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CDC Guidelines for Isolation Precautions in Hospitals Minnesota Dept. of Health Yale New Haven Hospital Infection Control Manual Use Airborne Precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. These include: Measles (rubeola) Varicella (chicken pox) – requires Contact Prec. as well Herpes Zoster (shingles), disseminated – requires contact prec. as well TB Severe Acute Repiratory Syndrome (SARS) Airborne Precautions include personal respiratory protection and special ventilation and air handling. Airborne transmission occurs through either: airborne droplet nuclei (small particles, 5 micrograms or smaller, of evaporated droplets containing microorganisms that remain suspended in the air for long periods of time) or dust particles that contain an infectious agent. Microorganisms carried by the airborne route can be widely dispersed by air currents and may become inhaled by a susceptible host in the same room or over a long distance form the source patient – depending on environmental factors such as temperature and ventilation. Airborne precautions include Standard Precautions plus personal respiratory protection (N95 respirator) or powered air-purifying respirator (PAPR) and airborne infection isolation room (AIIR). These rooms must, at a minimum, provide negative pressure with a minimum of 6 air exchanges per hour, and exhaust directly to the outside or through HEPA filtration. Droplet Precautions: droplets can be transmitted during coughing, sneezing, talking, and during certain procedures such as suctioning or bronchoscopy. Droplets generally travel no further than 3 feet from patient. Droplet precautions include Standard Precautions plus surgical mask worn when working within 3 feet of the patient. In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to have serious illnesses transmitted by large particle droplets. These include: Invasive Haemophilus influenza (H.influenza), type b disease, including meningitis, pneumonia, epiglottitis, and sepsis Invasive Neisseria meningitides disease, including meningitis, pneumonia, and sepsis Other serious bacterial respiratory infections spread by droplet transmission, including: Diptheria (pharyngeal) Mycoplasma pneumonia Pertussis Pneumonic plague Strep (group A) pharyngitis, pneumonia, or scarlet fever in infants and young children Serious viral infections spread by droplet transmission, including: Adenovirus Influenza Mumps Parvovirus B19 Rubella (German Measles) Contact Precautions In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include: Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance Enteric infections with a low infectious dose or prolonged environmental survival, including: o Clostridium difficile o For diapered or incontinent patients: enterohemorrhagic Escherichia coli O157:H7, Shigella, hepatitis A, or rotavirus Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children Skin infections that are highly contagious or that may occur on dry skin, including: o Diphtheria (cutaneous) o Herpes simplex virus (neonatal or mucocutaneous) o Impetigo o Major (noncontained) abscesses, cellulitis, or decubiti o Pediculosis o Scabies o Staphylococcal furunculosis in infants and young children o Zoster (disseminated or in the immunocompromised host)† Viral/hemorrhagic conjunctivitis Viral hemorrhagic infections (Ebola, Lassa, or Marburg) Measles (rubeola) requires Standard Precautions and Airborne Precautions. *No mask required if immune to measles. *Note: All healthcare workers should have received 2 doses of the measles vaccine if born after 1957. If born prior to 1957, one is considered immune. Limit transport of patient; if transporting is necessary, place N-95 mask on patient. Private-Negative Pressure Room Required. Duration of Precautions: Duration of illness German Measles (Rubella) requires Standard Precautions and Droplet Precautions. Duration of Precautions: Until 7 days after onset of rash Group A and Group B Strep, invasive: requires Standard precautions. Extrapulmonary Tuberculosis (draining lesion, including scrofula) requires Standard Precautions. Tuberculous Meningitis requires Standard Precautions. Note: Patient should be evaluated for evidence of concurrent (active) pulmonary tuberculosis. If evidence exists for active pulmonary tuberculosis Airborne Precautions are required. Pulmonary Tuberculosis, confirmed or suspected (including laryngeal disease) requires Standard Precautions and Airborne Precautions. Wear N-95/ HEPA respirator prior to entering patient's room. Limit transport of patient; if transporting is necessary, place N-95 mask on patient. Private-Negative Pressure Room Required. Duration of Precautions: Duration of illness Chickenpox (Primary Varicella zoster infection) requires Standard precautions, Airborne Precautions and Contact Precautions. Negative pressure room required. *No mask required if immune to Varicella. Limit transport of patient; if transporting is necessary, place a N-95 mask on patient; all staff who have contact with patient during transport must be immune. Contact Precautions: Don and remove gown and gloves upon entering and exiting pt’s room. Dedicate non-critical pt care equipment. Duration of Precautions: Maintain precautions until all lesions are crusted. The average incubation period for varicella is 10 to 16 days, with a range of 10 to 21 days. Place exposed susceptible patients on Airborne Precautions beginning on the 10th day after exposure and continuing until 21 days after last exposure (up to 28 days if VZIG has been given). Anthrax – Cutaneous and Anthrax-Inhalational requires Standard Precautions. Anthrax may be a disease indicating possible bioterrorism. Clostridium difficile colitis requires Standard Precautions and Contact Precautions. Bronchiolitis (infants and young children) requires Standard Precautions and Contact Precautions. Candidiasis: Standard Precautions Chlamydia, all types: Standard Precautions Gastroenteritis, including cholera, e.coli, rotavirus, giardia, etc: requires Standard Precautions *but requires the use of Contact Precautions for diapered or incontinent patients including children under 6 years of age. CMV (cytomegalovirus) : Standard Precautions Croup requires Standard Precautions and Contact Precautions. Decubitis ulcer - major requires Standard Precautions and Contact Precautions. A major decubitus ulcer is one that is not contained by a dressing. Duration of Precautions: Until wound heals over and stops draining. Minor requires Standard Precautions only. Diptheria – Cutaneous and Diptheria -- Pharyngeal: Standard and Contact. Duration of Precautions: Until off all antibiotics and until two cultures obtained 24 hours apart are negative. Arthropod-borne Viral Encephalitis requires Standard Precautions. Examples: West Nile Encephalitis, Eastern Equine Encephalitis, Western Equine Encephalitis, St. Louis Encephalitis, California (LaCrosse) Encephalitis Invasive Hemophilus influenzae disease: ie: H. influenza meningitis, H. influenza epiglottitis: Standard and Droplet precautions. Duration of Precautions: until 24 hours of effective antimicrobial therapy has been given. Epstein-Barr Virus, including mononucleosis: Standard precautions Fifth’s Disease: Standard and Droplet, *but in an immunocompetent (normal) patient with acute disease, it is not communicable after onset of rash; thus, Droplet Precautions are not then necessary. Duration of precautions for others: For an immunocompromised patient with chronic disease--duration of hospitalization. aplastic crisis or red cell aplasia (e.g. sick cell patients) --maintain Droplet Precautions for 7 days Leprosy (Hansen’s Disease): standard precautions. Hepatitis A, B, C, D, E: standard precautions, except for diapered/incontinent patients and type A. Impetigo: standard and contact. Duration of precautions: until 24 hours after initiation of effective therapy. Kawasaki Syndrome: standard precautions Legionnaire’s Disease: standard precautions Meningococcal meningitis (due to Neisseria meningitides): standard and droplet precautions. Pneumococcal meningitis: standard precautions Mumps: standard and droplet. Duration of precautions: for 9 days after onset of swelling. Norwalk viral gastroenteritis: standard precautions *but requires the use of Contact Precautions for diapered or incontinent patients including children under 6 years of age. Duration of precautions is duration of illness. Respiratory Syncytial Virus (RSV): standard and contact precautions. Can be roomed with other RSV pts as long as there are no other significant organisms present (ie MRSA, VRE, etc) Smallpox: standard, airborne, and contact precautions. Smallpox is a public health emergency and may be a disease indicating possible bioterrorism. Linen: All laundry should be placed in biohazard bags and autoclaved before laundering. Patient transport requires approval of Hospital Epidemiologist or designee. Duration of Isolation: To be determined by Hospital Epidemiology. Smallpox vaccination requires Standard Precautions, Airborne Precautions and Contact Precautions if an individual presents with an acute medical complaint and the scab has not separated from the inoculation site (usually occurs by day 14-21 post-vaccination). Typhoid Fever, including Salmonellosis—all salmonella species: standard *but requires the use of Contact Precautions for diapered or incontinent patients including children under 6 years of age for duration of illness. Whooping Cough is Pertussis; requires standard and droplet precautions. Maintain precautions until 5 days after patient is placed on effective therapy. Re: Anyoone up for random FACT THROWING?? ELECTROLYTES 1. Na- Hypo (Below 135) Symptom: irritability, apprehension, confusion, postural hypotension, tachycardia, tremors, seizures, coma Intervention/Tx: Administer IV saline sol, restrict water intake Na- Hyper (Above 145) symptom: thirst, dry mucous mem, restlessness, agitation, postural hypotension, switching, seizures Intervention/Tx: Administer oral fluids or dextrose 5%, restrict oral sodium intake 2. K- Hypo (Below 3.5) symptom: thirst, dry mucous mem, restlessness, agitation, postural hypotension, switching, seizures Intervention/Tx: Administer K K- Hyper (5.1) symptom: irritability, anxiety, paresthesias, weaknessof lower extrem, diarrhea, adbominal cramps Intervention/Tx: eliminate oral and parentheral K intake, administer K wasting diuretics 3. Ca- Hypo (Below 8.6) symptom: numbness and tingling of fingers and circumoral region, hyperreflexia, muscle cramps, seizures Intervention/Tx: Administer ca salts, calcium gluconate, diet high in ca and vit d Ca- Hyper (10) symptom: lethargy, weakness, depressed reflexes, anorexia, nausea, vomiting, back pain Intervention/Tx: prevent with wt bearing exercise, hydration, calcitonin prevents bone resorption 4. Mg- Hypo (Below 1.6) symptom: muscle tremors. hyperactive deep tensdon reflexes, confusion, seizures, cardiac dysrhythmias Intervention/Tx: Administer Mg PO or IV Mg- Hyper (2.6) symptom: muscle tremors, hypoactive deep tendon reflexes, decreased rate and depth of respirations, cardiac arrest Intervention/Tx: administer, calcium chloride, calcium gluconate to oppose effects on cardiac muscle, increase fluids 5. PO4- Hypo (Below 2.7) symptom: confusion, coma, rhadbomyolosis, muscle weakness Intervention/Tx: oral supplement, diet- high in phosphorous, PO4- Hyper (4.5) symptom: muscle problems, tetany, calcium-phosphate precipitates in skin, soft tissue, cornea, blood vessels Intervention/Tx: identify and treat underlying cause diet- restrict foods and fluids high in phosphorous, adequate hydration, phosphate-binding agents Re: Anyoone up for random FACT THROWING?? ELECTROLYTES 1. Na- Hypo (Below 135) Symptom: irritability, apprehension, confusion, postural hypotension, tachycardia, tremors, seizures, coma Intervention/Tx: Administer IV saline sol, restrict water intake Na- Hyper (Above 145) symptom: thirst, dry mucous mem, restlessness, agitation, postural hypotension, switching, seizures Intervention/Tx: Administer oral fluids or dextrose 5%, restrict oral sodium intake 2. K- Hypo (Below 3.5) symptom: thirst, dry mucous mem, restlessness, agitation, postural hypotension, switching, seizures Intervention/Tx: Administer K K- Hyper (5.1) symptom: irritability, anxiety, paresthesias, weaknessof lower extrem, diarrhea, adbominal cramps Intervention/Tx: eliminate oral and parentheral K intake, administer K wasting diuretics 3. Ca- Hypo (Below 8.6) symptom: numbness and tingling of fingers and circumoral region, hyperreflexia, muscle cramps, seizures Intervention/Tx: Administer ca salts, calcium gluconate, diet high in ca and vit d Ca- Hyper (10) symptom: lethargy, weakness, depressed reflexes, anorexia, nausea, vomiting, back pain Intervention/Tx: prevent with wt bearing exercise, hydration, calcitonin prevents bone resorption 4. Mg- Hypo (Below 1.6) symptom: muscle tremors. hyperactive deep tensdon reflexes, confusion, seizures, cardiac dysrhythmias Intervention/Tx: Administer Mg PO or IV Mg- Hyper (2.6) symptom: muscle tremors, hypoactive deep tendon reflexes, decreased rate and depth of respirations, cardiac arrest Intervention/Tx: administer, calcium chloride, calcium gluconate to oppose effects on cardiac muscle, increase fluids 5. PO4- Hypo (Below 2.7) symptom: confusion, coma, rhadbomyolosis, muscle weakness Intervention/Tx: oral supplement, diet- high in phosphorous, PO4- Hyper (4.5) symptom: muscle problems, tetany, calcium-phosphate precipitates in skin, soft tissue, cornea, blood vessels Intervention/Tx: identify and treat underlying cause diet- restrict foods and fluids high in phosphorous, adequate hydration, phosphate-binding agents 6 Readers Gave Kudos CocoKat jadu1106 JoanieDee, LPN Melinurse nezz621 SWEETDREAMERINSOCAL 6 Readers Gave Kudos CocoKat jadu1106 JoanieDee, LPN Melinurse nezz621 SWEETDREAMERINSOCAL Report BURNS 1st degree burn (superficial partial thickness) -superficial tissue damage involving epidermis only -local pain and erythema, blisters are absent for about 24 hrs -mild to no systemic reponse -quick healing (3-5 days) without scarring 2nd degree (deep partial thickness) -tissue damage involving the epidermis and part of the dermis -skin appearing red to pale and moist -formation of wet blisters immediatelt after injury is sustained -intact pain sensory -healing takes 3-4 weeks with some scarring 3rd degree (full thickness) -tissue damage involving the epidermis and entire dermis, extending into SQ tissue -injury appears white, red, sometimes black -dry, hard leathery appearance due to loss of elasticity -edema, decreased elasticity -painless to touch due to destruction of superficial nerve endings in skin -require skin grafting Remember for the Rule of Nines: head area and trunk area of an infant is greater in percentage than that of an adult My Advice: 1) Don't be your own worst enemy, don't second guess yourself. Think through the questions but don't second guess yourself. Don't let the difficulty of the question throw you off ! Do your best, reread the question if you're having some difficulty narrowing down, select a choice, click next and start a new question and a fresh slate. 2) When studying, focus on the less known, less obvious signs and symptoms. For example, we all know about the pendulous abdomen, striae, moon face, hump back, etc associated with Cushing's but what about hyperuricemia? polycythemia? psychosis? 3) Content is great but you gotta gotta know your infection control guidelines and what diseases require what precaution. KNOW the diseases that require standard precautions well. I really would advise checking out the "Laharti: Priority, Delegation, Assignments" book. It really does something for your confidence level when, during the exam, you can say to yourself, "Hey, these questions are just like the ones I saw in that book!" 4) Know EXPECTED outcomes vs UNEXPECTED outcomes. For example, if a pt with ulcerative colitis has bloody diarrhea, you're not gonna FREAK OUT, cuz it's expected. Now if the pt had s/s of a COMPLICATION of Ulcerative colitis (s/s of bowel perf, etc) THEN you'd freak out and assign them a higher priority. So when studying my advice would be to know what is expected, what the complications are and what the signs and symptoms of the complications are. Hi, LanePN, I saw your response to my post about studying. I recently passed my NCLEX-PN and plan in the future to continue for my RN. I see you are studying for your NCLEX-PN now. After you pass your PN boards if you want to study RN material together you can PM me. Best of luck on your NCLEX-PN. Not everyone gets the same NCLEX questions but yes I did have many disease process, Delegation, Prioritization and Infection Control (which patient to put in which room, near the nurses station or in the room with another patient or not etc.) I was too late to receive all of Suzanne's plan but I did study using Saunder's and Suzanne's first tip. As well as Memory Notebook of Nursing's color pictures and Pneumonics. Suzanne's plan was designed for 2 months of study. I see you want to take your NCLEX in 3 weeks. Do lots of NCLEX practice questions and read the rationales for any you get wrong or need more understanding for. If you know what body systems or disease processes you are weak and strong in, then begin by doing questions and study in your weak areas, then if you run out of time for studying your strong areas you will probably be OK for those anyway. Also as you answer NCLEX questions keep a list of Test Taking Strategies beside you and practice using those strategies until you just start thinking through the questions that way. Saunders NCLEX Test Taking Strategies as Questions Say to yourself DID I..... Avoid reading into the question? Look for key words? Determine the issue of the question? Look for a true or false response question? Look for key words that indicate the need to ptioritize? Use the ABC's? Use Maslow's Use the Nursing Process? Look for key words that indicate I need to do an assessment? or if it is an emergency do I need to do an intervention? Is this an analysis question? Planning, Implementation, Evaluation Use therapeutic communication techniques to answer this question? Eliminate Similar Options? Eliminate options that Contain Absolute Words? Look for the Umbrella Option? Use the guidelines for DELEGATING? Determine the class of drug by the end of it's name? Use medical terminology to break down words? Test Item Check List Use this handy list to check yourself every time you answer a question. Say to yourself DID I CAREFULLY... Read the Stem? Read all of the Options? Read the stem again? Look for Key Words? Eliminate obviously incorrect answers? During peritoneal dialysis- client suddenly begins to breathe more rapidly, what do you do? Elevate the HOB! Will decrease the pressure fo the dialysate on the diaphragm and increase the vital capacity of the lungs, draining the cavity will further decrease the pressure. Normal platelet = 150,000- 400,000. Decreased platelet= increase risk for bleeding. No IM injections, use sm. gauge needle to prevent trauma, apply firm pressure to needlestick site for 10 min, soft bristled toothbrush , do not floss, and no hard fards Femoral to popliteal bypass graft= report if client becomes clammy. Hypovolemic shock is caused by an inadequate volume of blood caused by hemorrhage, severe dehyradtion, or burns. skin will be cold and clammy b/c the body redirects blood from the skin, kidneys, and GI tract to the brain and heart. Urine output and B/P decreases and pulse increase Pre-op teaching of extracapsular cataract removal -post-op- activites and restrictions needs to be taught. Protect eye from ICP that will cause the suture line to rupture. To bend at the knees, avoid sneezing, coughing, blowing nose, not to strain during a BM, to avoid vomiting, and do not lie down in an dependent position Hepatic encaphalopathy occurs with profound liver disease and results from the accumulation of ammonia in the blood. Low protein and high calorie diet. mother receiving DES is at risk for development of vag. cancer cervical cancer risk factor= sex at early age WHIPPLE PROCEDURE- for pancreatic cancer= removal of head of pancreas, distal portion of common bile duct, the duodenum, and part of the stomach for tx of cancer. NG tube is connected to intermittent low suction, assess tub for kinking. Postion client in semi-fowlers. Drainage should be serosanguineous- pinkish Post-op radical neck dissectino, detect the presence of stirdor, most probable cause is laryngeal obstruction! Is identified upon auscultation of the trachea with a stethoscope. A coarse- high pitched sound can be heard on inspiration d/t edema of the larynx. Re: Anyoone up for random FACT THROWING?? PRAYERS BEFORE YOU TAKE THE EXAM Dear God, Today I will have my examinations. You know how important they are to me. So I am humbly asking Your gracious help and divine assitance. I pray to you, my dear God, please neve rlet me be at ease and give my very best. Please never let me guess nor rely on pure luck, but enlighten my mind and let me think clearly. Please never let me resort to chances nor to dishonesty, but let me work to the fullest of my ability. I pray for Your guidance that i as i think, I may find the right solutions, I may be able to correctly answer the questions, I may solve those difficult problems. I ask, O God, Your intercession, that as I write, I may not be careless nor overconfident, I may not be distracted but be more concentrated, I may not be in a hurry nor take the exams too lightly. Today, O my Lord, I will take my examinations Let me, with Your help, give my best effort. Let me, because of You, receive the best and fruitful results. This I pray in Jesus name. Amen. My tips: Stages of Dying: DABDA Denial Anger Bargaining Depression Acceptance Normal growth and development Most People Can Get Stuff BIRTH to 1 year- Mobiles 1-3 years- Push and pull toys 3-5 years - Coloring 6-12 years- Board Games 12-19 years- own Stuff Diabetic KetoAcidosis (DKA): (5-10% mortality) – Almost exclusively in Type 1 diabetics – S/S: Polyuria, dehydration, ab pain, fruity breath, AMS, ↓ Na/Mg/Phos, ↑K (↓ total body), + following: • Hyperglycemia (>250) • Metabolic acidosis (pH <7.3,> 20) • Ketonuria/Ketonemia – TX: • IV insulin bolus (0.1 unit/kg) then IV infusion with same amount per hr AFTER making sure pt is not ↓ K – Continue until acidosis corrects then taper • NS immediately upon diagnosis – Switch to D5NS when glucose < 250 • Why in the world would I give D5NS when a patient still has high glucose levels? The most important problem is the acidosis that is occurring. To reverse this we give insulin to drive glucose into the cell. Remember that K rushes into the cell along with the glucose, and wherever K can go, H+ can go. Since high levels of H+ in the blood is the cause of the acidosis, we give insulin to drive this H+ intercellularly, thereby reversing acidosis. We can't give insulin if the level of glucose is too low, so we give D5NS to keep levels around 250 so we can give insulin until the acidosis is gone. • Add KCl to IV fluids once K < 5; replenish other electrolytes as necessary; Even though K usually appears high, it most often is total body low and when you give glucose, the K is driven into the cell, and hypokalemia can develop rapidly. Hyperosmolar Hyperglycemic nonketotic syndrome (HHNS): – Severe ↑ Glucose, almost exclusively in Type 2 diabetics – Similar to DKA but usually have much higher glucose (>600) and NO acidosis or ketonuria/ketonemia – Treat with fluids and low dose Insulin infusion – An important distinction is that DKA usually occurs in Type 1 Diabetics, while HHNS most often occurs in Type 2 Diabetics. Remember this as it is a common question in the NCLEX world. Hypoglycemia: – Patho: When glucose drops to 80 = insulin levels ↓ ; 70 = Glucagon ↑; 50 = epinephrine ↑ along with s/s such as sweaty, ↑BP, ↑HR, tremors; Also around 50 CNS s/s (drowsy, h/a, confused) begin – Note: S/S from epinephrine release are absent if pt is on a BB – TX: If pt is alcoholic give Thiamine before any other treatment to prevent encephalopathy • Can eat = ↑ sugar food; • Can Not eat = ½ - 2 amps D50 IV push; (Glucagon alternative option if no IV access is available, however is of no use in prolonged hypoglycemia because stores of glycogen are depleted) Points to remember: – For high sugar (DKA, HHNS) most of the signs and symptoms are from polyuria, so look for dehydration and electrolyte imbalances...remember High and Dry – For low sugar most of the signs and symptoms are from the release of epinephrine, so look for things that would happen when someone was high on adrenaline, such as hypertension, sweating, tachycardia and tremors. – Imperative that you can recognize the difference between these two, as you are almost guaranteed to see a question relating to this difference! Re: Anyoone up for random FACT THROWING?? PULMONARY EDEMA:TX "MAD DOG" Morphine Aminophylline Digitalis Diuretics Oxygen Gases in blood(ABG'S) drugs to treat viral respiratory infections "you'd get a respiratory infection if you shoot an ARO (arrow) laced with viruses into the lungs ARO Re: Anyoone up for random FACT THROWING?? d1206,thanks for the correction back to facts: Pnuemothorax symptoms P-THORAX Pleuritic pain Trachea deviation Hyper resonance Onset sudden Reduced breath sounds(dyspnea) Absent Fremitus X-ray shows collapse Hi everyone my simple "PHARMA" facts for today from COMMERCIALS: 1)Sumatriptan (IMITREX)---an NSAID for MIGRAINE 2)Alleve---for muscle pain 3)Advair---COPD, bronchitis, emphysema 4)Lipitor--- to decrease BP, and for CAD 5)Mucinex--- expectorant, can last for 12 hours 6)Zopidem (AMBIEN)---anti-insomnia, taken at bedtime with full glass of water in an empty stomach (seen this at Saunders Q & A too) 7) Enbrel---for Rheumatoid Arthitis SE: immunosuppression, fever and bruising Oh and GLUCERNA diet for people with DM.. So far those are the drugs that Ive seen on TV ads. and 1 came up on Saunders Q &A the ambienCR. ABCDE mnemonic --CAUSE of secondary hypertension A: Accuracy, Apnea, Aldosteronism B: Bruits, Bad Kidney C: Catecholamines, Coarctation of the Aorta, Cushing's Syndrome D: Drugs, Diet E: Erythropoietin, Endocrine Disorders MASLOW'S HIERARCHY examples and contraindications by vadee Updated Oct 08, 2008 at 04:18 PM by vadee Registered User Received 162 Kudos from 39 posts Join Date: Oct 2008 Posts: 70 As we all know, Maslow's hierarchy is important to know and understand. Yet there are examples where Maslow's hierarchy is contraindicated. With that being said, here is to refresh your memory on Maslow's hierarchy. PLEASE HELP GIVE EXAMPLES. --------------------------------------------------------------------------------IMAGINE that this is the pyramid: 1st (most) important (located at the bottom of the pyramid): BASIC PHYISIOLOGICAL NEEDS: airway, respiratory effort, heart rate, rhythm, and strength of contraction, nutrition, elimination 2nd most important (located above physiological on the pyramid): SAFETY AND SECURITY: protection from injury, promote feeling of security, trust in nurse-client relationship PSYCHOSOCIAL NEEDS 3rd most important: LOVE and BELONGING: maintain support systems, protect from isolation, fear 4th: SELF ESTEEM: control, competence, positive regard, acceptance/worthiness 5th (top of the pyramid): SELF ACTUALIZATION: hope, spiritual well-being, enhanced growth. ----------------------------------------------------------------example of when it is contraindicated: -a dehydrated and extremely suicidal client: safety comes before hydration -----------------------------------------------------------example of when physiological is more important than safety -cataract client: disturbed sensory perception (visual) is more important than risk of injury related to decreased vision )In myocardial infarction...MORPHINE first BEFORE OXYGEN... 