritization\/discrimination question think: \ue601\u201cIf I can only do one action, and then I must go home, what will the outcome be?\u201d 11) Therapeutic communication- reflect feelings and provide correct information 12) Do not ask \u201cwhy\u201d\ue601 questions (or yes\/no) and do not say \u201cI understand\u201d 13) An answer that delays care or treatment is usually wrong (Ex: reassess in 15 minutes, monitor the patient for a continuation of symptoms) 14) When determining interventions to enhance a client\u2019s wellness, consider options that promote healthy nutrition, regular exercise, proper weight maintenance, proper rest, and avoidance of harmful chemicals (nicotine) and risk-taking behaviors (not wearing a seat belt) 15) If two of the answer choices are the exact opposite, one is probably the answer (ie. bradycardia, tachycardia)
16) If two or three answers are similar, none are correct (*be careful\u2014sometimes answers may seem similar but in fact are saying something different) 17) Always look for the \ue601UMBRELLA\ue601 option\u2014one that is a broad universal statement and usually contains the concepts of the other options with it\u2014often the correct answer 18) If you have never heard of an answer\u2014do not eliminate it\u2014work around it\u2026if you can safely eliminate all other answers, that is your answer\u2014if you are down to two answers and you know one answer is right, \ue601go with what you know 19) Prioritize \ue601actual\ue601 problems over \ue601potential\ue601 problems 20) DO NOT\ue601 leave the patient \u2013 think safety 21) DO NOT \ue601 \u201cdo nothing\u201d- you always have to do something 22) If the question is about endorsement\u2014\ue601always report anything new or different to the next shift 23) Only select \u201c\ue601document\ue601\u201d if the assessment is normal 24) Put patients with the same or similar diagnoses in the same room-clean vs. dirty patients 25) Never increase a patient\u2019s fluids to \u201ccatch up\u201d 26) Answer SATA questions as true or false for each answer option 27) Rephrase the question in your own words\u2014this ensures you understand what the question is asking\u2014if you cannot rephrase the question, you do not know what the topic is 28) If you cannot determine the topic of the question, read all answer choices to help you understand the problem (look for patterns) 29) Try not to determine the answer before reading the answer choices\u2014NCLEX uses traps and answers that scream \u201cpick me\u201d but are wrong 30) More often than not, \ue601pain\ue601 will not be your answer — pain is considered psychosocial\u2014exception to this rule are signs and symptoms of compartment syndrome 31) Try to focus on the \ue601here \ue601and \ue601now\ue601 as much as possible 32) With positioning questions- you are trying to prevent or promote something\u2014evaluate the outcome of each option 33) When the question asks what is \ue601ESSENTIAL\ue601\u2014think \ue601SAFETY 34) If you do not know what a word means, try to break it down using medical terminology a. Ex: Rhabdomyosarcoma \u2013 muscle (myo), tumor (sarcoma) \ue601\u2192 tumor of the muscle tissue b. Same idea applies to medications- use suffixes and prefixes to recognize classifications 35) Make an educated guess\u2014if you can\u2019t make the best answer for a question after carefully reading it, choose the answer with the most information 36) When in doubt, \ue601SAFETY 2
\u201cKeep them breathing, keep them safe\u201d Prioritization Techniques \u25cfPrioritize \ue601systemic\ue601 vs. \ue601local\ue601 (life before limb) \u25cfPrioritize \ue601acute\ue601 before \ue601chronic \u25cfPrioritize \ue601actual\ue601 before \ue601potential\ue601 future problems \u25cfPrioritize according to Maslow\u2019s- \ue601physiological\ue601 needs before \ue601psychosocial (acute safety can take priority- ATI) \u25cfRecognize and respond to trends vs. transient findings (recognizing a gradual deterioration) \u25cfRecognize signs of emergencies and complications vs. \u201cexpected client findings\u201d \u25cfApply clinical knowledge to procedural standards to determine the priority action- recognizing that the timing of administration of antidiabetic and antimicrobial medications is more important than administration of some other medications How to tackle- WHO DO YOU SEE FIRST- questions: \u25cfWho is your most stable patient? ELIMINATE ANSWER \u25cfWho is your most stable patient (of the 3 remaining)? ELIMINATE ANSWER \u25cfWho is your most unstable patient (of the 2 remaining)? Airway? Breathing? Circulation? SELECT ANSWER Transmission-Based Precautions AIRBORNE MTV M- measles T- TB V- Varicella (chicken pox), varicella zoster (disseminated shingles) *\ue601Private room\ue601- negative pressure with 6-12 air exchanges\/hr, mask, N95 Chicken pox can be rapidly transmitted to other clients\u2014should be isolated quickly and placed in negative pressure room 3
CONTACT MRS. WEE M- multidrug resistant organism (MRSA) R- respiratory infection S- skin infections (localized herpes zoster) W- wound infections E- enteric infection \ue601\u2192\ue601 clostridium difficile E- eye infection \ue601\u2192\ue601 conjunctivitis (Also, Hep A) *A nurse with localized herpes zoster \ue601CAN\ue601 care for patients as long as the patients are \ue601NOT\ue601 immunocompromised and the lesions are covered! 4
DROPLET SPIDERMAN S- sepsis S- scarlet fever S- streptococcal pharyngitis P- parvovirus B19 P- pneumonia (pneumonic plague) P- pertussis I- influenza D- diphtheria (pharyngeal) E- epiglottitis R- rubella R- respiratory syncytial virus (RSV) M- mumps M- meningococcal (infectious meningitis) M- mycoplasma or meningeal pneumonia An- adenovirus *Private room or cohort, mask (door open, 3ft distance) Current CDC evidence-based guidelines indicate that droplet precautions for clients with meningococcal meningitis can be discontinued when the client has received antibiotic therapy for 24 hours! 5
Current CDC guidelines indicate that rapid implementation of standard, contact, and airborne precautions are needed for any client suspected of having SARS\u2014in order to protect other clients and healthcare workers Skin Infections VCHIPS V- varicella zoster C- cutaneous diphtheria H- herpes simplex I- impetigo P- pediculosis S- scabies Impetigo\ue601- caused by Staph and Strep, untreated can cause acute glomerulonephritis (periorbital edema\u2014indicates poststreptococcal glomerulonephritis) Order of PPE Application \u25cfGown \u25cfMask \u25cfGoggles\/face shield \u25cfGloves Order of PPE Removal \u25cfGloves \u25cfGoggles\/face shield \u25cfGown \u25cfMask Because the hands of health care workers are the most common means of transmission of infection from one client to another, \ue601the most effective\ue601 method of \ue601preventing the spread of infection\ue601 is to make supplies for \ue601hand hygiene readily available for staff to use. Because the respiratory manifestations associated with the \ue601avian influenza \ue601are potentially life threatening, the nurse\u2019s initial action should be to start oxygen therapy! \u25cfS\/S: SOB, diarrhea, abdominal pain, epistaxis \u25cfInstitute airborne and contact precautions According to the CDC, catheter associated UTIs are the most common health care-acquired infection in the US\u2014primary CDC recommendations include avoiding the use of indwelling catheters and the removal of catheters as soon as possible! 6
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Individuals who have contact with infants should be immunized against pertussis in order to avoid infection and to prevent transmission to the infant! The \ue601ventilator bundle\ue601 developed by the Institute for Healthcare Improvement includes recommendations for \ue601continuous elevation of the head of the bed (30 to 45 degrees)\ue601, daily \ue601assessment for extubation\ue601 readiness, and \ue601daily oral care\ue601 with \ue601chlorhexidine\ue601 solution. Chlorhexidine is more effective than the other options at reducing the risk for central-line associated bloodstream infections (CLABSIs) No pee, no K (do not give potassium without adequate urine output) El\ue601V\ue601ate \ue601V\ue601eins, d\ue601A\ue601ngle \ue601A\ue601rteries for better perfusion IV push should be given over 2 minutes<\/em> CONVERSIONS 1 oz 30 mL 1 cup 8 oz 1 kg 2.2 lbs 1 lb 16 oz 1 gr (grain) 60 mg *Convert C to F: C + 40 multiply by 9\/5 and subtract 40 *Convert F to C: F + 40 multiply by 5\/9 and subtract 40 Positioning \ue601_ Asthma \u25cfOrthopneic position where patient is sitting up and bent forward with arms support on a table or chair arms Air Embolism-\ue601 (S\/S: chest pain, difficulty breathing, tachycardia, pale\/cyanotic, sense of impending doom) \u25cfTurn patient to \ue601LEFT\ue601 side and \ue601LOWER \ue601 head of bed Pulmonary Embolism- \ue601(S\/S: chest pain, difficulty breathing, tachycardia, pale\/cyanotic, sense of impending doom) \u25cfElevate HOB Women in Labor with non-reassuring FHR-\ue601 (S\/S: late decels, decreased variability, fetal bradycardia, etc.) \u25cfTurn mother on \ue601LEFT \ue601side (and give O2, stop Pitocin, increase IV fluids) 7
Tube Feeding w\/ Decreased LOC \u25cfHead of bead \ue601ELEVATED\ue601 (to prevent aspiration) and position patient on RIGHT \ue601side (promotes gastric emptying) Postural Drainage \u25cfLung segment to be drained should be in the uppermost position to allow gravity to work During Epidural\/Lumbar Puncture \u25cfSide-lying \ue601(\u201cC\u201d curved spine)- lateral recumbent\/fetal position Post\ue601 Lumbar Puncture (LP) \u2013\ue601 (and also oil-based myelogram) \u25cfPatient lies in \ue601flat supine\ue601 (to prevent CSF leak and headache) for 2-3 hours \u25cfSterile dressing applied \u25cfFrequent neuro checks Thoracentesis \u25cfPosition patient with arms on pillow over bed table or lying on side \u25cfNO MORE THAN 1000cc at one time \u25cfPost- check blood pressure, auscultate bilateral breath sounds, check for leakage, sterile dressing Patient with Heat Stroke \u25cfLie \ue601flat \ue601with \ue601legs elevated Hemorrhagic Stroke \u25cfHOB elevated 30 degrees to reduce ICP and facilitate venous drainage Ischemic Stroke \u25cfHOB flat (supine) During Continuous Bladder Irrigation (CBI)\ue601- catheter is taped to thigh \u25cfLeg should remain \ue601straight\ue601 to prevent pulling on catheter Post\ue601 Myringotomy\ue601- surgical incision in eardrum to relieve pressure and drain fluid (tubes) \u25cfPosition on side of \ue601affected ear\ue601 after surgery (allows drainage of secretions) Post\ue601 Cataract Surgery \u25cfPatient will sleep on \ue601unaffected side\ue601 with night shield for 1-4 weeks (adequate vision may not return for 24 hours) 8
\u25cfPain that is not relieved by prescription pain medication may signal hemorrhage, infection or increased ocular pressure Infant with Spina Bifida \u25cfPosition \ue601prone \ue601 (on abdomen) to prevent sac from rupturing Buck\u2019s Traction \ue601(skin traction) \u25cfElevate \ue601foot of bed for counter-traction Post\ue601 Total Hip Replacement \u25cfDON\u2019T \ue601sleep on \ue601affected\/operative \ue601side \u25cfDON\u2019T \ue601flex hip more than \ue60145-60 degrees \u25cfDON\u2019T \ue601elevate HOB more than 45 degrees \u25cfMaintain \ue601hip \ue601abduction \ue601 by separating thighs with a pillow \u25cfNO adduction \ue601or\ue601 internal rotation Prolapsed Cord \u25cfKnee-chest \ue601or \ue601Trendelenburg \ue601(goal is to prevent pressure on cord) Vena Cava Syndrome (pregnant women) \u25cfPosition woman on her left side (relieves pressure off vena cava from fetus)\u2014knees flexed (blood return) oMother may present with hypotension Infant with Cleft Lip \u25cfPosition on \ue601back\ue601 or in an \ue601infant seat\ue601 to prevent trauma to suture line \u25cfWhile feeding, hold in \ue601upright\ue601 position Infant with Cleft Palate \u25cfProne 9
Pancreatitis \u25cfPatients should lie in fetal position \u25cfMaintain NPO status (to rest the gut)\u2014patient may also have PICC line inserted for TPN\/lipids To Prevent Dumping Syndrome \u25cfEat in \ue601reclining \ue601position \u25cfLie down after meals for 20-30min \u25cfRestrict fluids during meals, low carbohydrate, low fiber, high fat and protein \u25cf*GOAL: decrease gastric motility Enema Administration \u25cfPosition patient in left-side lying (Sim\u2019s position) with knees flexed Above Knee Amputation \u25cfElevate for first 24 hours on pillow \u25cfPosition \ue601prone \ue601daily to provide for hip extension \u25cfDo not keep leg elevated beyond 24 hours\u2014causes hip flexion which can lead to contractures \u25cfRewrap 3x day (elastic bandages) Below Knee Amputation \u25cfFoot of bed elevated for first 24 hours \u25cfPosition \ue601prone \ue601daily to provide for hip extension \u25cfDo not keep leg elevated beyond 24 hours\u2014causes hip flexion which can lead to contractures *\ue601Activity helps reduce the frequency and degree of phantom pain Detached Retina \u25cfArea of detachment should be in the \ue601dependent \ue601position (head in downward direction, lying on unaffected side) After Supratentorial Surgery \ue601(suture behind hairline) \u25cfElevate HOB 30-45 degrees After Intratentorial Surgery\ue601 (incision at nape of neck) \u25cfPosition patient \ue601flat\ue601 and \ue601lateral\ue601 on either side During Internal Radiation 10
\u25cfOn \ue601bed rest\ue601 while implant is in place *(Common NCLEX TOPIC) Autonomic Dysreflexia\/Hyperreflexia \ue601(S\/S: pounding H\/A, profuse sweating, nasal congestion, goose flesh, bradycardia, HTN) \u25cfPlace patient in \ue601sitting position- HIGH FOWLER\u2019S (elevate HOB- FIRST ACTION)\u2014\ue601decreases venous return \u25cfCheck for kinks in foley catheter tubing Spinal Cord Injury \u25cfImmobilize on spine board \u25cfHead in neutral position \u25cfImmobilize with padded C-collar \u25cfMaintain traction and alignment of head manually \u25cfLog roll client and do not allow to twist or bend Shock \u25cfBed rest with extremities elevated 20 degrees, knees straight, head slightly elevated (modified Trendelenburg) Head Injury \u25cfElevate HOB 30 degrees to decrease ICP Peritoneal Dialysis when Outflow is Inadequate \u25cfTurn patient from side to side \ue601BEFORE\ue601 checking for kinks in tubing (according to Kaplan) Nasogastric Tube \u25cfElevate HOB 30 degrees to prevent aspiration \u25cfMaintain elevation for continuous feeding or 1 hour after intermittent feedings Cardiac Catheterization \u25cfKeep site extended (usually involves femoral artery) Post-thyroidectomy \u25cfSemi-Fowler\u2019s position, prevent neck flexion\/hyperextension (support head, neck and shoulders) \u25cfTrach at bedside \u25cfMonitor respiratory status every hour Post-Bronchoscopy 11
\u25cfSemi Fowler\u2019s \u25cfCheck V\/S q15 min until stable \u25cfAssess for respiratory difficulty (stridor, dyspnea resulting from laryngeal edema or laryngospasm) Epistaxis \u25cfUpright and lean forward (prevent blood from entering the stomach and to avoid aspiration) Pelvic Exam \u25cfLithotomy position Rectal Exam \u25cfKnee-chest position, Sim\u2019s, or dorsal recumbent Post\ue601-Liver Biopsy \u25cfPlace patient on right side over a pillow to prevent bleeding (liver is very vascular) \u25cfNo heavy lifting for 1 week\u2019 Paracentesis \u25cfSemi-Fowler\u2019s or upright on edge of bed \u25cfVoid prior- prevent puncture of bladder \u25cfPost-\ue601 V\/S (BP), report elevated temp, observe for signs of hypovolemia Pneumonia \u25cfLay on affected side to splint and reduce pain \u25cfTrying to reduce congestion: the sick lung goes up Post-Appendectomy \u25cfPosition on right side with legs flexed GERD \u25cfLay on left side with HOB elevated 30 degrees (increases sphincter pressure) Postural Drainage \u25cfHead in dependent position Post-Radical Mastectomy \u25cfPosition in Semi-Fowler\u2019s with arm (affected side) elevated \u2013 if left mastectomy, elevate left arm, if right mastectomy, elevate right arm! 12
oThis facilitates removal of fluid through gravity and enhances circulation Think positively and you can achieve great things! Prior to \ue601liver biopsy\ue601 it is important to check lab results for PT time (vascular organ) Liver biopsy\ue601- (prior) administer Vitamin K, NPO at midnight, teach patient that he will be asked to hold breath for 5-10 sec, supine position with upper arms elevated Morphine\ue601 is \ue601contraindicated\ue601 in \ue601pancreatitis\u2014\ue601it causes spasm of the Sphincter of Oddi\u2014\ue601Demerol \ue601is the pain medication of choice! *After pain relief, it is important to \ue601cough and deep breathe\ue601 in pancreatitis\u2014because fluid is pushing up in the diaphragm *With chronic pancreatitis, pancreatic enzymes are given with meals Diabetes Mellitus\ue601- \ue601pancreatic disorder resulting in insufficient or lack of insulin production leading to elevated blood sugar \u25cfType I (insulin dependent)-\ue601 immune disorder, body attacks insulin producing beta cells with resulting \ue601Ketosis\ue601 (result of ketones in blood due to gluconeogenesis from fat) oExcessive thirst and weight loss are characteristic of T1DM \u25cfType II\ue601 \ue601(insulin resistant)-\ue601 beta cells do not produce enough insulin or body becomes resistant \u25cfNCLEX Points oAssessment \u25aa3 P\u2019s \u25cfPolyuria (excessive urination), polydipsia (extreme thirst), polyphagia (excessive hunger) \u25aaElevated blood sugar \u25aaBlurred vision \u25aaElevated HbA1C \u25aaPoor wound healing \u25aaNeuropathy \u25aaInadequate circulation \u25aaEnd organ damage is a major concern due to damage to vessels \u25cfCoronary artery disease oHTN, cerebrovascular disease 13
\u25cfRetinopathy oTherapeutic Management \u25aaInsulin \u25cfRequired for Type I and for Type II when diet and exercise do not control blood sugar \u25cfAssess for and teach the patient regarding peak action time for various insulins oOnly administer short acting insulins IV \u25cfDo not use vial that appears cloudy (NPH is the exception) \u25aaPatient should monitor blood sugar before, during, and after exercise \u25aaPatient should use protective footwear to prevent injury \u25aaInfections and wounds should receive meticulous care \u25aaFoot Care (inspect daily) \u25cfFeet should be kept dry \u25cfFootwear should always be worn (cotton socks are recommended as well as properly fitted shoes) \u25cfShould not wear tight fitting socks \u25aaSick Day \u2013 when patients with DM become ill, glucose levels become elevated \u25cfContinue to check blood sugars and \ue601do not\ue601 withhold insulin \u25cfMonitor for ketones in urine \u25aa15 Rule \u25cfIf blood sugar is low, administer 15g carbohydrates (5 lifesavers, 6 oz juice)- recheck in 15 minutes \u25aaComplications \u25cfLipoatrophy oLoss of subq fat at injection site (alternate injection sites) \u25cfLipohypertrophy oFatty mass at injection site \u25cfDawn phenomenon oReduced insulin sensitivity between 5-8AM oEvening administration may help oAdjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia \u2013 adjust do not eliminate (usually intermediate acting insulin is used) \u25cfSomogyi phenomenon oNight time hypoglycemia results in rebound hyperglycemia in the morning hours 14
Rapid-acting insulin should only be given if food is available and patient is ready to eat Repaglinide is a meglitinide analog drug\u2014short-acting agents used to prevent postmeal blood glucose elevation\u2014should be given within 1 to 30 minutes before meals and cause hypoglycemia shortly after dosing when a meal is denied or omitted 15
