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NCLEX PN diagnosis for bow ties Leave the first rating Students also studied Terms in this set (21) Science MedicineNursing Save ATI NGN questions 24 terms jamie_irvine8Preview Exam Cram NCLEX-PN PRACTICE Q...103 terms summer3266Preview HESI - Fundamentals practice questi...327 terms morganpruitt28 Preview NCLEX Teacher Tuto Urinary Tract Infections (UTIs)
Keywords: Dysuria, frequency, urgency, cloudy urine,
fever.
Vitals: Possible low-grade fever.
History: Recent catheterization, urinary stasis, or diabetes
Actions:
Encourage Fluid Intake: Increase water intake to help flush out bacteria.
Administer Antibiotics: As prescribed, ensuring the right medication and dose.
Teach Hygiene Practices: Proper wiping techniques, hydration, and voiding habits
Parameters to monitor:
Urine Output and Color: For signs of improvement or worsening infection.
Temperature: For fever indicating infection severity or response to treatment.
Pain Levels: Assessing for dysuria or flank pain reduction
Pneumonia
Keywords: Cough, sputum, chest pain, dyspnea, fever.
Vitals: Fever, tachypnea, possible hypoxia.
History: Recent flu-like symptoms, exposure to infections
Actions:
Positioning: Encourage semi-Fowler's position to aid breathing.
Administer Medications: Antibiotics, antivirals, or antifungals as prescribed, and possibly bronchodilators or mucolytics.
Respiratory Therapy: Use of incentive spirometry, chest physiotherapy.
Parameters to Monitor:
Respiratory Rate and Effort: For signs of respiratory distress or improvement.
Oxygen Saturation: Ensuring adequate oxygenation.
Lung Sounds: For crackles, wheezes, or clearing of secretions.
Heart Failure with preserved Ejection Fraction (HFpEF)
Keywords: Dyspnea on exertion, fatigue, orthopnea,
edema.
Vitals: Elevated BP, tachycardia, low O2 saturation.
History: Hypertension, diabetes, older age.
Actions:
Fluid Management: Monitor and restrict fluid intake if necessary.
Medication Administration: Diuretics, beta-blockers, or other heart failure
medications.
Activity Planning: Educate on energy conservation and limit activities that
exacerbate symptoms.
Parameters to Monitor:
Blood Pressure: For signs of hypotension or hypertension.
Weight Daily: For sudden increases indicating fluid retention.
Jugular Vein Distension (JVD) and Edema: Signs of fluid overload.
Cellulitis
Keywords: Redness, warmth, pain, swelling in an
extremity.
Vitals: Possible fever, increased heart rate.
History: Recent injury or skin break, diabetes
Actions:
Elevate Affected Limb: To reduce swelling.
Antibiotic Therapy: Oral or IV antibiotics as prescribed.
Wound Care: If there's a break in the skin, proper cleaning and dressing.
Parameters to Monitor:
Skin Changes: Redness, warmth, and induration.
Pain and Tenderness: For improvement or spread of infection.
Vital Signs: Especially for fever indicating systemic infection
Altered Mental Status (AMS)
Keywords: Confusion, disorientation, lethargy, agitation.
Vitals: Any abnormal vital signs could indicate underlying
cause.
History: Alcohol use, medication changes, head injury.
Actions:
Safety Measures: Ensure a safe environment to prevent falls or self-harm.
Neurological Assessment: Regular checks for changes in level of consciousness,
pupil response, etc.
Blood Glucose Check: Immediate check if diabetic or suspected hypoglycemia.
Parameters to Monitor:
Glasgow Coma Scale (GCS) or similar: For changes in consciousness.
Vital Signs: Especially blood pressure and heart rate for signs of shock or stroke.
Blood Glucose Levels: If relevant, for metabolic causes of AMS
Sepsis
Keywords: Fever or hypothermia, increased heart rate,
respiratory rate changes, altered mental status.
Vitals: Hypotension, tachycardia, tachypnea.
History: Known infection, recent surgery, or invasive
procedures.
Actions:
IV Fluids: Rapid administration to restore circulatory volume.
Broad-Spectrum Antibiotics: Immediate start if sepsis is suspected.