2) In sickle cell crisis...TREAT HYDRATION FIRST BEFORE OXYGEN in nclex,common sense is a key factor. you always think for the safety of the patient.I choose the extremely suicidal.For the other one,it only says "dehydrated". Offer some fluids.hehe apology..i meant to say this CLIENT was dehydrated plus suicidal....you would want to provide safety first before hydration. i reread my posting and realized that I made it sound like there were two clients involved rather than one. thanks and lets keep them coming. =) cataract client: disturbed sensory perception (visual) is more important than risk of injury related to decreased vision hhmmm physiologic need IS more important than safety/security. that being said, i believe if you can't see, (physiologic) then it'll probably lead you busting your butt along the way (safety/security) phyisiologic needs always come before safety, except in psy. When you think about these needs, you need O2, water, food. Also, think about ABC's then safety example of when oxygen is not administered first.... a client receiving parenteral nutrition with suspected air embolism. 1. First CLAMP the intravenous catheter (prevents the embolism from going through the heart to the pulmonary system). 2. Position the client to a LEFT trendelenburg position with the HOB lower (this will trap the air in the right side of the heart) 3. CONTACT the physician 4. Administer OXYGEN as prescribed 5. Take the VITALS frequently 6. document the occurrence so what i got from this is that you save the documentation for last. Before administering oxygen, you need to contact the Physician (remember that administration of oxygen requires Physician's order). usually you would want to do all that you can first before contacting the Physician. In this case which is considered an emergency, the vitals is taken after the physician is contacted and oxygen is administered. that being said, i believe if you can't see, (physiologic) then it'll probably lead you busting your butt along the way (safety/security) yes but risk for is a potential diagnosis and altered sensory perception is an actual diagnosis. Priority would be a diagnosis that is present not one that has the potential to be. Just remember that underneath that Maslow's triangle there is an imaginary "additional" line below the whole thing that is LIFE or DEATH. In other words, if the "safety" factor is a life or death issue, that takes priority over every other need. A client being hydrated isn't going to mean a hill of beans if he's dead. always draw up clear to cloudy when mixing insulin. 2. do not add potassium to the diet of someone who is taking potassium sparing diretics. 3. Give diretics in the am to avoid nocturia. 4. always check for tube placement with 10 cc of air before instilling ANYTHING in an NG tube. 5. An infant should double there birth weight by 6 months old. mother/baby stuff 1. Rh negative mom gets Rhogam if baby Rh positive. Mom also gets Rhogam after aminocentesis, ectopic preganancy, or miscarriages. 2. fetus L/S Ratio less than 2= immature lungs......2-3=borderline....greater than 3=good lung maturity dude!! may give dexamethasone to speed up maturity if baby needs to be delivered soon. 3. prolasped cord position knee chest or trend..call for help!! GET THAT BOTTOM OFF THE CORD! SUPPORT CORD WITH YA HAND 4. decelerations early vs late----always good to be early but dont ever show up late. early mirrors the contraction, late comes after the contraction 5. LOCHIA SEQUENCE...lochia rubra- red, clotty....lochia serosa...pink, brown....lochia alba..white.........SHOULD NEVER HAVE A FOUL ODOR! VEAL CHOP Variable deceleration -Cord compression Early deceleration - Head ompression Acceleration - O.k Late deceleration - Position change Pt with asthma - FIRST give bronchodilators (opens airways) and then stuff them with steroids 2. Antepartum client c/o leg cramps - teach client to dorsiflex foot 3. Pt who had thyroidectomy - assess for signs of hypocalcemia (muscle twitching: positive Chvostek's/Trousseau's sign, tetany) 4. NORMAL FINDINGS for a 6 month old child - sits up without support 5. DELEGATION/SUPERVISION RN's can assess (initial for sure, MOST IMPORTANTLY), teach, administer blood products, planning, evaluation, infusion of IV meds, LVN's can do dressing changes, administer enemas/antibiotics, oral care and routine observation, perform fingerstick glucose readings, gathering data and observations: breath sounds and pulse oximetry, set up equipment for oxygen and suctioning, checking and observing client for signs of infection, irrigating the ear, reminding client about post-op instructions given by RN, assisting with procedures in stable clients with predictable outcomes Nursing assistant's can do VS's, baths, ambulate client, brush/floss client's teeth, record intake and output, can remind client to perform actions that are already part of the plan of care, weighing the client, taking pulse and blood pressure, reinforce dietary and fluid restrictions after the RN has explained them to the client Remember that long-term corticosteroid use causes adrenal atrophy, which will decrease the ability of the body to withstand stress. Therefore, when a pt is made NPO before surgery, check with the MD because this medication may still need to be given. Sometimes you may also see the the dosage of a corticosteroid increased before surgery Re: Anyoone up for random FACT THROWING?? Burns Priority = 1-airway (ABCs), 2-Circulation (Fluids & E-lytes)= IV LR 3-Pain, 4-Infection Percaution= Cap, Gown, Mask, Gloves (use by nurse to infection. Wound Care= at least 1/day with carful Aseptic (sterile) techinique if pt with 50% burned. Meds= Morphine IV (monitor VS) Analgesic 30 min before wound care Tx= Silvadene (monitor urine for sulfa crystals) (Tx for psudomonas) Monitor= adequate fluid replacement check urinary output of 30ml/hr Lab= Hematocrit male 40-50, female 37-47 Diet= Calorie Carb protein / TPN may be used monitor BS / Sliding Scale for insulin supplments: Vit B, Vit C, Iron FyI: Most concern is a burn that does not blanch. Degree of Burns 1◦ = Pink to red; epidermis damage (superfical) ;uncontrollable painful 2◦ = red to white with blisters and edema; epidermis and dermis (partial thickness) ; painful = charred, waxy white and edema; damage skin, nerves, muscle, bones(called deep thickness burn), painless 3◦ = usually dry darkbrown or has a leathery appearence. ;damage to all the Epidermis and Dermis Skin grafting is recommended.( Full Thickness Burn) 4◦= The tissue beneath the skin is burned/destroyed. includes the muscles, tendons, ligaments and bones. Skin grafting is usually needed to close up the areas. Endocrine Glands Hypothalamus (Regulator) Pituitary Gland (Growth, Reproduction, Melanin, F&E) Pineal Gland (Melatonin, Circadan Rhythms) Thyroid (Metabolism, Energy, Growth) Parathyroid (Calcium Regulation) Thymus (Immune Response) Adrenal Glands (Stress Response, Metabolism, F&E) Pancreas (Fat, Protein, Carb Metabolism) Ovaries (Reproductive System, Sex Organs) Testes (Reproduction, Muscles, Bones, Skin, Hair) Hormones Hypothalmus (Releasing/Inhibiting Hormones) Ant. Pituitary (TSH, Growth Hormone, LH, FSH, ACTH) Posterior Pituitary (ADH, MSH, Oxytocin) Pineal (Melantonin) Thymus (Thymopoietin) Thyroid (T4, T3, Calcitonin) Parathyroids ( PTH) Adrenal Medulla (Epi, Norepi) Adrenal Cortex ( Glucocorticoids, Mineralocorticoids) Pancreas (Insulin, Glucagon) Addisson’s Disease Assessments Fatigue Weakness Dehydration Eternal tan Decreased resistance to stress Low Sodium Low Blood Sugar High Potassium Addisson’s Disease Implementations High protein, High carbohydrate, high Sodium, Low potassium diet Teach life-long hormone replacement Addisonian Crisis Assessments • Hypotension • Extreme weakness • Nausea vomiting • Abdominal pain • Severe hypoglycemia • Dehydration Addisonian Crisis Implementations • Administer NaCl IV, vasopressors, hydrocortisone • Monitor vital signs • Absolute bedrest Cushing’s Syndrome Assessments • Osteoporosis • Muscle wasting • Hypertension • Purple skin striations • Moon face • Truncal obesity • Decreased resistance to infection Cushing’s Syndrome Implementations • Low Carbohydrate, Low Calorie, High Protein, High Potassium, Low sodium diet • Monitor glucose level • Postop care after adrenalectomy or hypophysectomy Buck's traction is used to immobilize and reduce spasms in a fractured hip. Prioritizing Anyone threatening suicide/self-harm should be seen first, followed by anyone hearing command hallucinations to harm others. An infant experiencing vomiting and/or diarrhea should be seen before an older child, young adult, or adult experiencing vomiting/diarrhea. IRON-DEFICIENCY ANEMIA (IDA) * Anemia that results when iron supply is inadequate for optimal RBC formation because of excessive iron loss from bleeding, decreased dietary intake, or malabsorption Nursing assessment * * * * Fatigue and weakness Shortness of breath Pallor (ear lobes, palms, and conjunctiva) Brittle spoonlike nails * Cheilosis (cracks in the corners of the mouth) * Smooth, sore tongue * Dizziness * Pica (craving to eat unusual substances such as clay or starch) * Blood sample shows microcytic and hypochromic anemia (small RBC diameter with decreased pigmentation) and an increase in red cell size distribution width (RDW) * Decreased MCV, MCH, and MCHC; analyzed only when hemoglobin is low * Low serum iron level and elevated serum iron-binding capacity or low serum ferritin levels Therapeutic management * Examine stools for occult blood; endoscopic examination and other diagnostic procedures may be performed to detect possible sources of bleeding * Increase intake of iron-rich foods, such as organ meats, meat, beans, green leafy vegetables, molasses, and raisins * Administer iron supplements * Administer parenteral iron dextran (InFed) by deep IM route via Z-track method * Determine stool color, consistency, frequency, and amount; may appear greenish black and tarry; caution client that iron supplements usually cause constipation and client should take preventive measures (fluids, fiber) Client teaching * Take iron on an empty stomach; absorption of iron is decreased with food; ab*sorption may be enhanced when taken with an acidic beverage (such as one with vitamin C), but avoid grapefruit Mice * Foods high in iron include organ meats (beef or calf liver, chicken liver), other meats, beans (black, pinto, and garbanzo), leafy green vegetables, raisins, and molasses MEGALOBLASTIC ANEMIA * Vitamin B12, deficiency anemia * A type of anemia characterized by macrocytic RBCs Nursing assessment * Pallor or slight jaundice with a complaint of weakness * Smooth, sore, beefy red tongue (glossitis), and cheilosis (cracking of lips) * Diarrhea * Paresthesias (numbness or tingling in extremities) * Impaired proprioception (difficulty identifying one's position in space. which may progress to difficulty with balance) * Clients with this anemia tend to be fair-haired or prematurely gray Macrocytic (megaloblastic) anemia (RBC diameter >8) with increase in MCV and MCHC * Gastric secretion analysis reveals achlorhydria: absence of free hydrochloric acid in a pH maintained at 3.5 * Twenty-four-hour urine for Schilling test (a vitamin B12 absorption test th indicates if client lacks intrinsic factor by measuring excretion of orally ad-ministered radionuclide-labeled B12) confirms diagnosis of pernicious anemia Therapeutic management * Medication therapy: parenteral vitamin B12,100 to 1000 mcg subcutaneously daily for 7 days, then once a week for 1 month, then monthly for lifetime is usually prescribed; a nasal form is now available also Client teaching * Dietary sources of vitamin B12 include dairy products, animal proteins Folic acid—deficiency anemia Nursing assessment * Pallor, progressive weakness, fatigue * Shortness of breath * Cardiac palpitations * GI symptoms are similar to B12 deficiency but usually more severe (glossitis, cheilosis, and diarrhea) * Neurological symptoms seen in B12 deficiency are not seen in folic acid deficiency and therefore assist in differentiating these two types of anemia * RBC analysis shows macrocytic (megaloblastic) anemia (RBC diameter, high MCV with low hemoglobin, low serum folate level Therapeutic management * Includes dietary counseling and administration of folic acid Client teaching * Dietary sources of folic acid such as green leafy vegetables, fish, citrus yeast, dried beans, grains, nuts, and liver APLASTIC ANEMIA Nursing assessment * * * * * * * * * Pallor and fatigue Palpitations and exertional dyspnea Infections of the skin and mucous membranes Bleeding from gums, nose, vagina, or rectum Purpura (bruising) Retinal hemorrhage Blood counts reveal pancytopenia (decreased RBC, WBC, and platelets) Decreased reticulocyte count Bone marrow examination reveals decrease in activity of bone marrow or no cell activity Therapeutic management * Institute reverse isolation to protect client from infection * Monitor for evidence of bleeding * Avoid invasive procedures including rectal temperatures Client teaching * Methods to prevent infection such as avoiding crowds, maintaining good hygiene, hand washing, and elimination of uncooked foods from the diet * Methods to prevent hemorrhage such as using a soft toothbrush, avoiding contact sports, and use of an electric razor * Avoid drugs that increase bleeding tendency, such as aspirin Sickle Cell Disease Nursing assessment * Pallor and jaundice * Fatigue and possible irritability * Large joints and surrounding tissue may become swollen during crisis * Priapism (abnormal, painful, continuous erection of penis) may occur if penile veins are obstructed * Severe pain * Anemia with sickle cells noted on a peripheral smear * Hemoglobin electrophoresis to detect presence and percentage of hemoglobin is used for a definitive diagnosis * Elevated serum bilrubin levels * Elevated reticulocyte count Therapeutic management * Care of client in sickle cell crisis o Recognize that client may have severe pain and medicate accordingly, usually with opioid analgesics o Administer 02 to increase oxygenation to cells o Promote hydration to decrease blood viscosity; provide oral intake of at 6 to 8 quarts daily or IV fluids of 3 liters daily o Monitor for complications such as vaso-occlusive disease (thrombosis), hy*poxia, CVA, renal dysfunction, priapism leading to impotence, acute chest syndrome (fever, chest pain, cough, pulmonary infiltrates, and dyspnea), an substance abuse o Manage infection if appropriate Medication therapy * Narcotic (opioid) analgesics during the acute phase of sickle cell crisis, often at large doses Client teaching * Ways to prevent sickle cell crisis * Maintain an oral intake of at least 4 to 6 quarts a day; avoid conditions that might predispose to dehydration * Avoid high altitudes * Prevent and promptly treat infections * Use stress-reduction strategies * Avoid exposure to cold * Avoid overexertion Anemia * Children with persistent anemia might experience frequent bouts of otitis media and upper respiratory infections. Pernicious Anemia * For the exam, you should know the names for the various B vitamins and realize that they can be used interchangeably in test items; * B1 (Thiamine) * B2 (riboflavin) * B3 (niancin) * B6 (pyridoxine) * B9 (folic acid) * B12 (cyanocobalamin) Sikle Cell Anemia * When multiple transfusions are given, reduce iron overload and hemosiderosis with subcutaneous chelating injections of deferoxamine (Desferal) * Morphine is the drug of choice for acute pain in sickle cell anemia. Meperidine is contraindicated due to the possibility of central nervous system stimulation in these clients that could lead to seizure activity. * An easy to remember general nursing care for clients with sickle cell anemia is to remember the following * H - heat * H – hydration * O – oxygen * P – pain relief Polycythemia Vera This disorder is characterized by thicker than normal blood. There is an increase in the client’s hemoglobin to levels of 18 g/dL, RBC of 6 million/mm or hematocrit at 55% or greater and increased platelets) * With polycythemia, the client is at risk for cerebrovascular accident (CVA), myocardial infarction, (MI) and bleeding due to dysfunctional platelets. Hemophilia * Intracranial bleeding is the major cause of death in clients with hemophilia * Cryoprecipitates are no longer used for treatment of hemophilia because HIV and hepatitis cannot be removed. Transfusion Therapy * Severe reactions occur during the first 50mL of blood transfused. Stay with the patient for the initial 15-30 min of infusion Client with Burns BURN INJURY * An alteration in skin integrity resulting in tissue loss or injury caused by heat, chemicals, electricity, or radiation * There are several types of burn injury: thermal, chemical, electrical, and radiation * Thermal burn: results from dry heat (flames) or moist heat (steam or hot liq*uids); is most common type; causes cellular destruction that results in vascu*lar, bony, muscle, or nerve complications; thermal burns can also lead to inhalation injury if head and neck area is affected * Chemical burn: caused by direct contact with either acidic or alkaline agents; alters tissue perfusion and leads to necrosis * Electrical burn: severity depends on type and duration of current and amount of voltage; electricity follows path of least resistance (muscles, bone, blood vessels. and nerves); sources of electrical injury include direct current, alter*nating current, and lightning * Radiation burn: usually associated with sunburn or radiation treatment for cancer; usually superficial; extensive exposure to radiation may lead to tissue damage and multisystem injury o Nursing assessment: history of injury, estimate burn extent and depth, obtain past medical history and medication history including date of last tetanus pro*phylaxis; assess for other concurrent injuries o Systemic effects of severe burns include asphyxia from smoke inhalation that causes edema of respiratory passages; shock from fluid shifts; renal failure from shock; protein loss from open wound; potassium excess from tissue destruction and renal failure o Diagnostic and laboratory test findings: may have elevated hematocrit (Hct) and decreased hemoglobin (Hgb) caused by fluid shift, decreased sodium (Nat) and increased potassium (K+) caused by damage to capillary and cell mem*branes, elevated BUN and creatinine caused by dehydration, myoglobin in urine, and possible deterioration of arterial blood gases (ABGs) and oxygen (02) saturation readings depending on respiratory status o Therapeutic management * First aid: douse flames with water or smother them with a blanket, coat, or other similar object; cool a scald burn with cool water; flush chemical burns copiously with water or other appropriate irrigant after dusting away any dry powder if present; remove client from contact with an electrical source only after current has been shut off * Priority care is on ABCs: airway, breathing, and circulation; assess for smoke inhalation injury (singed nares, eyebrows or lashes; burns on face or neck; stridor, increasing dyspnea) and give 02 (up to 100% as prescribed), being prepared for possible intubation and mechanical ventilation if severe inhala*tion injury or carbon monoxide inhalation has occurred; assess for signs of shock caused by fluid shifts (increased pulse, falling BP and urine output, pal*lor, cool clammy skin, deteriorating level of consciousness [LOC]) * Fluid resuscitation: Brooke formula uses 2 mL/kg/% TBSA burned (3/4 crys*talloid plus 1/4 colloid) plus maintenance fluid of 2,000 mL D5W per o Medication therapy: analgesics—usually morphine sulfate IV, tetanus booster (> 5-10 years since last dose), topical antimicrobials, systemic antibiotics o Acute phase of burn management: begins with start of diuresis (usually 48 to 72 hours postburn) and ends with closure of burn wound o Therapeutic management + Wound care management includes debridement, dressing changes, hydrother*apy, and possible escharotomy, + Mafenide (Sulfamylon) may be applied in thin layer over open wound and covered with dressing + Sulfadiazine (Silvadene) may applied in thin layer over open wound and cov*ered with dressing; use with caution when impaired renal function exists; must be washed off and reapplied every 8 to 12 hours + Skin grafting may need to be done to achieve healing in full-thickness and large, deep partialthickness burns + Nutritional therapies (high-calorie, high-protein diet with vitamins and min*erals) and continue to maintain hydration status + Infection control with strict sterile technique + Maintain heated environment to prevent chilling + Physical therapy as needed + Psychosocial support # Rehabilitative phase of burn management: begins with wound closure and ends when client returns to highest level of health restoration # Therapeutic management * Prevent immobility contractures with exercises or ongoing physical therapy * Assist in returning to work. family, and social life * Client education * Environmental safety: use low temperature setting for hot water heater, en*sure access to and adequate number of electrical cords/outlets, isolate house*hold chemicals, avoid smoking in bed * Use of sunscreen to protect healing tissue and other protective skin; measures soft tissue injuries; or deep chemical or electrical + To prevent burns, hot water heaters should be set no higher that 120° Fahrenheit. Burn Classifications + Pain medication is given intravenously to provide quick, optimal relief and to prevent overmedication as edema subsides and fluid shift is resolving. + The cardiac status of a client with electrical burns should be closely monitored for at least 24 hours following the injury to detect changes in electrical conduction of the heart. + Full thickness burns can damage muscles, leading to the development of myoglobinuria in which urinary output becomes burgundy in color. The client with myoglobinuria require hemodialysis to prevent tubular necrosis and acute renal failure. Burn Measurement with TBSA + It will be beneficial to review your nursing textbooks for local and systematic reactions to burns because these injuries affect all body systems and cardiovascular and renal functions in particular. Nursing Care for Burn Victims + The eyes should be irrigated with water immediately if a chemical burn occurs. Follow-up care with an ophthalmologists is important because burns of the eyes can result in corneal ulceration and blindness. + Important Steps in treating a burn client include the following: * Treat airway and breathing – Traces of carbon around the mouth or nose, blisters in the roof of the mouth, or the presence of respiratory stridor, indicate the client has respiratory damage * Ensure proper circulation – Compromised circulation is evident by a drop in normal blood pressure, slowed capillary refill, and decreased urinary output. These symptoms signal impending burn shock. o It is important to remember that the actual burns might not be the biggest survival issue facing burn clients. Carbon monoxide from inhaled smoke can develop into a critical problem as well. Carbon monoxide combines with hemoglobin to form carboxyhemoglobin which binds to available hemoglobin 200 times more readily than with oxygen. Carbon monoxide poisoning causes a vasolidating effect causing the client to have a characteristic cherry red appearance. Interventions for carbon monoxide poisoning focus on early intubation and mechanical ventilation with 100% oxygen. The Consensus Formula o Fluid replacement formulas are calculated from the time of injury rather than from the time of arrival in the emergency room. The Intermediate Phase o Infections represent a major threat to the post-burn client. Bacterial infections (Staphylococcus, Proteus, pseudomonas, eshcerichia coil, and Klebsiella) are common due to optimal growth conditions posed by the burn wound; however, the primary source of infection appears to be the client’s own intestinal tract. As a rule, systemic antibiotics are avoided unless an actual infection exists, o Enzymatic debridement should not be used for burns greater thatn 10% TBSA, for burns near the eyes, or for burns involving muscle. Dressing for Burns o Dressing for burns include standard wound dressings (sterile gauze) and biologic or biosynthetic dressings (grafts, amniotic membranes, cultured skin, and artificial skin) o Biologic dressings are obtained from either human tissue (homograft or allograft) pr animal tissue (heterograft or xenograft). These dressing which are temporary are used for clients with partial thickness or granulating full thickness injuries. o Hemografts and allografts are taken from cadaver donors and obtained through a skin bank. These grafts are expensive and there is a risk of blood-borne infection. Heterografts and xenografts are taken from animal sources. The most common heterograft is pig skin (porcine) because of its compatibility with human skin. o Muslims and Orthodox Jews are two religious/ethnic groups who might be offended by the use of porcine grafts since the pig is considered an unclean animal. Christian groups such as Seventh Day Adventists might also reject the use of procine grafts. DIAGNOSTIC TEST AND ASSESSMENT Pulse oximetry * Monitors arterial or venous oxygen saturation ([percentage of 02] bound to he*moglobin [Hgb] compared to volume that Hgb is capable of binding); normal is usually 95% or greater in a client with no lung disease; in clients with lung dis*ease, target oxygen saturation is 90% or greater; may be measured intermit*tently (such as with vital signs or ambulation) or continuously * Uses a light spectroscopy