Drawing up regular insulin and NPH together Cloudy (air into NPH) Clear (air into regular) Clear (draw up regular) Cloudy (draw up NPH) Or RN- regular before NPH Hypoglycemia requires urgent treatment \u25cfSigns and Symptoms oHunger oIrritability oWeakness oHeadache oBG < 60 \u25cfConsume 10 to 15g of carbohydrate (15-Rule) \u25cfGlucose should be retested in 15 min \u25cfPatient should eat a small snack of carbohydrate and protein if the next meal is more than an hour away \u25cfRepeat carbohydrate treatment if symptoms do not resolve Alcohol\ue601 has the potential for causing \ue601alcohol-induced hypoglycemia\ue601\u2014it is important to know when the patient drinks alcohol and to teach the patient to ingest it shortly after meals to prevent this complication Guidelines\ue601 for \ue601exercise\ue601 are based on \ue601blood glucose \ue601and \ue601urine ketone level\ue601\u2014patients should test blood glucose before, during, and after exercise to be sure that it is safe. \u25cfWhen ketones are present the patient should not exercise because they indicate that current insulin levels are not adequate Diabetic Ketoacidosis (DKA)\ue601-\ue601 body is breaking down fat instead of sugar for energy\u2014fats leave ketones (acids) that cause \ue601pH\ue601 to \ue601decrease *DKA is rare in DM Type 2 because there is enough insulin to prevent breakdown of fats \u25cfSerum acetone and serum ketones increase in DKA \u25cfAs you treat the acidosis and dehydration expect the potassium to drop rapidly \ue601\u2192\ue601 be ready with potassium replacement \u25cfFluids are the most important intervention for DKA and HHNS oNS or LR \u25cfSecond voided urine is the most accurate when testing for \ue601ketones\ue601 and glucose \u25cfBringing the glucose down too much too quickly can result in increased ICP due to water being pulled into the CSF 16 \u25cfUrine ketone testing should be done whenever the patient\u2019s blood glucose is greater than 240 Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) \u25cfPotassium is low due to diuresis \u25cfFluids are the most important intervention \u25cfNo acidosis and no ketosis \u25cfWeight loss is a symptom \u25cfOften occurs in older adults with T2 Diabetes \u25cfRisk Factors oDiuretics oInadequate fluid intake (dehydration) HbA1c- assesses how well blood sugar has been managed over 3 month period- 4 to 6% is good; 8% or greater indicates poor control \u25cf7% is ideal for a diabetic Usually hold insulin prior to surgery and monitor blood glucose To Remember Blood Sugar Hot and dry, sugar high (hyperglycemia) Cold and clammy, need some candy (hypoglycemia) Laparoscopy-\ue601 CO2 is used to enhance visual\u2014general anesthesia, foley catheter Post-op:\ue601 EARLY AMBULATION to mobilize CO2 Myasthenia Gravis\ue601- \ue601decrease in receptor sites for acetylcholine- because the smallest concentration of ACTH receptors are cranial nerves, expect \ue601fatigue\ue601 and weakness \ue601in \ue601eye, mastication\/chewing, \ue601and \ue601pharyngeal muscles Sometimes the first sign is that the patient can\u2019t brush their hair *Not enough receptor sites for Acetylcholine to bind to for activation\u2014leading to muscle weakness *\ue601Worsens with exercise and improves with rest \u25cfDiagnosis is made via Tensilon test- improvement in muscle weakness (short period of time) indicates a positive reaction \u25cfAvoid alcohol, crowded places, try to reduce stress, avoid heat (sauna, hot tub, sunbathing), spread activities throughout the day, thicken liquids Myasthenic \ue601Crisis\ue601:\ue601 \ue601 often follows some type of infection\u2014client is at risk for inadequate respiratory function 17 \u25cfS\/S: elevated temperature, tachycardia, HTN, incontinent of urine and stool Cholinergic Crisis:\ue601 caused by excessive medication, stop med\ue601\u2192\ue601 Tensilon will make it worse Head injury\ue601 \ue601Medication \u25cfManntiol (osmotic diuretic)\u2014crystallizes at room temperature so ALWAYS\ue601 use a filter needle! Endocrine System Hormone Gland Growth Hormone (GH) Anterior Pituitary ADH Posterior Pituitary T3, T4 Thyroid PTH Parathyroid Glucocorticoids: cortisol Adrenal gland Insulin Pancreas *Parathyroid gland relies on the presence of Vitamin D to work Palpate \ue601the \ue601thyroid\ue601 gently- can cause thyroid storm in a patient with hyperthyroidism After removal of pituitary gland- watch for \ue601hypocortisolism\ue601 and temporary \ue601Diabetes Insipidus Myxedema\/Hypothyroidism\ue601- \ue601hyposecretion of thyroid hormone (TH) resulting in decreased metabolic rate (slowed physical and mental function) \u25cfMyxedema coma-\ue601 life threatening state of decreased thyroid production\u2014coma result of acute illness, rapid cessation of medication, hypothermia \u25cfNCLEX Points oAssessment \u25aaThink \ue601HYPO\ue601metabolic state \u25aaCardiovascular\ue601- bradycardia, anemia, hypotension \u25aaGastrointestinal\ue601- constipation (GI motility slows) \u25aaNeurological\ue601-\ue601 \ue601lethargy, fatigue (due to decreased metabolic rate\u2014\u201cbody is slow and sleepy\u201d), weakness, muscle aches, paresthesias \u25aaIntegumentary\ue601- \ue601goiter, dry skin, dry hair, loss of body hair 18 \u25aaMetabolic\ue601- cold intolerance, anorexia, weight gain (due to decreased metabolic state), edema, \ue601hypoglycemia oTherapeutic Management \u25aaCardiac monitoring \u25aaMaintain open airway \u25aaMonitor medication therapy (overdose with thyroid medications possible) \u25aaMedication therapy- \ue601levothyroxine (Synthroid) \u25cfTake in morning before breakfast to prevent insomnia (on empty stomach) \u25aaAssess thyroid hormone levels \u25aaIV fluids \u25aaMonitor and administer glucose as needed *Myxedema is COLD (hypothermia) Hyperthyroidism\ue601-\ue601 excess secretion of thyroid hormone (TH) from thyroid gland resulting in \ue601increased \ue601metabolic rate (\ue601accelerated\ue601 physical and mental function) \u25cfCauses oGraves disease \ue601(autoimmune reaction) oExcess secretion of TSH, tumor, medication reaction \u25cfThyroid Storm (Thyroid Crisis) oExtreme hyperthyroidism (life threatening) due to infection, stress, trauma \u25aaFebrile state, tachycardia, HTN, tremors, seizures \u25cfNCLEX Points oAssessment \u25aaElevated T3, T4, free T4, decreased TSH, positive radioactive uptake scan \u25aaGoiter \u25aaBulging eyes \u25aaCardiac- tachycardia, HTN (increased systolic, decreased diastolic), palpitations \u25aaNeurological- hyperactive reflexes, emotional instability, agitation, hand tremor \u25aaSensory- \ue601exophthalmos \ue601(Graves disease), blurred vision, heat intolerance \u25aaIntegumentary- fine, thin hair \u25aaReproductive- amenorrhea, decreased libido \u25aaMetabolic- increased metabolic rate, weight loss oTherapeutic Management \u25aaProvide rest in a cool quiet environment \u25aaAnti-thyroid medications (PTU, propylthiouracil) \u25aaCardiac monitoring \u25aaMaintain patent airway 19 \u25aaAvoid drinks that are stimulants (increases metabolic rate) \u25cfCaffeine- coffee, tea, soda \u25aaProvide eye protection \u25cfRegular eye exams \u25cfMoisturize eyes \u25aaRadioactive Iodine 131 \u25cfTaken up by thyroid gland and destroys some thyroid cells over 6-8 weeks oAvoid with pregnancy oMonitor lab values for hypothyroidism \u25aaSurgical removal \u25cfMonitor airway \u25cfMaintain in semi-Fowlers position \u25cfAssess surgical site for bleeding \u25cfMonitor for \ue601hypocalcemia oHave calcium gluconate available \u25cfMinimal talking during immediate post-op period \u25cf(Partial-thyroidectomy) Monitor temperature post-op\ue601\u2192\ue601 elevated temp by even 1 degree may indicate impending thyroid crisis\ue601\u2192\ue601 report to MD immediately *Think of MICHAEL JACKSON IN THRILLER -Skinny, nervous, bulging eyes, up all night, heart beating fast (Insomnia is aside effect of excess thyroid hormones\u2014due to increased metabolic rate\u2014body is \u201ctoo busy to sleep\u201d) Hypo-parathyroid:\ue601 \ue601decreased calcium (implement high calcium, low phosphorous diet; provide Vitamin D which aids in calcium absorption) *Trousseau\u2019s and Chvostek\u2019s signs CATS (S\/S): C- convulsions A- arrhythmias T- tetany S- spasms S- stridor Hyper-parathyroid:\ue601 increased calcium (implement low calcium, high phosphorous diet) S\/S: Fatigue, polyuria, muscle weakness, \ue601renal calculi \ue601(55% have urinary tract calculi), back and joint pain, \ue601monitor for bone deformities Pre-parathyroidectomy- low calcium, high phosphorous diet 20 *For patients who are not candidates for para-thyroidectomy, diuretics (furosemide) and hydration (IV NS) in combo help reduce serum calcium \ue601\u2192 furosemide increases kidney excretion of calcium when combined with IV saline in large volumes *BEST WAY TO EVALUATE FLUID STATUS (fluid volume deficit)- daily weight Hypovolemia\ue601:\ue601 (dehydration) increased temperature, rapid\/weak pulse (tachycardia), increased respirations, hypotension, anxiety, urine SG > 1.030 (dark urine), confusion (early sign) \u25cfIncreased sodium with dehydration \u25cfIncreased BUN with dehydration \u25cfIncreased hematocrit with dehydration Hypovolemic Shock \u25cfIsotonic fluids \u2013 increase intravascular volume (NS or LR) \u25cfAlbumin can be given too (expander) Hypervolemia\ue601:\ue601 (fluid volume excess\/overload) bounding pulse, SOB, dyspnea, crackles, peripheral edema, HTN, urine SG <1.010 (dilute urine); Semi-Fowler\u2019s *D5W-body rapidly metabolizes the dextrose and the solution becomes hypotonic Low phosphorous\u2014patient will exhibit generalized muscle weakness\ue601\u2192\ue601 may lead to acute muscle breakdown (rhabdomyolysis) \u25cfPhosphate is necessary for energy production in the form of ATP\u2014when not produced, leads to generalized weakness Diabetes Insipidus (DI):\ue601 \ue601hyposecretion\ue601 or failure to respond to \ue601ADH\ue601 from posterior pituitary\u2014leading to excess water loss \u25aaNCLEX Points oAssessment (S\/S) \u25aaExcessive urine output \u25cfDilute urine (USG <1.006) \u25aaHypotension leading to cardiovascular collapse \u25aaTachycardia \u25aaPolydipsia (extreme thirst) \u25aaHypernatremia \u25aaNeurological changes oTherapeutic Management \u25aaWater replacement \u25cfD5W if IV replacement is required \u25aaHormone replacement \u25cfDesmopressin \u25cfVasopressin 21 \u25aaMonitor urine output hourly and urine SG \u25cfReport urine output > 200mL\/hour \u25aaDaily weight monitoring Syndrome of Inappropriate Antidiuretic Hormone (SIADH)\ue601:\ue601 \ue601excessive secretion\ue601 of \ue601ADH\ue601 (from posterior pituitary) leading to \ue601hyponatremia\ue601 and water intoxication \ue601(excessive water retention) \u25cfCaused by trauma, tumors, infection, medications \u25cfNCLEX Points oAssessment (S\/S) \u25aaFluid volume excess (HTN, crackles, JVD) \u25aaAltered LOC \u25aaSeizures \u25aaComa \u25aaUrine specific gravity > 1.032 \u25aaDecreased BUN, hematocrit, Na (hyponatremia) oTherapeutic Management \u25aaCardiac monitoring \u25aaFrequent neuro exams \u25aaMonitor I&O \u25aaFluid restriction \u25aaSodium supplement \u25aaDaily weight (loss of 2.2 lbs or 1 kg = 1 L) \u25aaMedication \u25cfHypertonic saline (D5 w\/ NS) \u25cfDiuretics (furosemide) \u25cfElectrolyte replacement *Water intoxication \u2013 drowsiness and altered mental status Specific Gravity \u25cf1.010-1.030 \u25cfHigh- (concentrated\/dark urine) oDehydration oSIADH oHeart failure \u25cfLow- (dilute\/water-like urine) oCKD oDiabetes Insipidus oFluid volume overload Hypomagnesemia\ue601 \ue601(low Mg): tremors, tetany, seizures, dysrhythmias (life threatening ventricular arrhythmias), depression, confusion, dysphagia *Low Mg may lead to digoxin toxicity 22
Hypermagnesemia\ue601 \ue601(high Mg): depresses the CNS, hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations *Emergency Addison\u2019s Disease\ue601- hyposecretion of adrenal cortex hormones; decreased levels of glucocorticoids and mineralcorticoids leads to hyponatreamia, hyperkalemia, hypoglycemia, decreased vascular volume\u2014fatal if not treated \u25cfNCLEX Points oAssessment \u25aaHyponatremia (down) \u25aaHyperkalemia (up) \u25aaHypoglycemia (down) \u25aaDecreased blood volume (down)- anemia \u25aaHypotension (down) \u2013 most important assessment parameter \u25aaWeight loss \u25aaHyperpigmentation (tanned skin) \u25aaDecreased resistance to stress oTherapeutic Management \u2013\ue601 with Addison\u2019s you must \ue601add hormone (teaching about steroid replacement is important) \u25aaMonitor vital signs \u25aaMonitor electrolytes \u25aaMonitor glucose \u25cfTreat low blood sugar \u25aaAdminister replacement adrenal hormones as needed \u25aaLifelong medication therapy needed \u25aaManaging stress in a patient with adrenal insufficiency is important\u2014if the adrenal glands are stressed further it can result in Addisonian Crisis oAddisonian Crisis \u25aaCaused by acute exacerbation of Addison\u2019s Disease \u25aaCauses severe electrolyte disturbances \u25aaMonitor electrolytes and cardiovascular status closely \u25aaAdminister adrenal hormones as needed \u25aaS\/S: N\/V, confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased blood pressure \u25aaDuring times of stress- increase sodium intake\ue601 \ue601\u2192\ue601 a decrease in aldosterone leads to increase in excretion of sodium) Cushing\u2019s\ue601 \ue601Disease\ue601- hypersecretion of glucocorticoids leading to elevated cortisol levels; greater incidence in women; life threatening if untreated \u25cfNCLEX Points oAssessment \u25aaHypernatremia (up) 23
\u25aaHypokalemia (down) \u25aaHyperglycemia (up) \u25aaIncreased blood volume (up) \u25aaHypertension (up) \u25aaProne to infection \u25aaMoon face \u25aaBuffalo hump \u25aaMuscle wasting \u25aaEdema (signs of CHF) \u25aaRisk to bruising \u25cfTherapeutic Management \u2013\ue601 you have excess \u201ccushion\u201d of hormones oMonitor electrolytes and cardiovascular status \u25aaPrevent fluid overload \u2013 respirations are the first priority \u25aaCardiovascular feature- capillary fragility\ue601\u2192\ue601 results in bruising and petechiae oProvide skin care and meticulous wound care (paper thin skin that is easily injured) oProvide for client safety oAdrenalectomy (surgical removal of adrenal gland) oProtect client from infection oOften caused by tumor on adrenal or pituitary gland Pheochromocytoma\ue601-\ue601 vascular tumor of adrenal medulla (adrenal glands) leading to a hypersecretion of epinephrine\/norepinephrine \u25cfS\/S: persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding headache \u25cfManagement: avoid stress and frequent bathing, and take rest breaks (limit activity), avoid stimulating foods, avoid foods high in tyramine \u25cfAvoid palpating the abdomen as it can cause a sudden release of catelcholamines and severe HTN \u25cfTx: surgery to remove tumor Priority situation Neuroleptic Malignant Syndrome (NMS) NMS is like S&M -You get hot (increased temp\/hyperpyrexia) -Stiff (increased muscle tone) -Sweaty (diaphoresis) -BP, pulse, and respirations go up -You start to drool *Flu like symptoms *Never get pregnant with a German \ue601(German measles\/rubella is the dangerous one for pregnant women) 24
\u25cfExposure to rubella for a pregnant woman\u2014incubation is 14 to 21 days (communicable 7 days before) Pulmonary Embolism \u25cfFirst sign- sudden chest pain,\ue601 followed by dyspnea and tachypnea \u25cfO2 deprived\u2014first intervention is usually oxygen (check ABGs) oPatient may be hyperventilating as a compensatory mechanism Risk Factors \u25cfObesity \u25cfImmobility \u25cfPooling of blood in extremities \u25cfTrauma (MVA) Tetralogy of Fallot *\ue601Think \ue601DROP \ue601 (child drops to floor or squats) D- defect, septal R- right ventricular hypertrophy O- overriding aorta P- pulmonary stenosis For neonates with Tetralogy of Fallot- prostaglandin E1 infusion *Give O2 and morphine, IVF for volume expansion MAOIs *Pirates say \u201carrrr\u201d\u2014when pirates are depressed they take MAOIs -MAOIs used for depression have an \u201car\u201d sound in the middle (parnate, marplan, nardil) ..or.. PANAMA PArnate-\ue601 tranylcypromine NArdil-\ue601 phenelzine MArplan-\ue601 isocarboxazid *Avoid tyramine when taking MAOIs\u2014aged cheese, chicken liver, avocados, bananas, meat tenderizer, salami, bologna, wine, beer\u2014may cause HTN crisis Systemic Lupus Erythematous-\ue601 progressive systemic inflammatory disease resulting in major organ system failure; immune system \u201chyperactive\u201d attacks healthy tissue; no known cure \u25cfNCLEX Points oAssessment \u25aaAssess for precipitating factors \u25cfUV light \u25cfInfection \u25cfStress 25
\u25aaArthritis \u25aaWeakness \u25aaPhotosensitivity \u25aaButterfly rash \u25aaElevated ESR and C Reactive Protein oTherapeutic Management \u25aaAssess respiratory status \u25aaAssess end organ function \u25aaPlan rest periods \u25aaIdentify triggers \u25aaRefer to dietitian for dietary assistance \u25aaMedications \u25cfGlucocorticoids \u25cfNSAIDs \u25cfCyclophosamide (immunosuppressive agent) **Should be in remission (SLE) at least 5 months prior to conceiving *A high number of patients with SLE develop nephropathy, so an increase in blood urea may indicate a need for a change in therapy or for further diagnostic testing (such as creatinine clearance) Albumin\ue601 levels are the best indicator of long-term nutritional status (normal 3.5-5.0) \u25cf(Same range as potassium) One of the goals for a client with \ue601anorexia\ue601 is to achieve a sense of self-worth and self-acceptance that is \ue601not\ue601 based on appearance \ue601\u2192\ue601 encourage activities that will promote socialization and increase self-esteem Physical S\/S of \ue601anorexia \u25cfAmenorrhea \u25cfConstipation \u25cfHypotension \u25cfCold intolerance \u25cfBradycardia \u25cfFatigue \u25cfMuscle weakness \u25cfOsteoporosis Autonomic Dysreflexia\ue601- \ue601potentially life threatening emergency (seen with patients with spinal cord injuries) \u25cfElevate HOB to 90 degrees – FIRST \u25cfUsually T6 or above spinal cord injury \u25cfVasoconstriction below \u25cfVasodilation above \u25cfSudden, acute onset of HTN 26
\u25cfLoosen constrictive clothing \u25cfAssess for bladder distention and bowel impaction (can trigger AD)- SECOND \u25cfAdminister anti-HTN medications (may cause stroke, MI, seizure \u25cfMetallic bitter taste Thrombolytic therapy\ue601-\ue601 avoid injury\ue601\u2192\ue601 avoid activities that could cause bleeding (NO IM injections) *The Institute for Safe Medication Practices guidelines indicate that the \ue601use of a trailing zero\ue601 is \ue601not appropriate \ue601when writing medication orders\u2014because it is easily mistaken for a larger dose! First action after medication administration error is to assess the client for adverse outcomes Drug Schedules \u25cfSchedule I- no currently accepted medical use, research only (heroin, LSD, MDMA) \u25cfSchedule II- drugs with high potential for abuse and requires written prescription (Ritalin, hydromorphone\/Dilaudid, meperidine\/Demerol, and fentanyl) \u25cfSchedule III- requires new prescription after 6 months or five refills (codeine, testosterone, ketamine) \u25cfSchedule IV- requires new prescription after 6 months (benzodiazepines) \u25cfSchedule V- dispensed as any other prescription or without prescription (cough preparations, laxatives) Medication Considerations Digoxin\ue601- assess pulse for a full minute, hold if HR less than 60, check digoxin levels and potassium and magnesium levels (low K and Mg can lead to digoxin toxicity) S\/S of toxicity- yellow halo, N\/V *Digoxin is given with loading doses (normally 2- 0.5mg or higher)\u2014maintenance dose is typically 0.25mg **Increases ventricular irritability\u2014can convert a rhythm to V-Fib following cardioversion Aluminum Hydroxide (Amphojel)\ue601- (antacid) treatment of GERD and kidney stones- watch for constipation *Take after meals 27
Amiodarone-\ue601 treats life-threatening heart rhythm problems; watch out for diaphoresis, dyspnea, lethargy\u2014take missed dose any time in the day or skip it entirely\u2014DO NOT take double dose Warfarin (Coumadin)-\ue601 anticoagulant therapy; watch for signs of bleeding, diarrhea, fever or rash; stress the importance of complying with prescribed dosage and follow-up appointments \u25cfPatients taking warfarin should not make sudden dietary changes, because changing the oral intake of foods high in Vitamin K (green leafy vegetables, some fruits) will impact the effectiveness of the medication Methylphenidate (Ritalin)-\ue601 treatment of ADHD; assess for heart related side-effects and report immediately; child may need drug holiday because the drug stunts growth; poor appetite- parents should watch for weight loss E\ue601thambutol (TB)- negative effect on \ue601e\ue601yes (blurred vision, eye pain, red-green color blindness, any loss of vision\u2014more common with high doses); liver problems may occur Gemfibrozil\ue601- lowers high cholesterol and triglycerides; monitor liver functions \u2013 increased risk of gallstones \u2013 rhabdomyolysis Dextroamphetamine\ue601 (Dexedrine)- used for ADHD, may alter insulin needs, avoid taking with MAOI\u2019s, take in morning after breakfast (insomnia is a possible side effect) Hydroxyurea\ue601- used to help treat sickle cell, can help reduce the number of acute chest syndrome episodes, pain crises, and need for blood transfusions\u2014report GI symptoms immediately\u2014could be sign of toxicity Hydroxyzine\ue601 (Vistaril)- tx of anxiety (can also be used to help with itching)- watch for dry mouth- commonly given pre-operatively Haloperidol\ue601 (Haldol)\u2014preferred antipsychotic for elderly patients\u2014high risk of EPS (dystonia, tardive dyskinesia, tightening of jaw, stiff neck, swollen tongue, swollen airway)\u2014monitor early for signs of reaction (IM Diphenhydramine can be given) \u25cfSide Effects- galactorrhea (excessive or spontaneous flow of milk), lactation, gynecomastia, drowsiness, insomnia, weakness, headache \u25cfWhen given IM- should be given deep into large muscle mass\u2014is very irritating to subcutaneous tissue *\ue601If mixing antipsychotic medications (Haloperidol, Fluphenazine, Chlorpromazine) with fluids, incompatible with caffeine and apple juice 28
Risperidone\ue601 (Risperdal)- antipsychotic (schizophrenia)\u2014doses over 6mg can cause tardive dyskinesia\u2014first line antipsychotic in children \u25cfCauses weight gain, impairs temperature regulation, photosensitivity, orthostatic hypotension Fluoxetine \ue601(Prozac)- SSRI; doses that are greater than 20mg should be given in divided doses Midazolam\ue601 (Versed)- given for conscious sedation- watch for respiratory depression and hypotension (benzodiazepine) \u25cfContraindicated in patients taking protease inhibitors Protease Inhibitors\ue601- antiviral drugs used to treat HIV\/AIDs and hepatitis C *Decrease the metabolism of many drugs\u2014including midazolam Serious toxicity can occur when protease inhibitors are given with other medications R\ue601ifampin-\ue601 \ue601(treatment of TB)- watch for \ue601r\ue601ed\/orange tears, urine *Decreases effectiveness of contraceptives Propylthiouracil\ue601 (PTU) and methimazole (tapazole)- prevention of thyroid storm *Tx: hyperthyroidisim Oxybutynin\ue601 is an anticholinergic agent\u2014can lead to extremely dry mouth; max dose is 20 mg\/day; should be taken between meals as food interferes with absorption Neostigmine-\ue601 treats Myasthenia Gravis\u2014administer to clients 45 min before eating\u2014helps with swallowing and chewing *Also reverses the effects of anesthesia Procainamide\ue601 HCl- given to treat PVCs- withhold if severe hypotension\u2014adverse signs are bradycardia and hypotension Isoniazid\ue601 (medication for TB) causes peripheral neuropathy \u2013patients may be instructed to take Vitamin B6 to counter; hepatotoxicity (monitor LFTs); should not be taken with Phenytoin (Dilantin) as it can lead to toxicity; hypotension may occur initially but should resolve Trimethobenzamide\ue601 \ue601HCl\ue601 (Tigan)- tx of post-op N\/V and for nausea associated with gastroenteritis Alendronate\ue601- used for treatment and prevention of osteoporosis 29