Source Control: Identify and manage the infection source.
Parameters to Monitor:
Lactate Levels: For tissue perfusion status.
Blood Pressure and Heart Rate: For hemodynamic stability.
Urine Output: As an indicator of kidney perfusion.
Neurological Conditions
Keywords: Diplopia, inability to move eyes laterally,
headache.
Vitals: Usually normal unless secondary to increased ICP.
History: Trauma, hypertension, diabetes.
Actions:
Eye Protection: If unable to close the eye, use eye drops or patches.
Referral: To neurology or ophthalmology for further evaluation.
Symptom Management: Pain relief if headaches are present.
Parameters to Monitor:
Vision and Eye Movement: For progression or improvement.
Headache Characteristics: If present, for changes in intensity or frequency.
Neurological Signs: Other cranial nerve functions or signs of increased intracranial pressure.Diabetes Mellitus
Wording Clues: Terms like "polyuria," "polydipsia,"
"polyphagia," "glucose monitoring," "insulin administration."
Patient Presentation: Frequent urination, excessive thirst,
weight loss despite increased appetite, fatigue.
Vitals & History: Possible weight changes, family history
of diabetes, recent infections or stress.
Actions:
Blood Glucose Monitoring: Regular checks, especially before meals.
Administer Medications: Insulin or oral hypoglycemics as prescribed.
Diet Education: Teaching about carbohydrate counting and meal planning.
Parameters to Monitor:
Blood Glucose Levels: For control and response to treatment.
Signs of Hyperglycemia or Hypoglycemia: Symptoms like polyuria, polydipsia,
confusion, or sweating.
Chronic Obstructive Pulmonary Disease (COPD) Wording Clues: "Shortness of breath," "barrel chest," "use of accessory muscles," "cyanosis," "hypoxemia."
Patient Presentation: Dyspnea on exertion, chronic
cough, wheezing, barrel chest appearance.
Vitals & History: Smoking history, frequent respiratory
infections, use of inhalers.
Actions:
Oxygen Therapy: Administering with caution to avoid hypercapnia.
Bronchodilators: Use of inhalers or nebulizers.
Pursed-Lip Breathing: Teaching this technique to help with exhalation.
Parameters to Monitor:
Respiratory Rate and Effort: For signs of respiratory distress.
Oxygen Saturation: Ensuring it's within safe limits for COPD patients.
Sputum Characteristics: Color, amount, consistency for infection signs
Depression
Wording Clues: "Lethargy," "anhedonia," "suicidal
ideation," "antidepressant therapy."
Patient Presentation: Sad mood, lack of interest in
activities, changes in sleep or appetite, feelings of worthlessness.
Vitals & History: No specific vital changes, but history of
recent life changes, loss, or chronic illness.
Actions:
Safety Assessment: For suicide risk, especially in severe cases.
Medication Administration: Antidepressants, monitoring for side effects.
Therapeutic Communication: Engaging in active listening and providing emotional
support.
Parameters to Monitor:
Mood and Affect: Changes in mood, interest in activities.
Sleep Patterns: Insomnia or hypersomnia.
Appetite and Weight Changes: Common in depression.
Gastrointestinal Bleed
Wording Clues: "Hematemesis," "melena," "coffee-ground
emesis," "hemoglobin drop."
Patient Presentation: Vomiting blood or coffee-ground
material, black tarry stools, pallor.
Vitals & History: Hypotension, tachycardia, history of liver
disease, NSAID use, or alcohol abuse.
Actions:
Fluid Resuscitation: IV fluids to maintain blood pressure.
Medication: Proton pump inhibitors, possibly octreotide.
Preparation for Endoscopy: If indicated for diagnosis and treatment.
Parameters to Monitor:
Vital Signs: For signs of shock or hemodynamic instability.
Hematemesis or Melena: Monitoring for continued bleeding.
Hemoglobin Levels: For assessing blood loss
Acute Kidney Injury (AKI)
Wording Clues: "Decreased urine output," "elevated
creatinine," "fluid overload," "nephrotoxic drugs."
Patient Presentation: Oliguria or anuria, swelling, fatigue.