probe attached to a finger, earlobe, or nose * Accuracy is lower with diminished peripheral perfusion, brightly lit environ*ment, acrylic fingernails, and dark skin color Laboratory Sputum analysis: specimen obtained for microbiology (Gram stain, culture and sensitivity) or cytology * Specimens for acid-fast bacilli (mycobacterium tuberculosis) may be collected * on three different days; specimen collection following a long sleep period (early morning) is desirable because of greater concentration; if unable to ob*tain a sputum specimen for acid-fast bacilli, gastric specimen may be obtained because mycobacterium tuberculosis is not altered by acidic gastric contents * Specimen processing: collect specimens in appropriate container and send to laboratory promptly Skin testing: assesses for allergic reactions to specified antigens (type I hyper- sensitivity), exposure to tuberculosis-causing organisms (type IV hypersensiti vity), or fungi * Measure area of induration (if present), not reddened area; read result 48 to 72 hrs after placement; an uncertain reading at 48 hrs may be reread at 72 * Positive result: individual has been exposed to antigen; does not mean that individual currently has active disease, only that there has been exposure/ infection * When performing skin tests to assess for type I allergies, ensure that antihict*amines, which could interfere with test results, are discontinued 72 hours prior to testing COMMON NURSING TECHNIQUES AND PROCEDURES Airway management: goal is to maintain patent airway 1. Head and jaw position * Open airway by head tilt and anterior chin lift maneuver * In individuals with suspected neck injury, open airway by anterior chin dis*placement and/or jaw thrust; do not perform head tilt * Limit suctioning to 10 seconds per catheter pass (5 in children) to reduce risk of inadequate oxygenation and cardiac dysrhythmias from hypoxia Body positioning * Acute respiratory failure a. Elevate head at least 45 decrees to increase chest exnansion * Unilateral lung disease a. Position with unaffected lung in dependent position ("good lung down") Oxygen (02) administration Nasal cannula * Typical 02 flow of 1 to 6 L/min will provide 02 concentrations of 24% to 44% * Individuals with chronic obstructive pulmonary disease (COPD) should re*ceive low flow oxygen, about 1 to 2 L/min, to prevent respiratory depression; these clients are used to high CO2 levels and low 02 levels, so increased 02 (greater than 2 L/min) can cause a loss of respiratory drive Key ventilator settings * Rate: number of breaths per minute delivered by ventilator; is a number that is combined with the mode often in clinical practice (e.g., SIMV of 6/min) * FiO2: fraction of inspired 02 or 02%; amount of 02 in air inhaled via ventilator; is expressed as a decimal instead of a percentage (e.g., Fi02 of .40 versus 40%) * Tidal volume (VT): amount of air delivered with each breath; often expressed in milliliters or liters (e.g., 700 mL or 0.7 L) * PEEP: abbreviation for positive end-expiratory pressure; the amount of posi*tive-pressure set in system at end of exhalation; keeps alveoli open during ex*halation to increase gas exchange; is expressed in terms of centimeters of pressure (e.g., 5 cm) Nursing management * Position client for maximum alveolar ventilation and comfort; maintain soft restraints to avoid accidental extubation * Monitor for any changes in respiratory status or effort * Maintain ventilator settings as ordered and remain knowledgeable about how to troubleshoot ventilator alarms (high pressure frequently indicates need for suctioning or kinking/compression of ET tube; low pressure indi*cates leak or disconnection); manually ventilate client if alarms sound with*out apparent cause * Monitor arterial blood gases (ABGs) and maintain continuous 02 satura*tion monitoring * Complete a thorough physical assessment with emphasis on cardiac, neuro*logical, and respiratory areas * Administer antibiotics, neuromuscular blocking agents, and sedatives as ordered * Maintain nasogastric suction to prevent aspiration * Supply nutritional support as ordered * Perform frequent oral care and suctioning to maintain airway patency * Provide emotional support to client and family as well as alternative commu*nication method Potential complications: pneumothorax, GI stress ulcers, hypotension caused by decreased venous return from increased intrathoracic pressure, increased in*tracranial pressure, infection Laryngectomy Postoperative care * Maintain patent airway * Provide pain management * Provide appropriate nutritional support * Teach client and family how to care for tracheostomy and feeding tube (if applicable) * Provide access to communication devices, such as writing supplies, picture or word board, speaking tracheostomy valve * Provide emotional sunnort to client and family: make annronriate referrals Respiratory Isolation * Droplet precautions (transmission-based precautions) * In addition to standard precautions, persons should wear mask when near client who has known or suspected pathogen transmitted by droplet route * Limit client transport within facility; when transport is necessary, place mask on client * Limit contamination of equipment and/or environment * Place client in private room or with a cohort (client with same diagnosis) NURSING MANAGEMENT OF CLIENT HAVING THORACIC SURGERY Preoperative period * Reduce anxiety through preoperative teaching about procedure and postopera*tive course and care * Assess client's support systems and ability to care for self after surgery * Administer preoperative medications, such as antibiotics, opioid analgesics, and anti-anxiety agents, as ordered * Obtain baseline vital signs, oxygenation status, and cognitive status for compari*son postoperatively Postoperative period * Maintain patent airway * Position client for optimal ventilation and perfusion; note any specific surgeon-s orders for positioning; be prepared to initiate respiratory support (intubation. emergency tracheostomy, mechanical ventilation) as needed * Maintain client safety * Assess for and report possible surgical complications to maintain oxygenation * Change in level of consciousness (LOC) ranging from restlessness and agitation to lethargy or unresponsiveness * Increase in respiratory rate, unequal chest expansion, decreased breath sounds, and/or use of accessory muscles for breathing * Loss of water seal drainage in closed chest drainage system * Greater than desired volume of chest drainage (75-100 mL drainage over 1 hour is an average acceptable upper limit); orders should specify volume acceptable chest tube drainage; should decrease over first 24 hours Positioning client after lung surgery: orders should specify turning parameters for indvidual client * Lobectomy: positioning includes lying on back or turned to either side * Segmental resection: positioning includes lying on back and turned onto nonl erative side; positioning on operative side may place tension on sutures and mote bleeding * Pneumonectomy * Positioning includes lying on back and turned toward operative side * Avoid complete lateral turning to either side, which changes pressure dynam*ics within chest and could lead to mediastinal shift OBSTRUCTIVE PULMONARY DISEASES Emphysema a. Progressive destruction of alveoli related to chronic inflammation Assessment * "Pink puffer" is a classic clinical description characterized by barrel chest, pursed-lip breathing (caused by forced exhalation), obvious use of accessory muscles when breathing, and underweight appearance * Exertional dyspnea progresses with advancing disease * Persistent tachycardia is related to inadequate oxygenation * Overall diminished breath sounds, and possible wheezes or crackles * ABGs: slightly decreased P02; PCO2 is not elevated until later stages * Chest x-ray: hyperinflated lungs with a flattened diaphragm; heart size is nor*mal or small * Pulmonary function tests: low vital capacity and forced expiratory volume (FEVi) Therapeutic management * Goals are to improve ventilation and promote patent airway by removing se*cretions * Remove environmental pollutants and encourage smoking cessation * Prescribed treatments include bronchodilator therapy, beta-adrenergic ago*nists, corticosteroid therapy, oxygen and nebulization therapy, chest physio*therapy, intermittent positive-pressure breathing (IPPB), possibly mechanical ventilation, and possible surgical procedures such as bullectomy, lung volume reduction surgery, or lung transplantation * Provide education and referrals for clients with behaviors (such as smoking) that increase risk for COPD * Refer clients to a structured pulmonary conditioning program and provide reinforcement as appropriate * Teach clients to avoid pulmonary irritants * Assist clients to develop appropriate nutritional plans to provide ade*quate calories Chronic bronchitis A disorder of chronic airway inflammation with a chronic productive cough lasting at least 3 months during 2 years; is a form of COPD Assessment * Frequent cough, occurring during winter season, with foul-smelling sputum * Frequent pulmonary infections * Classic appearance of "blue bloater" includes tendency for obesity and bluish-red skin discoloration from cyanosis and polycythemia * Dyspnea and activity intolerance occurs as disease progresses * Increased anterior–posterior chest diameter * Elevated red blood cell count; hemoglobin and hematocrit elevated in later stages * Chest x-ray reveals enlarged heart, congested lung fields, and normal or flattened diaphragm * Pulmonary function indicates increased residual volume, decreased vital capacity, FEVi, and FEVi/FVC ratio Therapeutic management * Includes measures previously described in section on emphysema * Provide education or referrals to clients with behaviors that increase the risk of developing COPD * Refer clients to a structured pulmonary conditioning program and provide reinforcement as appropriate * Teach clients how to avoid pulmonary irritants * Assist clients to develop appropriate nutritional plans that provide adequate calories but maintain ideal weight * Administer supplemental low-flow 02 as necessary; be prepared to initiate mechanical ventilation * Surgical interventions include bullectomy, lung volume reduction surgery, lung transplantation * Medication therapy includes immunization against pneumonia and influenza antibiotics, possible bronchodilators (beta-adrenergic agonists, anticholiner-minimal client symptoms; air leak may progress until pressure between thoracic cavity and atmosphere equalizes and client is symptomatic. * Tension: disruption of chest wall or lungs causes air accumulation in pleural space; pressure on mediastinum causes pressure on other lung and interrupts venous return to heart; is a medical emergency that requires emergency placement of chest tube to relieve increasing pressure in thoracic cavity and restore adequate cardiac output PNEUMOTHORAX AND HEMOTHORAX Assessment * * * * * * * * Dyspnea Tracheal deviation toward unaffected side Diminished breath sounds on affected side Percussion dullness on affected side Unequal chest expansion (reduced on affected side) Crepitus over chest Chest x-ray reveals pneumothorax ABG shows decreased P02 Therapeutic management * In mild cases, no chest tube is required; if pneumothorax is significant, a chest tube is inserted and attached to water seal drainage * Spontaneous pneumothorax: in otherwise healthy client, may resolve without in*vasive treatment * If spontaneous pneumothorax occurs repeatedly, may require pleurodesis, an in*stillation of an agent (such as talc or tetracycline) in pleural spaces to allow pleura to adhere together; other procedures include partial pleurectomy, sta*pling, or laser pleurodesis for pleural sealing * Care of client with a chest tube: * Monitor respiratory and oxygenation status * Provide supplemental oxygen as indicated * Maintain infection control practices * Medication therapy: analgesics and antibiotics ATELECTASIS * Incomplete expansion or collapse of the lung resulting from obstruction of air*way by secretions or a foreign body Assessment * Low-grade fever * Breath sounds diminished or absent in affected area * Diminished rate and depth of respiration PULMONARY TUBERCULOSIS * Lung infection caused by Mycobacterium tuberculosis Assessment * Frequent cough with copious frothy pink sputum; nonproductive cough devel*ops first as an early symptom (especially in early morning) * Night sweats * Anorexia * Weight loss * History may indicate recent exposure to infected individual * Positive tuberculin skin test (indicates exposure) * Appearance of characteristic Ghon tubercle on chest x-ray * Positive acid-fast bacillus sputum cultures (provides definitive diagnosis of infection) Therapeutic management * Monitor respiratory and oxygenation status * Provide adequate nutrition and hydration * Institute standard precautions (Centers for Disease Control [CDC] Tier 1) and airborne precautions (Tier 2, transmission-based precautions * Use a private room with negative air pressure that has 6 to 12 full air exchanges per hour and is vented to the outside or has its own air filtration system * Wear specially fitted mask (N95 respirator) whenever entering client's room; fit-test the mask with each use * Provide visitors with appropriate masks * Wear gown and masks if client does not reliably cover mouth during cough*ing or sneezing to reduce risk of transmission to others * Provide client with a surgical mask if it is necessary to bring client to another department; choose shortest and least busy route and alert that department ahead of time about client's status; schedule tests for least busy times of day * Administer antimicrobial therapy as prescribed * Provide supplemental oxygen as indicated * Obtain periodic sputum cultures following onset of antimicrobial therapy Client education * Infection control measures, including handwashing, coughing into tissues disposing of them in a closed bag * Teach client, family, and close contacts about mechanisms of transmission antimicrobial therapy, including need to take medication for full course of apy to prevent recurrence and/or development of drug-resistant organisrm PULMONARY EMBOLISM * Emboli lodge in pulmonary vasculature and impede blood flow through pulmonary capillaries Assessment * * * * * * * * * * Restlessness, anxiety, agitation Vital signs: tachycardia, tachypnea, hypotension, fever Chest pain Hemoptysis Mental status changes with possible decreasing level of consciousness Cyanosis Recent history of thromboembolism and/or long bone fractures Lung crackles upon auscultation Atrial fibrillation Chest x-ray may be normal Therapeutic management * Supplemental oxygen therapy; maintain patent airway * Be prepared to initiate mechanical ventilation * Maintain IV access and provide circulatory support as needed * Anticoagulant and/or thrombolytic therapy * Opioid analgesies and anti-anxiety agents as needed * Embolectomy * To prevent future pulmonary emboli, a vena cava filter may be inserted to trap emboli from a known source BRONCHOGENIC CARCINOMA * Lung cancer is leading cause of death from malignancy Assessment * * * * * * * * * * * * Symptom onset is often late in course of disease Persistent cough with or without hemoptysis Localized chest pain Dyspnea Unilateral wheeze upon auscultation Swallowing difficulty Anorexia and weight loss Enlarged neck lymph nodes Mass visible on chest x-ray CT scan or MRI of chest may better differentiate mass Sputum for cytology reveals tumor cells Bronchoscopy for direct biopsy or washings for cytology reveal tumor cells Therapeutic management * o o o Surgical resection Pneumonectomy: removal of entire lung Lobectomy: removal of a lobe of lung Segmentectomy (segmental resection): removal of a segment or segments of a lung o * * * * Wedge resection: dissection and removal of a defined area in lung Chemotherapy Radiation therapy Laser therapy Immunotherapy CANCER OF THE LARYNX * Most laryngeal tumors are benign Assessment * Hoarseness and/or change in voice characteristics * Palpable jugular nodes * Pain when swallowing * Unexplained earache * Diagnostic test results: laryngeal biopsy findings, x-ray visualization, MRI findings, barium swallow visualization Therapeutic management * Depends on stage of disease and general condition of client * Radiation therapy or brachytherapy (placement of a radioactive sow next to tumor) * Chemotherapy * Laryngectomy * Radical neck dissection * Maintain patent airway (tracheostomy performed with laryngectomy) * Pain management * Provide adequate hydration and nutrition (temporary or permanent alter route for nutrition) * Provide alternate means for communication and plan for permanent mea communication (artificial larynx or esophageal speech) * Monitor respiratory and oxygenation status * Provide oxygen supplementation as indicated * Medication therapy: opioid analgesics and antipyretics THORACIC TRAUMA * Alteration of breathing mechanics and/or gas exchange caused by respiratory. system trauma Assessment * * * * * * * Chest pain, may be severe such as with flail chest Shallow breathing with splinting Possible unequal chest expansion Tachycardia, tachypnea, hypotension Crepitus over chest Chest x-ray findings show white opacifications ABGs reveal hypoxemia Therapeutic management: same as pneumothorax and hemothorax * * * * * Ventilation support Be prepared to initiate mechanical ventilation Maintain IV access Possible placement of chest tube with water seal drainage Medication therapy: opioid analgesics, patient-controlled or epidural analgesia may be appropriate CYSTIC FIBROSIS (CF) * Multisystem disorder of exocrine glands, leading to increased production of thick mucus in bronchioles, small intestines, and pancreatic and bile ducts Assessment * Sweat test (pilocarpine iontophoresis) analyzes Na+ and C1-- content in sw e chloride concentration greater than 60 meq/L is diagnostic of cystic fibrosis.. ents often report that infants taste salty when kissed Therapeutic management * Respiratory: ensure pulmonary hygiene is performed; auscultate breath sounds before and after treatments; encourage coughing and deep breath exercises and physical activity as tolerated; administer prescribed antibiotics and bronchodilator(s) * Digestive: provide high-calorie (150% above normal recommendations). high protein diet and snacks; give infants a predigested formula such as pregestnutramigen; administer pancreatic enzymes with all meals and snacks; indi ize to achieve stools as near normal as possible; administer fat-soluble vitamins determine food preferences to encourage acceptance of diet; weigh daily: avoid pulmonary treatments immediately after meals to decrease risk of vomiting * Medications: antibiotics for treatment of pulmonary infection and purulent cretions, pancreatic enzymes for fat absorption, vitamin supplementation. immucolytics to decrease viscosity of sputum, bronchodilators to improve lung function; see Chapter 37 for overview of commonly ordered respiratory cardiac medications * High-calorie, high-protein diet is essential; give pancreatic enzymes with all meals and snacks; may need extra salt in hot weather BRONCHOPULMONARY DYSPLASIA (BPD) * A chronic obstructive pulmonary disorder occurring in infants as a sequela to prolonged 02 therapy and mechanical ventilation Assessment * Diagnosed by chest x-ray, which reveals lung changes and air trapping with or without hyperinflation * Blood gases reveal hypercapnia (increased CO2) and respiratory acidosis * Respiratory observations include tachypnea (rapid respirations), tachycardia, in*creased work of breathing, retractions, wheezing, and barrel chest (rounding of chest caused by trapped air) * Pallor, activity intolerance, and poor feeding result from chronic hypoxia Therapeutic management * Infants with BPD are cared for in intensive care units and require an artificial airway; avoid pressure or trauma to ET tube and infant's airway * Suctioning, turning, and weighing is done carefully to ensure adequate 02 sat*uration levels are maintained * Monitor respiratory status continuously; infant's condition can worsen in a short period of time * Monitor for fluid overload; infants are at increased risk for pulmonary edema; weigh daily; maintain strict I & 0 * Strict handwashing; avoid exposure to respiratory infections * Cluster nursing care to minimize 02 requirements and caloric expenditure * Plan quiet stimulation and activities to foster normal infant development and parental bonding with extended and often repeated hospitalizations of in*fants with BPD Medications * * * * Bronchodilators open airways and increase lung compliance Corticosteroids reduce airway edema and inflammation Diuretics remove excess fluid from lungs and help prevent pulmonary edema Antibiotics may be given prophylactically LARYNGOTRACHEOBRONCHITIS (LTB) * Viral infection that causes inflammation, edema, and narrowing of chea, and bronchi; usually LTB is preceded by a recent upper respira% fection (URI) Assessment * Onset is gradual after URI * Child awakens with low-grade fever, barking cough, and acute stridor; noisy breathing and use of accessory muscles increase * Child is agitated, restless, has a frightened appearance, sore throat, and rhinorrhea * Pulse oximetry is used to detect hypoxemia; anteroposterior (AP) and lateral upper airway x-rays are ordered Therapeutic management * Monitor child's respiratory effort continuously to ensure a patent airway; ob*serve for diminished breath sounds, circumoral cyanosis, diminishing noisy breathing, and drooling * Quiet respiratory effort is a sign of physical exhaustion and impending respira*tory failure * Provide humidity and supplemental 02; IV fluids prevent dehydration and help liquefy secretions * Assist child to assume upright position or any position of comfort; promote a calm, quiet environment; keep parents nearby to decrease child's stress and to lessen crying * Keep emergency intubation equipment available at bedside; readily respond to call bell or requests for assistance * Assess parental and child's anxiety level; provide emotional support * Medications * Bronchodilators decrease mucosal constriction and laryngeal edema; nebu*lized racemic epinephrine has a rapid onset with improvement of symptoms, although relapse may occur within 2 hours * Corticosteroids decrease inflammation and edema Child and family education * Cool mist humidifier and parental presence can be initial treatment of crisis; comforting measures include cuddling, rocking, singing, and any calming mea*sures until breathing becomes easier * Instruct parents to seek medical attention immediately if breathing becomes la*bored, child seems exhausted or very agitated, or if symptoms do not improve after cool air humidity treatment EPIGLOTTITIS Inflammation and swelling of epiglottis. primarily affecting children ages 2 to 8 Assessments * Child awakens with sudden onset of high fever (102°F), extremely sore and pain on swallowing * Child is very anxious, restless, looks ill, and insists on sitting upright legs and arms, with chin thrust out and mouth open (tripod position) * Dysphonia (muffled voice), dysphagia (difficulty swallowing), drooling and distressed respiratory effort are classic signs * Edematous, cherry-red epiglottis is most reliable diagnostic sign * Examination of throat is contraindicated, however, unless emergency equipment and trained personnel are available; physical manipulation of hypersensitive and irritated airway muscles may result in spasm and a obstruction * Lateral neck-x-ray confirms an enlarged epiglottis; portable x-rays are completed in examination room with child on parent's lap to minimize stress maximize child's comfort and calm behavior * Complete blood count (CBC) and blood cultures are taken once child is - stabilized Therapeutic management * Assess continuously for respiratory distress and decrease in respiratory report changes in status * Never leave child unattended; support child in position of comfort; encourage parents to hug and cuddle their child * Keep ET and tracheotomy tubes and suction equipment at bedside; assist emergency ventilation if needed before child is taken to operating room for airway insertion * Child is usually intubated for 24 hours; restraints may be necessary to prevent tube dislodgment, because swelling of epiglottis may prohibit reintubation * Provide support for child and family and alleviate anxiety; explain all procedures clearly and calmly * All invasive procedures, including starting an IV infusion, ABGs, and blot surtures are performed in OR * Keep child NPO; IV fluids provide hydration; administer antipyretics and antibotics as prescribed * After extubation, monitor child closely in intensive care unit to ensure ir*ate assessment if respiratory effort is compromised * Medications * Antibiotics treat bacterial infection (usually given for 7 to 10 days); discharged in about 3 days with oral antibiotics * Antipyretics treat fever and manage pain of sore throat * Corticosteroids may be given for 24 hours before extubation Assessment * Clinical manifestations include worsening of URI with tachypnea, retractions, low-grade fever, anorexia, thick nasal secretions, and increasingly labored breathing; older infants may have a frequent, dry cough * Auscultation of lungs reveal wheezing or crackles * Nasopharyngeal washing to obtain respiratory secretions identifies causative virus; chest x-ray may be normal or indicate hyperinflation or nonspecific inflammation Therapeutic management * Assess respiratory status hourly; provide humidified 02 to ease respiratory ef*fort; use pulse oximetry to assess 02 saturation * Clear nasal passages with bulb syringe; elevate head of bed * Cluster nursing care to allow for rest; assess anxiety level of parents and provide support; maintain a calm environment * IV fluids may be needed if oral intake is compromised; monitor strict I & 0; weigh daily to assess fluid loss * Maintain strict handwashing and contact precautions; caregivers should not care for other high-risk children * Medications: bronchodilators and steroids are sometimes used; prevention of bronchiolitis in highrisk children under age 2 may be achieved with use of palivizumab (Synagis) or IV RSV immunoglobulin FOREIGN BODY ASPIRATION * Inhalation of an object into respiratory tract, intentional or otherwise * The type and shape of object, as well as small diameter of an infant's airway, de*termines severity of problem; round objects such as hot dogs, round candy, nuts, and grapes do not break apart and are more likely to occlude airway; latex bal*loons are particularly hazardous; objects with irregular shapes may irritate air*way and partially obstruct airflow Assessment * Sudden coughing and gagging is first sign, and objects in upper