\u25cfPhotosensitivity- wear sunscreen and protective clothing when outdoors \u25cfTake in the morning \u25cfIf missed dose, wait until next day to take Doxycyline-\ue601 antibiotic; dairy products inhibit the absorption of this medication Cholestyramine-\ue601 lower cholesterol \u25cfS\/E: constipation \u25cfShould not take with spironolactone- increases blood chloride levels \u25cfMany interactions- anticoagulants, beta blockers, diuretics, penicillins, hormonal contraceptives, phenobarbital CBT\ue601- Can Block Tremors (meds for Parkinson\u2019s) Carbidopa\ue601\/\ue601Levodopa\ue601 (Sinemet)- sweat, saliva, urine may turn reddish brown, causes drowsiness; patients should not take with MAOIs \u25cfLevodopa- contraindicated for patients with glaucoma, avoid Vitamin B6, avoid high protein diet (interferes with the body\u2019s response to medication) Benztropine\ue601 (Cogentin)- can be used for Parkinson\u2019s, as well as to treat EPS \u2013 may lead to the inability to move specific muscle groups or weakness (too much of an effect)\u2014anticholinergic (may lead to blurred vision, dry mouth) *Increase fluid intake Biperiden\ue601- Anti-Parkinson\u2019s used to counteract EPS Trihexyphenidyl\ue601 \ue601HCl\ue601 (Artane)- sedative effect Timolol\ue601 (Beta Blocker)- eye drops, used for treatment of glaucoma Propranolol \ue601(Beta Blocker)- decreases effectiveness of atorvastatin Sulfamethaxozole\ue601\/\ue601Trimethoprim\ue601 (Bactrim)- antibiotic- do not take if allergic to sulfa- diarrhea is a common side effect, drink plenty of fluids Simvastatin\ue601- tx of hyperlipidemia, take on empty stomach to enhance absorption at night, report any unexplained muscle pain (could indicate rhabdomyolysis)\u2014especially if fever is present Bromocriptine\ue601- used to treat menstrual problems *Take with meals to avoid GI upset Dabigatran-\ue601 anticoagulant with NO antidote- do not take with other anticoagulants Gout Probenecid\ue601 (Benemid)- increases uric acid secretion in urine Colchicine\ue601- prevention of gout Allopurinol\ue601- acute 30
Hydralazine\ue601- Tx of HTN or CHF, report flu-like symptoms, rise slowly from sitting\/lying positions to prevent orthostatic hypotension, take with meals Dicycloverine\ue601- Tx of irritable bowel- assess for anticholinergic side effects Verapamil\ue601- CCB- tx of HTN, angina, and dysrhythmias- assess for constipation Sucralfate\ue601- tx of duodenal ulcers (coats ulcer)- \ue601take before meals (1 hour)\ue601- best on empty stomach *Protects from acid Cimetidine\ue601- H2 *Take with meals and at bedtime S\/E: constipation Theophylline\ue601- tx of asthma and COPD *Therapeutic drug level: 10-20 (12 letters in theophylline\u201412 is in between 10 and 20, also the \u201c1\u201d in 10 and \u201c2\u201d in 20 = 12) N-Acetylcysteine\ue601- antidote for Tylenol and is administered orally Glipizide\ue601- effective for client diagnosed with Type 2 DM, who produces minimal amounts of insulin (oral hypoglycemic agent) Acetazolamide\ue601 (Diamox)- tx of glaucoma, high altitude sickness, increased ICP- DO NOT take if allergic to sulfa *Can cause hypokalemia Indomethacin\ue601 (Indocin)- NSAID- tx of arthritis (osteo, rheumatoid, gout), bursitis, tendonitis *Ototoxic Levothyroxine\ue601 (synthroid)- tx of hypothyroidism- may take several weeks to take effect, notify doctor if chest pain\u2014take in AM on empty stomach, can lead to hyperthyroidism Chlordiazepoxide\ue601 (Librium)- tx of alcohol withdrawal- do not take alcohol with this (including mouth wash that contains alcohol), very bad nausea and vomiting can occur Terbutaline\ue601\u2014can lead to maternal tachycardia- withhold if HR is elevated prior to administration 31
Vincristine\ue601 (oncovin)- tx of leukemia (anti-leukemic)- IV only Ganciclovir\ue601 (Cytovene)- used for retinitis caused by cytomegalovirus- patient will need regular eye exams, report dizziness, confusion, or seizures immediately Sertraline \ue601(Zoloft)- SSRI, depression; S\/E: agitation, disruption in sleep, dry mouth Serotonin Syndrome \u25cfRare, life threatening \u25cfS\/S: abdominal pain, fever, sweating, tachycardia, HTN, delirium, myoclonus (jerky movements), irritability, mood changes Clozapine\ue601- schizophrenia; S\/E: agranulocytosis (low WBC count), tachycardia, seizures *Significant toxic risk associated with clozapine is \ue601blood dyscrasia Agranulocytosis-\ue601 flu-like symptoms (fever, sore throat, lethargy) Lindane\ue601 (Kwell)- Tx of scabies (lotion) and lice (shampoo) Scabies- apply lotion once and leave on for 8-12 hours Lice- wash hair with shampoo and leave on for 4 minutes with hair uncovered, then rinse with warm water and comb with a fine tooth comb Dantrolene (Dantrium)-\ue601 treats muscle spasms caused by MS\u2014may take a week or more to be effective Pentamidine\ue601- helps treat and prevent pneumocystis pneumonia \u25cfCan cause fatal hypoglycemia\u2014monitor blood glucose (low BG may indicate need to change treatment) Doxepin HCl\ue601- antidepressant *Signs of overdose: excitability and tremors Premarin\ue601 (conjugated estrogen tablets)- tx after menopause- estrogen replacement *Estrogen can cause dry eyes Furosemide \ue601(Lasix)- loop diuretic \u25cfOtotoxic especially when given with other ototoxic drugs \u25cfMonitor BP \u25cfMonitor U\/O 32
\u25cfMonitor K+ \u25cfCan lead to anorexia due to reduced potassium Phenytoin\ue601 (Dilantin)- tx of seizures *Therapeutic drug level = 10-20 S\/E: rash (stop med), gingival hyperplasia (practice good dental hygiene) Toxicity- poor gait + coordination, slurred speech, nausea, lethargy, diplopia Can cause leukopenia (low WBC)-\ue601 stop medication Thiothixene\ue601 (Navane)- tx of schizophrenia- assess for EPS Naproxen\ue601 (NSAID)- used to mild to moderate pain \u25cfCan cause gastrointestinal bleeding- monitor stools for blood 5-Fluorouracil (5-FU)- \ue601chemotherapy agent Sulindac (NSAID)\ue601- S\/E are typically GI distress (GI bleeding, ulcers, perforation of the stomach and\/or intestines) Theophylline-\ue601 used for COPD and asthma (bronchodilator) \u25cfCauses GI upset, take with food \u25cfAvoid use of alcohol and caffeine while taking this medication \u25cfWatch for toxicity (10 to 20 is therapeutic range)- >20 is considered toxic (persistent nausea and vomiting are signs) \u25cfMany drug interactions Dopamine\ue601- treatment of hypotension, shock, low cardiac output, poor perfusion to vital organs (ex: kidneys)- monitor EKG for arrhythmias, monitor BP Phenobarbital\ue601 \ue601CAN\ue601 be taken during pregnancy- \ue601phenytoin \ue601is contraindicated *\ue601All psych meds (except Lithium) have the same side effects- SNS (exception is hypotension) SNS- increase BP, HR, and RR, dilated pupils (blurred vision), urinary retention, constipation (decreased GI motility), constricted blood vessels, and dry mouth Only specific medications require double verification Epidural \u25cfWhen doing epidural anesthesia, hydration beforehand is a priority \u25cfHypotension, bradypnea and bradycardia are major risks and emergencies \u25cfPatients will have a foley catheter due to the inability to void 33
Forget your past mistakes and focus on your successes! When caring for a pregnant woman who follows a vegetarian diet, the nurse should begin with an assessment of the diet (24 hour diet recall) because vegetarian practices vary widely\u2014assess the diet for deficiencies before making recommendations for supplementation Maternity Normal Values \u25cfFetal Heart Rate- 120 to 160 bpm \u25cfAmniotic fluid- 500- 1200 mL \u25cfAPGAR- 7 and above = normal; 4 to 6 fairly low; 3 and below are critically low oDone at 1 and 5 minutes Prenatal vitamins\ue601 should be taken with something acidic (orange juice) at bedtime (Vitamin C increases absorption) Pregnant women should increase calories by \ue601300\ue601 for fetal growth, maternal tissues and placenta Placenta previa requires c-section Hyperemesis gravidarum\ue601- bed rest, NPO to rest GI tract, anti-emetics, IVF Symptoms of onset of labor \u25cfGush of fluid down legs \u25cfSome blood in vaginal discharge \u25cfLow back pain Fetal Heart Rate Patterns VEAL CHOP VC EH AO LP V= variable decels, Cord compression E = early decels, Head compression A = accelerations, OK L = late decels, Placental insufficiency (baby is not receiving enough oxygen and nutrients) 34
*For \ue601cord compression\ue601, place the mother in \ue601TRENDELENBURG\ue601 position- this removes the pressure of the presenting part from the cord (baby is no longer being pulled out of the body by gravity) \u25cfIf the cord is prolapsed- cover it with sterile saline gauze to prevent drying of the cord and to minimize infection *For late decels, turn the mother on the left side to allow more blood to flow to the placenta- give mother O2 via face mask, stop Pitocin, open IV fluids (increase) *Sometimes it is hard to determine who to check on first, mom or baby\u2014it is usually easy to tell the right answer if the mother or baby involves a machine\u2014if you are not sure who to check on first, and one of the choices is a machine, that\u2019s the wrong answer- \ue601eliminate If the baby is in a posterior position- the sounds are heard at the sides If the baby is in an anterior position- the sounds are heard closer to midline, between the umbilicus and where and where you would listen to a posterior position *If the baby is breech- sounds are high up in the fundus (usually above or around the umbilicus) *If baby is vertex (head is down), they are a little above the symphysis pubis on the left or right side NEVER APPLY FUNDAL PRESSURE IN THE CASE OF SHOULDER DYSTOCIA! A newborn discharged before 72 hours of life should be seen by an RN or MD within 2 days of discharge A newborn should feed between 8 and 12 times in 24 hours ALWAYS\ue601 protect the newborn\u2019s eyes when undergoing phototherapy and monitor temperature carefully! Breastfeeding is encouraged to avoid dehydration and increase passage of meconium (which helps excrete bilirubin) Normal Contraction Pattern \u25cfContractions every 2-5 minutes for 60 seconds (<90 seconds) oLonger lasting and shorter intervals is \ue601NOT \ue601normal (could be a complication of Pitocin) Palpating uterine contractions is done with fingertips 35 AVA\ue601: The umbilical cord has two arteries and one vein Amniotic fluid\ue601 is \ue601alkaline-\ue601 turns nitrazine paper blue Urine and normal vaginal discharge are acidic and turn the nitrazine paper yellow\/orange (some color charts vary) If a woman\u2019s water breaks and she is at a (-) station, you should be concerned about a potential prolapsed cord Post-delivery \u25cfPitocin should only be administered after the placenta separates from the uterine wall oSigns: gush of blood, umbilical cord out of vagina, uterus contracting Umbilical cord care\ue601: clean cord several times a day and expose to air frequently (to encourage drying and prevent infection) Oxytocin should always be a secondary infusion controlled by IV pump Pregnancy weight gain\ue601: \u25cf2-5 lbs. in 1\ue601st\ue601 trimester \u25cf0.6-1.1 lbs. weekly in 2\ue601nd\ue601 and 3\ue601rd\ue601 trimesters Transition phase of labor- woman should pant with pursed lips\ue601\u2192\ue601 allows client to control pain and urge to push and promotes adequate oxygenation of fetus Other 36 \u25cfMethotrexate is teratogenic and should not be used by patients who are pregnant Administration of \ue601antiviral\ue601 \ue601medications\ue601 to the pregnant woman and the newborn, cesarean birth, and avoidance of breastfeeding have reduced the incidence of perinatal transmission of HIV from approximately 26% to 1-2% The incidence of congenital anomalies is 3x higher in the offspring of diabetic women\u2014good glycemic control during preconception and early pregnancy significantly reduces this risk A multiparous patient in active labor with an urge to have a bowel movement will probably give birth imminently\u2014it is time to push\u2014should not be allowed up to use the bathroom at this time! Central Lines \u25cfJugular veins are more prone to infection \u25cfHigher risk of infection with nontunneled lines \u25cfPICC lines and midline catheters are associated with a lower incidence of infection \u25cfImplanted ports are placed under the skin and are the least likely central line to be associated with catheter infection VENTILATOR ALARMS HOLD H\ue601igh pressure alarm- \ue601O\ue601bstruction due to increased secretions (mucus plug), kink in tubing, patient coughs, gags or bites L\ue601ow pressure alarm- \ue601D\ue601isconnection or leak in ventilator or patient airway cuff, patient stops spontaneously breathing Increased ICP and Shock- OPPOSITE V\/S Increased ICP\ue601 (Cushing\u2019s Triad)- increased BP, decreased pulse (bradycardia), decreased respirations Shock\ue601- decreased BP, increased pulse, increased respirations Heroin withdrawal for a neonate -Irritable -Poor sucking 37 -High pitched cry *Withdrawal seen 12-24 hours later Heroin Withdrawal\ue601 (Adult) \u25cfMimics S\/S of fu- runny nose, yawning, fever, muscle and joint pain, diarrhea JEWISH-\ue601 No meat and milk together Milk products and carbonated beverages have sodium For \ue601CPR\ue601 of an infant \u2013 brachial pulse Test child for lead poisoning around 12 months of age Fruits high in potassium- bananas, potatoes, citrus fruits *Cultures are always taken BEFORE starting IV antibiotics A patient with \ue601leukemia\ue601 may have \ue601epistaxis\ue601 due to low platelets Best way to warm a newborn:\ue601 skin to skin contact on mother\u2019s chest with a blanket *Below 97.7 is a CONCERN When patient comes to hospital in active labor- nurse\u2019s first action is to listen to fetal heart rate Phobic disorders- Systematic desensitization- relaxation and gradual exposure to anxiety producing stimulus GERD \u25cfRisk Factors oFemale oSmoking o>45 years old oObesity oCaucasian \u25cfLimit spicy foods, caffeine, lie with 2 pillows Low residue \ue601means \ue601low fiber 38
Fiber adds bulk- patients who are constipated should add fiber to their diet High fiber\ue601- oatmeal, celery, green beans Aminoglycosides\ue601 (vancomycin and gentamicin) can cause nephrotoxicity and ototoxcity if given too quickly \u2013 monitor BUN and creatinine \u201cRed Man\u201d syndrome occurs when vancomycin is infused too quickly\u2014because the client needs the medication to treat infection, the vancomycin should not be discontinued\u2014antihistamines my help decrease the flushing, but vancomycin should be administered over atleast 60 min! ARDS\ue601 (fluid in alveoli), \ue601DIC\ue601 (disseminated intravascular coagulation) are always secondary to something else (another disease process) \u25cfCardinal sign of ARDS is hypoxemia (low oxygen level in tissues) oFirst sign\ue601 is usually \ue601increased respirations\ue601 \ue601\u2192\ue601 later comes dyspnea, retractions, air hunger, cyanosis Edema is in the interstitial space NOT in the cardiovascular space Weight is the best indicator of hydration status (dehydration) Wherever there is sugar (glucose), water follows NO ASPIRIN TO CHILDREN\ue601- can cause Reye\u2019s Syndrome (encephalopathy) \u25cfS\/S of Reye\u2019s: vomiting, lethargy, unusual sleepiness, increased RR, diarrhea, confusion, loss of consciousness ASPIRIN OVERDOSE SIGNS \u25cfTinnitus \u25cfGastric distress COLD\ue601 for acute pain (sprain, fracture), \ue601HOT\ue601 for chronic pain (rheumatoid arthritis) Pain is usually the highest priority for rheumatoid arthritis Cultures taken before first dose of antibiotics Stool (+) \u2013 Salmonella \ue601\u2192\ue601 contact precautions Detached retina- photophobia, loss of a portion of visual field 39
COPD\ue601 is chronic, pneumonia is acute\u2014emphysema and bronchitis are both COPD \u25cfIn COPD patients, baroreceptors that detect the CO2 level are destroyed\u2014therefore, O2 level must be low because high O2 concentration blows the patient\u2019s stimulus for breathing oEx: Patient is on O2 at 6L\/min- this is too high\ue601\u2192\ue601 causing high serum oxygen levels, which results in decreased respiratory rate \u25cfEncourage pursed-lip breathing (promotes CO2 elimination) \u25cfEncourage fluids \u25cfHigh Fowler\u2019s and leaning forward (tripod position) Exacerbation- acute, distress Gout\ue601- \ue601(acute attack)\u2014encourage partial weight bearing Epinephrine is always given in TB syringe Prednisone toxicity\ue601\u2192\ue601 Cushing\u2019s syndrome \u2013 buffalo hump, moon face, hyperglycemia, HTN (too much steroid) Prednisone Adverse Effects \u25cfOsteoporosis \u25cfHyperglycemia (patient may require more insulin) \u25cfHypokalemia \u25cfHypernatremia \u25cfFluid retention and edema \u25cfDecreased immune response (greater risk of infection\u2014\ue601BUT\ue601 do not see changes in bone marrow) \u25cfGastrointestinal bleeding\u2014monitor stool for bleeding *Rapid weight gain and edema are signs of excessive drug therapy and the dosage of the drug needs to be adjusted (contact physician to report) Four options for cancer management:\ue601 chemo, radiation, surgery, palliative\/hospice (treatment\/management can be a combination of these four) Chest tubes\ue601 are placed in the pleural space \u25cfPlaced to remove air\/fluid from pleural cavity \u25cfCreates a vacuum- \ue601NEGATIVE PRESSURE \u25cfAir in the pleural space \u2013 pneumothorax \u25cfBlood in the pleural space \u2013 hemothorax \u25cfShould be below chest level \u25cfCough and deep breathing is encouraged \u25cf3 chambers oCollection chamber 40
\u25aaCollects drainage- should be serosanguinous \u25cfAssess drainage q4h (if new chest tube, assess more frequently) \u25cfNotify MD if drainage is bright red (could indicate possible hemorrhage) \u25cfShould not be more than 100mL\/hour oWater seal chamber \u25aa2 cm of water \u25aaCreates a one way valve that allows air to come out but nothing to go in \u25aaContinuous bubbling is a bad sign\ue601\u2192\ue601 air leak \u25aaShould see gentle tidals (fluctuates with respirations) oSuction control chamber \u25aaTells you how much suction is applied to the client \u25aaMD sets the suction parameters \u25aaShould see bubbling in suction chamber\u2014means it is functioning properly What NOT to do with Chest Tubes: \u25cfMilk the catheter \u25cfNever try to reinsert the tube if it is pulled out The immediate intervention after a sucking stab wound\ue601 (open) is to dress the wound and tape it on 3 sides\u2014allows air to escape but not reenter\ue601\u2192\ue601 occlusive dressing would convert the wound from open to closed\ue601\u2192\ue601 could lead to tension pneumothorax\u2026which is worse! *After dressing the wound: chest tube, labs, IV Continuous bubbling\ue601 indicates air leak\ue601 that must be identified: \u25cfWith the physician\u2019s order, you can apply a padded clamp to the drainage tubing close to the occlusive dressing\u2014if the bubbling stops, the air leak may be at the chest tube insertion, which will require you notifying the MD \u25cfIf the air leak does not stop when you apply the padded clamp, the air leak is between the clamp and the drainage system\u2014you must now assess the system to carefully locate the leak 41