Vitals & History: Recent contrast exposure, dehydration,
use of nephrotoxic medications, hypotension episodes.
Actions:
Fluid Management: Careful monitoring of intake and output.
Medication Review: Adjusting or holding nephrotoxic drugs
Dietary Modifications: Limiting fluids, sodium, and potassium as needed.
Parameters to Monitor:
Urine Output: For signs of oliguria or anuria.
Serum Creatinine and BUN: For kidney function assessment.
Electrolytes: Especially potassium, as hyperkalemia can be life-threatening.
Preeclampsia/Eclampsia
Clues: High blood pressure, protein in urine, sudden
weight gain, headaches, visual disturbances.Look for: Terms like "hypertension," "edema," "seizures," "magnesium sulfate."
Actions:
Administer Magnesium Sulfate: For seizure prophylaxis.
Blood Pressure Management: Use of antihypertensives like Labetalol or
Nifedipine.
Frequent Monitoring: Of both mother and fetus.
Parameters to Monitor:
Blood Pressure: Regular checks for hypertension.
Deep Tendon Reflexes: For signs of magnesium toxicity or preeclampsia severity.
Urine Output: For kidney function and magnesium sulfate toxicity.
Gestational Diabetes
Clues: Elevated blood sugar levels during pregnancy,
frequent thirst, fatigue.
Look for: "Glucose tolerance test," "insulin," "diet
management."
Actions:
Dietary Management: Low glycemic index diet.
Blood Glucose Monitoring: Multiple times daily.
Insulin or Oral Hypoglycemics: If diet alone isn't sufficient.
Parameters to Monitor:
Blood Glucose Levels: Pre and post-meal.
Fetal Growth: Ultrasound for macrosomia risk.
Maternal Weight Gain: To ensure it's within normal ranges.
Preterm Labor
Clues: Contractions before 37 weeks, cervical changes.
Look for: "Contractions," "cervical dilation," "tocolytics."
Actions:
Tocolytics: Medications to stop contractions if safe and appropriate.
Corticosteroids: To promote fetal lung maturity if delivery is imminent.
Bed Rest: Sometimes recommended, though evidence varies.
Parameters to Monitor:
Contraction Frequency: Using tocodynamometry.
Cervical Changes: Length via ultrasound.
Fetal Heart Rate: For signs of distress.
Postpartum Hemorrhage
Clues: Excessive bleeding after delivery, low blood
pressure, rapid heart rate.Look for: "Heavy bleeding," "uterine atony," "oxytocin."
Actions:
Uterine Massage: To promote contraction and reduce bleeding.
Oxytocin Administration: To enhance uterine contraction.
Fluid Resuscitation: IV fluids, possibly blood products.
Parameters to Monitor:
Vital Signs: For shock indicators like tachycardia, hypotension.
Blood Loss Estimation: Quantifying blood loss.
Uterine Tone: For atony, which is a common cause
Placenta Previa
Clues: Painless vaginal bleeding in the third trimester,
ultrasound findings.
Look for: "Painless bleeding," "placental location."
Actions:
Avoid Vaginal Exams: To prevent bleeding.
Prepare for C-section: If bleeding occurs or upon delivery decision.
Monitor Bleeding: Continuous assessment.
Parameters to Monitor:
Vaginal Bleeding: Amount and frequency.
Fetal Heart Rate: For signs of distress due to bleeding.
Maternal Hemodynamics: Blood pressure, pulse.
Abruptio Placentae
Clues: Painful vaginal bleeding, uterine tenderness, fetal
distress.Look for: "Sudden onset pain," "bleeding," "fetal heart rate changes."
Actions:
Stabilize Mother: IV fluids, possibly blood transfusion.
Delivery: Often necessary, especially if severe or fetal distress.
Pain Management: Analgesia as appropriate.
Parameters to Monitor:
Pain Level: Location, intensity.
Fetal Heart Rate: For signs of distress or compromise.
Maternal Coagulation: For disseminated intravascular coagulation (DIC) risk.
Intrauterine Growth Restriction (IUGR)
Clues: Fetus smaller than expected for gestational age,
reduced fetal movements.
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