airway may be expelled by coughing * Partial obstruction may cause symptoms of respiratory infection for days or even weeks; child may have hoarseness, croupy cough, wheezing, and dyspnea Therapeutic management * Assess respiratory status to determine severity of problem and degree of ob*struction; continuously monitor and provide assistance if obstruction worse * If total airway obstruction occurs, perform back blows and chest thrusts for infants and Heimlich maneuver in children older than 1 year * Keep NPO; foreign body is usually removed in surgery * Position for comfort and to optimize airway; provide emotional support to parents and child and alleviate anxiety * After removal of object, assess for additional obstruction that may result from laryngeal edema and tissue swelling Asthma * When both antibiotics and aminophylline are administered intravenously, the nurse should check for compatibility. If only one IV site is used, the nurse should use the SAS procedure (saline, administer medication, saline) for administering medications. Administer IV doses using a controller. * Clinets receiving aminophylline should be maintained or cardiorespiratory monitoring because aminophylline affects cardia and respiratory rates as well as blood pressure. Because toxicity can occur rapidly the nurse should monitor the client’s aminophylline level. Symptoms of toxicity are nausea, vomiting, tachycardia, palpitations, hypotension. In extreme cases, the client could progress to shock, coma and death. * The therapeutic range for aminophylline is 10-20 mcg/mL. Pneumonia * Some medications used in the treatment of pneumonia require special attention: * Tetracycline should not be given to women who are pregnant or to small children because of the damage it can cause to developing teeth and bones * Garamycin, an aminoglycoside, is both ototoxic and nephrotoxic. It is important to monitor the client for signs of toxicity. Serum peak and trough levels are obtained according to hospital protocol. Peak levels for Garamycin are drawn 30 minutes after the third or fourth IV or IM dose. Trough levels for Garamycin are drawn 30 minutes before the third or fourth IV dose. The therapeutic range for Garamycin is 4-10mcg/mL. Pulmonary Embolus * Remember the three Fs of fat emboli: o Fat o Femur o Football player * Most fat emboli come from fractured femurs; most fractured femurs occur in young men 18-25, the age of most football players. * Streptokinase is made from beta strep; therefore, clients with a history of strep infections might respond poorly to anticoagulant therapy with streptokinase because they might have formed antibodies. * Streptokinase is not clot specific; therefore, the client might develop a tendency to bleed from incision of injection sites. Registered User Received 278 Kudos from 61 posts Join Date: Jun 2008 Posts: 64 Oct 27, 2008, 02:55 AM Updated Oct 27, 2008 at 02:59 AM by SWEETDREAMERINSOCAL Re: Anyoone up for random FACT THROWING?? Here are some things to review: In a peds patient who has a low h/h the best approach for the nurse to do is to plan nursing care around lengthy rest periods due to the inability of rbc’s to carry O2 to the blood. In a patient with Bulimia a nurse would expect to see a decreased K+ due to the loss of electrolytes. A peds patient who is postop placement of ventriculoperitoneal shunt the nurse needs to assess for abdominal distention because CSF may cause peritonitis or postop ileus as a complication of distal catheter placement. In a malfunctioning ventriculoperitoneal shunt the infant is most likely to display irritability because of increased ICP. After a tonsillectomy and adenoidectomy in a peds patient, increased restlessness should be reported immediately because that is a sign of hemorrhage as well as increased resp. rate and heart rate. In a stage two skin ulcer, it is best to apply a hydrocolloid or foam dressing as evidence shows that these best promote healing. Tetany and parasthesia are signs of hypocalcemia as well as muscle cramps and seizures. Hypocalcemia may be secondary to damage to the parathyroid gland after a thyroidectomy. Blood urea nitrogen (BUN) should be monitored closely after burns to the body since the glomerular filtration rate is decreased with fluid shift. Kidney function should be monitored closely otherwise, renal failure may occur. The peak air flow volumes decrease about 24 hours before clinical manifestations of exacerbation of asthma. If a woman complaints about painless vaginal bleeding while pregnant, she should be prepared for an abdominal ultrasound as these are signs and symptoms of placenta previa and it is diagnosed with an abd us. A potential complication of renal bx (biopsy)is hemorrhage; therefore, vital signs should be assessed to determine if this is happening. Medications Beta-blockers block the release of epinephrine to the cells therefore resulting in hypotension which decreases libido and impotence. Decadron increases the production of HCL acid, causing ulcers; therefore it should be taken with milk or food. PT should be monitored with Coumadin therapy; the dosage is ordered daily based on the PT results. Coumadin affects the Vit K clotting factors. Signs of digitalis toxicity include nausea, vomiting, abd cramps and halo vision. K+ levels should be reviewed as low K+ levels lead to digitalis toxicity. Patient should be taught take adequate K+ intake. Infusion of a unit of packed RBC’s should be a limited to a max of over 4 hours. Pancreatic enzymes for a child with cystic fibrosis should be taken with every meal and every snack to allow for the digestion of all the food that is eaten. In a child who has ingested half a bottle of aspirin you would expect to see epistaxis since the ASA lowers platelet levels and prolongs the bleeding time. When a patient is on Lasix, it is essential to include in the shift report the urine output. Lactulose will decrease lethargy if given to a patient, since this removes ammonia from the patient’s body decreasing hepatic encephalopathy which is lethargy and confusion. Best site for injection for a 5 year old is the vastus lateralis muscle. Dilantin causes swollen and tender gums; therefore good oral hygiene must be maintained. Signs of tardive dyskenisia include smacking lips, grinding of teeth and “fly catching” tongue movements. When administering a suppository the patient should be laying on their left side. The suppository melts after 10-15 minutes therefore they can move around. Administering epinephrine supersedes maintaining airway in the event of an allergic reaction to the flu shot. This is done when the patient has not lost consciousness and is normotensive. Foods and more Foods rich in Iron include: red meats, fish, egg yolks, green leafy vegetables, legumes, dried fruit, whole grains. Sickle cell crisis should be symptom management; management of pain would be a priority. Cow milk should not be given to infants younger than 1 year. Solid food should be added at 4-6 months of age one at a time and should start with an iron fortified cereal. NIDDM patients should keep a regular schedule of meals and snacks and should be taught to read labels and make good choices about food. Give a diet low in sodium when the patient is minimal change of Nephrotic syndrome. When a child has had mild diarrhea for two days they should continue with regular diet and oral rehydration fluids. Potato chips have no gluten in them therefore a child with Celiac Disease should have this as a snack. Corn, rice, soybeans and potatoes are digestible by persons with celiac disease. A heart murmur would alert the nurse to a complication of Ineffective Endocarditis. A hematocrit of 60 on a patient with Diabetic ketoacidosis would alert the nurse for immediate action as this means they are severely dehydrated which all systems are at risk of hypoxia from a lack of or sluggish circulation. In the absence of insulin, fats and proteins are broken down by the body to supply energy ketones, a by-product of fat-metabolism which can accumulate and cause metabolic acidosis. Excessive vomiting causes metabolic alkalosis because of the loss of acid in the stomach and vice versa, diarrhea causes metabolic acidosis because of the loss of bicarbonate. Signs of metabolic alkalosis include irritability, increased activity, hyperactive reflexes, muscle twitching and elevated pulse. Assessment is the first step of the nursing process. When a child is injured and appears to have fractured a leg, assessment and inspection of the child is a priority. Synthetic casts usually set in 30 minutes and dry in a few hours and the patient can stand up in 24 hours. Plaster casts (thicker) take up to 72 hours to dry and set. Both should be uncovered in the first 24 hours because they give off a lot of heat. Applying ice can relieve itching. There is a strong relationship between Group A streptococci and Rheumatic fever usually occurring within 2-6 weeks. Live immunizations (MMR) should be delayed for the child with Kawasaki’s Disease going home with immunoglobulin therapy because this may interfere with the formation of antibodies. Tracheoesophageal fistula priority nursing diagnosis would be ineffective airway clearance and to prevent aspiration. In asthma attack the airways are narrowed therefore a wheezing sound results. Slurred speech or changes in LOC may be indicators of continued bleeding or extension of stroke in a patient admitted with possible CVA, therefore slurred speech should be reported immediately for further testing. In Hep C, findings may show many years later; for example having a blood transfusion 15 years ago. In a newborn with neural tube defect, the sac must be kept moist by applying a moist sterile nonadherent dressing before closure. They should be changed frequently to prevent drying. A Milwaukee brace is used to correct curvature of the spine and is usually long term (1-2 years) during the growing phase of the child. Pain related to ischemia should be the priority nursing diagnosis in a patient with a diagnosis of MI. Pain increase BP, pulse, O2 demand to myocardium and anxiety. When expiratory wheezes are suddenly absent in one lobe in a patient with an acute asthma attack, this means an emergency because the small airways have collapsed. It is important to monitor hourly urine output on a patient who has had a pulseless Dysrhythmia since the perfusion to the kidney was diminished, this caused for the Glomerular perfusion to be diminished which can lead to pre-renal failure. If an infant is spitting up frequently and has a lot of gas, this may be indicative of an allergy to the formula or experiencing GERD. Mucus production, irritability and restlessness are some of the signs the infant will display. In a newly diagnosed Alzheimer’s patient the most helpful intervention would be for the nurse to help the family find effective communication strategies since this will help the family enhance their ability to relate to the patient. In a patient with Grave’s Disease (Hyperthyroidism), it is important for the nurse to intervene if noted on the initial nursing assessment if the patient has exophthalmoses (protruding eye balls). This can lead to corneal abrasion or damage when the eyelid is not able to complete close over the eyeball. Signs of neuroblastoma include irregular abdominal mass the crosses the midline, weight loss, pallor, irritability, anorexia and weakness. An infant with respiratory distress syndrome is unable to maintain alveolar surface tension due to the fact that the lungs did not mature completely. A child with Fetal Alcohol Syndrome will most likely display s/slike deformities in the joints, limbs and fingers, thinned upper lip, small teeth with faulty enamel and will have delayed development. A child with pinworm will display s/s like itching in the perianal area, bed wetting, irritability, poor sleep patterns, and short attention span. last for today ..study hard goal toddlers ages 1-3, separation anxiety is at its peak. When performing an assessment on a toddler, first approach the toddler with minimal physical contact to gain his/her cooperation, then proceed slowly with simple explanations prior to contact; be flexible. The DTaP immunization is associated to have the most reactions like crying inconsolably, child feels very warm and shaking spells. The immunization is contraindicated if the reactions are severe or signs of encephalopathy within 7 days. In a couple who has experienced a miscarriage, the best therapeutic communication for the nurse to use is to help the couple begin the grieving process by sharing their feelings and use support persons. On the 2nd of a patient who experienced an MI, the focus should be on the daily needs and what needs to be done that day. When planning home care for a patient the nurse first needs to assess the cognitive ability of the patient and the availability of a caregiver. Animal dander is very common to affect children with asthma therefore when interviewing the parents it is important to assess the child’s environment for household pets. A fracture in the epiphysis may result in retarded bone growth therefore one leg being shorter than the other one. Increased amounts of folic acid prevent neural tube defects; therefore women of child bearing age should increase their consumption in dietary supplements or diet. For a four year old, it is best to relate time to a known event like supper, dinner, breakfast, etc. since they don’t understand time completely. Telangientatic nevi or stork bites are small salmon patches in that disappear in 1-2 years of age. To prevent lead contamination in infants, let tap water run for a few minutes before filling up the bottle to mix it with formula. Diagnosis of pediculous capitis may be made by observing whitish oval specks sticking to the hair. Treatment consists of using of medicated shampoo for children over 2 years old and meticulous brushing of hair. The concrete operations stage consists of moral judgment and logical thinking therefore a child can make the assumption that stealing is wrong. The best response for the nurse to give to a client who is worried that her spouse will not come near her after a mastectomy would be “ Are you worried that the surgery will lead to changes?” since this leaves a channel open for discussion. The most effective intervention for a withdrawn patient is to give opportunities to have interaction with one person since they feel uncomfortable in social interaction. The priority in accidental poisoning in children is to empty the child’s mouth to prevent further ingestion of the substance. More falls occur in the bedroom than anywhere else in the house, therefore to prevent falls on elderly patients, night lights should be placed in the bedroom as a priority intervention. All healthcare personnel should be aware of balloon allergies since this is an allergy to latex. The best way to protect ourselves from a patient suspected of having TB is to wear a particulate respirator mask. Giving sips of water to a toddler who has ingested drain cleaner will help dilute the corrosive substance prior to gastric lavage. Seclusion should only be used when there is an immediate threat of violence to staff, other patients or the patient himself. If it is not used appropriately charges against the nurse may result in unlawful seclusion and restrain even though the patient cooperated. If a patient had MRSA and passed away the body should be labeled with MRSA so contact precautions can be implemented. The immediate action by a nurse who just got stuck with a needle is to wash the site vigorously. A four year old can help with the care of an infant when he is supervised and helps feel the four year old not left out and encourages bonding with the infant. A child with severe deep abrasions over 98% of his body is considered to not survive since the deep abrasions should be thought of as 2nd or 3rd degree burns. The child is at great risk of both infection and shock. In accidental poisoning it is most important to identify the substance that was ingested, then the age and weight of the child to prepare the antidote that is needed and then the time of ingestion. If the advance directive is available when a patient comes in and is unconscious, that should be given the priority to guide the care of the patient. Employers must provide reasonable accommodations for disabled individuals based on the Americans with Disabilities Act. Assertive communication respects the needs of all parties to express themselves therefore requesting a private meeting with a provider that is loudly criticizing a nurse and the nurse is the most appropriate thing to do in order to protect patients and other staff from the display. Effective time management for a nurse manager is also setting goals and prioritization of the work. Nurses are more satisfied with autonomy and control. This improves team morale. Patients who were admitted voluntarily can request to be discharge any time they want in a psychiatric facility as long as they are not a threat to themselves or others. If a nurse is reluctant to interact with a patient, she must discuss feelings with a peer or supervisor so she can discover attitudes and feelings that influence nurse-client relationship. The LVN should not have the care of a patient who was newly admitted and has not had stability established. When large amounts of fluids are given to a patient in a short period of time the priority is to Auscultate the patient’s lungs since the fluid overload may lead in worst cases to heart failure with lung congestion. In the Glasgow’s Coma Scale, any score less than 13 indicates neurological impairment. When a psych patient is sharing his grandiose ideas, the best therapeutic approach is to listen quietly without commenting on it. When a patient is depressed and states a desire to not live anymore, the best approach is to ask about thoughts of hurting themselves. Repeated actions of OCD are done to relieve anxiety. Neologism is associated with a thought disorder and it means that the patient invents new words to describe something that no one else understands. In a psych setting, the nurse should limit contact to handshaking has hugging may be interpreted by the patient as sexual advances. The therapeutic milieu is meant to provide safety and test for grounds for patterns of new behaviors. A depressed patient is at highest risk of committing suicide 7-14 days after they start meds or therapy because that is when they gain the energy to go on with the plan. Dental erosion and parotid gland enlargement are signs of bulimia since the parotid gland enlarges due to the self induced vomiting and the teeth get damaged by the acid in the stomach. few more to share: Flail chest is caused by fracture of multiple adjacent ribs, causing the chest wall to become unstable and respond paradoxically. The chest in the affected side is pulled inward during inspiration and bulges outward during expiration. 5-digit system (GTPAL)– 1st digit accounts for the # of times the uterus has been pregnant, 2nd is the # of term deliveries, 3rd is the # of preterm deliveries, 4th is for the # of abortions and 5th is the # of living children. Hemoglobin A1c – 7% or less indicates good control, 7%-8% indicates fair control and 8% or higher indicates poor control. This test measures the amount of glucose that has become permanently bound to the RBC from circulating glucose. At the end of 12 weeks gestation th e sex of the baby can be determined by the appearance of the external genitalia. Gynecoid pelvis is a normal female pelvis and is the most favorable for successful labor and birth. Android pelvis (resembling a male pelvis) would not be favorable for labor because of narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate, with platypelloid pelvis (flat pelvis) has a wide transverse diameter, but the anteroposterior diameter is short, making the outlet inadequate. Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward causing the fetus to rise. The fetus then sinks and the examiner feels a gentle tap on the finger. 12 week gestation the fundal height should be at the umbilicus Second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate.. 12-month-old infant – RR: 20-40 breaths/min, HR: 90-130 beats/min, BP: 90/56 mmHg Toilet training – bowel control usually is achieved before bladder control. The child should not be forced to sit for long periods. The ability to remove clothing is one of the physical signs of readiness. The physical ability to control anal and urethral sphincters is achieved some time after the child is walking, between 18-24 months. Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamentals to ageism are the view that older persons are different from “me” and will remain different from “me”. Therefore, they are portrayed as not experiencing the came desire, needs and concerns. Reye syndrome – decreasing stimuli and providing rest decreases stress on the brain tissue, checking for jaundice will assist in identifying the presence of liver dysfunction that occurs in Reye’s syndrome. The vomiting that occurs is caused by cerebral edema and is a symptom of increased intracranial pressure. Ventriculoperitoneal shunt – Treatment for hydrocephalus. If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The CSF will build up in the cranial area. The result is increased ICP, which then causes a high-pitched cry in the infant. Myringotomy is the insertion of tympanoplasty tubes into middle ear to equalize pressure and keep the ear aerated. Parents should be instructed that the child should not blow his or her nose for 7 to 10 days. For children younger than age 3, the auditory canal is straightened by pulling the lobe down and back. For children older than 3, the pinna is pulled up and back. Feeding an infant with cleft palate, ESSR – enlarge the nipple; stimulate the sucking reflex, swallow and rest to allow the infant to finish swallowing what has been placed in the mouth. Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the convalescent phase. Proper steps in administering vaccines: The nurse should first verify the order and then obtain parental consent. The nurse should also question the parents about the presence of any allergies in the child. The nurse should next prepare the injection and document the lot number (located on the medication vial) of the vaccination. The nurse then selects an appropriate site and administers the vaccination. The nurse then documents that the vaccination has been administered and provides an updated immunization record to the parents. Psoriasis occurs equally among women and men, although the incidence is lower in darker skinned races and ethnic groups. A genetic predisposition has been recognized in some cases. Emotional distress, trauma, systemic illness, seasonal changes, and hormonal changes are linked to exacerbations. CUSHING’S SYNDROME - A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a client with Cushing’s syndrome. Such a diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue. Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) have only motor components and control, in a coordinated manner, the six cardinal fields of gaze. This is tested by moving an object in six directions (involving horizontal and diagonal movements). Corneal reflex is the function of the trigeminal nerve (cranial nerve V). Pupillary response and accommodation is the function of cranial nerve III (oculomotor) alone. Individuals at risk for developing a latex allergy include health care workers, individuals who work in the rubber industry or those who have had multiple surgeries, have spina bifida, wear gloves frequently, such as food handlers, hairdressers, and auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts. To test for Kernig’s sign, the leg is raised with the knee flexed. Then, the leg is extended at the knee. If any resistance is noted or pain is felt, the result is a positive Kernig’s sign. This is a common finding in meningitis. Brudzinski’s sign occurs when flexion of the head causes flexion of the hips and knees. Chvostek’s sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau’s sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. Late decelerations are correlated with uteroplacental deficiency. + PKU – offer the infant Lofenalac; infant lacks enzyme necessary to convert phenylalanine to tyrosine that causes accumulation in the tissues and leads to mental retardation. Lofenalac is low in phenylalanine but contains minerals and vitamins required by the infant. Codeine phosphate (Paveral) – analgesic used for moderate to severe pain for Hemophilia A. Terbutaline (Brethine) – S/E are maternal tachycardia nervousness, tremors, headache, and possible pulmonary edema. Fetal S/S includes tachycardia and hypoglycemia. Perphenazine (Trilafon) – can cause extrapyramidal side effects. Thiothixene (Navane) is an anti-parkinsonian agent, used to counteract extrapyramidal side effects. Procainamide HCL (Pronestyl)– A/E severe hypotension or bradycardia. Ketoconazole (Nizoral) – drug of choice for treatment of candidiasis (mouth pain, difficulty swallowing and a white discharge in the back of the throat. Hyponatremia – headache, apprehension, lethargy, muscle twitching, convulsions, diarrhea, fingerprinting of skin. Right-sided heart failure is manifested by congestion of the venous system, resulting in peripheral edema. Also there is congestion of the gastric veins, resulting in anorexia and eventual development of ascites. Gemfibrozil (lopid) – lipid-lowering agents used with patients with high serum triglyceride levels. S/E abdominal pain, cholelithiasis; taken 30 minutes before breakfast and supper. Monitor aspartate aminotransferase (AST) for liver function. Normal AST 8-20 units/L and normal ALT 8-20 units/L. Hydrochloride (Zantac) – taken at hour of sleep. Hip spica cast – patient complaining of pain, assessment symptom of circulatory impairment from cast by pressing nail of great toe to indicate circulatory function. Compare speed with which color returns with result on the opposite side. Sluggish return indicates circulatory impairment; too rapid return indicates venous congestion. Addison’s disease – steroid replacement is the most important information the client needs to know. Fluoxetine HCL (Prozac) is an “energizing” antidepressant; positive response would be an increased energy level and being able to participate more in milieu. Hemolytic reaction of blood transfusion – N/V, pain in lower back, hematuria. Most dangerous type of reaction. sympathetic-dilates pupils, inhibits salivation, relaxes bronchi, accelerates heart, inhibits digestive activity, stimulates glucose released by the liver, secretes epi & norepi from kidney, relaxes bladder, and contracts rectum. parasympathetic-constrict pupils, stimulates salivation, inhibits heart, consticts bronchi, stimulates digestive activity, stimulates gallbladder and contracts bladder, also relaxes the rectum. They are the opposite of each other. Good luck studying!!! THERAPEUTIC LEVELS while i was reading this thread, someone ask to post about the theraputic levels, but a little was discussed so im just listing some common drugs.. Acetaminophen-------------------------- 5-20 ug/ml Acetylcysteine-------------------------- 5-20ug/ml Carbamazepine (Tegretol)---------------- 3-14ug/ml Cycloserine----------------------------- 25-35ug/ml Digoxin (Lanoxin)------------------------ 0.5-2ng/ml Digitoxin (Crystodin)--------------------- 15-25ng/ml Gentamycin (Garamycin)----------------- 5-10ug/ml Lidocaine (Xylocaine)-------------------- 1.5-5ug/ml Lithium (Lithobid)------------------------ 0.5-1.3mEqL Magnesium So4-------------------------- 4.8-8mg/dL Phenytoin (Dilantin)---------------------- 10-20mgug/dL Phenobarbital (Luminal)-------------------10-30ug/ml Procainamide (Pronestyl)-----------------4-10ug/ml Propanolol (Inderal)----------------------50-100ng/ml Salicylate (Aspirin)----------------------100-250 ug/ml Theophylline (Aminophylline)--------------10-20ug/ml Vancomycin-----------------------------30-40ug/ml 1. Ritalin should be administered after the child has eaten breakfast 2. Oligohydramnios is associated with intrauterine growth restriction. 