Angina\ue601 (low oxygen to heart tissue) = no dead heart tissues Myocardial Infarction (MI)\ue601 = dead heart tissue present \u25cfMI pain tends to be in morning hours Blood tests for MI:\ue601 myoglobin, CK and Troponin \u25cfTroponin levels are elevated 3 hours after onset of MI- most specific to cardiac muscle injury or infarction MONA- FIRST GIVE OXYGEN *Most common complication following MI- arrhythmias (ventricular being the most serious) Chest pain\ue601 in a client undergoing a stress test indicates myocardial ischemia and is an indication to stop testing to avoid ongoing ischemia, injury, or infarction Anti-cholesterol\ue601 \ue601medications\ue601 should be given with evening meal (at night) Nitroglycerine\ue601 is administered up to 3 times (every 5 minutes)\u2014if chest pain does not stop- GO TO HOSPITAL or call 911\u2014do not give if blood pressure is <90\/60 Preload affects amount of blood that goes to the right ventricle, afterload is the resistance the blood has to overcome to leave the heart Calcium channel blockers \ue601affect afterload \u25cfDO NOT DRINK GRAPEFRUIT JUICE WITH CCB DO NOT GIVE BLOCKERS (BETA BLOCKERS, CALCIUM CHANNEL BLOCKERS) to PATIENTS WITH HEART BLOCKS 42 For a \ue601CABG\ue601, when the great saphenous vein is taken, it is turned inside out due to the valves that are inside Unstable angina is not relieved by nitro Prochlorperazine maleate\ue601 (Compazine)- should be considered incompatible with all other medications in syringes Angiotensin II\ue601 is a potent vasodilator (from lungs) Aldosterone attracts sodium The past is gone- focus on the present and future! REVERSAL AGENTS\/ANTIDOTES a. Heparin = protamine sulfate b. Coumadin = vitamin K c. Ammonia = lactulose d. Acetaminophen = n-Acetylcysteine e. Magnesium sulfate= Calcium gluconate f. Iron = deferoxamine g. Digoxin = digibind h. TPA = aminocaproic acid (amicar) i. Methotrexate toxicity = leucovorin j. Alcohol withdrawal = Librium (Chlordiazepoxide) k. Opioids\/Narcotics = Naloxone (Narcan) l. Methadone is an opioid analgesic used to detox patients addicted to narcotics Low potassium\ue601 potentiates digoxin toxicity (low Mg too) Heparin prevents platelet aggregation COMMON NCLEX TOPIC PT- \ue60110- 14 seconds \u2013 therapeutic is 1.5 to 2 times INR\ue601- 0.8 to 1.2- therapeutic is 2 to 3 times PTT\ue601 \u2013 20-45 seconds- therapeutic is 1.5 to 2.5 times 43 Oral anticoagulant therapy\ue601 should be instituted 4-5 days before discontinuing heparin therapy Cardiac output decreases with dysrhythmias- dopamine increases blood pressure Med of choice for \ue601v-tach\ue601 and \ue601PVCs\ue601 is \ue601lidocaine Med of choice for \ue601SVT\ue601 and \ue601paroxysmal atrial tachycardia\ue601 is \ue601adenosine Med of choice for \ue601asystole\ue601 is \ue601atropine Med of choice for \ue601CHF\ue601 is \ue601ACE-Inhibitor Med of choice for \ue601burn pain management\ue601 is \ue601morphine sulfate Med of choice for \ue601candidiasis\ue601 is \ue601ketoconazole Med of choice for \ue601anaphylaxis\ue601 is \ue601epinephrine Med of choice for \ue601Status Epilepticus\ue601 is \ue601benzodiazepine\ue601 \ue601(valium, lorazepam) Med of choice for \ue601bipolar\ue601 is \ue601lithium \u25cfIncrease fluid intake with lithium (2500-3000 mL\/day) \u25cfMaintain adequate salt intake (2-3 grams per day) 44 \u25cfS\/E: increased U\/O and dry mouth \u25cfNo ETOH with lithium \u25cfTherapeutic level- 0.4 to 1.4 \u25cfToxic level \u2013 2 to 3: N\/V\/D, tremors (give mannitol and acetazolamide if signs of toxicity are present) Amiodarone\ue601 (anti-arrhythmic) is effective in both \ue601ventricular \ue601and \ue601atrial complications S3 (heart sound) is normal in CHF, not normal in MI *May also hear S3 in fluid volume overload Give sucralfate (anti-ulcer) before meals to coat stomach Pantoprazole (Protonix) is given prophylactically to prevent stress ulcers (PPI) Always check gag reflex following endoscopy TPN is given via subclavian line (requires central line) Diverticulitis\ue601 (inflammation of the diverticulum in the colon)- pain in LLQ \u25cfCan cause chronic or severe bleeding, if no obvious blood in the stool, the stool may be tested for occult blood Bipolar Disorder *\ue601Avoid competitive games when in manic phase (leads to increase in agitation) Schizophrenia-\ue601 inappropriate affect ETOH Dependence \u25cfIndication of need for more sedation- steadily increasing vital signs\u2014client is approaching DTs Appendicitis\ue601 (inflammation of the appendix)- pain is in RLQ with rebound tenderness Portal hypertension + albuinemia = ascites Beta cells of the pancreas produce insulin Trousseau \ue601(carpal spasm with upper arm compression)\ue601 \ue601and \ue601Chvostek\u2019s sign (facial nerve) are observed in \ue601hypocalcemia 45 \u25cfChvostek- twitching- tapping face just below and in front of ear\u2014neuro manifestation Never give K+ in IV push Blood Transfusions \u25cfALWAYS ALWAYS ALWAYS \ue601NORMAL SALINE \u25cfUse Y-connector \u25cfLarge-bore needle should be used (usually 20 gauge) \u25cfShould be infused as soon as possible after they are obtained \u25cfIf patient presents with S\/S of reaction- STOP the INFUSION! Types of Reactions \u25cfAllergic-\ue601 Mild facial flushing, hives\/rash, increased anxiety, wheezing, dyspnea, hypotension \u25cfFebrile- \ue601Fever, chills, anxiety, headache, tachycardia, tachypnea \u25cfHemolytic-\ue601 N\/V, pain in lower back, hypotension, tachycardia, decreased urinary output, hematuria, fever, chest pain *FOR ALL REACTIONS- Stop\ue601 infusion and maintain line with NS Also supportive care (oxygen, Benadryl, airway), obtain urine specimen, blood product goes back to lab 46 Avoid douching before pap smear\u2014affects appearance of cells in vaginal smear Mineral (fludrocortisone- help manage bp) and glucocorticoids (hydrocortisone) are given in Addison\u2019s disease Sign of fat embolism\ue601- \ue601petechiae\ue601- treated with heparin For knee replacement- use CPM machine Give prophylactic antibiotic therapy before invasive procedures Glaucoma\ue601 patients lose \ue601peripheral\ue601 vision- treated with medications Cataracts\ue601- cloudy, blurry vision \u2013 treated by lens removal-surgery CO2 causes vasoconstriction Most \ue601spinal\ue601 \ue601cord\ue601 \ue601injuries\ue601 are at the \ue601cervical\ue601 or \ue601lumbar\ue601 regions \u25cfFlaccid bladder- GOAL- want to promote acidic urine oClient should drink cranberry juice, tomato juice, bouillon Autonomic dysreflexia\ue601 (life threatening- inhibited sympathetic response of nervous system to harmful stimulus- spinal cord injuries at T7 or above)- usually triggered by a full bladder Spinal shock\ue601 occurs immediately after spinal injury 47 Multiple Sclerosis\ue601- chronic progressive disease with destruction of myelin sheath, disruption in nerve impulse conduction\u2014affects white matter of the brain and spinal cord *Hyperactive deep tendon reflexes, vision changes, fatigue and spasticity are common symptoms \u2013 UTIs are common and may lead to sepsis \u25cfMotor:\ue601 limb weakness, paralysis, slow speech \u25cfSensory:\ue601 numbness, tingling, tinnitus \u25cfCerebral:\ue601 nystagmus, ataxia, dysphagia, dysarthria Huntington\u2019s Chorea-\ue601 autosomal dominant disorder (50% chance of inheriting) S\/S:\ue601 chorea (jerky, involuntary movement effecting shoulders, hips, and face); gait deteriorates with no ambulation, \ue601no cure, palliative Guillan-Barre Syndrome\ue601 = ascending paralysis (feet to head)- watch for respiratory system challenges Parkinson\u2019s\ue601 = RAT \ue601\u2192\ue601 R- rigidity, A- akinesia (loss of muscle movement), T- tremors \u25cfTx: CBT (Can Block Tremors)- \ue601C\ue601arbidopa\/Levidopa, \ue601B\ue601enzotropine, T\ue601rihexyphenidyl HCl *\ue601Drooling in Parkinson\u2019s is a concern\u2014risk for aspiration (airway) Transient Ischemic Attack\ue601 (TIA)- mini stroke with no dead brain tissue Cerebrovascular accident\ue601 (CVA) \u2013 dead brain tissue Hodgkin\u2019s disease\ue601 = cancer of lymph- very curable in early stages Ranitidine \ue601\u2013 if taking once daily, should take at hour of sleep (absorption not affected by food) When pulse rate \ue601drops\ue601 in a patient with a \ue601pacemaker\ue601, it is cause for concern! Polycythemia\ue601- increase in RBCs as compensation for decrease in oxygenation- seen in right-sided heart failure Cor Pulmonae:\ue601 right sided heart failure caused by left ventricular failure (S\/S- edema, JVD) Pulmonary sarcoidosis leads to \ue601right sided \ue601HF DO NOT PICK COUGH over TACHYCARDIA for signs of CHF in an infant! 48 Congestive Heart Failure Ventricular gallop is the earliest sign of CHF Early signs\/stage of circulatory overload (seen in CHF) is change in character of respirations 49 Rule of Nines\ue601 for \ue601Burns m. n. Head & neck (front and back) = 9% o. Torso = 18% (upper\/chest and lower\/abdomen are each 9%) p. Back = 18% (upper back- 9%; lower back\/buttocks \u2013 9%) 50 q. Each arm is 9% r. Each leg is 9% s. Groin\/genitalia = 1% *Example: If an adult had burns on both legs (9% + 9%), their groin (1%), and the chest (9%) and abdomen (9%) \u2013 55% of their body is burned! This rule helps guide treatment and fluid replacement! Parkland Formula\ue601- 4mL x kg body weight x % of total burned surface = amount of fluid to be infused over 24 hours **Half that amount of fluid is to be infused over the first 8 hours (minus any fluid infused pre-hospital) (Page 159 in ATI review book) Priorities with Burns\ue601- 1) ABCs 2) Cardiac output 3) Fluids 4) Infection Electrical burns\ue601- EKG Chemical burn\ue601- \ue601do not touch\ue601 until decontaminated (need to know the type of chemical) Thermal burn\ue601- breathing is the #1 concern Smoke\ue601- look inside nose for signs of smoke inhalation *\ue601WITH BURNS TO FACE AND CHEST- BE CONCERNED ABOUT AIRWAY EDEMA Important to maintain aseptic technique with burns- high risk of infection Emergency care of partial thickness burns\u2014remove clothing and wrap in clean sheet *\ue601No soaps or ointments should be used in an emergency burn situation BURNS \u25cf1\ue601st\ue601 degree-\ue601 red and painful \u25cf2\ue601nd\ue601 degree-\ue601 blisters \u25cf3\ue601rd\ue601 degree- \ue601no pain because blocked and burned nerves 51 Birth weight doubles by 6 months and triples by 1 year of age If HR is <100 in children, hold digoxin Cystic Fibrosis\ue601-\ue601 inherited by autosomal recessive trait First sign of cystic fibrosis may be meconium ileus (bowel obstruction) at birth\u2014baby is inconsolable, does not eat, does not pass meconium \u25cfRespiratory problems are the chief concern oAirway clearance techniques are critical (postural drainage\/chest physiotherapy) \u25cfGive aerosol bronchodilators, mucolytics and pancreatic enzymes \u25cfCystic Fibrosis- diet oLow fat oHigh sodium oFat soluble vitamins- ADEK Heart defects\ue601- \ue601Cyanotic = 3 T\u2019s\ue601 (Tetrology of Fallot, Truncus arteriosus, transposition of the great vessels)\u2014blood does not adequately return to the heart\ue601\u2192\ue601 if problem does not fix itself, or cannot be corrected surgically, CHF will occur\ue601\u2192\ue601 followed by death With \ue601right-sided cardiac catheterization\ue601- look for valve problems With \ue601left-sided cardiac catheterization\ue601- look for coronary complications Rheumatic fever\ue601 can lead to cardiac valve malfunctions\/disease *Group-A strep precedes rheumatic fever \u25cfPatients experience chorea (grimacing, sudden jerky body movements) \u25cfJoint pain is common \u25cfPenicillin is usually given \u25cfWatch for anti\ue601strep\ue601tolysin O to be elevated 52 Cerebral palsy\ue601 = poor muscle control due to birth injuries and\/or decreased oxygen to brain tissues Phenytoin (Dilantin) therapeutic level \u2013 10-20; can cause gingival hyperplasia Meningitis\ue601- \ue601nuchal rigidity, headache, photosensitivity, fever-\ue601 Kernig\u2019s and Brudzinski\u2019s sign *CSF in meningitis- \ue601high protein\ue601, low glucose Wilm\u2019s tumor\ue601- usually encapsulated above the kidneys- causing flank pain- \ue601DO NOT PALPATE THE ABDOMEN Focus on your achievements rather than your failures\u2014look at what you managed to do well and how you can improve! Traction Skin Traction \u25cfBuck\u2019s Traction- used to maintain proper alignment- hip fractures- want to maintain skin integrity and circulation \u25cfBryant\u2019s \u25cfCervical halter \u25cfPelvic Skeletal Traction \u25cfApplied directly to a bone to reduce a fracture or maintain a surgically manipulated bone alignment oPins or wires inserted through skin and soft tissue into the bone oBalanced suspension using splints, slings, weights External Fixation Devices \u25cfRigid metal frames with attached percutaneous pins or wires used to align and immobilize oHalo Traction- THINK SAFETY FIRST\u2014always have a screwdriver nearby *Place apparatus first, then place the weights when putting a patient in traction Nursing Considerations for Traction \u25cfTeach about movement 53 \u25cfDO NOT ADJUST WEIGHTS\ue601 (they should NEVER be on the floor\u2014not exerting pulling force) \u25cfReport pain (look for signs of compartment syndrome) \u25cfMaintain skin integrity and circulation *Nurse must always follow the chain of command \u2013 report to nursing supervisor or nurse manager Compartment Syndrome\ue601-\ue601 \ue601EMERGENCY SITUATION \u25cfParesthesia\ue601 and \ue601increased pain\ue601 are classic symptoms\u2014neuromuscular damage is irreversible 4-6 hours after onset A patient with a vertical c-section will more likely have another c\/s Perform \ue601amniocentesis\ue601 (14-16 weeks) to check for fetal anomalies- Down Syndrome, Trisomy 18, Trisomy 13; detect presence of AChE in neural tube defects *When it is performed late in pregnancy it can assess fetal lung maturity and fetal well-being **Administer Rhogam to Rh- women Rhogam \ue601is a blood product\u2014as such, for NCLEX purposes, \ue601ONLY\ue601 RN\u2019s can administer Rhogam IM to client (do not delegate to LPN\/LVN) 54 Indirect Coomb\u2019s Test\ue601- \ue601Negative (normal) result means no antibodies are found; positive (abnormal) result means antibodies were found\u2014\ue601DO NOT ADMINISTER RHOGAM TO A WOMAN WHO IS \ue601POSITIVE\ue601! RhoGAM\ue601 must be given \ue601prior\ue601 to the \ue601Rh negative women becoming sensitized\u2026 which is why \ue601RhoGAM\ue601 is given \ue601prophylactically\ue601: \u25cfDuring pregnancy (at 28-30 weeks) or any time the mother is exposed to fetal blood (such as after an amniocentesis, miscarriage, etc) \u25cfThen \ue601after the birth of each Rh positive newborn\ue601, if no antibodies are identified in the mother (negative indirect Coombs), within 72 hours after delivery Nagele\u2019s Rule\ue601: Subtract 3 months and add 7 days to first day of last menstrual period Anterior\ue601 fontanel closes by 18 months Posterior\ue601 fontanel closes by 6-8 weeks *Posterior closes before anterior Caput succedaneum\ue601 = diffuse edema of the fetal scalp that crosses the suture lines- swelling reabsorbs within 1-3 days Pathological jaundice\ue601- occurs \ue601before 24 hours\ue601 and lasts \ue6017 days 55 Physiological jaundice\ue601- occurs \ue601after 24 hours \u25cfPhototherapy considered for infant with total serum bilirubin >15 mg\/dL at 72 hours of age Placenta previa\ue601- bright red bleeding, no pain- \ue601NO VAGINAL EXAMS Placental abruption\ue601- pain, no bleeding, rigid\/board-like abdomen (monitor fluid volume stauts\/I&O) Betamethasone\ue601 = surfactant- given to mothers in pre-term labor to help baby\u2019s lungs mature before delivery \u2013 given in 2 doses (12-24 hours apart) Magnesium sulfate\ue601- anticonvulsant for pregnant women with risk of seizures due to HTN *Also used as a tocolytic to halt pre-term labor \u2013 contraindicated for women with myasthenia gravis, also with absent deep tendon reflexes \u25cfMagnesium sulfate-\ue601 (CNS depressant) can cause slowing of respirations and hyporeflexia; oliguria is another S\/E Oral (PO) medications are not recommended in labor\u2014decreased GI motility When breastfeeding- only wash breasts with water\ue601\u2192\ue601 soap should be avoided as it causes dryness Fundal height should correlate with weeks of pregnancy *26 weeks = 26cm Epigastric pain in pregnancy\ue601\u2192\ue601 usually a sign of impending convulsion (according to Kaplan) Crisis intervention = short term FIVE INTERVENTIONS FOR PSYCH PATIENTS 1. Safety 2. Setting limits 3. Establish trusting relationship 4. Medications 5. Least restrictive methods\/\ue601environments\ue601 to most restrictive Most antidepressants take 3 weeks to take effect Obsession = thought Compulsion = action Hallucinations- \ue601redirect patient Delusions- \ue601distract patient 56
Thorazine, Haldol (antipsychotics) can lead to EPS Alzheimer\u2019s disease\ue601 is a chronic, progressive, degenerative cognitive disorder that accounts for more than 60% of all dementias \u25cfPatient\u2019s do not do well with short term memory \u25cfReality orientation- orient to what is going on right \ue601now \u25cfSafety and reorientation \u25cfPlace calendar and clock in obvious area \u25cfRemind client of room and bathroom location Atropine\ue601 can be used to decrease secretions (drops)- blocks acetylcholine \u25cfHolding pressure on the inner canthus (eye) decreases the amount of medication absorbed systemically (atropine drops) *\ue601Atropine Overdose \u25cfHot as a Hare \u2013 elevated temperature \u25cfMad as a Hatter- change in LOC \u25cfRed as a Beet- flushed face \u25cfDry as a Bone- thirsty Decreased acetylcholine\ue601 is related to senile \ue601dementia Dementia \u25cfGeriatric client should be encouraged to talk about his life and important things in the past Jill\u2019s Favorite Medication: Promethazine\ue601 (Phenergan): anti-histamine; can be given as an antiemetic for nausea\u2014crosses BBB\u2014sedative effect \u2013 monitor fluid status (anticholinergic effects- anorexia, dry mouth and eyes, constipation, orthostatic hypotension) Iron injections should be given Z-track method so they do not leak into SQ tissues Diazepam\ue601 is commonly used as tranquilizer\u2014to reduce anxiety before surgery Open wound in chest cavity\ue601- air needs to escape but not re-enter *Three sided dressing Auscultation of Heart Sounds- A\ue601ll– Aortic P\ue601igs– Pulmonic E\ue601at\u2014Erb\u2019s point 57
T\ue601oo\u2014Tricuspid M\ue601uch\u2014Mitral Cranial Nerves \ue601(mnemonic from \u201coriginal GOLD\u201d) Oh (Olfactory I) Some (Sensory) Oh (Optic II) Say (Sensory) Oh (Oculomotor III) Marry (Motor) Tiny (Trochlear IV) Money (Motor) Tits (Trigeminal V) But (Both) Are (Abducens VI) My (Motor) Fun (Facial VII) Brother (Both) And (Auditory VIII) Says (Sensory) Give (Glossopharyngeal IX)Big (Both) Virgins (Vagus X) Bras (Both) Awkward (Accessory (XI) Matter (Motor) Hips (Hypoglassal XII) More (Motor) 58
HYPERNATREMIA \ue601(greater than 145) S\ue601kin flushed A\ue601gitation L\ue601ow grade fever T\ue601hirst HYPONATREMIA\ue601 (less than 135) Muscle twitching Convulsions Diarrhea Headache Apprehension Lethargy Developmental 2-3 months\ue601- demonstrates head lag, able to turn head up (can lift off mattress), tummy time, can turn side to side, cooing or gurgling noises and can turn head to sound, palmar grasp 4-5 months\ue601- rolls from back to side (4), places objects in mouth, rolls from front to back (5) 6-7 months\ue601- rolls from back to front, holds bottle\/sippy cup, sits at 6 and waves bye\/bye; can recognize familiar faces and knows if someone is a stranger, moves objects from hand to hand 8-9 months\ue601- stands straight at 8; sits unsupported, begins using pincer grasp, has favorite toy, plays peek-a-boo 59
10-11 months\ue601- crawling, changes from a prone to a sitting position (belly to butt), grasps rattles by its handles, finger foods 12-13 months\ue601- sits down from a standing position without assistance, starts walking (uses furniture to cruise), tries to build a two-block tower without success; cries when parents leave *Twelve and up, drink from a cup Hepatitis -ends in a VOWEL and comes from the BOWEL (Hep A) -Hepatitis \ue601B\ue601- \ue601B\ue601lood and \ue601B\ue601odily fluids -Hepatitis C is just like B GLASGOW COMA SCALE -Eyes, verbal, motor *It is similar to measuring dating skills- max 15 points, one can do it! If \ue601below 8\ue601, you are in a \ue601coma -\ue601To start dating, you have to open your \ue601EYES\ue601 first- if you are able to do that spontaneously and use them correctly to \ue601SEE\ue601 whom you are dating, you earn 4 points\u2014but if she has to scream at you to make you open them it is only 3 points. If you dare not to open your eyes, even if she kicks you, you only get 1 point! -If you get good EYE contact (4 points) then move on to \ue601VERBAL\ue601\u2014talk to her\/him, if you can do that you are oriented (4 points)\u2014if you like her try not to be \ue601CONFUSED\ue601 (3 points), and of course do not use \ue601INAPPROPRIATE WORDS\ue601 (3 points) because she won\u2019t like it\u2014try not to respond with INCOMPREHENSIBLE SOUNDS \ue601(2 points)\u2014but if you just don\u2019t like her\u2014do not respond at all- \ue601NO VERBAL RESPONSE\ue601 (1 point) -Since you now have EYE and VERBAL contact you can MOVE to Motor Response- this is VERY important, because good moves give you 6 points! You\u2019re simply the BEST- better than all the rest! The person who hyperventilates is likely experiencing \ue601respiratory alkalosis Avoid \ue601salt substitutes\ue601 when taking digoxin and K-supplements\u2014because they contain high levels of potassium Signs of\ue601 \ue601hypoxia\ue601: restless, anxious, cyanotic, tachycardia, increased respirations (also monitor ABGs) For \ue601blood types\ue601: \u201cO\u201d is the universal donor (remember \u201cO\u201d in donor) \u201cAB\u201d is the universal recipient 60