3. Varicose Veins predispose the client to thrombophlebitis. 4. Bile drainage for the first 24 hours is 300-500 mL 5. Early Heart failure characteristic = Increased Respiration rate 6. T-tube is not irrigated! 7. Rocker bottom feet is found in infatns born with Trisomy 18 8. ECG should be done before taking imipramine (Tofranil) 9. Antidote to morphine = Naloxone (Narcan) 10. Tinnitus is a common symptom of aspirin toxicity Hope those are helpful PRIORITY Emergent Priority (1st): requires immediate attention and continuous evaluation yet have a high survival rate -trauma -chest pain -severe respiratory deficits -chemical splashes to the eyes Urgent Priority (2nd): injuries non life threatening - .treated within 1-2 hours and are evaluated every 30 to 60 minutes thereafter. -simple fracture -asthma without respiratory distress -fever -hypertension -abdominal pain -renal stone Nonurgent Priority (3rd): clients can wait several hours before being seen and require 1-2 hours of evaluated thereafter. -minor laceration -sprain -cold symptoms So if someone came in with a chest pain because they ate something wrong and another person that came in with a high blood pressure, do pick the chest pain first. DELEGATIONS CNAs -skin care, feeding, toileting, vital signs (not initials), height, weight, I & O, ROM exercises, ambulation, transporting, grooming, and hygiene measures of stable clients. LPNs/LVNs -physiologically stable clients with predictable outcomes -dressings, suctioning, urinary catheterization, med administrations (only oral, subcutaneous, and intramuscular), no rectal or IV meds RN associated: -care for individual in a structured health care environment RN BSN: -care for individuals, families, groups, and communities in both structured and unstructured health settings. RN (all): -assessment/planning care, initiating teaching, IV meds RN can not delegate these tasks: -initial assessments of clients -evaluation of client data -nursing judgment -client/family education/evaluation -Nursing diagnosis These are my fives 1) Hypocalcemia < 8.6 mg/dl manifested by prologued ST-interval on EKG and prologued QT-interval. 2) A patient with hypocalcemia has to have a heart monitor and placed on seizure precautions. 3) A patient with hypocalcemia would be positive sign to Chvostek's and Trousseau's sign and would show hyperactive deep tendon reflexes. 4) ST-interval on the EKG represents ventricular repolarization. 5) QT-interval last 0.32-0.4 secs. it represents the time needed for ventricular depolarization. feliz3 A new nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a tam nursing approach. The nurse understands that planning of care delivery will be based on which characteristic of this type of nursing model of practice? 1.A task approach method is used to provide care to clients 2.A single RN is responsible for providing nursing care to a group of clients 3.Managed care concepts and tools are used in providing client care 4.Nursing personnel are led by an RN leader in providing care to a group of clients. I need you help! Thank you ! That's my answer NO. 4. Team nursing model is led by an RN seen this in saunders Pharmacology Notes: Librium - antianxiety used to tx symptoms of acute alcohol withdrawal. Cogentin - used to tx parkinsonian side effects of Thorazine (antipsychotic med) Methadone Hydrochloride - opiod analgesic; tx for narcotic withdrawal Procardia - antianginal med (CCB) decreases myocardial O2 demand. Digoxin - strengthens myocardial contractio0n & slows conduction thru AV node Coumadin - inhiits prothrombin synthesis Amicar - antifibrinolytic; prevents recurrence of subarachnoid hemorrhage. Lithium - tx manic phase of bipolar Nimodipine - CCB; decreases spasm in cerebral blood vessels Diltiazem - CCB; inhibits Ca+ influx in vascular smooth muscle; reduces myocardial O2 demand & decreases force of ventricular contraction Clotrimazole - antifungal; treats rashes. Terbutaline (Brethine) and Magnesium Sulfate- treatment for preterm labor Dilantin can cause gingival hyperplasia, advise good oral hygiene and freq. dental visits, IVPush for Dilantin should be - 25-50 mg/min (or 2-3 mins) Pharmacology - any of the –mycin - check for tinnitus or hearing loss Don’t give beta blockers to anyone with respiratory problems i.e asthma, copd. Vasopressin is also known as antidiuretic hormone NEVER NEVER NEVER administer KCl via IV push. Beta Blockers and ACE Inhibitors are less effective in African Americans than Caucasians. Vinca Alkaloids (Vincristine) lead to neurotoxicity and can present with numbness and tingling in the legs or paralytic ileus. No narcotics to any head injury – won’t be able to accurately assess LOC, so pick the narcotic if you have an order to question. Mannitol for ICP Narcan is given for to reverse respiratory depression...a rate of 8 or less is too low and requires nursing action. Celebrex is contraindicted in pts with a history of cirrhosis. Foscarnet (Foscavir) can be toxic to kidneys so creatinine is monitored. Calcium isn't an antidote for hypermagnesemia. Renal filtration is how excess Mg is removed-- that or of course dialysis. Instead, calcium helps to stabilize the electrical gradients of muscle and nerve cells, which helps to prevent dysryhthmias. Hi, I want to make a few comments about two medications on your list, the first one is magnesium sulfate which is also an antidysrhythmic that suppress dysrhythmias by inhibiting abnormal pathways in the electrical conduction system of the heart. This drug also is used as anticonvulsant for seizure prevention in pregnant women with eclampsia. This antidote to this drug is calcium gluconate. A person given an infusion of magnesium sulfate needs to have a heart monitor in place, frequent assessment of respirations, blood pressure and neurological functions. This drug cannot be given with food because food affects its absorption. It is imperative to monitor respirations when using this drug because one of the sides effects of it is reduced respiratory rate. This drug is contraindicated if the patient has a heart block, myocardial damage or renal failure. If the patient has preeclamsia this drug is continued for the first 12 hours postpartum. High doses of this drug can cause loss of deep tendon reflexes, heart block, respiratory paralysis and cardiac arrest. You must have calcium gluconate readily available in case the patient manifests drug toxicity symptoms. Mannitol(Osmitrol) is another drug used with extreme caution for clients with increased intracraneal pressure. First, this drug comes in in chrystal form which needs to be dissolved in warm water and the nurse must use a special filter in the syringe before administering this drug. Must monitor renal function for diuresis is expected...meaning the patient is going to urinate a lot for this drug draws fluid from the brain cells. A patient with increased intracraneal pressure must have the head of the bed eleveted 30 degrees, by the way. feliz3 what does sympathetic and para sympa do to our body? i messed up ^^ just want to make sure... tnx guys This is how I remember it...hope it helps you. p-sympth ( cholinergic) feed/breed actelycholine increase GI, Gu, decrease BP, heart rate, resp, const. pupils Sympth (adrenergic) fight/flight epi, norepi, dopamine increase BP, heart rate, resp.,decrease GU, GI, dilate pupils Another thing I want to add concerning Mannitol is that this drug has to have a port of its own, meaning, it cannot go through the same port with other drugs for there is a risk to form crystals when in contact with other drugs through the port wall. This fact is true about Dilantin (anticonvulsant) and Potassium. Potassium cannot be given IVPush or intramuscular injection ever because Potasium is caustic, and it will burn and possibly colapse the patient's vein. It is imperative to assess the needle site where potassium is infused for signs of infiltration, phlebitis and cellulites. Potassium when given IV must be diluted, the patient must have a renal assessment and have a heart monitor in place. feliz3 Giving in to a child’s temper tantrum is detrimental to the child’s emotional health. It teaches the child that if they have a tantrum, they will be given what they want. Giving in to a temper tantrum leads to habitual tantrums that can extend far past three years of age. When a child has their first tantrum, caregivers can try to soothe and calm the child. If the child is unresponsive to the attempts made to soothe their frustrations, caregivers should ignore the tantrum. When a child realizes that he or she will not be indulged or rewarded for their tantrums, temper tantrums generally subside. THERAPEUTIC LEVEL 10-20 mcg/ml Theophylline Acetaminophen Phenytoin Chloramphenicol Serum Digoxin - 0.5 - 2 mg/dL Carbamazepine - 4 - 12 mcg/dL One is resistant to Vancomycin and the other is resistant to Methicillin. (Methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-Resistant Staphylococcus aureus) Vancomycin as the drug of choice for treatment of methicillin-resistant Staphylococcus aureus (MRSA) and (VRSA) is susceptible to trimethoprim/sulfamethoxazole, minocycline,linezolid, and quinupristin/dalfopristin. Precautions are contact and you can place these patients in rooms together or private Preop teaching for lobectomy pt - sitting position, the client will take a deep breath, exhale through the mouth, and cough from deep in the lungs. Ativan- used for symptoms of severe anxiety: rapid pulse, diaphoresis, tightness in the chest, and inability to see connections between details. Patient identification - check the chart against the name and hospital number on the client’s armband; in the hospital environment the client should not participate in his identification. Child with RSV involves contact with a medication (Ribavirin) that is teratogenic and is classified as Pregnancy Risk Category X Age 12 months - hepatic metabolism of drugs is similar to an adult. Most impt cause of adverse drug reaction in older adults - reduced renal excretion Until the child walks or is 1 year of age, the vastus lateralis muscle is the preferred injection site. Robaxin - a muscle relaxant. Buccal medications - administered by placing the medication between the upper molar teeth and the cheek; should not be swallowed and should not be administered with water. An oral syringe or a pediatric medication dispenser is a useful device for measuring small quantities of medications for infants; it is placed at the side of the mouth. Nasal drops - position the head back over the edge of the bed or pillow with the head turned toward the side Vaginal suppository - should be lubricated with a sterile water-based jelly and inserted approximately 3 to 4 inches into the vaginal orifice; dorsal recumbent position, not on the side. To reduce pain during IM injection - applying pressure at the site of an IM injection may reduce the pain experienced by the client. Fluid overload - may experience headache and dizziness from the increase in circulating volume, which increases cerebral vascular pressure. Long-term NSAIDs use impairs ability to clot; NSAIDs decrease platelet adhesiveness or stickiness, which impairs coagulation Sulfonamides, tetracyclines, phenothiazines - photosensitivity is common to all of these medications. Increasing fluid intake - important with sulfonamides to prevent crystalluria. Unusual bruising - early indication of an untoward effect of phenothiazine, which is associated with bone marrow depression. IgG - major antibody against viruses and bacteria. IgG is the principal mediator of the secondary immune response.. IgA - secretory immunoglobulin found in tears, saliva, and mucous secretions of the lungs and gastrointestinal tract IgE - mediates allergic reactions Oral polio, measles-mumps-rubella, and varicella vaccines - contraindicated in the immunocompromised client. Cyclosporine - powerful immunosuppressant and is the drug of choice for preventing organ rejection after allogenic transplantation. Common s/e are hyperglycemia, infection, tremor. Valacyclovir (Valtrex) - form of acyclovir, which is indicated in the oral treatment of herpes zoster and recurrent genital herpes in immunocompetent adults. Oncological emergencies - life-threatening problems that arise as a result of the tumor or the treatment. They may be obstructive —superior venal caval syndrome, third space syndrome, spinal cord compression, or intestinal obstruction; metabolic — SIADH, hypercalcemia, tumor lysis syndrome, septic shock, and disseminated intravascular coagulation (DIC); and infiltrative — cardiac tamponade and carotid artery rupture. both systolic and diastolic blood pressures tend to increase with normal aging, but the elevation of the sytolic is greater. -Tachycardia is the major side effect of tocolytic drugs. (brethine, Yutopar) -Although Flagyl is the treatment of choice for some vaginal infections, it is contraindicated in the first trimester of pregnancy -Clients with abruptio placentae or placenta previa should undergo no abdominal or vaginal manipulations. -HgB norms for children Newborn: 14-24 Infant: 10-15 Child: 11-16 -take axillary temp in children with congenital megacolon -paralytic ileus is a common problem in comatose clients. A gastric tube aids in gastric decompression. -the body's response to illness and stress is to produce glucose. therefore, any illness results in hyperglycemia. -an early sign of colon cancer is rectal bleeding. -restricting sodium reduces salt and water retention, thereby reducing vascular volume and preload. -during aortic aneurysm repair, the large arteries are clamped for a period of time, and kidney damage can result. -normally, kidneys excrete approximately 1 ml or urine per kg of body weight per hr, which is about 1 or 2 liters in 24 hrs. -exposure to tobacco smoke is the primary casue of COPD in the US -the symptoms of anterior MI characteristically last more than 15 min and are more intest than angina. -before drawing blood for an ABG, check Allen test to assess collateral circulation. Pseudomembranous colitis may result from a superinfection with C. difficile during clindamycin therapy. Risperidone (Risperdal) has a lower incidence of extrapyramidal effects than do the typical antipsychotics. Risperdal does produce anticholinergic effects, and neuroleptic malignant syndrome can occur. Erythromycin is the drug of choice for treating Legionnaires' disease. Warfarin is used to prevent clot formation. Pinworms come out of the intestine through the anus at night to lay eggs, causing perianal itching. The child wakes up and may begin scratching. Eggs under the fingernails are carried to the mouth if the child chews on his nails, and the life cycle of the pinworm continues. In addition to teaching children not to bite their fingernails, parents should keep the nails short and encourage hand washing before food preparation and eating Adverse reactions to gentamicin include ototoxicity and nephrotoxicity. The nurse must monitor the client's hearing and instruct him to report any hearing loss or tinnitus. Signs of nephrotoxicity include decreased urine output and elevated BUN and creatinine levels Gentamicin has a therapeutic serum medication level . therapeutic range= 5-10mcg/ml meaning a serum amount of this medication beyond that range the nurse must assess cranial nerve VIII(auditory) and assess for symptoms of kidney problems, talk to the doctor about a higher drug range than recommended and document it. Educate patient about side effects and to report immediately what the patient is experiencing. feliz3 Pernicious Anemia= Vitamin B12 deficiency caused by impaired absorption of Vit. B12. The body will not make enough red blood cells for lack of vitamin B-12. This type of anemia is seen in patients who have lost the ability to absorb Vit. B-12, the elderly, alcoholics and in patients with stomach surgery, or gastritis. Pernicious anemia is due to the lack of a stomach protein which helps in the absortion of Vit. B-12. This protein is called intrinsic factor which is produced by the gastric cells. Vit. B-12 is absorbed in the ileum. Patients with problem with the ileum need to be watch for pernicious anemia. Injections of intrinsic factor are given to patients with Vit. B-12 deficiency, it could be done once a week or once a month, but they must have that injection, and an insulin syringe used for giving intrinsic factor shots. Lab tests needed CBC, neurological assessment, lack of vit. B-12 may change the surface of the tongue and shrink or thin the stomach lining. feliz3 From my previous post clarification when to use this sequence for type of examination Hope this helps. S Abdominal Assessment Sequence Inspection Auscultation Percussion Palpation In this order because sequence prevents altering bowel sounds. By performing palpation before auscultation. BUT for all other assessments Inspection Palpation Percussion Auscultation Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is the vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration. According to the American Heart Association,these should be perform during cardiac arrest 1. the nurse should first assess responsiveness. 2.If the client is unresponsive, the nurse should activate the emergency medical system 3.call for a defibrillator. 4.Next, the nurse should assess breathing by opening the airway and then looking, listening, and feeling for respirations. 5.If respirations aren't present, the nurse should administer two slow breaths, 6. then assess the pulse. 7.If no pulse is present, the nurse should start chest compressions. Ketoacidosis early symptoms: 1)thirst or dry mouth 2)frequent urination 3) increased glucose levels 4) increased level of ketones in urine ketoacidosis late symptoms: 5) constantly feeling tired 6) dry, flushed skin 7) nausea & vomiting 8) short, deep breaths (Kussmal's breathing pattern) 9) fruity breath odor 10) confusion This is seen in people with diabetes mellitus type and rarely seen in patients with diabetes II---older people with diabetes II may be the exception. When blood glucose is greater or equal to 240 mg/dl test urine for ketones every 4-6 hours. An infection and a fever will increase blood sugar levels in diabetics. Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) symptoms: 1) blood sugar level greater or equal to 600 mg/dl 2) dry, parched mouth 3) extreme thirst (may gradually disappear) 4) warm, dry skin that does not sweat 5) high fever (greater or equal to 101 F degrees) 6) sleepiness or confusion 7) loss of vision 8) hallucinations 9) weakness on one side of the body 10) dark urine Prone to happen to patients with diabetes II (non insulin dependent) Usually brought by an illness or an infection. feliz3 Marijuana: causes hunger Boy being evaluated for DM expect: bed wetting (Poyuria). MVA – unonscious head injury Higest priority: turn patient q 2 hours Left sacrum posterior= Assess FHR: above ubilicus on mother’s left side Liver biopsy Exhale hold breath T Tube 12 hours post cholesectomy of:300 ml drainage good/ok document Delay in development in a 9 month old is: child uses a palmar grasp to hold objects (p234 Prentice Hall) This should have disappeared at 1-3 months Radium Implant Cervical Cancer nurse should: Keep the used linen in room till implants are removed If patient states I can’t feel my toes: Assess by checking skin temperature of Foot. **NOT ask him to wiggle toes!! Adrenocortical Insuffciency nurse would expect: Decreased sodium, glucose, Increased potassium FHR initally 150, after apex of contraction: The FHR drops to 12; when contracion is completed the FHR is 130 this is: Late Deceleration DPT @ 4 wks than again at ? Infant cutting teeth: has 26 teeth Women 35 weeks getation (I find unexpected): Rbc: 4.9 HGB: 15 HCt: 45% Conversion (Defense Mechanism): Client converts his anziety over school performance on exams into a physical symptom that interfers w/ability to perform e.g. “I was unable to take my final B/C I was unable to write. Obbssive compulsive ritual: means patient is attempting to achieve: Avoid severe levels of Anxiety (not exressing anxiety- but strategy to avoid it) Calan Verapamil a Ca Chanel blocker (CCB) that depress myocardial contractions, dialates : used along with otherantihypertensves can cause HTN, HRT Failure assess: for peripheral edema Early Fetal deceleration: a slowing early in the conraction, usually a normal finding on heart tracings Myelogram test involves a lumbar puncture: w/ injection of contrast media alllowing x-ray visual of vertebral canal. Total hip replacement: Okay for side lying as long as abduction is maintained Cuffed Tracheostomy tube in place: purpose of cuff is to risk of aspiration intro trachea by the cuff sealing the tracheostomy from the trachea ECT Can dissrupt short term memory Can cause HA Can cause transiet confusional state Report “Backache” to MD S/P ECT B/C it’s NOT USUAL AFTER ECT! Infant Reflexes Moro’s Reflex Dissappears after 3 to 4 months Suddan jarring extention & abduction of extremities & Fanning of fingers w/index finger & thumb in C-shape Tonic Neck Reflex Disappears 3 to 4 months When head is turned to side arm & leg extends on that side & Oppisite arm/leg flexes Grasp Reflex Touching palms of hands on soles of feet cause flexion of hands/toes Palms Grasp Disspear after 3 mos Planter Grasp Lessened by 8 mos. Babiniski Reflex Disappears after 12 months Toes will fan out Incision line is Red: Complication (swelling under sutures is expected) Feeding tube feedings: Rinse bag Change form every 4 hours is approprate B/C there is an of organisms after 4 hours growth Health Promotion & Maintance Safety Droplet precautions Meningococcal meningitis = Droplets Wear: gown Gloves Mask Goggles **(NOT FOR: Lyme disease (ticks) Pnumonia Carnii) TB= Droplet Meningococcal vaccine High risk group: college students B/C dorms / closed quarters can be viral or bacterial worse B/C of excudate Total hip patient: Place in a room with a patient w/blanced suspension traction (clean with clean) Sickle Cell Crisis: clean so place in a room with patient with multiple sclerosis (MS)= (clean also) Lyme DX: connectient Lyme, connectient ABT: usually BID Pottery Cup: Lead poisoning potential *Toxic Hepatitis : From a medication (commonly Tylenol)…considered Safe/clean Patient Cesium implant : for CA of Abdomen- Ok to disgard Urine /geces In hospital bathroom (Does not need biohazard container) Unidentified contaminent exposed : Frist- determine the ceontamination that occurred in the field (doesn’t matter which type of contaminate it was) Trunk toys= dangerous Amniocentesis at 16 weeks gestation: Nurse should have patient void/empty bladder prior to amniocentesis. Re: Anyoone up for random FACT THROWING?? a couple more facts and I off to bed.... Brain Hemisphere Function Left hemisphere -detail Sequential, logical, analytical Decodes the sequence and structure of language Right hemisphere Processes information Associated with imagination Spatial perception Lobes Frontal Lobe Cognition Memory Prefrontal ability to concentrate Gate keeper to judgment and inhibition Personality and emotional traits Movement Motor cortex Controls voluntary motor activity Language controls motor speech Parietal Processes sensory input sensory discrimination , body orientation Occipital Controls primary visual reception area and visual association Temporal Controls auditory receptive area and association areas Controls language and memory. Re: Anyoone up for random FACT THROWING?? [FONT='Times New Roman','serif']mnemonics[/font] [FONT='Times New Roman','serif']To remember the clinical findings associated w/UTI think urinary tract is FULL of infection: F-frequent urge to void U-urine that is foul smelling and cloudy L-low grade fever L-lethargy No P No K. If the patient isn't peeing, they are probably retaining potassium, therefore they shouldn't be getting it. Nursing Considerations for renal failure --KIDNEY: K - Keeping fluid balance I - Inspecting the skin for Pruritus D - Dietary Instructions N - No to Acidosis E - Electrolyte imbalance maintainance Y - Your blood counts ASSESSMENT on dehydration D=dry skin & mucous membrane E=eyeball/fontannel sunken H=hypotension Y= you feel coolness/mottling of the extremeties D=delayed capillary filling time R= response to stimuli/LOC changes A= absence of tears T=tachycardia I=increase urine specific gravity O=oliguria N=no/loss skin turgor and elasticity[/font] stomatitis provide and instruct patient on good oral hygieneinspect mouth regularly, use non-alcoholic mouthwash (e.g.)diluted hydrogen peroxide),removal of ill-fitting dentures, use of soft-brsitled toothbrush provide health teachings on the importance of: o keeping mucous membranes moistlet patients suck on popsicle o avoidance of hot and spicy foodspasta and tacos o avoidanceof acidic and/or carbonated food and drinks,cola, orange juice, grapefruit juice o keeping food at room temperature or slightly cool apply water-soluble lubricant such as KY jelly to dry, cracked lips offer viscous lidocaine before meals to minimize discomfort more to come later: A prickling sensation is an indication of compartment syndrome and requires immediate action by the nurse. The most important aspects of home care for a child with acute spasmodic croup are humidified air and increased oral fluids. Moisture soothes inflamed membranes. Adequate systemic hydration aids is mucociliary