**In emergency situations where typing and cross-matching have not yet been completed, \u201cO\u201c can be given! Medications to be given with food:\ue601 \ue601NSAIDs, corticosteroids, medications for Bipolar Disorder, cephalosporins, and sulfonamides When using a bronchodilator in conjunction with a glucocorticoid inhaler, administer the \ue601bronchodilator first! Theophylline increases the risk of digoxin toxicity and decreases the effects of lithium and phenytoin Peptic ulcers\ue601 caused by H. \ue601pylori\ue601 are treated with Metronidazole (Flagyl), Omeprazole (Prilosec), and Clarithromycin (Biaxin)\u2014this treatment kills bacteria and stops production of stomach acid- \ue601it does not heal the ulcer! A \ue601board-like abdomen\ue601 with shoulder pain is a symptom of a perforation, which is the most lethal complication of peptic ulcer disease Projectile vomiting can be a signal of obstruction in the GI tract Diaphragm must stay in place for 6 hours after intercourse *Also must be re-fitted if patient loses or gains a significant amount of weight! Best time to take medications: Growth Hormone (PM) Steroids (AM) Diuretics (AM) \u2013 prevent nocturia Donepezil (Aricept) (AM)- Alzheimer\u2019s medication Cholesterol medications (PM) Sulcrafate (before meals)- acts as a mucosal barrier\u2014S\/E: constipation Cimetidine (with meals and\/or at bedtime)- many interactions Antacids (1 hour after eating or when experiencing heartburn)- large amounts of antacid consumption can lead to osteoporosis Glaucoma\ue601- intraocular pressure is greater than normal\u2014give \ue601miotics\ue601 to constrict (pilocarpine) \u2013\ue601 NO ATROPINE \u25cfTonometer is used to measure IOP and diagnose glaucoma oNormal- 10 to 21 mmHg (according to Kaplan) Dietary calcium-\ue601 dairy products, seafood, nuts, broccoli, spinach Non-dairy sources of \ue601calcium-\ue601 RHUBARB, SARDINES, COLLARD GREENS \u25cfDaily calcium intake- 1000 to 1500mg With low back pain\/aches, bend knees for pain relief (\ue601William\u2019s position\ue601) 61
When taking \ue601allopurinol\ue601, patients should increase fluids to flush uric acid out of system! Koplik\u2019s spots\ue601 are red spots (commonly found in mouth) with a bluish\/whitish center\u2014characteristic of \ue601PRODROMAL\ue601 phase of \ue601MEASLES Tuberculosis (TB)-\ue601 medications must be taken for 6 to 9 months Endemic to Asia, Middle East, Africa, Latin America, Caribbean A \ue601positive PPD confirms infection\ue601, not just exposure\u2014a sputum test confirms \ue601active \ue601disease PPD\ue601 is (+) if induration is: \u25cf>5mm\ue601 for immunocompromised patients \u25cf>10mm\ue601 for high risk populations (IV drug users, recent immigrants, lab personnel, children <4 years) \u25cf>15mm\ue601 positive in any person (patients with no risk factors) If a TB patient is unable\/unwilling to adhere with treatment\u2014may need supervision (direct observation) \ue601\u2192\ue601 TB is a public health risk TB medications are toxic to the liver Adverse reaction is peripheral neuropathy Most accidental eye injuries (90%) could be prevented by wearing eyewear for sports and hazardous work Eye Drop Application Apply eye drops to the conjunctiva sac\u2014apply pressure to lacrimal duct\/inner canthus (prevents systemic absorption) Trendelenburg test for varicose veins\ue601\u2014patient lies in supine position, leg is flexed at the hip and raised above the heart, the veins will empty due to gravity (or with the assistance of the examiner\u2019s hand squeezing the blood towards the heart)\u2014a tourniquet is then applied around the upper thigh to compress the superficial veins but not too tight as to occlude the deeper veins\u2014the leg is then lowered and the patient is asked to stand. If the superficial veins fill more rapidly (than 30-35 seconds) with the tourniquet, there is valvular incompetence below the level of the tourniquet in the \u201cdeep\u201d veins\u2014after 20 seconds, if there is no rapid filling, the tourniquet is released\u2014if there is sudden filling at this point, it indicates that the deep veins are competent but the superficial veins are incompetent! *\ue601If superficial veins fill with tourniquet\u2014deep veins are incompetent *If there is sudden filling after tourniquet it removed\u2014superficial veins are incompetent 62
Precautions when giving KAYEXALATE \u25cfAssess for dehydration (K+ has inverse relationship with Na\u2014when you decrease potassium, sodium increases) \u25cfAssess patient for bowel sounds before administering\u2014if hypoactive or absent bowl sounds\u2014\ue601HOLD \u25cfMonitor for electrolyte imbalances \u25cfInteractions oCaution with Digoxin (hypokalemia can lead to digoxin toxicity) oKayexalate may decrease the absorption of \ue601lithium oKayexalate may decrease the absorption of thyroxine Yogurt has live cultures- \ue601do not give to immunocompromised patients For itching under a cast- cool air via blow dryer, ice pack on cast for 10-15 minutes\u2014\ue601NEVER\ue601 stick anything in the cast to scratch the area After \ue601PERITONEAL DIALYSIS\ue601- it is \ue601OKAY\ue601 to have abdominal cramps, blood tinged outflow, and leaking around the site \ue601IF \ue601it was placed in the last 1-2 weeks\u2014\ue601IT IS NEVER NORMAL \ue601to have \ue601CLOUDY OUTFLOW Amniotic fluid\ue601-\ue601 yellow with particles = meconium stained (baby is stressed) Hyper-reflexes\ue601- upper motor neuron issue (\u201cyour reflexes are over the top\u201d) Hypo-reflexes\ue601 (absent)- lower motor neuron issue Order of Assessment\ue601- \ue601(IPPA) \ue601Inspection, Palpation, Percussion, and Auscultation\ue601\u2192\ue601 \ue601EXCEPT\ue601 with abdomen\u2014you do not want to activate the bowels with your assessment so the order is: inspection, auscultation, percussion, palpation (also, if patient is presenting with abdominal problem, palpation and percussion may be painful so should be left for the end) SIGNS \u25cfMurphy\u2019s Sign\ue601- pain with palpation of gall bladder area (seen with cholecystitis) \u25cfCullen\u2019s Sign\ue601- ecchymosis in umbilical area, seen with pancreatitis (bruising) \u25cfTurner\u2019s Sign\ue601- ecchymosis (grayish blue) over flank areas- sign of pancreatitis (\ue601bad sign\ue601) \u25cfMcBurney\u2019s Point\ue601- pain in RLQ indicative of appendicitis \u25cfRebound tenderness\ue601 in RLQ\u2014appendicitis \u25cfRLQ pain\ue601- appendicitis, watch for peritonitis \u25cfLLQ pain\ue601- diverticulitis (should maintain low reside diet, no seeds, nuts, peas) 63
\u25cfGuthrie Test\ue601- tests for phenylketonuria in newborns\u2014babies should eat source of protein first \u25cfAllen\u2019s Test\ue601- occlude both ulnar and radial arteries until hand blanches, then release ulnar\u2014if the hand returns to pink color\u2014ulnar artery is good and you can use for ABG\/radial arterial line\/stick as planned\u2014ABGs must be drawn in a heparinized tube, placed on ice and sent immediately to lab\u2014should also inform lab of how much oxygen the patient is on (and via NC, mask, etc.) \u25cfSchilling Test\ue601- tests for pernicious anemia\u2014how well one absorbs Vitamin B12 LATEX ALLERGY- \u25cfAssess patient for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnut, tomatoes, peaches (also see above diagram) Amyotrophic Lateral Sclerosis (ALS)\ue601 is a condition in which there is degeneration of motor neurons in both the upper and lower motor neuron systems Transesophageal Fistuala (TEF)\ue601-\ue601 esophagus does not fully develop (this is a surgical emergency) *\ue601The 3 C\u2019s of TEF in newborn \u25cfChoking \u25cfCoughing \u25cfCyanosis The \ue601MMR vaccine\ue601 is given \ue601SQ\ue601 not IM -First dose recommended between 12 months and 15 months 64
-Contraindicated with allergy to gelatin and neomycin (also should not be given to immunocompromised patients because it is a live vaccine) -Should not be given to pregnant women -Because MMR is a live vaccine, it is \ue601not\ue601 uncommon to spike a fever Triage in Disaster\/Mass-Casualty Situations *Greatest good for the greatest number Red\ue601-\ue601 IMMEDIATE\/EMERGENT: unstable, injuries are life threatening but survivable; \ue601do not delay \ue601treatment\u2014airway, breathing, and circulation Ex: Airway obstruction, shock Yellow\ue601-\ue601 URGENT: major injuries that require treatment; \ue601can delay treatment 1-2 hours Ex: Open fracture Green\ue601-\ue601 NONURGENT: minor injuries that do not require immediate treatment, can delay 2 to 4 hours Ex: \u201cWalking wounded\u201d, closed fracture, contusions Black\ue601- EXPECTANT: expected and allowed to die, prepare for morgue, comfort measures if possible Ex: Profound hemorrhage, cardiac arrest DOA\ue601- Dead on Arrival Orange\ue601-\ue601 psychiatric, non-urgent Greek heritage- use of protective charms or amulet (necklace) around baby\u2019s neck to protect against evil 4 year old kids cannot interpret TIME\u2014they need time to be explained in relationship to a known common event\u2014Ex: Mom will be back after supper Allergies and Interactions \u25cfHep B Vaccine\ue601 \u2013 should not receive if allergy to \ue601yeast \u25cfHep A Vaccine\u2014\ue601should not receive if pregnant \u25cfFlu shot\ue601\u2014should not receive if allergy to \ue601eggs \ue601(also contraindicated for patient\u2019s with a history of Guillain Barre)\u2014\ue601OK \ue601to give to immunocompromised patients oIf a child has a cold, it is okay to give immunizations \u25cfDTaP\/Tdap\ue601- contradindicated with occurrence of seizures within 3 days of vaccine (possible adverse reaction- seizures) oHigh fever 48 h after DTap is a valid contraindication for vaccine \u25cfRotavirus\ue601 \ue601Vaccine- \ue601do not give if allergy to \ue601mycin\ue601 drugs (aminogylcosides) 65
\u25cfVaricella\ue601 \ue601Vaccine\ue601- should not receive if allergy to gelatin and neomycin or immunocompromised \u25cfMeningococcal Vaccine\ue601- should not receive if history of Guillain Barre) \u25cfHPV Vaccine\ue601- should not receive if allergy to yeast and\/or pregnancy \u25cfPenicillins \ue601and\ue601 cephalosporins\ue601- crossover allergy (question orders of administering med if patient has documented\/known allergy to either \u25cfAspirin\ue601 and \ue601Naproxen\ue601- crossover allergies with NSAIDs Adult Immunizations Schedule \u25cfTetanus booster- every 10 years \u25cfMMR- one or two doses at ages 19 to 49 \u25cfVaricella- two doses if no history of disease \u25cfPneumococcal (PPSV)- once after the age of 65; recommended for immunocompromised, COPD, and living in long-term care facility \u25cfHepatitis A- two doses for high risk clients \u25cfHepatitis B and HPV- three doses for high risk clients (Hep B repeated @ 1 and 6 months) oHPV should be given ideally before the patient is sexually active \u25cfSeasonal influenza- annually; give to immunocompromised \u25cfMeningococcal vaccine- students entering college, adults older than 65 repeat every 5 years for high-risk clients \u25cfHerpes zoster- over age 60 Live Vaccines-\ue601 do not give to immunocompromised and pregnant women \u25cfMMR \u25cfVaricella \u25cfNasal spray (flu) When on nitroprusside, monitor thiocynate (cyanide)\u2014normal value should be 1 \u2192\ue601 >1 is heading towards toxicity Severe Acute Respiratory Syndrome (SARS)\u2014\ue601airborne and contact (just like varicella) Hepatitis A is contact precautions \u25cfNot infectious within a week or so after onset of jaundice Tetanus, Hepatitis B, HIV are \ue601STANDARD\ue601 precautions Avoid high fat diet for Hepatitis B NO VITAMIN C with ALLOPURINOL No longer contagious after 24 hours of antibiotics 66
HIV \u25cfMedications need to be taken very consistently\u2014failure to take the medications daily can lead to mutations and the emergence of more virulent forms of the virus \u25cfViral load testing measures the amount of HIV genetic material in the blood, so a decrease in the viral load indicates that the HAART is effective \u25cfRapid HIV testing must be confirmed by another test, usually Western blot test \u25cfInfants born to an HIV-positive mother \ue601should receive all immunizations\ue601 on schedule \u25cfA positive \ue601Western blot\ue601 in a child < 18 months (presence of HIV antibodies) indicates only that the \ue601mother \ue601is infected \u2013 two or more positive \ue601P24 antigen\ue601 tests will confirm HIV in children <18 months\u2014\ue601P24\ue601 can be used at any age \u25cfKaposi\u2019s sarcoma lesions should be cleaned and dressed daily to prevent secondary infection \u25cfAvoid OPV (polio) and varicella vaccines in HIV + (both live)\ue601\u2192 pneumococcal and influenza are OKAY oMMR is \ue601only\ue601 avoided if \ue601severely\ue601 immunocompromised oParents should wear gloves for care, avoid sharing utensils and avoid kissing on the mouth (due to immunocompromised status\u2014not for transmission purposes) Signs of fractured hip:\ue601 external rotation, shortening of affected leg, adduction Rotavirus\ue601- spread via fecal-oral route- contact precautions for diapered and incontinent patient\u2019s Fat embolism\ue601- blood tinged sputum (related to inflammation), elevated ESR, respiratory alkalosis (related to tachypnea), hypocalcemia, increased serum lipids, \u201csnow storm\u201d effect on chest X-ray Complications of Mechanical Ventilation\ue601- pneumothorax, ulcers, pneumonia (ventilator associated) Paget\u2019s Disease\ue601-abnormal bone destruction and regrowth; cause unknown (may be genetic or due to virus early in life) *S\/S: tinnitus, bone pain, enlargement of bone (though weak\/soft), headache, hearing loss, reduced height, bowing of the legs, hypercalcemia Intravenous Pyleogram (IVP)-\ue601 requires bowel prep in order to better visualize the urinary tract (bladder, kidneys, ureters, urethra) Acid Ash Diet- meat, poultry, cheese, fish, eggs, grains, cranberries, prunes, plums 67 Greenstick fractures\ue601 are commonly seen in children (also known as buckle fractures)\u2014bends on one side and cracks on the other BOTOX\ue601 can be used for strabismus (12 and older)\u2014patch the \ue601GOOD\ue601 eye to allow the weaker eye to get stronger COPD\ue601 patients- 2L via NC or less (hypoxic not hypercapnic drive), PaO2 in 60\u2019s and SaO2 of 90% is normal\u2014chronic CO2 retainers Amphotericin B- \ue601(\ue601Amphoterrible\ue601): treats infection caused by a fungus *Should only be given to patients with severe, life threatening fungal infection Side Effects: fever (common), hypokalemia *Must \ue601premedicate-\ue601 Tylenol and Benadryl can be used Mebendazole\ue601 (Vermox) is used to treat worm infections (pinworms, roundworms, hookworms)\u2014increase fat in diet to increase absorption Kidney glucose threshold\ue601 is 180\u2014when the blood glucose levels exceed 160-180 mg\/dL, the proximal tubule becomes overwhelmed and begins to excrete glucose in the urine Glucose Tolerance Test\ue601 for pregnant women- results of 140 or higher needs further evaluation Lymes is found mostly in Connecticut For \ue601asthma\ue601 and \ue601arthritis\ue601\u2014swimming is best Intercostal retractions and asthma\ue601\u2014\ue601BE CONCERNED\ue601 \u2013 also, if the asthma patient in the waiting room becomes silent\u2014wheezer stops wheezing (\ue601RED FLAG\ue601) Coughing without other S\/S is suggestive of asthma Increased pulse rate with asthma\u2014indicating decreased oxygenation Tardive Dyskinesia\ue601- irreversible, involuntary movements of the tongue, face, and extremities\u2014may happen after prolonged use of antipsychotics Akathisia\ue601- motor restlessness; treated with Anti-Parkinson medications\u2014can sometimes be mistaken for agitation Before \ue601Pulmonary Function Tests\ue601 (PFTs)\u2014bronchodilators should be withheld and they are not allowed to smoke for 4 days prior 68 For a \ue601lung biopsy\ue601\u2014position patient on side of bed with arms raised up on pillows over bedside table\u2014have patient hold breath in mid expiration, chest x-ray is done immediately to check for complications (pneumothorax)\u2014sterile dressing is applied- patient should lie on right side following biopsy EEG\ue601- \ue601before\ue601–hold medications 24-48 hours prior (anti-seizure medications), no caffeine or cigarettes for 24 hours prior, patient \ue601can\ue601 eat, must stay awake the night before the exam\u2014\ue601during\ue601 exam patient may be asked to hyperventilate and watch a bright flashing light\u2014\ue601after\ue601 exam- assess patient for seizures, patient is at an increased risk Decorticate\ue601- towards the \ue601cor\ue601d Decorticate positioning in response to pain = \ue601COR\ue601tex involvement Decerebrate\ue601- away from body Decerebrate positioning in response to pain = \ue601CEREB\ue601ellar, brain stem involvement *Definitive diagnosis for \ue601Abdominal Aortic Aneurysm\ue601 (AAA)- CT Scan WBC\ue601- shift to the left means there are a high number of immature white blood cells present\u2014most commonly this means there is an infection or inflammation present and the bone marrow is producing more WBCs and releasing them into the blood before they are fully mature Chronic Kidney Disease (Renal Failure) \u25cfProgressive, irreversible loss of renal function with associated decline in GFR \u25cfAll body systems affected- dialysis is required \u25cfEnd stage renal disease occurs with GFR <15 mL\/min 69 \u25cfCauses: oDM (leading cause) oHTN (second cause) oUnreversed acute kidney injury oGlomerulonephritis oAutoimmune disorders \u25cfNCLEX Points oAssessment \u25aaAzotemia (elevated BUN and creatinine) \u25aaCardio\ue601- HTN, hypervolemia, CHF \u25aaHematologic\ue601- anemia, thrombocytopenia \u25aaGastrointestinal\ue601- anorexia, N\/V \u25aaNeurological\ue601- lethargy, confusion, coma \u25aaUrinary\ue601- decreased urine output, proteinuria \u25aaSkeletal\ue601- osteoporosis oTherapeutic Management \u25aaEpoetin alfa aids in countering anemia \u25aaAvoid administering aspirin \u25aaMonitor K levels \u25cfElevated potassium can lead to EKG changes (peaked T waves, flat P, wide QRS, blocks, asystole) \u25cfProvide low potassium diet \u25cfPotassium lowering medications oKayexalate oInsulin oCalcium gluconate oContinuous cardiac monitoring \u25aaPhosphate binders may be required to lower phosphorous levels \u25aaMonitor daily weights \u25aaMonitor for signs of heart failure \u25aaMonitor electrolyte levels (will see low magnesium) and BUN\/Creatinine \u25aaAssess peripheral nerve function and monitor for peripheral neuropathy \u25aaVision can be affected- monitor and provide for a safe environment \u25aaInstruct client on dialysis and provide end of life care as needed \u25cfStage I- diminished kidney reserve \ue601\u2192\ue601 function is reduced but healthier kidney is able to compensate (polyuria and nocturia) oGFR >90mL\/min \u25cfStage II oGFR 60 to 89 mL\/min 70
\u25cfStage III oGFR 30 to 59 mL\/min \u25cfStage IV o15 to 29 mL\/min \u25cfStage V (End Stage Renal Disease) o<15 mL\/min Hemodialysis\ue601- process of cleansing the blood of accumulated waste products and fluids\u2014used for ESRD or for the acutely ill that require short-term treatment \u25cfHold meds prior to hemodialysis \u25cfMonitor BP- concerned about BP \u25cfCheck circulation \u25cfWeigh before and after \u25cfAV Fistula oAuscultate for whooshing sound over fistula (bruit and thrill), palpate for warmth and tenderness oNo weight on extremity oNo BP or blood work from fistula side oDo not lift heavy objects Peritoneal Dialysis\ue601- alternative method using the peritoneum to remove fluids, electrolyte, and waste products from the blood \u25cfWarm dialysate \u25cfAllow to flow in by gravity \u25cf5-10 min inflow time- close clamp immediately \u25cf30 min of equilibriation (dwell time) \u25cf10-30 min of drainage (should be clear and pale yellow) \u25cfMonitor for complications: peritonitis, bleeding, respiratory difficulty, abdominal pain, bowel or bladder perforation Continuous Ambulatory Peritoneal Dialysis (CAPD) \u25cfPermanent indwelling catheter inserted into peritoneum \u25cfFluid infused by gravity (1.5 to 3L) \u25cfDwell time- 4 to 8 hours \u25cfDialysate drains by gravity- 20 to 40 min \u25cfFour to five exchanges daily (7 days\/week)\u2014some elect to do it at night \u25cfFull colon can create outflow problems Uremic Fetor\ue601- urine smelling breath (seen in patients with uremia\u2014elevated serum urea level)\u2014seen in chronic kidney disease Normal Creatinine\ue601- 0.6 to 1.2 Normal BUN\ue601- 10 to 20 (some sources say 9 to 20) Normal GFR\ue601- 85 to 135 (<80 indicates decreased function) 71 Clients with kidney disease are susceptible to CNS effects (confusion and dizziness)\u2014dosage my need to be reduced Signs and Symptoms of Kidney Rejection \u25cfDiffuse pain over kidney (tenderness) Congenital Gastrointestinal Disorders Hypertrophic Pyloric Stenosis\ue601- \ue601projectile vomit \u25cfThickening of pyloric sphincter; genetic \u25cfManifestations:\ue601 \ue601vomiting\ue601 that occurs 30-60 min after a meal and becomes \ue601projectile\ue601 as obstruction worsens oConstant hunger oOlive-shaped mass in RUQ oPeristaltic wave that moves left to right when lying supine oFailure to gain weight and signs of dehydration \u25cfNursing Interventions oPlace child on side with head elevated when vomiting to prevent aspiration oDaily weight and I&O oMonitor fluid and electrolyte balance to assess for deficits oIV fluid replacement as needed oNPO oMonitor NG tube \u25cfTherapeutic Management oSurgical incision into the pyloric sphincter (pylorotomy) Hirschsprung\u2019s-\ue601 \ue601failure to pass meconium, ribbon-like stool \u25cfOccurs when a section of the colon is aganglionic \u2013 absence of ganglion cells (nerves that contribute to peristalsis)\u2014problem that prevents stool from moving forward in the GI tract \u25cfManifestations oNewborn\ue601-\ue601 failure to pass meconium\ue601 within 24-48 hours, refusal to eat, episodes of bilious vomit, abdominal distention oInfant- failure to thrive, constipation, abdominal distention, episodes of vomiting and diarrhea oOlder child- constipation, abdominal distention, \ue601ribbon-like stool\ue601, palpable fecal mass, malnourished \u25cfNursing Interventions oPosition child on side or with head elevated when vomiting to prevent aspiration oMonitor fluid and electrolyte balance to assess for deficits oProvide oral care after vomiting \u25cfTherapeutic Management oSurgical removal of the aganglionic section (colostomy may be temporary) 72 oSerial rectal irrigation may be used to decompress bowel prior to surgery Intussusception\ue601- \ue601bloody stool (red currant jelly) \u25cfTelescoping of the intestine upon itself; not a congenital condition but often occurs with congenital conditions such as \ue601cystic fibrosis \u25cfManifestations oNormal comfort interrupted by periods of sudden and acute pain oPalpable, sausage-shaped mass in RUQ of abdomen and\/or tender, distended abdomen oStools that are mixed with blood and mucus (red currant jelly) \u25cfNursing Interventions oPosition child on side or with head elevated when vomiting to prevent aspiration oMonitor fluid and electrolyte balance to assess for deficits oAssess for currant jelly stools \u25cfTherapeutic Management oSurgical reduction if inflating the bowel with air or administering barium enema is not successful oProton Pump Inhibitors (Omeprazole) oH2 Receptor Antagonists (Ranitidine) Cleft Lip (CL) and Cleft Palate (CP)\ue601-\ue601 aspiration \u25cfMultifactorial, but there are strong indicators of genetic or environmental factors \u25cfCleft palate \ue601is more common in \ue601males \u25cfCleft lip\ue601 is more common in \ue601females\ue601 (THINK: you are able to better visualize cleft lip externally\u2014females generally