clearance and keeps secretions thin, white, watery, and easily removed with minimal coughing This priority intervention prevents pressure caused by pooling of blood, thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Opioid narcotics are given for severe pain. Cold stress causes increased risk for respiratory distress. The baby delivered in such circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97 degrees Fahrenheit (36 degrees CelsiusAfter delivery. the high glucose levels which crossed the placenta to the fetus are suddenly stopped. The newborn continues to secrete insulin in anticipation of glucose. When oral feedings begin, the newborn will adjust insulin production within a day or two Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. A rigid board like abdomen is a sign of: peritonitis, a possible life-threatening condition. Epigastric pain occurring 90 minutes to 3 hours after eating: indicates a duodenal ulcer. Anorexia and periumbilical pain: are characteristic of appendicitis. Appendicitis risk of rupture is minimal with the 24 hours: but increases significantly after 48 hours. A client with a large-bowel obstruction: may have ribbionlike stools. Cullen’s sign: is evidenced by discoloration at the periumbilical area. This sign may indicate an underlying subcutaneous intraperitoneal hemorrhage. Chvostek’s sign: is a facial nerve spasm and trousseau’s sign is a carpopedal spasm; both signs occur with hypocalcemia. Chvostek’s definition: a spasm of the facial muscles elicited by light taps on the facial nerve. This spasm signals tetany and is seen in clients with hypocalcemia. Broca’s area: not sign, is an area within the brain that controls the motor functions involved in speech. Esophagogastroduoscopy: Endoscopic examination of the esophagus, stomach and duodenum; usually performed using a fiber-optic instrument. A physician inserts a fiberoptic endoscope via the mouth: to visualize the esophagus, stomach, and duodenum. Bleeding:, though rare, signals the complication of perforation. Sore throat, drooling, and absent gag reflex are: normal findings after an EGD. The endoscope can cause the sore throat. Clients my drool until the gag reflex returns and they’re able to swallow their saliva. Before performing the Esophagogastroduoscopy, the physician administers a local anesthetic that inactivates to the gag reflex, so the reflex may be absent for a period after the procedure. Black, tarry stools: are a sign of bleeding high in the GI tract, as form a gastric ulcer, and result from the action of digestive enzymes on the blood. Vomitus associated with upper GI Tract bleeding: commonly is described as coffee-ground-like. Clay-colored stools are: associated with biliary obstruction. Bright red stools indicate: lower GI tract bleeding. The nurse should tell the client that it’s the nurse’s professional obligation to maintain client privacy and confidentiality. Promising the client that she won’t tell anyone isn’t a professional response to the client’s concern. Telling the client that she can’t lie if asked about the client’s procedure is an inappropriate response that doesn’t uphold the client’s right to privacy. Telling the client that she’ll avoid any questions is an unprofessional response that doesn’t truly address the client’s concerns. A client who’s dizzy and anemic: is at risk for injury b/c of his weakened state. Assisting him with the bedpan: would best meet his needs at this time without risking his safety. The client may fall: if walking to the bathroom, left alone to urinate, or trying to stand up. Cirrhosis: a chronic, degenerative liver disease in which the lobes are covered with fibrous tissue, the liver parenchyma degenerates, and the lobules are infiltrated with FAT. Prothrombin synthesis in the liver: requires vitamin K. In Cirrhosis, vitamin K is lacking: precluding Prothrombin synthesis and, in turn, increasing the client’s PT. An PT, which indicates clotting time: increases the risk of bleeding. Therefore, the nurse should expect to administer phytonadione (Vitamin K1) to promote Prothrombin synthesis. Spironolactone and Furosemide are diuretics and have no effect on bleeding or clotting time. Warfarin: is an anticoagulant that prolongs PT. The client diagnosed with Clostridum difficle diarrhea: requires contact isolation. Contact isolation precautions: require the use of glove and gown if soiling is likely. A mask, face shield, & N-95 respirator: aren’t necessary to maintain contact isolation. A client with a small- bowel obstruction: can’t tolerate oral intake, fluid volume deficit may occur and can be life-threatening. Therefore, maintaining fluid balance is the primary goal. Pain relief and maintaining body weight: don’t reflect lifethreatening conditions. The client’s normal bowel pattern: can be reestablished after fluid volume is stabilized. Nurse should tell the client to drink 8 to 13-oz glasses of fluid daily: to replace fluids lost through diarrhea. Kaolin and pectin mixtures should be taken: after each loose bowel movement for up to eight doses daily. The client should avoid self-medication: for longer than 48 hours. The client should consult physician: if diarrhea persists longer than 48 hours despite treatment. The surgeon should collaborate with the enterostomal nurse: who can address the client’s concerns. The enterostomal nurse may schedule a visit: with client who has a colostomy to offer support, to the client. The clinical educator can provide: information about the colostomy when the client is ready to learn. The staff nurse and social worker aren’t specialized in colostomy care: so they aren’t the best choices for the situation. The nurse should intervene by providing additional teaching: if the client reports that he takes antacids. Antacids can interact with ranitidine (zantac): and interfere with its absorption. Ranitidine doesn’t interact with: antibiotics, antipsychotics, or antiarrhythmics. The RN must confirm that the LPN has specialized IV training: before asking her to begin IV therapy for the client. Initiating IV therapy: is beyond the usual scope of the practice for an LPN. Weighing the client, teaching coughing and deep breathing exercises, an teaching the client how to collect a urine specimen: are within the scope of LPN practice and don’t require additional training. Pseudomembranous colitis: may result from superinfection with C. Difficle during Chidamycin therapy. Chidamycin-induced Pseudomembranous colitis isn’t caused: by S. aureus, B. fragilis or E. coli. Shock definition: An abnormal physiologic state characterized by reduced cardiac output, circulatory insufficiency, tachycardia, hypotension, restlessness, pallor, and diminished urine output. Shock may be caused b various conditions, including trauma, infection, hemorrhage, poisoning, myocardial infarction, and dehydration. Shock and bleeding must be controlled: before oral intake, so the client should receive nothing by mouth. When the bleeding a controlled:, the diet is gradually increased, starting with ice chips and then clear liquids. Skim milk shouldn’t be given: b/c it increases gastric acid production, which could prolong bleeding. A clear liquid diet: is the first diet offered after bleeding and shock are controlled. The nurse should instruct the client to take antacids (Aluminum-magnesium complex (RIOPAN) with: water B/C water helps transport an antacid to the stomach. The client shouldn’t take an antacid with: fruit juice or a food rich in vitamin C or D B/C the antacid may impair absorption of important nutrients in the juice or food. The medical record must include a signed DNR form: so that all health care team members are aware of the client’s wishes. The nurse must also act as an advocate: for the client and support his wishes. Urging the client to agree to a proposed treatment regimen he doesn’t want and assuring the family that everything possible will be done for the client are in opposition to the client’s wishes. The Health Insurance Portability and Accountability Act: prevents the nurse from discussing the issue with the family unless the client has given permission. Crohn’s Disease: A chronic inflammatory bowel disease of unknown cause, usually involving the terminal ileum, with scarring and thickening of the bowel wall. Signs and symptoms: include frequent episodes of diarrhea, severe abdominal pain, nausea, fever, chills, anorexia, and weight loss. The nurse may not release any confidential information: to unauthorized individuals, such as the client’s boss. Telling the client’s boss the diagnosis and asking the boss to come in to discuss the issue breach client confidentiality. The client requires further teaching if he suggest: that he acquired the virus through sexual contact. Hepatitis A is transmited by: the ORAl-FECAL route or through ingested food or liquid that’s contamiated with the virus. Hepatitis A is rarely transmitted: through sexual contact. Clients with hepatitis A: need to take every effort to avoid spreading the virus to other members of thir family with precautions such as preparing food carefully, washing hands often, and taking medications as ordered. The correct sequence of abdominal examination is: inspection, auscultation, percussion, and palpation. This sequence differs from that used for other body regions: (inspection, palpation, percussion, and auscultation) B/C palpation and percussion intestinal activity, ltering bowel sounds. Therefore, the nurse shouldn’t palpate or percuss the abdomen before: auscultatin. Assessment of any body system or region starts with inspection: therefore, auscultating or palpating the abdomen first would be incorrect. Disseminated herpes zoster Private room, airborne precautions & contact precautions wear N-95 mask: keep door closed @ all times; remove gown shoes etc. before leaving room. Doppler ultrasound device: Hold probe at 45 degree angle to artery being assessed; move distal to proximal; conductive gel helps sound transmissionok to warm the gel & it’s important to warm the gel to allow vasodilatation and better sound /ultrasound : mark pulses with water poof pen.(does not wash off). Hepatitis A vaccine: indicated if patient is traveling out of country to Africa also, South America and Asia for example; Hep A spread via Fecal/Oral route. Also those w/chronic liver disease, hemophilia, who’s receiving clotting factor Standard Precautions req’d to care for Hep A patients. Judaism: Milk/ and Milk products NEVER enter along with meats. Raise HOB & Stop Infusion: If patient appears restless and c/o of difficulty breathing- lung sounds noted bibasilar crackles (Rales). Place Patient in sitting positions FIRST to reduce that high B/P – if noted with autonomic dysreflexia- (severe rapid HTN), (sever HA), T5 injury, temperature extremities noxious stimuli temperature skin pressure diaphoretic nauseated, brydiacardic, seizures (T-6 and above = Autonomic dysreflexia) Phenazopyridine (Pyridium): instruct if skin or sclera develops a yellow tinge call the physician – indicates drug accumulation due to renal impairment Pernicious anemia: requires monthly vitamin B 12 injections; without them death will occur in 1-3 years Cane walking: Going upstairs, lead with strong leg and follow with weaker leg and cane (always hold can in hand opposite of weak leg) (when going downstairs, lead with the bad leg and then the cane) Signs/Symptoms impending labor: contractions that continuously for an hour (e.g. contractions occurring every 5 mins for an hour). Generally = Labor: in true labor, contractions, are regular with decreasing intervals between contractions in intensity and duration, intensity usually increases with w/ walking, cervix dilates and effaces. Passing mucous plug is NOT s/sx of labor: as passing mucous plug may occur up to 2 weeks before onset of labor, client may not notice it! A contraction 3-4 min apart and bloody show is a sign of Labor: But may expel blood 24-48 hours before labor onset. Oxygen in oxygen tent: Most important to intervene if Birthday Candles on cake for toddler’s are – Oxygen combustible w/ flames/birthday candles. Propranolol (Inderal) ordered: to a client w/ type I DM (IDDM) Patient takes NPH & Reg insulin Q morning – instruct: Inderal may ask symptoms of hypoglycemia, removing your body’s early warning system. Question propranolol (Inderal) if ordered for patient w/history bronchial asthma- may cause bronchospasm. Dilantin Phenytoin: can cause vitamin D deficiency- intake of milk, cantaloupe and Kale. Extrusion reflex: normal neonate reflex – disappears by 3 months; extrusion reflex= tongue moving outward when tongue is touched. ASA Toxicity= tinnitus, HA, hyperventilation, agitation, confusion, diarrhea, and seating- withhold ASA and all physician. Re: Anyoone up for random FACT THROWING?? a little more for ya... Tuberculosis: classic symptoms= c/o dry cough for several weeks with freq night sweats, low grade fever- place in negative air pressure room or fit w/ N-95 mask until confirmations made on TB. Toddlers play with these toys: Pounding board, cloth picture books Preschoolers play with these toys: educational computer programs play clothes for dressing up, tricycle, and skates. *change peri-pads: every time she uses lavatory and when soiled (not just when soiled) Emphysema: client breathless, ashen in color, VS-Temp 98.8 ◦F, Pulse 114, RR 36, B/P 138/108, 02@2L min via NC. **What is most concerns nurse? Client’s skin color is pink within first 20 mins. Of oxygen delivery= BAD (if w/in 1st 30 mins of 02) – this may be oxygen induced hypoventilation-improving apnea/Resp arrest Low back pain secondary to multiple myeloma: Position: in bed HOB up 45 and hips & knees moderately flexed & knees should be higher than hips for comfort. African American hair- use oil application (not shampooshampoo dries makes hair brittle) Adrenal insufficiency client on Prednisone 5 mg PO bid is going for surgery- MD will: dose of prednisone due to surgical stress.Surgery increases demand for corticosteroids (due to stress, trauma) Physiological jaundice: baby is jaundiced B/C the liver is unable to clear bilirubin from the blood caused by Rh-negative mother and baby is Rh positive also a 2nd pregnancy. Safety precautions for children: Blow nose, with both nostrils open: DO NOT occlude one nostril at a time. Cotton-tipped applications used: only on outer ears-never push inside ears. Never irrigate a foreign object out of an ear, such as a bean, pasta, peanut, or other vegetable. Heroin overdose- client gets Narcan- expect: Tachycardia, HTN due to Opioid withdrawal, nausea, vomiting, restless andabdominal Cramping. 9 month old development (expected): infant sits unsupported; infant pulls himself to standing position & holds on furniture compares two cubes (does not build w/blocks until 12 months). Responds to simple verbal commands-comprehends NO- No! At 9 months. 12 month old development (expected): attempts to build twoblock tower, can say 3-5 words; infant hugs parent upon request at 12 months. Alcohol withdrawal symptoms: Hyper-alert startles easily, and anorexia, increased pulse, anxiety, remorse insomnia, hallucinations. Narcotic withdrawal symptoms: watery eyes, cramps, and tremors. Cannabis withdrawal symptoms: insomnia, hyperactivity and appetite *Malignant Hyperthermia: “I hope they keep the O.R. cool. My grandpa died during Surgery when he got very hot└>genetic predisposition- live-threatening complication of general anesthesia – tachy, Dysrhythmia Tachypnea hyperthermia hypotension, TX: Dantrolene (DonTrium). Client in early labor c/o “not being able to hold my urinenurse should first: check the pH for the fluid (to determine if a fluid is amniotic (Alkaline) or urine (acidic). Normal PTT: 20-45 seconds; PTT therapeutic level: 1.5 -2.5 times control; maximum PTT is 112 seconds. *If PTT is >150 seconds: STOP heparin and notify MD (don’t admin protamine sulfate yet!) Digoxin: with hold med if infant’s heart rate is below 90-110 excessive slowing of beats may indicate digitalis toxicity. *Hepatitis A in a child = most likely s/s of hepatitis A in young children: * ANOREXIA*, malaise, lethargy, easily fatiguing. Prednisone (Deltasone): B/C a steroid should be taken with meals- early morning w/breakfast prednisone causes gastric irritation, ulceration, and w/prednisone! So take w/meals –breakfast in A.M.! Theophylline (Aminophylline): for acute respiratory problemswithhold if: Tachycardia & hypotension and nausea & vomiting and notify physician. Newborn head circumference: average head circumference = 33-35 cm (increased to 4 cm = hydrocephaly, or IICP) Hemophilia clients: (Pediatric clients) most at risk for “crippling knee” – joint deformities”-most frequent site of bleeding (in hemophiliacs) is into joints and muscles- cause changes in bone/joints muscles. *Inhaled chemical takes priority: over swallowed chemical. * CNA collect sputum culture specimen: for C&S, and also check blood glucose** Trifluoperazine (Stelazine) antipsychotic:-excreted in breast milk-breast feeding is CONTRAINTICATED with Stelazine. Indocien (Indomethacn) - use w/ caution w/PVD – Indocin is an NSAID- Risk PVD bleeding! SLE: sun exposure, working in garden, infection, and joint stress are problems, skin of patients w/SLE often has discoid lesions and can become erythematosus on exposure to sunLupus victims should avoid all direct sun exposure: and to lay UV light, tanning beds – immunosuppressed should NOT work w/ impossible to garden/dig. ADHD: “When asked to sit, child wanders in hallway; child looks out window when RN talks to him child repeatedly doesn’t to leave always on the go interrupts often. Chronic renal Failure – diet: lean meat, eggs, fish, poultry, high protein, with CRF (also low Na, Low K+). Cataracts: form due to –as aging lenses of eyes gradually moisture and the lenses density increases. MRI: CONTRINDICATED if suspecting something in his eyes 2 to an MVA maybe metal -esp. if patient c/o “something wrong w/my L eye “Be cautious safety Respiratory syncylial Virus RSV: requires “Contact” precautions -causes bronchiolitis -Private Room w/sleeping accommodations Influenza: =Droplet precautions -w/sleeping accommodations Kawasaki Syndrome: = “Acute Systemic Vasculitis” unknown cause TX: IV immuneglobulin & Salicylates therapy = Standard Precautions 65 year-old & older – most reliable sign of infection: =TACHYCARDIA, TACHYPENA, CONFUSION, (fever may be absent-is absent in 25-30% of clients) “INFECTION IN ELDERLY” (more than 20% of elderly may present w/out any leukocytosis) NGT tube feeding: HOB up 30; warm feeding to RM temperature (RN measures pH aspirate); infuse no less than 30 mins. Clamp proximal end of feeding tube at end of feeding: - prevents air from entering stomach. *Chronic Alcoholic: c/o tremors, confusion & heart is feeling as if its racing -chronic alcohol use is most common cause. -*of Hypomagnesemia (< 1.5 MEq/L) =which may result in Cardiac Arrest. -Cardiac Arrest └> Manifestations: neuromuscular irritability, tremors, tetany, and seizures. *IVF in active Labor= Lactated Ringers Solution: (has electrolytes) even if requesting an epidural for pain! Begin physical assessment while patient is lying in bed: then, ask patient to sit on side of bed, transfer to chair, then observe gait. ** myelomeningocele: (Neonate born w/ this) Place in position: on Abdomen w/face turned to side -prevents pressure onto the sac-like protrussion on his back- pressure would result in IICP or may rupture sac- or meningitis, due to infection -leading to meningitis infection; cover lesion w/most sterile drsg. CHf if pink-tinged sputum:intervene-may be blood/fluid accumulation in lungs. FHR 150-160 at apex of contraction: FHR is 125:returns to baseline at completion of contraction -RN should: continue to monitor FHR: (the above indicates early deceleration- B/C of head compression- this is reassuring fetal heart tone pattern. Ileostomy: measure output from the ileostomy Ileostomy: never use lotions Conversion reaction: = “Repression” defense mechanism -instructive drives & their accompanying anxiety are repressed & converted into a physical symptom. Sulfaslazine (Azulfidine): Sulfonamides used to treat inflammatory bowel disease IBD (e.g. ulcerative Colitis) └> increases fluids to prevent crystallization in the kidney tubules └> may turn urine orange-red, temporarily └> decreases bowel inflammation –take w/food └>diarrhea is common s/sx ulcerative colitis- continue taking Sulfaslazine (Azulfidine) Sulfaslazine (Azulfidine): for IBD Ulcerative Colitis *If IV set delivers 60 drops per minute: drops per minute equals ml per hour Child receiving 40 drips IVF per minute. IV set has drip factor of 60 drops per ml At this rate, how many hours will it take nurse to infuse 400ml? 40 drops/min = 40 ml/hr 400 ml = 10 (10 hrs) 40 ml/hr See First? 19 y/o scheduled for tonsillectomy – not priority 25 y/o scheduled for inguinal hernia repair- stable 32 y/o scheduled for mastoidectomy -chronic ear infection often cause vertigo Priority client due to safety 39 y/o scheduled for removal of nasal polyp –stable client Black Colosh – may cause hypotension when used: in comb w/ antihypertensive drugs (Tenormin) (atenolol) (Metorolol) Dyspareunia (painful intercourse): explore/assess personal menstrual history. **Priority side effect surgery on a 2 month old infant: =“encourage the parents to stroke the infant” – tactile stimulation is imperative for infants emotional development & – stimulate post surgery sedation! Digoxin Toxicity s/sx: confusion & reports of seeing yellow halos around lights – Digoxin toxicity is of great concern in presence of diarrhea (hypokalemia) or attention of elytes. *Lithium toxicity early signs: -Slurred speech, -muscle weakness -N/V diarrhea -thirst, -polyuria expected w/lithium=mild thirst Advanced signs of lithium toxicity = cause hand tremors, in coordination , GI upset, mental confusion Severe toxicity= Ataxia (definition=which is the unsteady and clumsy motion of the limbs or torso due to the failure of the coordination of muscle movements.) Developmental milestones: 13-15 months= walks without help at 13-15. 18 months = builds a tower of 3 to 4 blocks at 18 months 24 months= uses 2 to 3 word sentences at 24 months 30 months= jumps with both feet at 30 months Chronic CNS disorders assoc with alcoholism Korsakoff’s psychosis: assess for “confabulation” or memory disturbance in order to fill in gaps, patient invents elaborate happenings Wernieke’s syndrome: form of dementia related to thaimine deficiency – s/sx: nystagmus , diplopia, confusion, atazia, apathy, disorentation. Polyarterstis nodosa: (inflammation of the small arteries causing diminished blood) └>* tx w/ “cortisone” now results in a 90 % remission rate* **Hyperbilirubinemia- phototherapy lights ( treatment on infant ): s/e (ok) frequent loose stools & increased urine output. *eye patches used – must be adequately placed on infant* -if NOT adequately placed eye ptches: then the jaundice around infant’s eyes will begin to diminish –This is BAD* indicates eye patches ineffective. Phototherapy is considered: total serum bilirubin> 15 mg/dl @ 72 hours of age. Postpartum mother-instructs: Call for assistance first time getting up: ( possible othstatic hypotension) = safety Expect small clots the size of a dime or quarter (normal post delivery): golf ball size clot indicating more than anticipated uterine bleeding/ If dry / cracked nipples: may use Lanolin (emolients) (for breast-feeding mom’s) Apgar Scores: 2 points given for each of the following (in total) (elvaluated at 1 and minutes) 1. heart rate = 2 pts WNL’s 2. color = 2 pts (B/C central color is pink, hands blue) 3. muscle = 2 pts ( B/C moderate flexion of & extremities) 4. Respiratory effect = 2 pts WNL’s 5. Reflex immlablity = 1 pt (B/C slight reponse to foot tap) *10 year-old child SPORTS safety teachings most likely: (NOT water safety; Water safety more for toddler & preschool) (Recreational water safety for adolescents) Ascities management: FIRST administer: Albumin- to pull back fluids into blood vessesl so diuretics can remove excess first. Second administer: spiroaldactone 2 year-old: Provide with finger food, (2 yr working on autonomy- finger foods provide this independence!) Instruction moving Patient: supine position to standing position at left side of bed with walker: (S/P spinal fussion) Focus on using arms, the left elbow as a pivot w/the left hand grasping mattress edge & the right hand pushing on the mattress above the elbow, then slide legs over side of the mattress - This maintains spinal alignment & prevents injury; easy to accomplish spine must be kept straight through out transfeer) - (entire - DO NOT bend knees w/spinal fusion; swinging legs contraindicated Too! - Prenatal Home Visit to a pregnant client – most important for nurse to follow-up /intervene is: a cat is sleeping on the windowsill* (cat= toxoplasmosis RISK to pregnant client & unborn infant) (this “CAT” is even more priorty than throw rugs on the dam floor) *FIRST- determine clients needs * (physical needs FIRST)** Frontal Lobe responsible for: Personality Behavior / voluntary activities Emotions, & Intellect function Parietal Lobe responsible for: Sensation Temporal Lobe responsible for: Auditory Occipital Lobe responsible for: Visual Clozapire (Clozaril) – RISK for Agranulocytosis (check WBC’s) - c/o of sore throat ,cough , fever - have WBC’s checked - (if < 2000 WBCs drug will be D/C’d - Potentially LIFE-THREATENING Atypical antipsychotic side effect: - Leukopenia, - gram-negative - septicemia, - Drowsiness, - Hypotensiton - Tachycardia, - Agranulocytosis Skateboard accident: Assess what FIRST? Head injury is PRIORITY “Did you hit your Head? “NOT”; “Wear you wearing a helmet?” Hypothermia rewarming patient : - Monitor for “ventricular fibillation” (Due to rewarming & myocardial irrtablity) Acyclovir (Zovirax): Take with FOOD: may cause N/V └>Antiviral for Tx: Herpes *ECT: alert physician if client takes Alendronate (Fosamax): used to TX: osteoporosis- place client at risk for ECT report Fosamax to M.D. Strategy: 1 grain= 60mg gri = 60 mg grii = 120 mg grii= 2 grains Administer: Phenobarbital (Luminal) grii PO to a 3 year-old child. Label reads: 160 mg/5 cc How many cc of pheobarbital should nurse administer? 