care more about their appearance\u2014therefore, cleft lip is more commonly seen in females) \u25cfManifestations oCleft lip is visible oCleft palate alone may only be visible when examining the mouth oIndividuals are prone to ear, nose, and throat infection oLong-term problems include speech, hearing, and dentition problems \u25cfNursing Interventions oAssess respiratory status and ease of respiratory effort oKeep suction equipment and bulb syringe at bedside oAssess ability to suck and swallow oModify feeding techniques utilizing obturators, special nipples, feeders oFeed in upright position in frequent, small amounts, burp frequently oDaily weight and monitor I&O \u25cfTherapeutic Management 73 oRepair usually completed by 12 to 18 months of age to prevent speech problems oSurgery may be performed in stages Avoid Vitamin C \ue601prior to occult stool test- can lead to false + All activities that the client participated in before a colostomy may be resumed after appropriate healing of the stoma and incisions Hypospadias-\ue601 abnormality in which the urethral meatus is located on the ventral aspect of the penis (below) Epispadias-\ue601 abnormality in which the urethral meatus is located on the dorsal side of the penis (top) Priapism\ue601- painful erection lasting longer than 6 hours Mastectomy-\ue601 complaints of \u201cwet sheets\u201d \u2013 could indicate hemorrhage from operative site Thank You Mary- Anticholinergic Effects Can\u2019t Spit- dry mouth Can\u2019t Shit- constipation Can\u2019t Pee- urinary retention Can\u2019t See- blurry vision When you see coffee-brown emesis\u2014think \ue601peptic ulcer Fluid retention- think heart problems first! Erikson\u2019s Stages of Psychosocial Development \u25cfInfants- 0 to 1 year oTrust vs. Mistrust- trust develops as needs are met \u25cfToddlers- 1 to 3 years oAutonomy vs. Shame and Doubt- toddlers want to make choices \u25cfPreschooler- 3 to 6 years oInitiative vs. Guilt- guilt may occur if unable to successfully complete a task or if they are \u201cpunished\u201d for an unsuccessful try \u25cfSchool-Age Child- 6 to 12 years oIndustry vs. Inferiority- a sense of industry is achieved through advancements in learning; fears of ridicule are common \u25cfAdolescent- 12 to 20 years 74 oIdentity vs. Role Confusion- families strongly influence personal identity, peer groups greatly influence behavior, interest in opposite sex, career planning, may see themselves as invincible \u25cfYoung Adult- 20 to 35 years oIntimacy vs. Isolation- ability to love deeply and commit oneself in relationships vs. remaining uncommitted and alone \u25cfMiddle Adult- 35 to 65 years oGenerativity vs. Stagnation- ability to give and care for others vs. self-absorption and inability to grow as a person \u25cfOlder Adult- 65 years and older oIntegrity vs. Despair- sense of accomplishment in life vs. feeling dissatisfied with life Fetal Alcohol Syndrome IM administration for 6 month old infants- \ue601vastus lateralis IM administration for toddlers (>18 months)- \ue601ventrogluteal IM administration for children- \ue601deltoid\ue601 and \ue601 gluteus maximus Eye Abbreviations OU-\ue601both eyes OS\ue601- left eye OD\ue601- right eye (dominant side is usually right side- right eye) Ear Abbreviations AU-\ue601 both ears AS- \ue601left ear AD-\ue601 right ear( dominant side is usually right side- right ear) 75
COAL C\ue601ane O\ue601pposite A\ue601ffected L\ue601eg Walker W\ue601andering- \ue601Walker W\ue601ilma- \ue601With A\ue601lways- \ue601Affected L\ue601ate- \ue601Leg Stand slightly behind the patient using a cane (on strong side) For CT scan- assess for allergies to contrast (allergy to shellfish) MRI- claustrophobia, \ue601NO METAL \u25cfContraindicated for patients with pacemaker, stents, cochlear implants, surgical implants \u25cfTitanium joint replacements \ue601CAN\ue601 have MRI \u25cfRemove transdermal patches prior to MRI 76
Cardiac Catheterization \u25cfNPO 8-12 hours prior \u25cfEmpty bladder \u25cfCheck pulses and mark \u25cfTell patient he may feel palpitations or desire to cough with dye \u25cfPost- V\/S, keep leg straight (insertion site is typically in groin), maintain bed rest 6-8 hours Early Signs of Increased ICP \u25cfPupil changes \u25cfChange in LOC\/mental status changes Increased ICP in Infants\/Neonates \u25cfHigh pitched cry Intracranial Pressure (ICP)\ue601 should be < 20 mmHg \u2013measure head circumference\u2014Normal ICP is usually between 10-15 mmHg (opening pressure) Early Signs of Subdural Hematoma and Cerebral Edema \u25cfDecreased level of consciousness \u25cfIpsilateral pupils (same side as hematoma) \u25cfHeadache \u2013 \ue601usually the first symptom NO MORPHINE WITH HEAD INJURY- MASKS SIGNS OF INCREASING ICP Fixed and dilated pupils represents a neuro emergency Clear fluid draining out of ear indicates rupture of meninges and presents a possible complication of meningitis Self-catheterization (urine)- \ue601clean\ue601 procedure (not sterile) Strabismus\ue601- sign: child closes one eye to see a poster on the wall\u2014visual axes are not parallel so the brain receives two images Cholecystectomy \u25cfDo not need to restrict fat post-op T-Tube \u25cfPost-cholecystectomy 77
oUsed to drain bile\u2014if change in urine color, bile is draining into the liver oShould not be irrigated, aspirated or clamped without a specific order from the physician Hemovac\ue601- closed system (requires negative pressure) \u25cfUsed often after mastectomy \u25cfEmpty when full or q8h \u25cfRemove plug, empty contents, place on flat surface, cleanse opening and plug with alcohol sponge, \ue601compress evacuator completely\ue601 \ue601to remove air\ue601, release plug, check system for operation Anthrax-\ue601not spread person to person (can be spread from contaminated clothing\u2014so patients should undergo decontamination\u2014removal and disposal of clothing and showering is the initial action in possible anthrax exposure) \u25cfAccording to the CDC, antibiotics should be administered only if there are signs of infection or the contaminating substance tests positive for anthrax (LaCharity) oCiprofloxacin is the antibiotic used to combat anthrax \u25aaTeaching for Ciprofloxacin \u25cfDrink plenty of fluids \u25cfAvoid taking a multivitamin within 6 hours of taking this medication \u25cfAvoid exposure to sun \u25cfAvoid caffeine \u25cfMay take with meals Generally speaking, \ue601exposure\ue601 does \ue601not\ue601 mean \ue601active\ue601 disease Lactose Intolerant- \u25cfFoods high in calcium but no dairy\/milk products Tracheostomy \u25cfFenestrated (cuffed) tracheostomy oWhen capping a fenestrated cuff\u2014\ue601deflate \ue601the cuff first o80-120 mmHg wall suction pressure 78
Vasectomy \u25cfNo permanent effect on sexual function \u25cfShould use condom for first 6 weeks post-op V-\ue601fib\ue601, de\ue601fib\ue601rillate You are at risk for developing cervical cancer if you have\/had multiple sex partners Women who begin menstruating at an early age (such as 9 years old), are at risk for breast cancer Absence of menstruation\ue601 leads to \ue601osteoporosis\ue601 in the patient with anorexia 24 hour urine specimen collection \u25cfIf a woman starts menstruating during the collection\u2014contact physician It is not unusual for an adolescent who just started menstruating to not have a period every month (usually expect to have around 4 in the first year) Breast buds\ue601 usually appear between 9-13 years of age\u2014should be investigated if they appear later Glucagon\ue601 (1mg SQ) is given when patient is unconscious with \ue601severe hypoglycemia or those who cannot take PO fluids *Increases the effects of \ue601anticoagulants Crohn\u2019s Disease \u25cfLow fat \u25cfLow residue (fiber) 79
\u25cfHigh protein Priority assessment- \ue601respiratory distress \u25cfListen to patient\u2019s breath sounds (most clear assessment) Femoral angiogram\ue601- locate and note the presence of peripheral pulses (easier to find after the procedure) \u25cfKeep leg straight \u25cfCheck dressing \u25cfIncrease hydration to excrete dye Breath Sounds \u25cfAsthma oHigh-pitched, musical sounds on expiration (wheezing) \u25cfPneumonia oSoft, high-pitched sounds on inspiration (crackles) \u25cfBronchitis oDeep, low-pitched rumbling on expiration (rhonchi) Ileostomy- \ue601seen with spinal cord injuries, Crohn\u2019s disease, and to rest the colon \u25cfClean with warm water, dry thoroughly \u25cfAppliance should fit snugly around the opening \u25cfShould not take laxatives \u25cfCan take multi-vitamins \u25cfNo enteric coated meds or capsules\u2014breakdown in large intestines \u25cfStoma site should be assessed at least once a day \u25cfBags can be changed as needed \u25cfLiquid stool *DO NOT CONFUSE ILEOSTOMY WITH COLOSTOMY* Maintain bathroom schedule for incontinent patients- every 2 hours When transferring a patient to another unit\u2014you do not want to bring a \u201cthreat\u201d to the floor\u2014clean vs. dirty patient\u2014risk of infection to a \u201cclean\u201d unit is not a good choice For the initial dose of an ACE-Inhibitor\u2014should not give with diuretics and other medications that can decrease blood pressure (with the initial dose, hypotension is concern) 80
Oral fluid intake\u2014\ue6011500 mL in 24 hours Patient who is agitated- reorient to place and time, assign LPN to stay with patient In pH regulation, two organs of concern are lungs and kidneys (lungs- respiratory, kidneys- metabolic) ARTERIAL BLOOD GASES Risk factors for acid-base imbalances include chronic kidney disease and pulmonary disease Metabolic Acidosis \u25cfLow\ue601 pH, \ue601Low\ue601 HCO3 \u25cfRisk Factors oType 1 Diabetes (at risk for DKA) oSalicylate toxicity oAcute renal failure (decreased production of HCO3) oSevere diarrhea oHyperkalemia Metabolic Alkalosis \u25cfHigh\ue601 pH, \ue601High\ue601 HCO3 \u25cfRisk Factors oGI losses- vomiting or gastric suctioning or drainage \u25aaNasogastric suctioning can result in a decrease in acid components leading to metabolic alkalosis\u2014clients decrease in rate and depth of ventilation in an attempt to compensate by retaining carbon dioxide oDiuretic therapy that leads to sodium and chlorine losses oMineralcorticoid excess oHypokalemia Respiratory Acidosis \u25cfLow\ue601 pH, \ue601High\ue601 PaCO2 \u25cfRisk Factors 81 oRespiratory depression (decreased respiratory rate) oCOPD and\/or asthma oInability to ventilate properly (seen in myasthenia gravis, ALS, muscular dystrophy, and Guillain Barre) Respiratory Alkalosis \u25cfHigh\ue601 pH, \ue601Low\ue601 PaCO2 \u25cfRisk Factors oHyperventilation (blowing of CO2) oMechanical ventilation oAny condition that causes shortness of breath 82 From the a<\/em>* (diarrhea) = metabolic acidosis From the mouth (vomitus) = metabolic alkalosis With \ue601hyperkalemia\ue601- pulse is the first vital sign you check (due to dysrhythmias) Diet for Iron-Deficiency Anemia 83
Oysters, clams, scallops are top-10 sources of iron \u25cfOrgan meats (red meats), fortified cereals, dark leafy vegetables, egg yolks are also good sources of dietary iron Iron supplements\ue601 should be taken with orange juice (Vitamin C) as it facilitates absorption Documentation should be specific and factual\u2014\u201cVital Signs Stable\u201d is \ue601NOT acceptable\u2014what are the vital signs? Herbal Medications \u25cfPotency varies between medications \u25cfConsidered dietary supplements \u25cfNot regulated by FDA \u25cfMa Huang should not be used by patient\u2019s with HTN \u25cfGinkgo\ue601 \u2013 improves cerebral circulation to treat dementia and memory loss–increases risk of bleeding, increases effects of MAOIs, may reduce effectiveness of insulin\u2014\ue601discontinue 2 weeks prior to surgery, may cause seizure with overdose \u25cfGarlic\ue601 acts as blood thinner \u25cfBlack cohosh\ue601- used to treat menopause \u2013 large doses have been known to cause seizures, visual disturbances, increased sweating, bradycardia \u25cfFeverfew\ue601- prevention and treatment of migraines, arthritis, and fever–\ue601should\ue601 \ue601not\ue601 be taken with coumadin, aspirin, NSAIDS, thrombolytics or antiplatelet meds\u2014prolongs bleeding \u25cfGinseng\ue601- improves strength and stamina\u2014prevents and treats cancer and DM–it decreases the effects of anitcoagulants and NSAIDS\u2014\ue601contraindicated for women who are pregnant\ue601\u2014may increase effectiveness of antidiabetic agents and insulin \u25cfEchinacea\ue601-\ue601 \ue601prevents and treats the common cold, stimulates the immune system, promotes wound healing\u2014\ue601may reduce the effects of immunosuppressants\ue601, may increase serum levels of alprazolam, CCB, and protease inhibitors \u25cfSt.\ue601 \ue601John\u2019s Wort\ue601- depression and anxiety\u2014may reduce the effects of many medications\u2014theophylline, HIV protease inhibitors, cyclosporine, diltiazem, and nifedipine \u2013 \ue601should not be taken with other medications Patients with \ue601hearing loss\ue601 may exhibit suspiciousness of strangers\u2014results from interference with communication Nausea is a concern\/priority following eye surgery\u2014risk of increased IOP *Patient\u2019s undergoing eye surgery should receive flu shot before\u2014can cause client to sneeze, cough, or blow nose (increasing IOP) 84
Esophageal speech-\ue601 (following a total laryngectomy)- swallows air & eructates while forming words (Organ) Transplant patients-\ue601 require protective isolation following surgery Most at risk for developing \ue601herpes zoster\ue601\u2014immunocompromised Cytomegalovirus\ue601- common virus \u2013once infected, virus remains in body for life *Standard precautions are used\u2014\ue601eyewear worn with risk of splash Decreased RBCs\/Erythrocytopenia S\/S:\ue601 fatigue and dyspnea on exertion, pallor, dizziness, malaise, tachycardia Tetracycline\ue601- antibiotic \u25cfCauses photosensitivity \u2013 wear sunscreen and hat outdoors \u25cfShould be taken on an empty stomach \u25cfContraindicated for pregnant women Sickle Cell Crisis *Adequate hydration \u25cfDehydration perpetuates cell sickling\u2014should be at least 200cc\/hr \u25cfDo not give cold packs\u2014further decreases blood flow to area and increases sickling DO NOT GIVE DEMEROL (meperidine) TO PATIENTS WITH SICKLE CELL CRISIS 85
Phlebitis\ue601- reddened area or red streaks at site of catheter Blanching sign\ue601- pressing nail of big toe\u2014indicates circulatory function Blanching or hyperemia that does not disappear in a short time is a warning sign of pressure ulcers Severe to panic level of anxiety\ue601- patient is unable to process thoughts and feelings for problem solving Priority when managing a \ue601physically assaultive client\ue601\u2014\ue601restore the client\u2019s self-control and prevent further loss of control Reward non-attention seeking behaviors by giving client unsolicited attention Nasogastric Tube \u25cfPatient is nauseated and decreased flow of gastric contents\u2014aspirate and check pH to confirm placement (should be between 0 and 4) \u25cfIf irrigation is necessary, use normal saline \u25cfIntermittent feeding oCheck pH of aspirated contents (normal is pH 0-4) oUse large barreled syringe to aspirate oFlush with 30 mL of air before aspiration History of psych patient\ue601 should include biopsychosocial data; psychosocial and physical status are evaluated along with an assessment of the family system and social support network; evaluation of cognitive ability is important during physiological status assessment Patients in seclusion should eat at regular time but remain in seclusion for client\u2019s safety 86
Joint legal custody with divorced parents\ue601- consent from either parent is sufficient Battery\ue601 is harmful or offensive touching of another person unless court ordered *For example: Patient refuses medication due to fear that it will poison him\u2014nurse administers medication IM \u25cfClients have the right to refuse medication even if psychotic Myelogram \u25cfNPO 4-6 hours \u25cfHistory of allergies \u25cfPhenothiazines, CNS depressants, and stimulants withheld 48 hours prior \u25cfTable will be moved in various positions during test \u25cfPost- neuro checks q2-4h, oral analgesics for H\/A, encourage PO fluids, assess for distended bladder, inspect insertion site \u25cfWater soluble- \ue601HOB raised \u25cfOil soluble-\ue601 HOB down Common Signs and Symptoms \u25cfPulmonary TB\ue601- low grade afternoon fever \u25cfPneumonia\ue601- rusty sputum \u25cfAsthma\ue601- wheezing on expiration \u25cfEmphysema\ue601- barrel chest \u25cfKawasaki\ue601 \ue601Syndrome\ue601- strawberry tongue. Peeling skin on fingers and toes \u25cfPernicious\ue601 \ue601Anemia\ue601- red beefy tongue, pallor, tachycardia \u25cfDown\ue601 \ue601Syndrome\ue601- protruding tongue \u25cfCholera\ue601- rice watery stool \u25cfMalaria\ue601- stepladder-like fever with chills \u25cfTyphoid\ue601- rose spots on abdomen \u25cfDiphtheria\ue601- pseudo membrane formation \u25cfMeasles\ue601- koplik\u2019s spots (clustered white lesions on buccal mucosa) \u25cfSystemic\ue601 \ue601Lupus\ue601 \ue601Erythematous\ue601- butterfly rash \u25cfLiver\ue601 \ue601cirrhosis\ue601- spider-like varices \u25cfLeprosy\ue601- leonine facies (thickened folded facial skin) \u25cfBulimia\ue601- chipmunk face (parotid gland swelling), poor dental status \u25cfAppendicitis\ue601- rebound tenderness, psoas sign (pain from flexing the high to the hip); Rovsing\u2019s sign (palpation of LLQ elicits pain in RLQ) \u25cfMeningitis\ue601- \ue601K\ue601ernig\u2019s sign (\ue601k\ue601nee flex and pain on extension), \ue601B\ue601rudzinski sign (neck flex = lower leg flex\/\ue601b\ue601end), nuchal rigidity, photosensitivity \u25cfTetany\ue601- hypocalcemia (+) Trousseau\u2019s sign\/carpopedal spasm, Chvostek sign (facial spasm) \u25cfTetanus\ue601- risus sardonicus \u25cfPancreatitis\ue601- Cullen\u2019s sign (ecchymosis of umbilicus); (+) Grey Turner\u2019s spots 87
\u25cfPyloric\ue601 \ue601Stenosis\ue601- olive-like mass, projectile vomiting \u25cfPatent\ue601 \ue601Ductus\ue601 \ue601Arteriosus\ue601- washing machine-like murmur \u25cfAddison\u2019s\ue601- bronze-like skin pigmentation (tanned) \u25cfCushing\u2019s\ue601- moon face and buffalo hump \u25cfGrave\u2019s\ue601\/\ue601Hyperthyroidism\ue601- exophthalmos (bulging of the eyes) \u25cfIntussusception\ue601- sausage shaped mass, Dance sign (empty portion of RLQ), red currant jelly stools \u25cfMultiple\ue601 \ue601Sclerosis\ue601- Charcot\u2019s Triad (nystagmus, intention tremor, scanning speech) \u25cfMyasthenia\ue601 \ue601Gravis\ue601- descending muscle weakness, ptosis (drooping eyelid) \u25cfGuillain Barre-\ue601 ascending muscle weakness\/paralysis \u25cfDVT\ue601- Homan\u2019s sign \u25cfChicken\ue601 \ue601Pox\ue601- vesicular rash (central to distal), dew drop on rose petal \u25cfAngina\ue601- crushing stabbing pain, relieved by NTG \u25cfMyocardial Infarction\ue601- crushing stabbing pain- radiates to left shoulder, neck, arms, unrelieved by NTG \u25cfLaryngotrachebronchitis\ue601- inspiratory stridor \u25cfTransesophageal\ue601 \ue601Fistula\ue601- 4 C\u2019s- Coughing, choking, cyanosis, continuous drooling \u25cfEpiglottitis\ue601- 3 D\u2019s- drooling, dysphonia, dysphagia (acute emergency) \u25cfHodgkin\u2019s\ue601 \ue601Lymphoma\ue601- painless, progressive enlargement of spleen and lymph tissues, Reedstenberg cells \u25cfInfectious Mono\ue601-\ue601 \ue601sore throat, cervical lymph adenopathy, fever, fatigue \u25cfParkinson\u2019s\ue601-\ue601 \ue601pill-rolling tremors \u25cfCytomegalovirus (CMV) infection\ue601- Owl\u2019s eye appearance of cells (huge nucleus in cells) \u25cfCystic Fibrosis\ue601-\ue601 \ue601salty skin, intussuception \u25cfDiabetes Mellitus-\ue601 polyuria, polydipsia, polyphagia \u25cfDKA-\ue601 Kussmaul respirations (deep, rapid RR), acetone breath \u25cfBladder cancer- \ue601painless hematuria \u25cfBenign Prostatic Hyperplasia-\ue601 reduced size and force of urine \u25cfRetinal Detachment-\ue601 visual floaters, \ue601flashes of light\ue601, curtain-like shadow vision (emergency situation) \u25cfGlaucoma-\ue601 \ue601painful\ue601 vision loss, \ue601tunnel\ue601\/gun barrel\/halo \ue601vision (peripheral vision loss) \u25cfCataract-\ue601 \ue601painless\ue601 vision loss, opacity of the lens, blurring of the vision, change in color vision \u25cfRetinoblastoma-\ue601 Cat\u2019s eye reflex (grayish discoloration of pupils)\u2014seen in photos \u25cfPregnancy Induced Hypertension-\ue601 proteinuria, HTN, edema \u25cfAcromegaly-\ue601 coarse facial feature \u25cfDuchenne\u2019s Muscular Dystrophy- \ue601Gower\u2019s sign (use of hands to push one\u2019s self from the floor) 88
\u25cfGERD- heartburn, \ue601Barrett\u2019s esophagus (erosion of the lower portion of the esophageal mucosa) \u25cfHepatic encephalopathy-\ue601 flapping tremors (asterixis) \u25cfHydrocephalus-\ue601 Bossing sign (prominent forehead) \u25cfIncreased ICP-\ue601 HTN, Bradypnea, Bradycardia (Cushing\u2019s Triad) \u25cfShock-\ue601 Hypotension, Tachypnea, Tachycardia \u25cfMeniere\u2019s Disease-\ue601 vertigo, tinnitus \u25cfCystitis-\ue601 burning on urination \u25cfHypocalcemia-\ue601 (+) Chvostek and Trousseau\u2019s \u25cfUlcerative Colitis-\ue601 recurrent bloody diarrhea \u25cfLyme\u2019s Disease-\ue601 Bull\u2019s eye rash \u25cfBuerger\u2019s Disease-\ue601 intermittent claudication (pain at buttocks or legs from poor circulation resulting in impaired walking) \u25cfHirschsprung\u2019s Disease (Toxic Megacolon)-\ue601 ribbon-like stool STIs \u25cfHerpes Simplex Type II- \ue601painful vesicles on genitalia \u25cfGenital Warts- \ue601warts 1-2 mm in diameter \u25cfSyphillis- \ue601painless chancres \u25cfChancroid-\ue601 painful chancres \u25cfGonorrhea- \ue601green, creamy discharges and painful urination \u25cfChlamydia- \ue601milky discharge and painful urination \u25cfCandidiasis- \ue601white, cheesy, odorless vaginal discharges \u25cfTrichomoniasis- \ue601yellow, itchy, frothy, and foul-smelling vaginal discharges CSF Ottorhea- sign of basilar fracture Battle\u2019s sign and raccoon eyes NO Nasotracheal suctioning\ue601 with \ue601head injury\ue601 or \ue601skull fracture\ue601 (increases ICP) 89
Take iron elixir with juice or water- never with milk! Therapeutic Drug Levels Dilantin- 10 to 20 Theophylline- 10 to 20 Acetaminophen \u2013 10 to 20 (do not excess 4000mg in one day) Lithium- 0.4 to 1.4 Digoxin- 0.5 to 2.0 Osteomyelitis\ue601 is an infectious bone disease- blood cultures and antibiotics\u2014if necessary, surgery to drain abscess Nephrotic Syndrome\ue601- S\/S edema (periorbital and generalized), dark, foamy urine (indicating proteinuria), and weight gain due to excessive fluid retention; also HTN \u25cfCharacterized by massive proteinuria \u25cfDecreased serum albumin \u25cfPatient will receive corticosteroids *Risk for impaired skin integrity Glomerulonephritis\ue601- cola colored urine, HTN, edema, proteinuria \u25cfV\/S q4h \u25cfDaily weights Common Diets \u25cfAcute Renal Disease\ue601- protein-restricted, high-calorie, fluid-controlled, sodium and potassium controlled \u25cfAddison\u2019s Disease\ue601- increased sodium, low potassium diet \u25cfADHD and Bipolar\ue601- high-calorie and provide finger foods \u25cfBurns\ue601- high protein, high calorie, increase in Vitamin C \u25cfBowel Surgery\ue601-\ue601 \ue601low residue \u25cfCancer- \ue601high-calorie, high-protein \u25cfCeliac Disease-\ue601 gluten-free diet (No BROW- barley, rye, oat, and wheat) \u25cfChronic Renal Disease-\ue601 protein-restricted, low-sodium, fluid-restricted, potassium-restricted, phosphorous-restricted \u25cfCirrhosis (stable)-\ue601 normal protein \u25cfCirrhosis with hepatic insufficiency \u2013\ue601 restrict protein, fluids, and sodium \u25cfConstipation-\ue601 high-fiber, increased fluids 90
\u25cfCOPD-\ue601 soft, high-calorie, low-carbohydrate, high-fat, small frequent feedings \u25cfCystic Fibrosis-\ue601 increase in fluids, high-sodium \u25cfDiarrhea-\ue601 liquid, low-fiber, regular, fluid and electrolyte replacement \u25cfGallbladder disease-\ue601 low-fat, calorie-restricted, regular \u25cfGastritis-\ue601 low fiber, bland diet \u25cfHepatitis-\ue601 regular, high-calorie, high-protein \u25cfHyperlipidemias-\ue601 fat controlled, calorie-restricted \u25cfHTN, HF, CAD-\ue601 low-sodium, calorie restricted, fat-controlled \u25cfKidney Stones-\ue601 increased fluid intake, calcium-controlled, low oxalate \u25cfNephrotic Syndrome-\ue601 sodium-restricted, high-calorie, potassium-restricted \u25cfObesity, overweight-\ue601 calorie restricted, high fiber \u25cfPancreatitis-\ue601 low fat, regular, small frequent feedings, tube feeding or TPN \u25cfPeptic ulcer-\ue601 bland diet \u25cfPernicious Anemia (B12)-\ue601 increase B12, found in high amounts in shellfish, beef, liver and fish \u25cfSickle Cell Anemia- \ue601increase fluids to maintain hydration since sickling increases when patients become dehydrated \u25cfSpinal Cord Injury- \ue601high fiber, low fat (prevent constipation and straining) \u25cfStoke-\ue601 mechanical, soft, regular, or tube-feeding \u25cfUnderweight-\ue601 high-calorie, high protein \u25cfVomiting-\ue601 fluid and electrolyte replacement An ill child regresses in behavior Assessing \ue601extraocular eye movements\ue601- check cranial nerves 3, 4, & 6 DVT \u25cfGoal: \ue601promote venous return and decrease in venous pressure \u25cfBed rest with elevated extremity Stomas \u25cfDusky- poor blood supply \u25cfProtruding \u2013 prolapsed \u25cfSharp pain + rigidity- peritonitis \u25cfMucus in ileal conduit is expected Tension pneumothorax\ue601 \u2013 trachea shifts to opposite side Change in color\ue601 is \ue601always\ue601 a LATE sign 91
Incentive Spirometer\ue601- steps: 1) sit upright 2) exhale 3) insert mouthpiece 4) inhale for 3 seconds and then hold for 10 seconds MRSA\ue601- contact only VRSA\ue601- contact \ue601AND\ue601 airborne (private room, door closed, negative pressure) Thrombocytopenia\ue601-\ue601 bleeding preacautions \u25cfSoft bristled toothbrush \u25cfNo insertion of anything (suppositories, etc.) \u25cfNo IM meds as much as possible Risk of MRSA \u25cfIndwelling foley catheter \u25cfReceiving medication through port, vascular access device, ET tube \u25cfImmunocompromised Iron deficiency anemia- \u25cfFe PO- give with vitamin C or on an empty stomach \u25cfFe via IM- inferon via Ztrak Pernicious anemia\ue601 (B12)- red beefy tongue, will take B12 for life Meniere\u2019s Disease\ue601- restrict sodium, lay on affected ear when in bed, diuretics to decrease endolymph in cochlea Triad:\ue601 vertigo, tinnitus, N\/V Dehiscence of abdominal wound\ue601 with \ue601organ evisceration\ue601\u2014elevate HOB to 15 degrees \ue601\u2192\ue601 reduces stress on suture line *May also be placed supine with hips\/knees bent Gastric ulcer pain\ue601- occurs 30 min to 90 min after eating, not at night and does not go away with food Pediatric Tips \u25cfIntraosseous infusion\ue601- in pediatric life-threatening emergencies, when IV access cannot be obtained, an osseous (bone) needle is hand-drilled into a bone (usually tibia), where crystalloids, colloids, blood products and drugs can be administered into the marrow\u2014it is temporary- when venous access is achieved it is d\/c\u2019d oOnly medication that \ue601CANNOT\ue601 be administered IO is isoproterenol (a beta agonist) \u25cfWith \ue601glomerulonephritis\ue601- consider blood pressure to be the most important assessment paremeter 92
oDietary restrictions you can expect- fluids, protein, sodium, and potassium \u25cfIn \ue601congenital\ue601 \ue601cardiac\ue601 \ue601defects\ue601 that result in \ue601hypoxia\ue601- body attempts to compensate for with an influx in immature RBCs\u2014labs that support this: increase Hct, Hgb, and RBC count \u25cfThere is an association between low-set ears and renal anomalies- develop around the same time (they are also similar in shape)\u2014if a newborn has low-set ears, this warrants renal function tests \u25cfSchool-age kids (5 and up) are old enough and should have an explanation of what will happen a week before surgery (such as tonsillectomy) \u25cfFirst sign of \ue601pyloric\ue601 \ue601stenosis\ue601 in a baby is mild vomiting that progresses to projectile vomiting \u2013 later you may be able to palpate a mass, the baby will seem hungry often, and may spit up after feedings \u25cfKawasaki\u2019s\ue601 \ue601Disease\ue601- causes heart problems\u2014coronary artery aneurysms due to inflammation of blood vessels \u25cfA child with a \ue601VP shunt\ue601 will have a small upper-abdominal incision\u2014this is where the shunt is guided into abdominal cavity-\ue601watch for:\ue601 abdominal distention \ue601\u2192\ue601 fluid from the ventricles (in brain) will be redirected to abdomen; \ue601watch for signs of increasing ICP\ue601\u2192\ue601 irritability, bulging fontanels, high-pitched cry in an infant; lack of appetite and headache in a toddler oBed position \ue601after shunt placement-\ue601 FLAT\ue601\u2192\ue601 do not want the fluid to shift too rapidly (if signs of increasing ICP are present\u2014elevated HOB 15-30 degrees) \u25cfMechanical ventilation can cause \ue601bronchopulmonary dysplasia\ue601\u2014other causes: infection, pneumonia, or conditions that result in inflammation and scarring \u25cfIt is essential to maintain nasal patency in a child < 1 year because they are nose breathers \u25cfA child should not be drinking too much milk- it reduces the intake of other essential nutrients\u2014especially iron (could lead to anemia) \u25cfIf you can remove the white patches from the mouth of a baby it is formula- if you can\u2019t it is candidiasis \\ 93
\u25cfMMR\ue601 and \ue601Varicella\ue601 \ue601immunizations\ue601 come later (15 months)- letters are later in alphabet \u25cfUndescended testis or \ue601cryptorchidism\ue601 is a known risk factor for testicular cancer- start teaching boys about self testicular exams around 12 \u2013 most cases of testicular cancer occur in adolescence \u25cfStranger anxiety\ue601 is greatest between 7-9 months \u25cfSeparation anxiety\ue601 starts around 4-8 months, peaks in toddlerhood (1-3 years) \u25cfFor a child exhibiting \ue601separation\ue601 \ue601anxiety\ue601\u2014offer favorite blanket or toy, talk to infant when leaving room, allow to hear parent\u2019s voice on telephone \u25cfChildren frequently set their own pace for development \u25cfMock run through surgery is a great way to prepare a 5 year old \u25cfAlways report suspected cases of child abuse \u25cfEardrop administration for kids <3 years- pinna down and back \u25cfWith \ue601omphalocele\ue601 and \ue601gastroschisis\ue601 (herniation of abdominal contents) dress with \ue601loose saline dressing with plastic wrap (non-adherent)\u2014monitor temperature (lose heat quickly) \u25cfAfter \ue601hydrocele\ue601 repair, provide cold therapy (ice) and scrotal support \u25cfNO phenylalanine \ue601with positive \ue601PKU\ue601 (no meat, no dairy, no aspartame\/artificial sweetener) oLofenalac formula \u25cfThe \ue601biggest \ue601concern with \ue601cold stress\ue601 and the newborn is \ue601respiratory distress \u25cfNormal RR for newborn: 30- 60 \u25cfToddlers need to express autonomy (independence) \u25cfTheories about bed-wetting relate it to immature bladder and deep sleep patterns\u2014most children stop bed-wetting by the time they start school \u25cfAverage circumference of the head ranges from 32-36 cm (increase in size may indicate hydrocephalus or increased ICP) 94
\u25cfBetween ages 6 and 12, children grow about 2 inches per year and gain 4.5-6.5 lbs\/year \u25cfThe incidence of once-common infectious disease such as measles, chickenpox, and mumps has been most effectively reduced by the immunization of all school-age children \u25cfExposure to chemicals in the eyes\ue601\u2192\ue601 irrigate for 20 minutes \ue601\u2192\ue601 another adult, if present, should call the Poison Control Center and 911 \u25cfChildren have proportionately larger heads that predispose them to head injuries \u25cfHypoxemia is more likely in children because of their higher oxygen demand \u25cfLiver and spleen injuries are more likely because the thoracic cage of children offers less protection \u25cfHypothermia is more likely because of children\u2019s thinner skin and proportionately larger body surface area \u25cfKawasaki disease\ue601 is the only exception for children taking aspirin oImportant for children\u2019s to receive immunizations \u25cfNational guidelines indicate that medication dosing for pediatric patients should be based on the child\u2019s weight (kg) oSome sources say that BSA is the most accurate method for dosing in children Safety- Pediatrics Infant \u25cfAspiration and suffocation\ue601- chop food in fine pieces, appropriate toys, no plastic bags and balloons (latex balloons are the leading cause of pediatric choking deaths) \u25cfBodily harm\ue601 \u2013 keep sharp objects out of reach, keep infants away from heavy objects they can pull down on themselves, do not leave unattended with animals, monitor for shaken baby syndrome 95
\u25cfBurns\ue601- check temperature of water, working smoke detectors in home, handles of pots and pans should be turned to back of stoves, sunscreen should be used, electrical outlets should be covered, clothing should be flame retardant oWater heater should be set to no greater than 120 degrees \u25cfDrowning\ue601- never leave infant unattended near water such as tubs, toilets, and swimming areas \u25cfFalls-\ue601 never leave unattended, place safety gates on stairs \u25cfPoisoning\ue601- lock or remove all toxic substances, mediations should be stored in safety bottles and locked in cupboard, never refer to medication as candy, poison control number handy \u25cfMotor Vehicle Injuries\ue601- placed in approved rear-facing car seats in the backseat- preferably in the middle (away from airbags and side impact)\u2014rear facing car seats until 2 years of age and they exceed the manufacturer\u2019s recommended weight (usually 20lbs) Toddler \u25cfAspiration and suffocation-\ue601 avoid common causes of choking- hot dogs, nuts, grapes, peanut butter, raw carrots, tough meat, popcorn, no balloons or plastic bags, no pillows in cribs, no drawstrings on clothing \u25cfBodily harm-\ue601 firearms kept in locked boxes, stranger safety \u25cfBurns-\ue601 (same as above) \u25cfDrowning\ue601- (same as above), taught to swim \u25cfFalls\ue601- (same as above) \u25cfMotor Vehicle Injuries\ue601- airbags near the child should be inactivated, forward-facing until they exceed manufacturer\u2019s weight limit, backseat, booster seat after they have exceeded weight for forward-facing carseat \u25cfPoisoning\ue601- avoid exposure to lead paint, safety locks Preschooler (3 to 6) \u25cfSame as above \u25cf*Encourage safety equipment (helmet) School-Age Child (6 to 12) \u25cfBodily harm\ue601- firearms should be kept in locked boxes, no trampolines, safe areas for play, stranger safety, wear helmets \u25cfBurns\ue601- teach fire safety and potential burn hazards \u25cfDrowning\ue601-\ue601 teach to swim \u25cfMotor vehicle injuries\ue601- younger than 13 should be in back seat, airbags inactivated \u25cfSubstance abuse\ue601-\ue601community resources, family involvement Adolescent (12 to 20) \u25cfThree leading causes of death in adolescents are \ue601homicide\ue601, \ue601suicide,\ue601 and motor vehicle accidents 96
Potassium\ue601 is lost when a client is taking a thiazide diuretic \u2013 monitor K, increase dietary K \u25cfShould not be taken at night- prevent nocturia Hypokalemia \u25cfECG changes- ST segment depression, inverted T waves, prominent U waves\u2014may also experience heart block \u25cfLethargy and muscle weakness Neck veins are normally distended when patient is supine\u2014veins flatten when sitting *Decreased plasma volume\ue601\u2192\ue601 flattened neck veins when supine Nurse is not required to explain delegated assignments Migraines \u25cfFatigue is a trigger Validation of a nurse having a substance abuse problem does not override quality client care! Take care of the patient first! Hemorrhagic shock\ue601- \ue601PRIORITY\ue601\u2192\ue601 identify source of bleeding and apply direct pressure ECT \u25cfNPO after midnight \u25cfGeneral anesthesia \u25cfMemory loss is an expected outcome Patients with severe immunodeficiency may be unable to produce an immune response\u2014as a result, a negative TB skin result does not completely rule out a TB diagnosis for this patient \ue601\u2192\ue601 chest x-ray and sputum culture will be ordered. Patients taking \ue601immunosuppressive\ue601 \ue601medications\ue601 are at an increased risk for development of cancer! Cultural Considerations \u25cfAfrican Americans\ue601- many believe that illness is caused by supernatural causes and seek advice and remedies from faith healers; family oriented; higher incidence of HTN and obesity; high incidence of lactose intolerance 97
\u25cfArab Americans\ue601- may remain silent about health problems such as STIs, substance abuse and mental illness; if Muslim- many avoid pork and alcohol \u25cfAsian Americans\ue601- may value ability to endure pain and grief with silent stoicism; hot\/cold, yin\/yang, sodium intake is generally high; may prefer to maintain a comfortable distance; may believe prolonged eye contact is rude and invasion of privacy \u25cfLatino Americans\ue601- may view illness as sign of weakness, punishment for evil doing; family members are typically involved in all aspects of decision making such as terminal illness \u25cfNative Americans\ue601- may turn to a medicine man to determine the true cause of an illness, may value the ability to endure pain or grief with silent stoicism, diet may be deficient in Vitamin D and calcium due to lactose intolerance, obesity and diabetes are major concerns \u25cfWestern Culture\ue601- may value technology almost exclusively in the struggle to conquer diseases; health is understood to be the absence, minimization or control of disease process Delegation Tips DO NOT \ue601delegate what you can \ue601EAT E- evaluate \ue601(nursing judgment) A-assess \ue601(nursing judgment) T-\ue601 \ue601teach \u25cfDelegate \ue601sterile skills\ue601 to RN or LPN \u25cfWhere non-skilled care is required, delegate stable client to nursing assistant \u25cfAssign the most critical client to the RN \u25cfClients who are being discharged should have the final assessments and teaching done by the RN \u25cfA new nurse should receive stable patients who require routine care (same applies to nurses that are transferred to different units for the day) \u25cfThe LPN can monitor clients with IV therapy, insert urinary catheters, feeding tubes, and apply restraints \u25cfLPN\/LVN cannot handle blood \u25cfLPN\/LVN are given stable patients \u2013 can perform sterile procedures on stable patients \u25cfExperienced LPNs can use observation of patients to gather data regarding how well they perform interventions that have \ue601already been taught (including checking for therapeutic response\/adverse effects of medications) \u25cfAssisting with ADLs is appropriate for assistive personnel (record I\/O too) Always check for allergies\ue601 before administering antibiotics (especially penicillin) \u2013 or any medication for that matter! 98
Neutropenic precautions\ue601-\ue601 no live vaccines, no fresh fruits, no flowers, no sick visitors, no milk \u25cfAny temperature elevation in a neutropenic patient may indicate the presence of a life-threatening infection \u25cfPatients who are neutropenic should be place in a positive-airflow room In the event of a fire- \ue601RACE\ue601\u2192\ue601 \ue601(R) Remove the patient (A) Activate the alarm (C) Contain the fire by closing the door (E) Extinguish the fire if it can be done safely Informed consent\ue601- patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phases; the risks involved, possible complications\u2014\ue601always allow patient to ask questions! Veracity is truth\ue601 and is an essential component to a therapeutic relationship between a healthcare provider and patient Beneficence\ue601 is the action that is done to benefit others Nonmaleficence \ue601is the duty to do no harm Projection\ue601 is the unconscious assigning of a thought, feeling, or action to someone or something else Sublimation\ue601 is the channeling of unacceptable impulse into socially acceptable behavior Repression\ue601 is an unconscious defense mechanism whereby unacceptable or painful thoughts, impulses, memories, or feelings are pushed from the consciousness or forgotten People with \ue601obsessive-compulsive disorder \ue601realize that their behavior is unreasonable, but are powerless to control it Hypervigilance\ue601 and \ue601d\u00e9j\u00e0\ue601 \ue601vu\ue601 are signs of \ue601PTSD Health Screening for Cancer 99
CAUTION C-\ue601 change in bowel or bladder habits A-\ue601 a sore that does not heal U-\ue601 unusual bleeding or discharge T-\ue601 thickening or lump in breast or elsewhere I-\ue601 indigestion or difficulty swallowing O-\ue601 \ue601obvious change in a wart or mole N-\ue601 nagging cough or hoarseness Common sites for \ue601metastasis\ue601- liver, brain, lung, bone, lymph When a cancer patient is receiving \ue601radiation\ue601- main concern is preventing infection because radiation causes leukopenia Radioactive Iodine\ue601- want to flush it out of body \ue601\u2192\ue601 increase fluid intake for 2 days (3-4 liters unless otherwise contraindicated)\u2014flush the toilet twice after using *Limit contact with patient to 30 min\/day NO PREGNANT VISITORS\/NURSES and no kids The main \ue601hypersensitivity\ue601 reaction seen with antiplatelet drugs is bronchospasm\ue601 (anaphylaxis) \u25cfEx: clopidogrel, aspirin Do not fall for the \u201creestablishing a normal bowel pattern\u201d as a priority with small bowel obstruction\u2014the patient can\u2019t take in oral fluids, \u201cmaintaining fluid balance\u201d comes first! Basophils release histamine during an allergic reaction Other than to initially test tolerance- \ue601G tube and J tube feedings\ue601 are usually given as continuous feedings Tamoxifen\ue601 (chemotherapy agent) can cause \ue601visual\ue601 \ue601changes\ue601\u2014can be irreversible\u2014assess visual acuity throughout treatment You should ask every new admission if he\/she has an advance directive Succinylcholine Chloride (Anectine)-\ue601 used for short-term neuromuscular blocking agents for procedures like intubation and ECT Typical adverse reactions\ue601 to oral \ue601hypoglycemic\ue601- rash and photosensitivity Hypotension\ue601 may alter the accuracy of O2 sats 100
An \ue601antacid\ue601 should be given to a mechanically ventilated patient with NG tube if the pH of the aspirate is <5.0\u2014aspirate should be checked at least q12h Ambient air (room air) contains 21% oxygen Normal PCWP (pulmonary capillary wedge pressure) is 8-13 \ue601\u2192\ue601 readings of 18-20 are considered \ue601high High potassium (hyperkalemia)\ue601 is expected with \ue601carbon dioxide narcosis\ue601 (hydrogen floods the cell, forcing potassium out)- carbon dioxide narcosis causes increased \ue601ICP An \ue601NG Tube\ue601 can be irrigated with \ue601cola\ue601 and should be taught to the family when a client is going home with the tube If your normally lucid patient starts seeing bugs, check respiratory status FIRST\u2014the first sign of \ue601hypoxia\ue601 is restlessness, followed by agitation (continues to decline from there) \ue601\u2192\ue601 leads to delirium and hallucinations, and eventually coma! \u25cfCheck O2 stat \u25cfABGs if possible Status epilepticus \ue601\u2013 most important assessment is level of consciousness Pneumonia\ue601 may manifest itself as mental confusion due to hypoxia Can\u2019t cough \ue601\u2192\ue601 ineffective airway clearance If a patient has low Hgb\/Hct\u2014should be evaluated for signs of bleeding (dark\/black stools) A patient with liver cirrhosis and edema may ambulate, then sit with legs elevated to try to mobilize the edema Safety over nutrition in a severely depressed patient Depression\ue601 can manifest itself in somatic ways- such as psychomotor retardation, GI complaints and pain Prolonged\ue601 \ue601hypoxemia\ue601 is a likely cause of cardiac arrest in a child Coarctation\ue601 \ue601of the aorta\ue601 causes increased blood flow and \ue601bounding pulses in the arms Newly diagnosed HTN- assess BP in both arms 101
Place a wheelchair parallel to the bed on the strong side Gonorrhea is a reportable disease! Stairway to Heaven (Crutches) \u25cfThe \ue601good\ue601 go to heaven- good leg goes up the stairs first with crutches (crutches move with the affected leg) \u25cfThe \ue601bad \ue601to to hell (down)- bad leg goes down the stairs first (crutches move with the affected leg) Vasopressin\ue601- \u201cpress in\u201d \ue601\u2192\ue601 vasoconstriction (used when patient is hypotensive) Burning sensation in the mouth and brassy taste are adverse reactions to Lugol Solution (iodine) \u2013 used in treatment of hyperthyroidism Nonfat milk reduces reflux by increasing lower esophageal sphincter pressure When the \ue601oxygen\ue601 \ue601flow\ue601 \ue601rate\ue601 is higher than 4L\/min, the mucous membranes can be dried out- the best treatment is to add \ue601humidification\ue601 to the oxygen delivery system (applying water-soluble jelly to the nares can also help decrease mucosal irritation) A \ue601nonrebreather\ue601 \ue601mask\ue601 can delivery nearly 100% oxygen\u2014when the patient\u2019s oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present\u2014usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless healthcare providers intervene by providing \ue601intubation and mechanical ventilation The \ue601endotracheal\ue601 \ue601tube\ue601 should be marked \ue601at the level\ue601 where it touches the incisor tooth or nares\u2014this mark is used to verify that the tube has not shifted Infections\ue601 are always a \ue601threat\ue601 for the patient receiving \ue601mechanical ventilation\ue601\u2014elevated temperature is cause for concern 102
Confusion\ue601 in a patient taking enoxaparin (Lovenox) could indicate intracerebral bleeding! Removing large quantities of fluid from the pleural space can cause fluid to shift from the circulation into the pleural space, causing hypotension and tachycardia\u2014may need IV fluids to correct this Low sodium diet is 2g or less Persistent and irritating cough\ue601 (dry cough caused by accumulation of bradykinin) is a possible adverse effect of ACE-inhibitors (enalapril) and is a common reason for changing to another medication category such as ARBs The goal when treating HTN with medication is reduction of blood pressure to under 140\/90 Because continuous chest pain lasting more than 12 hours indicates that reversible myocardial injury has progressed to irreversible myocardial necrosis, fibrinolytic drugs (TPA) are not recommended for clients with chest pain that has lasted for more than 12 hours The \ue601goal in pain management \ue601for the client with an \ue601acute MI\ue601 is to completely eliminate the pain. Even pain rated at a level of 1 out of 10 should be treated with additional morphine sulfate Hyperkalemia\ue601 is a common adverse effect of both ACE inhibitors and potassium-sparing diuretics Proton pump inhibitors\ue601 (omeprazole) affect the metabolism of clopidogrel and decrease its effectiveness The most common complication after coronary arteriography is hemorrhage\u2014earliest indication of hemorrhage is an increase in heart rate PVCs occurring in the setting of acute MI can lead to ventricular tachycardia and\/or v-fib (cardiac arrest), so rapid treatment is necessary Anticoagulant medications\ue601 are high-alert meds and require special safeguards- such as double-checking medication by two nurses before administration B-type natriuretic peptide levels\ue601 increase in clients with poor left ventricular function and symptomatic heart failure and can be used to differentiate HF from other causes of dyspnea and fatigue (such as pneumonia) 103
A patient with \ue601thrombocytopenia\ue601 (low PLT count) should not take aspirin routinely\u2014aspirin decreases platelet aggregation When a \ue601hemophiliac\ue601 patient is at high risk for bleeding, the priority intervention is to maximize the availability of clotting factors (administer Factor VII) Hemophilia is x-linked\ue601 \u2013 mother passes to son Joint pain in hemophilia indicates bleeding\u2014treatment includes factor VII and RICE Bence Jones proteins\ue601 in the urine indicate multiple myeloma Increased risk of \ue601infection\ue601 after \ue601splenectomy\ue601\u2014monitor for elevation of temperature Fatal hyperkalemia\ue601 may be caused by \ue601tumor lysis syndrome\ue601, a potentially serious consequence of chemotherapy in acute leukemia A \ue601non-tender lump\ue601 or swelling near lymph nodes may indicate that the patient has developed \ue601lymphoma\ue601 (possible adverse effect of immunosuppressive therapy A newly-admitted patient needs to be assessed as soon as possible\u2014if all patients are stable, the new admission takes priority because plan of care needs to be completed Order of a newborn bath: \u25cfPlace on warm surface \u25cfCleanse eyes \u25cfCleanse face \u25cfCleanse body with warm water \u25cfWrap infant in pre-warmed blanket \u25cfShampoo head\/hair If \ue601TPN\ue601 is not ready when it is due, D10W or D20W should be administered \u25cfAlways check the order before administering TPN\u2014generally each bag is individually prepared by the pharmacist \u25cfSolution should not be cloudy or turbid \u25cfPrime the tubing and thread the pump \u25cfTo prevent infection, scrub the hub and use aseptic technique when inserting the connector into the injection cap and connecting the tubing to the central line \u25cfSet the pump at the prescribed rate 104
Probiotic therapy-\ue601 live microorganisms similar to those found in GI track\u2014when colonized they enhance the immune response and stabilize the mucosal barrier in the digestive track \u25cfPatients who may benefit: oAntibiotic associated diarrhea oIBS oLactose intolerance (+) \ue601nitrite\ue601 in urine is indication of \ue601UTI \u25cfOther signs: elevated WBC count, elevated temp, confusion in elderly, burning with urination 3-minute hand scrub is particular to the newborn nursery area and included in medical asepsis Medical asepsis = clean technique Two identifiers\ue601 must be used when administering medication \u25cfName on bracelet \u25cfPhoto \u25cfBar code system \u25cfAsking patient to state name \u201cTime Out\u201d \u25cfCalled before the initiation of any surgical procedure \u25cfPatient can be involved \u25cfGoals oCorrectly identify the patient oCorrectly identify the site and side oVerify that OR team agrees on procedure Oculogyric crisis\ue601- eyes locked upward (acute dystonic reaction from antipsychotic medications)\u2014contact physician- anticipate administration of anticholinergic medication- benztropine (cogentin) Talipes equinovarus\ue601- club foot The \ue601priority\ue601 for \ue601migraine\ue601 headache is \ue601pain\ue601 management A client with a \ue601seizure disorder\ue601 should not take OTC medications without consulting with the health care provider first 105
First priority\ue601 for the client with a \ue601spinal cord injury\ue601 is assessing respiratory\ue601 patterns and ensuring an adequate airway Priority intervention\ue601 for a client with \ue601Guillain Barre Syndrome\ue601 is maintaining adequate respiratory function\ue601\u2014clients with Guillain Barre are at risk for respiratory failure, which requires urgent intervention Clients with \ue601right cerebral hemisphere stoke\ue601 often manifest \ue601neglect syndrome\ue601\u2014lean to the left, when asked, respond that they believe they are sitting up straight\u2014often neglect the left side of their bodies and ignore food on the left side of their food trays Bacterial meningitis\ue601 is a medical emergency- antibiotics are the priority medication (cultures and specimens should be drawn before) Priority action during a generalized \ue601tonic-clonic seizure\ue601 is to protect the airway by turning the client to one side\u2014oxygen is used in postictal phase Exophthalmos\ue601- instill artificial tears (hyperthyroidism- Graves) Bulge test\ue601 confirms presence of fluid in knee- leg should be extended Side rails should always be elevated for disoriented patients Bismuth subsalicylate\ue601 absorbs PO meds and should be administered separately Normal CVP\ue601- 3-12 mmHg (cm of water) Early signs of hepatic encephalopathy \u25cfImpaired thought process \u25cfInsomnia and sleep disturbances \u25cfTremors Sengstaken-Blakemore tube\ue601- have scissors at bedside (airway obstruction\ue601\u2192 cut balloon with scissors) Nurse is obligated to share client information with personnel directly involved in care Bowel perforation\ue601 requires emergency surgery (result of increased intraluminal pressure)\u2014intestinal contents are released into peritoneum leading to peritonitis 106
Heat in cast is a sign of pressure, which can indication poor circulation! Requires fast assessment! Hypotonic\ue601 (0.45% NS) shifts fluid into intracellular space Radium implant\ue601- strict bed rest (so no, they cannot use a bedside commode) Cyclophosphamide\ue601 \u2013 will likely cause alopecia 4-5 weeks after starting Bell\u2019s Palsy\ue601- use artificial tears (4x\/day) Cocaine Abuse S\/S \u25cfInsomnia \u25cfRhinorrhea \u25cfTachycardia \u25cfEuphoria *Cocaine is a stimulant Low titer means risk for developing disease Breathing slowly will enhance relaxation of abdominal muscles Shingles\ue601- able to care for non-high risk clients\u2014cover lesions \u25cfShould not care for pregnant women, premature infants, immunocompromised Parenteral Nutrition (PN)-\ue601 monitor serum glucose and electrolytes \u25cfMost common complication involves fluid and electrolytes No Beta-Blockers with COPD No lidocaine with heart blocks\ue601\u2192\ue601 diminishes existing ventricular response Causes of tinnitus \u25cfAspirin \u25cfDiuretics \u25cfNeurological conditions \u25cfLoud noises \u25cfImpacted earwax or foreign bodies in the ear \u25cfEar infections A bulging red or blue tympanic membrane is a possible sign of otitis media or perforation 107
Vertigo\ue601 \ue601without\ue601 hearing loss should be further assessed for nonvestibular causes, such as cardiovascular or metabolic problems! Stapedectomy\ue601 (surgical procedure of the middle ear; used for hearing loss related to otosclerosis) \u25cfHeavy lifting should be avoided for at least 3 weeks after the procedure \u25cfWater in the ear, and air travel should be avoided for at least 1 week \u25cfCoughing and sneezing should be performed with the mouth open to prevent increase pressure in the ear Ear Irrigation \u25cfUse an otoscope to assess the ear first \u25cfFill syringe with warm fluid \u25cfAngle the syringe to allow the fluid to flow along the side of the ear canal, not directly at the eardrum \u25cfFlush with continuous pressure, rather than a pumping action \u25cfYou should see fluid return with cerumen \u25cfIf not, wait at least 10 minutes and repeat \u25cfTipping the head allows gravity drainage of fluid left in the ear canal Basilar invagination\ue601 (platybasia) causes brainstem manifestations- can be life threatening 4 C\u2019s of Communication 1) Clear 2) Concise 3) Correct 4) Complete *Ensures the staff understands what is being said Postoperative pain \ue601and\ue601 numbness \ue601occur for a longer period of time with endoscopic carpal tunnel release \ue601than with an open procedure. \u25cfHand movements, including heavy lifting, may be restricted for 4-6 weeks after surgery \u25cfPatients experience discomfort for weeks to months \u25cfSurgery is not always a cure \u25cfIn some cases CTS may recur months to years after surgery Fat embolism syndrome\ue601 is a serious complication that often results from fractures of long bones\u2014its earliest manifestation is altered mental status caused by a low arterial oxygen level 108
The \ue601goal of bowel training\ue601 is to establish a pattern that mimics normal defecation, and many people have the urge to defecate after a meal Refeeding syndrome\ue601 occurs when aggressive and rapid feeding results in fluid retention and heart failure\u2014monitor for signs of fluid volume overload Substance abuse\ue601 may exclude a person from the \ue601transplant\ue601 list The presence of \ue601glucose\ue601 in the \ue601nasal drainage\ue601 indicates the fluid is \ue601CSF (cerebrospinal fluid) \ue601and suggests a CSF leak Vitiligo\ue601, or patchy areas of pigment loss with increased pigmentation at the edges, is seen with \ue601primary\ue601 \ue601hypofunction\ue601 of the \ue601adrenal glands \ue601and is caused by autoimmune destruction of melanocytes in the skin Silver scaling\ue601 on skin is associated with \ue601psoriasis Wounds should be debrided before obtaining wound specimen for culturing Isotretinoin\ue601 \u2013 oral medication used for acne\u2014has high incidence of birth defects\u2014important to stop using medication at least a month before attempting to become pregnant Wheals \ue601(on the skin) are frequently associated with allergic reactions\u2014asking the patient about exposure to new medications is the most appropriate question Chemical\/toxic \ue601exposure to skin\ue601\u2192\ue601 \ue601priority\ue601 is to remove the chemical from contact with the skin to prevent ongoing damage Prostate disease\ue601 increases the risk of UTIs in men because of urinary retention A \ue601cystoscopy\ue601 is needed to accurately diagnose interstitial cystitis A patient with \ue601urge incontinence\ue601 can be taught to control the bladder as long as the patient is alert, aware, and able to resist the urge to urinate by starting a schedule for voiding, then increasing intervals between voids Women should avoid irritating substances such as bubble baths, nylon underwear, and scented toilet paper to prevent UTIs Bruising\ue601 is expected post-lithotripsy and can be quite extensive 109
A patient with \ue601only one kidney\ue601 should avoid \ue601all\ue601 contact sports and high-risk activities to protect the remaining kidney from injury and preserve kidney function During the \ue601oliguric\ue601 phase of\ue601 \ue601acute kidney failure\ue601, a patient\u2019s urine output is greatly reduced. Fluid boluses and diuretics do not work well. This phase usually lasts from 8-15 days Patients with \ue601acute kidney failure \ue601usually go through a \ue601diuretic\ue601 phase 2 to 6 weeks after the oliguric phase\u2014the diuresis can result in an output of up to 10L\/day of dilute urine\ue601\u2192\ue601 during this time it is important to monitor for electrolyte and fluid imbalances MAP\ue601 = [ (2 x diastolic) + systolic ] divided by 3 A palpable bladder and restlessness are indicators of urinary retention, which requires action to empty the bladder (such as catheterization) Benign prostatic hyperplasia (BPH) \u25cfClient will have trouble starting a urinary stream \u25cfElevated level of prostate-specific antigen Irregularly shaped \ue601and \ue601nontender lumps\ue601 are consistent with a diagnosis of breast cancer Transurethral Resection of the Prostate (TURP) \u25cfBladder spasms may indicate that clots are obstructing the catheter, which would indicate the need for irrigation of the catheter with 30 to 50 mL of NS using a piston syringe (irrigation would be first action) \u25cfHemorrhage is a major complication following a TURP\u2014signs would be catheter draining deep red blood Tamulosin\ue601- used to treat BPH — monitor for orthostatic hypotension \u25cfImproves symptoms by relaxing the muscles in the prostate and bladder neck\u2014making it easier to urinate \u25cfForce of urinary stream may increase Testicular Torsion \u25cfScrotal swelling and severe pain\u2014likely not relieved or decreased by elevation of the scrotum \u25cfEmergency\ue601 situation that requires immediate assessment and intervention because it can lead to testicular ischemia and necrosis within a few others 110
Sildenafil\ue601 \ue601(Viagara)- potent vasodilator used in the treatment of erectile dysfunction \u25cfHas caused cardiac arrest in clients who were also taking nitrates such as nitroglycerin After an \ue601A&P\ue601 \ue601repair \ue601(vaginal wall repair\/anterior and posterior), it is essential that the bladder be empty to avoid putting pressure on the suture lines \u25cfAbdominal firmness and tenderness indicate that the bladder is distended\u2014requires catheterization Rapid Response Team (RRT) \u25cfRole of RRT is the immediate assessment and stabilization of a client First-degree relatives of patients with the \ue601BRCA\ue601 \ue601gene\ue601 should be screened annually with both mammography and MRI Severe spontaneous hemorrhage is not expected until the \ue601platelet count\ue601 drops below 20,000 mm\ue6013 Frequent swallowing\ue601 following T&A may indicate bleeding Tracheal deviation\ue601 suggests \ue601tension pneumothorax\ue601- priority situation\ue601\u2192 requires chest tube Synthetic surfactant \ue601improves respiratory status and decreases the incidence of pneumothorax in premature infants with respiratory distress syndrome (RDS) Crackles throughout both lungs indicate that a child has severe left ventricular failure as a complication of \ue601endocarditis Decreased responsiveness in a patient with a clotting disorder may indicate intracerebral bleeding\u2014priority situation Chlamydia \ue601is the most prevalent STI in the US\u2014screening is strongly recommended for all sexually active females 25 years or younger Iron\ue601 is a toxic substance that can lead to massive hemorrhage, coma, shock, and hepatic failure\u2014\ue601deferoxamine\ue601 is an antidote that can be used for severe cases of iron poisoning Triage\ue601 requires at least one experienced RN Primary survey\ue601 for a trauma patient arriving to ED includes a brief neurologic assessment to determine level of consciousness and pupil reaction 111
Secondary survey\ue601 includes measuring vital signs, assessing the abdomen, and checking pulse oximetry readings Heat\ue601 \ue601stroke\ue601 is a medical emergency that increases the risk for brain damage You respond to a call for help from the ED waiting room\u2014an elderly client is lying on the floor\u2026. \u25cfEstablish responsiveness first (the client may have fallen and sustained a minor injury) \u25cfIf the client is unresponsive, get help and activate the code team \u25cfPerforming the chin lift or jaw thrust maneuver opens the airway \u25cfThe nurse is then responsible for starting CPR oCPR should not be interrupted until the client recovers or it is determined that all heroic efforts have been exhausted \u25cfA crash cart should be at the site when the code team arrives\u2014however, basic CPR can be effectively performed until the team is present Pulsating mass\ue601 in abdomen indicates abdominal aneurysm\u2014concern is rupture A person who experienced a threat to his or her own life is at the greatest risk for psychiatric problems following a disaster incident (such as PTSD) Appropriate in Disaster Triage \u25cfCheck airway, breathing, circulation \u25cfAssess the level of consciousness \u25cfVisually inspect for gross deformities, bleeding, and obvious injuries \u25cfNote color, presence of moisture, and temperature of the skin \u25cfCheck vital signs, including pulse and respirations Patients with \ue601conversion disorders\ue601 are experiencing symptoms, even though there is no identifiable organic causes\ue601\u2192\ue601 therefore they should be assisted in learning ways to cope and live with the disability Family history of completed suicide is a risk factor for an individual committing suicide Before someone enters an \ue601alcohol rehabilitation\ue601 program, there should be a medically-supervised detoxification When \ue601delegating\ue601 \ue601psychiatric\ue601 \ue601patients\ue601 to new RNs, try to avoid assigning a psychotic patient \u2013 they can be very threatening to new RNs Restraints\ue601 must be tied to a stationary portion of the bed using quick-release knots\ue601\u2192\ue601 distal pulses should be checked \u25cfRestraints are rarely a planned event 112
Take time for yourself\u2014a mind that is fried, is not a good use of time! 113<\/p>\n","protected":false},"excerpt":{"rendered":"

GOLD 1 Nothing is impossible- the word itself says \u201cI\u2019m Possible\u201d NCLEX TIPS 1) Do not read into the question\ue601- never assume anything that has not been specifically mentioned (in the question) and do not add extra meaning or history to the question\u2014do not make up a story to validate choosing an answer 2) NCLEX […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-114389","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/114389","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=114389"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/114389\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=114389"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=114389"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=114389"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}