1gr__ = 2gr X = 120 mg 60mg Xmg 160mg = 120 = 600 = 3.75 cc = 3.8 cc 5 cc Xcc 160x Absent “RED REFLEX” in newborn BAD: opthalmic emergency –Light is NOT being:Transmitted to retina and the early suppression of optic nerve fucntion which results from the obsturction of the light causes: blindness -Notify physician immediately. Newborn facial drooping = facial paralysis CN VII (Facial): –occurred in delivary –usually resolves with in few days to 3 weeks -can be permanent Acute Phase of Cerebrovascular Accident-positon client: Supine w/head of bed elevated 15-30 degrees (-facilitates venous drainage from brain; ICP,keeps head midline) Here you go somemore facts: LTB diagnosis Laryngotracheobronchitis: Inspiratory stridor and restlessness Fear of heights = projection and displacement 8 weeks gestation and test positive for VDRL = Must instruct client the importance of penicillin for the prescribed time Note:The renal threshold for glucose is elevated in elderly Ultrasound detects: gestational age Amniocentesis: determines spinal cord problems and blood problems Head lice: must instruct to repeat shampoo in 7 to 10 days For patient with mental retardation: – Must assess level and determine client’s comprehension. Early signs and symptoms of preclampsia: Facial swelling and Proteinuria Most likely to observe in IV drug users: Cellulitis With a CVA nurse can only prevent: corneal abrasion With A CVA Nurse CAN Not prevent: inability to talk, loss of gag reflex or open affected eye. Play 4 year old : associative play Infant: solitary play Toddler: parallel play = toddler Addisonian crisis:restlessness and rapid weak pulse Fundus location : umbilicus for palpation in 4th stage of labor Post – Op patient of cataract surgery: you would caution the patient from sudden movements and bending over due to causes pressure on suture lines. Alcohol problems: Tremors increased temp. nocturnal leg cramps complaints of joint pain Dwarfism: Delicate features (appear younger then chronological age) Rocephin (cephalosporin): Most important for nurse to monitor, The surface of tongue (Hairy tongue) Note: Black Hairy Hairy tongue (lingua villosa) is a common condition caused by defective desquamation results from a variety of precipitating factors. Some of these factors include poor oral hygiene, tooth loss (because a soft diet does not allow for normal desquamation from rough food scraping the tongue), chronic or extensive use of antibiotics, and radiation treatments to the head and neck. Patients with hairy tongue are more often than not coffee or tea drinkers and often use tobacco. Read More: http://en.wikipedia.org/wiki/Hairy_tongue Hypothyroidism: should avoid narcotic sedatives Clomid (Clomiphene) medication (fertility drug): – induces ovulation by changing hormonal effects on ovary. Naprosyn (naproxen)– NSAID (anti-inflammatory): Nurse should assess: for fluid retention and dizziness Cortisol Converts: protein and fat into glucose and also an antiinflammatory agent Note:Cortisol is a steroid hormone released from the adrenal cortex in response to a hormone called ACTH (produced by the pituitary gland). It is usually referred to as the "stress hormone" as it is involved in response to stress 6. It increases blood pressure and blood sugar, and reduces immune responses. Read More:http://en.wikipedia.org/wiki/Cortisol Calan medication: Nurse should check patient’s heart rate Note: Calan (verapamil) (calcium channel blocker) indicated to treat supraventricular tachycardias. Breast feeding mother should increase her calorie intake: by 500 calories per day. Note: The fluid in water seal chamber doesn’t fluctuate with respiration = this indicates no more air leaking into pleural space. 3 month old scheduled for barium swallow: = Should be NPO 3 hours prior to the procedure. Note: When preparing for cholesterol screening only sip water for 12 hours are permitted for 12 hours before plasma cholesterol screening to achieve accurate results Toddler with lead poisoning: The fluid to be encouraged when given a choice of water, fruit punch, orange juice and milk. **Milk due to vit – D which optimized deposition of lead in long bones. Second stage after denial is Anger: 1st stage= Denial 2nd stage= Anger 3rd stage = bargaining, 4th stage = Depression 5th stage = acceptance Intravenous pyelogram (IVP): Able to examine the urinary tract by x-ray. Evaluates the kidney function. Nephrotic syndrome: = client teaching for diet is = adequate protein and low sodium. Colostomy: Needs to be irrigated at the same time everyday. Prior to sending client for cardiac cauterization: = Most important to report if client has an allergy to shellfish Note: Iodine is uesed. – This will avoid anaphylactic shock during procedure. A few more facts for today: SCI Spinal Cord Injury– assessment findings are – Sever pounding headache, profuse nasal congestion and Piloerection(Goose Flesh) NOTE: Piloerection:Erection of the hair of the skin. When caring for a child with RSV Respiratory syncytial virus – Gown and gloves need to be on. S/SX: resemble the common cold. However, RSV infection can also result in pneumonia, especially in the very young, the very old or those with weakened immune systems. Symptoms generally begin four to six days after exposure. Symptoms generally develop slowly over a period of several days. The contagious period is usually less than 10 days after symptoms begin, but occasionally is longer. Note: Respiratory syncytial virus is a respiratory illness caused by a virus. It is spread through contact with droplets from the nose and throat of infected people when they cough and sneeze. RSV can also spread through dried respiratory secretions on bedclothes and similar items. Amniocentesis – Detects blood disorders such as hemolytic disease Hemolytic reactions – Hypotension, low back pain, and fever Graves Disease – Nurse expects weight loss 10 in 3 weeks, also restless, heat intolerance, reflexes hyperactive. Reminiscing Group – provides an environment for social interaction and companionship Hypocalcemia – Positive for troussear’s sign Hypercalcemia – Constipation, depressed reflex, decreased muscle strength. Radium implant – Most important to chart, date, and time of removal with total time of implant treatment Miller Abbott Tube – Reason to remove fluid and gas from small intestines – provides for intestinal decomporssion, intestinal tube is often used for treatment of paralytic ileus. PKU test – (Phenyiketonuria) – specimen should be collected as close to discharge as possible but not after 7 days. A common reaction of a husband of a rape victim – Emotionally distressed and needing assistance FAS – (fetal alcohol syndrome) of a newborn – Replace vitamins, depleted – Note: adequate intake of vit-B complex is necessary for normal CNS function Addison’s Disease – Darker skin that is more pigmented Best to start toilet training at 20 months TURP – continuous irrigation is used to enable urine to keep flowing TPN– discontinued abruptly – results in hypoglycemia – S/SX: are diaphoresis, confusion, and tachycardia. RML – right middle lobe of lung to auscultate – Right anterior chest between 4th and 6th intercostals. Note: Can Not auscultate the RML from the posterior. Myasthenia Gravis – Client has increased muscle fatigue so nurse needs to assess muscle groups towards the end of the day. Meniere’s syndrome – Nurse stands directly in front of patient so – client doesn’t have to move or turn head to see nurse. Decreasing movement of head decreases vertigo attacks. MRI– Takes approx. 90 minutes with no discomfort and no dye is used for this procedure IVP – (pyelography) – Nurse should contact physician if client state that they are on Metformin (Glucophage) – Note: this should be discontinued 48 hours prior to procedure due to contrast media can cause life threatening lactic acidosis. Patient refusing cancer meds – require an RN due to assessment skills needed for this patient – should not be deligated. Narcan – short half life and may need to be repeated in 2 to 3 minutes. Normal Lab Values K+ - 3.5 to 5.0 Ca+ - 4.5 to 5.3 AST (SGOT) – 8 – 20 U/L ALT (SGPT) – 8 – 20 U/L PT – 11 to 15 seconds Hgb – males 13.5 – 17.5 females 12.1 – 16.0 BUN – 10 20 Creatine – 0.6 – 1.2 WBC – 5,000 – 10,000 per MM3 Iron needs – * women 15 mg per day : 1,200 – 1,500 Kcal Cushing's Syndrome= overproduction of cortisol hormone produced in the adrenal cortex which is part of the adrenal glands which sit on top of the kidneys. Signs: 1) high blood sugar---makes the patient prone to infections 2) sodium increase---fluid retention---elevated blood pressure 3) watch for Potassium which tends to decrease---heart arrhythmias 4) fat face due to fluid retention 5)truncal obesity 6)buffalo hump (fat accumulation on the back of the neck) 7) exosthalmus ( eyes look "bug out") due to increase level of cortisol 8) extremities appear thin, presence of muscle wasting, leg sores that do not heal Note this patient is not a good candidate for steroids in general people with high blood sugar as in diabetic are definitely not good candidates for steroids...but patient need a good antiinflammatory such as a steroids are known to be. Therefore, if this patient has to on steroids(cortisone0 please watch for side effects of steroids which are: a) increase blood sugar---remember this patient has high blood sugar to begin with as a result of an increased level of cortisol b) increased risk for infection c) increased edema This patient is going to need emotional support for this disease changes the persons appearance negatively. Addison Disease= Decreased production of cortisol. Signs: 1) craving salt---low sodium level, so the patient craves salty foods 2) hyponatremia---watch for low blood pressure 3) hypoglycemia---complains of weakness, tired all the time, low energy this lack of energy is the most insidious in times of stress 4) anorexia, nausea, vomiting, diarrhea 5) as sodium is low, so is water---remember water follows sodium, so the patient is seriously dehydrated 6) weight loss---remember, anorexia, the reason for the weight loss 7) skin turned bronzed---due to increased levels melanocite stimulating hormone(MSH) TX: coticorsteroids---avoid Addisonian Crisis which would be precipitated by a mayor stressor such as adrenal insufficiency Signs of Addsinian Crisis: 1) profound weakness---cannot get out of bed-no energy for that 2) severe abdominal, back and leg pain 3) high fever---hypothermia 4) peripheral vascular collapse 5) renal failure must have a muscle strengthening medication Prostigmin or Mestilon on time. Sx: 1) dropping eyelids---difficulty moving her face muscles, this patient cannot even open his/her eyes 2) patient does not have sensory deficit, no loss of reflexes or muscle atrophy---the patient can feel but has a hard time moving the muscles needed to move around even to take in a breath of air Note: Time is of the essence with this kind of patient. Myasthenia Gravis is a progressive disease caused by failure in the transmission of nerve impulses by a neurotransmitter called acetylcholine. If there is no acetylcholine there is no muscle movement remember we use the muscle of the diaphragm for respiration: no acetylcholine we die for we cannot breathe! This disease is very serious, and on top of that it is tricky. We need to learn to recognize the difference between a cholinergic crisis (too much acetylcholine circulating) versus myasthenic crisis ( no acetylcholine at all--I told you what that means for the poor patient) Tensilon is a drug with a short half life that will strenghten muscle weakness if the patient is having an myasthenic crisis. If the patient is having a cholinergic crisis Tensilon would do nothing, but it is a good diagnostic tool for figuring out fast what's wrong with the patient. Management of Myastenia Gravis: 1) Do not allow the patient to exercise or get an infection of any kind. 2) Must administer medications on time otherwise the patient will end up hooked to a ventilator 3) Must avoid sedatives, tranquilizers, muscle relaxants ( no, kidding...) which cause respiratory depression 4) During a myasthenic crisis do not give to the patient anything to eat or drink ---high risk for aspiration--5) after the crisis assess, assess, assess--ability to swallow and if the patient has improved give a soft diet easy to swallow. feliz3 must have a muscle strengthening medication Prostigmin or Mestilon on time. Sx: 1) dropping eyelids---difficulty moving her face muscles, this patient cannot even open his/her eyes 2) patient does not have sensory deficit, no loss of reflexes or muscle atrophy---the patient can feel but has a hard time moving the muscles needed to move around even to take in a breath of air Note: Time is of the essence with this kind of patient. Myasthenia Gravis is a progressive disease caused by failure in the transmission of nerve impulses by a neurotransmitter called acetylcholine. If there is no acetylcholine there is no muscle movement remember we use the muscle of the diaphragm for respiration: no acetylcholine we die for we cannot breathe! This disease is very serious, and on top of that it is tricky. We need to learn to recognize the difference between a cholinergic crisis (too much acetylcholine circulating) versus myasthenic crisis ( no acetylcholine at all--I told you what that means for the poor patient) Tensilon is a drug with a short half life that will strenghten muscle weakness if the patient is having an myasthenic crisis. If the patient is having a cholinergic crisis Tensilon would do nothing, but it is a good diagnostic tool for figuring out fast what's wrong with the patient. Management of Myastenia Gravis: 1) Do not allow the patient to exercise or get an infection of any kind. 2) Must administer medications on time otherwise the patient will end up hooked to a ventilator 3) Must avoid sedatives, tranquilizers, muscle relaxants ( no, kidding...) which cause respiratory depression 4) During a myasthenic crisis do not give to the patient anything to eat or drink ---high risk for aspiration--5) after the crisis assess, assess, assess--ability to swallow and if the patient has improved give a soft diet easy to swallow. feliz3 I added RSV to the droplet precautions, now making the SPIDERMAN look like this: DROPLET (CONTACT +) think of SPIDERMAN! (having a runny nose) (4 Ss, 5 Ps & 3 Ms) (The spider DROPS from the ceiling) S - Scarlet fever S - Sepsis S - Streptococcal pharyngitis S – Streptococcus, group A P – Parainfluenza P - Parvovirus B19 P - Pertussis (whooping cough) P – Pneumonia (Haemophilus influenzae) P – Pneumonic plague I - Influenza D - Diptheria (pharyngeal) E – Epiglottitis due to H. influenzae R – Respiratory Syncytial Virus (RSV) R - Rubella M - Mumps M – Meningitis, bacterial M - Mycoplasma or meningeal pneumonia An – Adenovirus And, according to the CDC website regarding varicella, it should have airborne precautions, at least until the vesicles have crusts, so now that makes VCHIP change to CHIPS: * Skin Infections: CHIPS C - Cutaneous diptheria H - Herpes simplex I – Impetigo (ok to care by pregnant nurse, need to wear gloves and gowns) P - Pediculosis S - Scabies, Staphylococcus And here's the Standard & Airborne. Please correct me if you see anything not up to par! STANDARD: Localized Herpes Zoster (cold sore) Standard Lyme disease (caused by ticks) Standard AIRBORNE: (Starv) Avian influenza Airborne, Contact & Droplet (including N95 respirator) Rubeola (measles) Airborne Sars Airborne, Contact, Droplet Smallpox Airborne, Contact, Droplet Tuberculosis Airborne Varicella (chickenpox) Airborne Varicella zoster (herpes zoster, shingles) Airborne Vesicular rash (at first) Airborne S = SARS, smallpox (airborner, contact, droplet) T = Tuberculosis A = Avian influenza (airborne, contact, droplet) R = Rubeola V = Varicella (chickenpox), varicella zoster (shingles); vesicular rash (to begin with -- until vesicles heal over) Trendlenburg Test: Used with patients who may have varicose veins. Imipramine (Tofranil) Tricyclic antidepressant Nurse Should -teach a patient to report: S/E: of sore throat, fever, increased fatigue, vomit and diarrhea. POC: Having a pt. turn cough and deep breath Q2H – Promotes ventilation and prevents respiratory acidosis. Type 1 diabetic: When providing good foot care includes having feet measured everytime you buy new shoes Note: feet enlarge with age. After cast is placed on a preschool child action the nurse should take next is to elevate arm on two pillows. Note: (this minimizes swelling) Cystic Fibrosis: Diet: -should be high in protein and calories and low in fat. A cleansing enema is usually ordered before: an IVP. Pyelogram When going down stairs: – lead with crutches and bad leg followed by the good. When going up stairs: –lead with good leg and follow with crutches and bad leg. **remember good girls go up to heaven & **bad girls go down to Infant not interested in nursing: either from the mother or formula. The nursing diagnosis in this case is -Fluid volume deficit Note: failure to thrive is a medical diagnosis. Hiatal hernia - classic symptoms / associated with reflux. Ex: complaints of awakening at night with hearburn. AIMS – (abnormal involuntary movement scale) – examination to test for tardive dyskinesia. IBS – irritable bowel syndrome – Pattern alternates from diarrhea to constipation. AKA – above the knee amputation – with an immediate prosthetic fitting it is most important for the nurse to provide cast care on affected extremity. Note: case applied to provide uniform compression, prevent pain and contractures. Appropriate Play for a 5 y/o. – Talk on phone imitating father. Rheumatoid arthritis – When inflammation is sever, decrease the number of repetitions when exercising. Tetracycline (anti infectives): –use max protection sunscreen when out doors and -never take with milk or antacids. -Should take with a full glass of water -1 hr before meals or 2 hrs after. Cushings Syndrome: –signs and symptoms include: -Buffalo hump, -hyperglycemia, -hypernatremia. AKA – above the knee amputation -an indication of infection are complains of: -persistent pain at the operation site. (characteristics of inflammation and infection) Mechanism of conversion – Pt. says: -“Unable to take final because unable to write” –coverts anxiety into physical symptoms. Obsessive Compulsive Disorder – Rituals are to avoid sever levels of anxiety. Note: attempt to avoid or alleviate increasing levels of anxiety. Guillain Barre: –S&S are: -Respiratory failure, -flaccid paralysis, -urinary retention. Note: Early fetal decelerations are usually a normal sign. Myelogram – Test involves: -a lumbar puncture with injection of contrast medium, -allowing x-ray visualization of vertebral canal. Tracheotomy Cuff: -seals trachea and -helps prevent aspiration. Note: an unexpected affect of ECT: -is a backache. Confusion and disorientation is an expected outcome. Babinski Reflex – should be present at 9 months. -This reflex disappears after 1 year of age. Acute Hypoparathyroidism – Most important for nurse to have is a tracheotomy set. 48 hours post-op hernia repair – Findings that indicate possible complication – incision line is red. Note: the incision line should be pink, -other BAD indications would be warmth and tenderness, pain, purulent or odorous drainage. Continuous Tube feedings (around the clock) – Rinse bag and change every 4 hours – Note: there is an increase in microorganisms. 32 week gestation 4 lb 10oz: -baby with mottling, -acrocyanosis -irregular respiration 60 indicates –cold stress. Here is my last one for today... Burns: Clothing should be removed and they should be wrapped in a clean sheet. This is best to prevent infections. Note: should never apply soap or ointments with 2nd or 3rd degree burns. DPat – Immuzation shot: -Low grade fever appears within the first 48 hours. Trilafon medication (perphenazien) – (antipsychotic) –Client on this drug now displays: -head turned side -neck arched at an angle -stiffness -muscle spasms Nurse should expect to give Aiperiden (akineton) (Antiparkinson agent) -used to counteract extra pyramidal side effects. Alcohol Withdrawls – Steadily increasing vitals with a client withdrawing from alcohol is a sign that d.t.’s (Delirium Tremens) are approaching, can be avoided with additional sedation. Bronchoscopy – Client recovering from bronchoscopy should be positioned in semi-fowler’s position. -Check vitals Q15 min. until stable. –Assess for respiration difficulties like stridor -dyspnea results from laryngeal edema -laryngospasm Ketoconazole (nizoral) – 200mg daily – drug of choice to treat candidiasis. Hyponatremia s/s – H/A apprehension and -lethargy -muscle twitching -convulsions -diarrhea finger printing of skin. Haldol s/sx –include galactorrhea lactation (excessive or spontaneous flow of milk) -gynecomastia – (excessive growth of male mammary glands Note: must explain to the client that it’s S/E of haldol. Antiembolism stockings – should be worn the entire hospital stay only removed for baths and replaced after skin is dry. MS pt. –39 weeks gestating with -BP 127/72 -pulse 72 -cervix 4 cm -FHT 124. -Nurse should anticipate reduction in amount of pain medication to a MS pt. Note: there is an overall decrease in pain perception due to Multiple Sclerosis. Lumbar Puncture – To confirm meningitis in a child most important action by the nurse: -is to restrain the child. Note:This prevents trauma during the procedure. Priority – Client admitted for a CVA whose prescription for warfarin Coumadin expired 2 days ago takes priority over -immuno-suppressed patients. Note: Possible recurence of a stroke. Salem sump NG tube – HOB elevated 60 to 90 degrees. (gravity is used to help with placing this tube.) SLE – should be in remission for at least 5 months prior to trying to conceive. Kussmaul Respiration – A sign of hyperglycemia Diaphoresis and trembling – A sign of hypoglycemia Informed Consent – From either divorced parent is sufficient. Resp Rate of 8 – is too low. If morphine was adminstered. -This sign should necessitate a nurse to administer Narcan immediately – Respiratory Depression Child poisoned with – lighter fluid: –should induce vomiting. However vomiting is contraindicated: with ingestion of hydrocarbons due to danger of aspiration. Manic Patient – During meal time if patient is in seclusion – they should be kept in seclusion and the meal served while remaining in seclusion for safety. Aseptic Techniques (sterile) – with 50% burn over body due to high risk for infection. Diabetes – When morning self-monitoring of blood glucose (SMBG) reading shows 214 and 230 and the patient is on regular and NPH insulin. -Best action by the nurse: is to adjust NPH by increasing it 3 units. Never want to eliminate evening snacks completely, only adjust and encourage exercise is good. Compazine (prochlorperazine) (anxiolytic) – should be considered incompatible in a syringe with all other medications. Nutritional Status – Best indicator is albumin levels 4.09/dl. Note: weigh gain could be ascites. Sickle Cell Crisis – Adequate hydration is a priority with sickle cell crisis. Billroth 1 – Note: After gastrectomy and vagotomy planning discharge have client avoid large meals high in simple sugars. To avoid dumping syndrome. Glipizide (glucotrol) (antidiabetics)– Is effective for diabetics who produce minimal amounts of insulin. Hemophilia A – Best medication for a child with Hemophilia A =codeine Phosphate (paveral)(Therapeutic) NOTE: Assess Blood pressure, pulse, RR- assess level of sedation Terbutaline (brethine) (bronchodilator) – Should be withheld with heart rate 144. Note: S/E of this med is tachy, nervousness, tremors, H/A, possible pulmonary edema. Hep A – 18 month old with hep A: -contact precaution -child is placed in a private room. Haldol Decanoate (Haloperidol)(antipycotic) –Should be given in deep large muscle mass with 2” needle 21 gauge – single dose. NOTE: Patient should lie in recumbent position for 1 hour after administration of this drug. PVC’s – Lidocaine (Antiarrhythmic Agent) is the drug of choice for PVC’s or for consecutive PVC’s. Note: it is unexpected for a 3 month old to grasp a toy just out of reach – unexpected until 6 months of age. Gout Pain – Encourage weight bearing while ambulating. Note: that ROM may aggravate pain HIV – Newborn of an HIV+ mother admitted to the nursery should include (Standard precaution) in POC. S&S of post infusion phlebitis – reddened area -red streaks at the site Addison’s disease – Most important for nurse to instruct: -steroid replacement HX of oliguria: -HTN -periph. Edema (with bun 25) -Nurse should restrict protein in patient’s diet. Cranial Nerve # 7 – Facial Nerve: -provides motor activity to facial muscle. Ex: crooked smile nurse should assess #7. Priority – During discharge with a client with HIV taking AZT (Azidothymidine zidovudine) (Nucleoside reverse transcriptase inhibitor) at home Nurse writes a schedule of when the medicine should be taken planning and written is more effective for adherence to time frame. POC for client - on bed rest to promote evening rest and sleep the most important is to = encourage daytime activities. Colon Surgery – An appropriate action to take with a client returning from colon surgery: -is to ask the client to lift his head off the pillow –This assesses if there is remaining effects of neuromuscular blocking agents Note: may block ability to breathe deeply. Penrose Drain – when changing dressing on incision remove one layer at a time (to avoid dislodging drain) Developmental Stage of a 40 y/o – Starts to measure life accomplishments with goals. Note: Sterile = Aseptic Clean = Antiseptic Rheumatoid Arthritis – Most important is: -assist client with heat application -ROM exercise Note: This reduces swelling, increases circulation, diminishes stiffness while preserving joint mobility. MYXEDEMA – There is a slowing of all body functions. Note: Decreased Temperature would be revealed. Esophageal Speech – Client swallows air and then eructates it while forming words with his mouth. Increased ICP – 4 month old with increased ICP -High pitched cry. Findings – find a 2 year old with: -FX femur -several lacerations -bruises of unexpected origin Report finding to CPS. Reduced oxygen level- Symptoms that indicate reduction of O2 levels –Ex: BP 150/90, pulse 90 -pulling of NG tubing -picking at bed covers Ewald Tube – Is large, orogastric tube -designed for rapid lavage: Note: insertion often causes gagging and vomiting, suction equipment must be available. Oxytocin (Pitocin) (misc OB/GYN Agents) – Important for safe administration of oxytocin = Palpate the uterus frequently. Narcotic – With drawl is very much like the flu. -Runny nose -yawning -fever -muscle and joint pain -diarrhea. Battery – Harmful or offensive touching Here is my send for today.. Flaccid Bladder – You want to produce -acid urine to minimize risk of UTI. - produce acid urine: -prune -cranberry -tomato juices produce alkaline urine: -Milk -lemonade produce Hep B – Vaccines additional injections at -one month -six month Baseline Data – must be collected to design an effective behavior modification program. Parlodel (bromocriptine) (Antiparkinson Agent) administration: – Should be taken with meals to decrease GI upset. Post op – Abdominal surgery low fowlers position 15 degrees takes pressure off of suture line. Pressure ulcers S&S – Blanching or hyperemia that doesn’t disappear is a warning sign for pressure ulcers Late decelerations – Stop infusion of pitocin(Oxytocin)(misc OB/GYN Agents) Abdominal Surgery – with complaints of left leg dull aches Nursing Intervention: – elevate extremities to promote venous return and -decrease venous pressure to relieve pain and edema. Systematic Desensitization: Note:Phobias are a learned response and the goal is to eradicate the phobic response by replacing with relaxation responses by using muscle relaxation techniques with it. (Guided imagery) Detached Retina – Classic signs are: -bright flashes of light -client stating that protions of visual field is dark Impetigo – with a child the nurses 1st priority: -is to notify the child’s parents first. Infant with samonella: –Priority is contact precausion 1st to prevent transmission. -Then other implementations can be performed. Note: - Magnesium Sulfate (IV) (Mineral and electrolyte replacement/supplements) can cause: -slowing of the respiratory rate in an infant and hyporeflexia. -The normal resp. rate for an infant is 30 – 60 per min. -So 18 respiration indicates a problem. Doxepin hydrochloride (Sinequan)(antianxiety agent, Antidepressant) - Is an antidepressant, - signs of overdose include: - -excitability - -tremors Child age 7: – Periods of shyness are to be expected -nightmares are frequently experienced at this age Decreased RBC – s/sx: -Fatigue -pallor -exertional dyspnea Rheumatic Fever – Is the most common cause of mitral valve problems. Ex: mitral stenosis. Paracentesis – Most important Nurse Intervention in preparing a client for this procedure to to have them void just before the procedure. Swan Ganz – Indirectly measures pressure in the ventricles. Note: CVP reading measure the pressure in the R ventricles. The Swan Ganz catheter measures the Pulmonary Artery wedge pressure which is an indirect reading of the pressure in the L ventricle. Trigeminal Neuralgia – (Tic Douloureux) – The nursing care should be directed toward preventing stimuli to the area and decreasing pain – Ex: eat soft warm foods. DIC – Disseminated intravascular coagulation (DIC) - There is oozing blood from the venipuncture site and abdominal incision. Note: DIC is an acquired clotting disorder from overstimulation, prolonged oozing from sites of minor trauma first symptom. Lecithin Sphingomyelin (L/S) ratio = 3:1. – With a 33 week gestation - Nurse anticipates c-section delivery due to lungs adequately mature there is no need to postpone delivery and csection is preferred with preterm infants. Diabetes Type 1 – Client states “ I have a quivering feeling in my stomach” is given priority due to the fact that this is a sign of hypoglycemia. Hypoglycemia signs also include: -tachycardia -cold clammy -skin, -weakness -pallor Nurse: Check BS -offer milk. Abdominal Abscess – Drain inserted: – Assessment that is best made by nurse to report is the character of the drainage – Ex: purulent or otherwise major priority over amount and consistency. Appendectomy – Following surgery nurse notices large amount of serosanguineous drainage on dressing. Most important for the nurse to obtain is: -“Was tissue drain placed during surgery” –This is frequently done during surgery to prevent accumulation in wound, Dressing should be reinforced. Third trimester of pregnancy – Nurse most concerned with: -epigastric pain –Indicates impeding convulsion -takes precedence over SOB because this is expected. Pyloric stenosis – 4 week old – The statement expected from the mother is “My son is fussy and hungry all the time. Baby becomes lethargic, dehydrated, and malnourished. Tagamet – (cimetidine) (anti ulcer agent) – An indication that further teaching is necessary if client’s statement is “ My stool may change color while I’m on this medication”. Note: no change in stool color with cimetidine. Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate but no stool color change. Mononucleosis – S&S include -sore throat, flu-like symptoms for the previous 2 weeks and physical exam reveals enlarged lymph nodes. -Advise family not to share drinking glass or silverware with anybody. Note: Mono is spread by direct contact avoid contact with cups and silverware for about 3 months. Bulimic – Most therapeutic to analyze a bulimic client’s eating habits and the circumstances that precipitate the client’s eating problems – Note: assigning a Thought Feelings Action (TFA) journal relating to client’s eating behaviors will be most helpful to the nurse and therapeutic to the client. Bacterial Meningitis – Mother is afraid of perminant brain damage of her child. Most therapeutic communication is : “ It is unlikely possibility, but if your child doesn’t develop normally, your pediatrician will help you with any problems”. Note: Bacterial Meningitis If treated early, good prognosis: may be complications and long term effects (seizure disorders, hydrocephalus, impaired intelligence, visual and hearing defects). Herniorrhaphy – Most important one hour before is confirm that the consent form has been signed. Note: surgical consent should be rechecked before going to surgery. Note: Assessment for allergies should be done earlier then 1 hour before surgery. Addison’s Disease – Increased salt should be increased during periods of stress. Note: with decrease in aldosterone, there is an increased excretion of sodium: sodium intake should be increased. Note:The nurse should be concerned with auscultating an S3 ventricular gallop on a 78 year old woman. Note: ventricular gallop is an early sign of Heart Failure (HF). Note: Teaching is effective with a PCA pump when client says” If I start itching I need to call you” Note: itching is a common side effect of narcotics used in PCA pain management. Thorazine (Chlorpromazine) (Antipsychotic)–Client should report if they have difficulty urinating. Note: dry mouth, weight gain and constipation can be resolved at home. Difficulty with urination can become a severe health problem unless treated. Digoxin (lanoxin) (antiarrhythimics) -Theraputic level is 0.5 –2.0. If blood level comes back 2.0. **Medication should be held and physician notified. Pleur evac –Fluid in the water seal chamber does not fluctuate, indicates re-expansion of lung. And x-ray will confirm this. Glasgow coma scale –5 indicates coma, client requires frequent assessment. Note: After MI the most common complication following is dysrhythmia, with ventricular types being the most serious. Cholecystectomy –Expected drainage is 500-1000 ml/day, However complaints of sever abdominal pain after surgery could indicate peritonitis or wound infection Colonoscopopy– Note:All activities that the client participated in before the colostomy may be resumed after appropriate healing of the stoma or incisions. 3 year old –When assisting a parent on foods it is best to allow finger foods for this age group. Note: Child is going through autonomy versus shame and doubt stage -finger foods allow child the necessary independence for this stage. Note: Distended abdomen with splenomegaly – Possibility of internal bleeding, life-threatening situation Acute asthma attack – Most concerned if patient’s respiration rate increases from 86 to 100 beats per minute. Note: pulse increase is due to decrease in oxygenation of tissues. Note: pallor is unreliable indicator of deterioration of status. Demerol 100 mg PO q4h (meperidine)(opioid analgesics) – Without much relief. Valid suggestion for the nurse to make to the physician regarding pain medication – Administer medication Q4 around the clock. Note: around the clock (ATC) administration of analgesics is more effective in maintaining blood levels to alleviate the pain associated with cancer. Elderly with dementia – When planning care it is best to speak slowly in a face to face position. Note: providing flexibility leads to confusion schedules need to be routine. Note: Propranolol (Inderal) (antianginals, antiarrhythmics) decreases the effectiveness of atorvastatin. (Lipitor) (lipid-lowering agents) Note: patient on lipitor and the following statement made by client should be told to the physician “ I take Inderal. Droplet precausion – A child with pertussis. Note: bronchitis is the inflammation of large airway, standard precautions., Tonsillitis standard precaution. Total hip replacement – Most important for the nurse to apply thigh high TED hose to promote venous return. Note: use of antiembolic hose and or sequential compression devices decreases venous stasis and reduces risk of thrombus formation. Hip fracture with Buck’s traction – Most important action by the nurse is to turn the client every 2 hours to the unaffected side. Immobility is the leading cause of problems with Buck’s traction, Important to turn client to unaffected side. Reflux – With infant should be maintained in an upright position: HOB should be raised at a 30 degree angle. After an appendectomy. – Patient complains of pain. After administering analgesics the following action should be to elevate the HOB 30 to 45 degrees. Note: This would reduce stress on suture line and provide for comfort. Lumbar puncture (LP) - Best to prepare a 5 year old is to - Do a mock run-through of the procedure. Note: Excellent method to use with a child because it incorporates actually “Feeling:” many aspects of the procedure as they are explained. Parathyroidectomy – Should be concerned with a client eating quantities of food from which of the following food groups – Milk products Note: Low calcium diet is recommended preoperatively. -Diet should be high in phosphorus and low in calcium. Thermal injury – Most concerned with: -Increased respiratory rate -decrease BP. Note: May indicate burn wound sepsis, a life threatening complications of thermal injury. Elderly Client – Drinks plenty of fluids however has a diet that consists of starch. He lives alone with a limited income – Most important to increase protein intake. Note: Protein is needed to slow down the degeneration process of aging. Test positive for tuberculosis: –Client placed on isoniazid (INH) 4 weeks ago. -Nurse is most concered if client has fatigue and dark urine. Note: This is an initial indications of hepatic dysfunction. Dx with schizophrenia – Becomes increasingly withdrawn to point of mutism. Most important action is to - Sit with client for brief period of time. Note: nurse should maintain contact with client but not make demands to communicate or participate in activities. Wet to dry – dressing for a client of an infected abdominal incision. The nurse should intervene if client’s spouse wets the old dressing with sterile saline before removing it. Note: it is contraindicated – dressing should be removed dry so wound debris and necrotic tissue are removed with old dressing. Spina bifida – Of an 2 day old infant in for surgery repair. Mother is concerned that infant would be confined to a wheelchair. Best statement by nurse – “ The corrective surgery will not change your child’s physical disability” Note: Spinal nerves that are destroyed by the myelomeningocele cannot be corrected: nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele. Electrical burns – Note: electrical burn injuries are typically more injurious to underlying tissue, such as nerve and vascular tissue, which require complex and timely treatment. Child of 5 years old – with Closed head injury – Best action is to assess orientation to person, place and time every hour. *Early signs of increased ICP are alterations in orientation. Cystic Fibrosis – Statement that indicates parental understanding about the cause of their newborn’s diagnosis of CF – “ Both of us carry a recessive trait for cystic fibrosis. Note: cystic fibrosis is inherited by an autosomal recessive trait. Right sprained ankle – Learning to walk with a cane. Nurse should be positioned by standing on the client’s left side and slightly behind the client. Note: Stand slightly behind client on strong side. Note:If resistance is met with trying to flush diluted heparin into a subclavian triple lumen catheter. Action nurse should take is to secure the lumen with a luer - lock cap and notify the physician. Note: streptokinase (Streptase,or Kabbikinase) (thrombolytics) may be used to dissolve clot. If unsuccessful, lumen is labeled as clotted off. Administration of medication to a 4 month old – Most appropriate is to place the medication in an empty nipple and allow the infant to suck. Note: never add to child’s formula feeding. Note: Nurse should verify the order with a physician about IM injection of Demerol for pain to a client receiving thrombolytic therapy. Note: bleeding can occur with IM injections. Note:Douching makes Pap smear inaccurate. Have client avoid douching for 24 hours. Medication contraindicated – For a patient with hemophilia A = Oxycodone terephthalate (percodan)(equals oxycodone and aspirin) (opioid analgesics) – Contraindicated for persons with bleeding disorder, contains aspirin. Patient with sickle cell crisis with an infiltrated IV – Is a priority due to IV fluids are critical to reduce clotting and pain Questions about peak expiratory flow are in connection with mechanical ventilation, but before discussing that subject, I want to post facts about lung sounds and where to locate them when using the stethoscope. Types of breaths sounds and their location: 1) Bronchial---------------------- trachea and larynx tracheal, tubular (other names for the same sounds) 2) Broncovesicular--------------- over the major bronchi 3) Vesicular --------------------over the peripheral lung fields where air enters the bronchi If you read a question describing broncovesicular sounds, now you know which area of the lungs the question is talking about. Tracheal breath sounds high-pitched, loud, harsh, hollow sounding, equal on inspiration and expiration. Bronchial breath sounds High-pitched, blowing, muffled, expiratory sound slightly longer than inspiratory. Broncovesicular breath sounds louder and harsher than vesicular sounds, muffled vesicular sound combined with with loud guttural sound, equal on inspiration and expiration. Vesicular breath sounds soft and low-pitched, rustling or breezy, three times longer on inspiration than expiration. Mechanical ventilation: Tidal volume=the volume of air the patient receives with each breath, that will be determined by the doctor and the ventilator would be set according to his orders. Fraction of inspired oxygen(FiO2)= O2 concentration delivered to the patient which is determined by the patient's condition and arterial blood gases (ABGs). Rate=number of ventilator breath delivered per minute. Sighs= volumes of airthat are 1.5 to 2 times the set tidal volume. The sighs are delivered 6-10 times per hour. Sighs may be used to prevent atelectasis (collapsed, airless lung). Peak Airway Inspiratory Airway Pressure= the pressure needed for the ventilator to deliver a set tidal volume at a given compliance (the elasticity, extensibility and distensibility of the lungs and the thoracic structures) Causes of Ventilator Alarm: Note: Assess your patient first and the ventilator second. High-Pressure alarm 1) increased secretions 2) wheezing or broncospasm causes decreased airway size, remember, the ventilator is preset according to certain compliance (see above definition) 3) Displacement of endotracheal tube 4) Endotracheal tube obstruction due to water or a kink in the tubbing. 5) patient is anxious or fights the ventilator Low-Pressure alarm 1) Patient spontaneously breathing--that's nice 2) disconnection or leak in the ventilator or in the patient's airway cuff occurs Important Definitions: Assault= Putting a client in fear of a harmful or offensive contact. The victim fears and believes that harm will result as a direct consequence from the threat perceived coming from the care giver. Battery= An intentional touching of a client's body without his/her consent. Invasion of privacy= Includes violating confidentiality, intruding on private client or family matters and sharing client information with unauthorized persons. False Imprisonment= A client is not allowed toleave a health care facility; however, there is no legal justification for detaining the client. False imprisonment is committed when restraining devises are used without an appropriate clinical justification. Defamation= False communication or a careless disregard for the truth that causes damage to someone's reputation. This could be done in writing(libel) or verbally(slander). Fraud= Results from a deliberate deception intended to produce unlawful gains. Negligence=Failure to provide care that a reasonable person ordinarily would use in similar circumstances. Malpractice= Failure to met the standards of acceptable care, which results in harm to another person. Restrains: Definition= Devises designed for protecting the client used for limiting the physical activity of a client or to immobilize him/her or an extremity. Kinds of restrains: Physical--restricts client's movements through the application of a physical devise Chemical--drugs given to a patient for inhibiting a specific behavior or movement, for example a sick patient in a mechanical ventilator who fights the machine is given vecuroniun bromide, a paralytic agent which relaxes skeletal muscles so the patient cannot fight the mechanical ventilator. Obviously that chemical restrain is needed for that patient to breathe. There are specific rules governing the use of any kind of restrains on a patient: 1) A restrain must have a doctor's order. 2) There cannot be a standing order for a restrain. 3) Physician's order must state a) the type of restrain b) identify the behavior for which the restrain is used c) identify the limit or time frame for use 4) Physician"s orders for restrains must be renewed within a specific time frame which is usually 24 hours. 5) Restrains are not to be ordered PRN(as needed) 6) The reason for the use of the restrain has to be told to the patient and his/her family and their permission must be asked. 7) Restrains should not interfere with any treatment given to the patient or affect the patient's health. 8) to secure the restrain a half-bow knot should be used for it is easy to undo and it is safe. 9) The patient must have enough slack to allow movement of the body. Do not secure the restrains to the bed's side rails, use for that the bed's frame or a chair. 10) Assess the skin integrity, neuromuscular and circulatory status every 30 minutes and remove the restrain every 2hours to permit muscle exercise and promote circulation. Continually assess and document the need for restrain. Note: Not following those rules while restraining a patient is definedby law as false imprisonment. feliz3 Asian Americans - higher incidence of stomach and liver cancers. Rape victim - obtaining informed consent for examination is a priority before any action is taken, including obtaining laboratory specimens and notifying the police. This is part of process which initiates the chain of custody of the specimens and their collection. Hostage response is when victims assume responsibility for the violence inflicted on them. Victims tend to blame themselves for the abuse and develop a sense of unworthiness. Valacyclovir (Valtrex) - a form of acyclovir; indicated in the oral treatment of herpes zoster and recurrent genital herpes in immunocompetent adults. Down syndrome - have a high incidence of congenital heart disease, especially atrial defects. When assisting in the medical treatment of alcohol withdrawal, the nurse should encourage intake of fluids providing they are not too somnolent. Alcohol depletes the body of fluid, Alcohol withdrawal - anorexia, irritability, nausea, tremulousness, insomnia, nightmares, hyperalertness, tachycardia, increased blood pressure, diaphoresis, and anxiety. Bulimia nervosa - Russell's sign, which is the presence of bruises or calluses on the thumb or hand, caused by trauma from self-induced vomiting. Cocaine - can cause seizures, which is one of the most serious side effects of cocaine use. Cocaine withdrawal - physical activity will help to dissipate anxiety and decrease the cravings Delirium tremens - alcohol withdrawal syndrome, which occurs most often after 24 hours; visual and tactile hallucinations, confusion, tachycardia, and possibly seizures Dementia - symptoms of confusion are worse at night. This may be referred to as “sundowning syndrome” in clients with Alzheimer’s disease. Chlorpromazine (thorazine) - One of the common side effects of antipsychotic medications is drowsiness; it usually diminishes after the client has taken the medication for a few days. Postural hypotension occurs with phenothiazides (chlorpromazine, fluphenazine) Li toxicity - diarrhea, confusion, ataxia, slurred speech, hypotension, seizures, oliguria, coma, and death; increased thirst and urination; polydipsia, polyuria, and fine tremors are some of the very early signs of lithium toxicity Generalized anxiety - can be managed with either benzodiazepines (Librium) or an antidepressant. Donepezil (Aricept) - cholinesterase inhibitor drug indicated for treatment of Alzheimer's type dementia Clozapine (Clozaril) - antipsychotic that can cause a potentially fatal blood dyscrasia characterized by agranulocytosis (decreased WBCs, specifically neutrophils) Older adult with alcohol withdrawal - Short-acting benzodiazepines, such as Ativan, are preferred in older clients or when liver damage is suspected, because it is not metabolized by the liver. Methotrexate- causes GI tract irritations from toxicity; avoid sunlight and maintain effective birth control while on the medication. Sulfamylon (burn cream) - carbonic anhydrase inhibitor, and when systemically absorbed, can precipitate metabolic acidosis; used to treat bacterial growth under the eschar; causes a burning or stinging sensation on application, and pain management should be planned; old ointment should not be removed. Glaucoma has a strong hereditary tendency; those with a family history of glaucoma should have intraocular pressure monitored yearly after the age of 30 instead of waiting until after the age of 40 as would low-risk individuals. Myringotomy - to promote drainage by making a surgical incision into the tympanic membrane, which also relieves the pressure, prevents eardrum perforation, and reduces pain. Meniere’s Disease - assess the frequency and severity of attacks to plan best for the client’s safety. Infants are obligate-nose breathers - nose drops given before feeding promotes clearance of the nasal passages; limit use of it once a day Conductive hearing loss - may result from acute otitis media, perforation of the eardrum, and obstruction of the ear canal, as by cerumen Stapedectomy - experience dizziness, vertigo, and nystagmus from changes in endolymph fluid; observe fall precautions Hydrochlorothiazide - is a diuretic that may be used to decrease the lymph fluid buildup in the ear (i.e. Meniere’s disease) High priority patient who has a cast that complains of a funny feeling: affected extremity indicates neurovascular compromise, and requires immediate assessment. Note: client in early stages of labor with a diagnosis of complete placenta previa must be prepared for an immediate cesarean section. Implementation, cannot deliver vaginally. Note: Patient with epiglottitis who is having an early complications of hypoxemia: will present with heart rate of 148 beats per minute. The HR correlates with hypoxemia and is an early finding, along with restlessness. After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is best? – Ans. 1. Limit visiting hours to promote optimal rest 2. Arrange for a psychologist to visit with the family. 3. Arrange for the family to meet with a social worker to discuss financial aid. 4. Arrange for clergy to visit with the client and family as requested. Should remove nitro-patch before MRI is performed. If a family member verbalizes that a family member will closely watch the apnea monitor at all times. Nurse should be concerned because this indicates a feeling that monitor may not let them know if their infant stops breathing. Patient admitted to the hospital with dry mucous membranes and decreased skin turgor. Vital are BP – 120/70, temp, 101 degrees F, pulse 88, resp 14. Lab tests indicate the serum sodium is 150 mEq/L and the Hct is 48%. The nurse expects the physician to order which of the following IV fluids? – Ans. 1. -D5 NS, 2. -0.9 Na Cl 3. -lactated ringer 4. -0.45% Na Cl, Note: Isotonic solution pushing fluid back to the cells. Specific to dehydration. “I should wash my hands before redressing my wound” – Indicated understanding of asepsis, hallmark is hand washing. A mother with a 4 year old comes in to confirm her second pregnancy. The most important action for a nurse to do is identify the client’s general health needs. (Physical Needs) The priority for a nurse in caring for a client diagnosed with perforated bowel secondary to a bowel obstruction is to prepare the client for emergency surgery. Note: this can lead to peritonitis if not addressed. A mother brings her 17 month old son to the well baby clinic for a routine checkup. She confides to the nurse that she is concerned because her son sucks his thumb, especially at night when he is put to bed. Which of the suggestions by the nurse is best? – Don’t intervene at this time. This behavior usually subsides after 24 months of age. Note: Normal behavior, peaks at 18 – 20 months, most prevalent when child is hungry or tired. When administering Calcium EDTA (edetate calcium disodium) (antidotes) and dimercaprol (BAL inOil)(antidotes) for elevated blood lead levels the action that has the highest priority is to rotate the injection sites. This with prevent tissue damage and promote tissue absorption of the medicine. NOTE: dimercaprol (BAL inOil)(antidotes) treatment of acute poioning with: -mercury -Gold -Arsenic Used adjunct with edetate calcium disodium in treatment of server lead poisoning accompaneied by encephalopathy or blood level > 100mcg/dl Priority question for OB _ Immediate intervention is always given to a multipara woman at four weeks gestation reporting unilateral , dull abdominal pain. This indicates an etopic pregnancy and needs to be evaluated. A patient with a thermal injury to the right arm – The observation that is most important to report to the doctor is – Gastric PH less than 6.0 – Note: decrease in gastric PH could indicate hypersecretion of hydrogen ions,predisposing factor to stress ulcer formation. Note: situational crisis: priority is to determine how client coped with crisis in the past and build on client’s coping strategies. Note: -if oil is placed on a wound it is most important to wash the burn with soap and water – Note: cooking fat applied to an open wound increases the possibility of infection: burns should be rinsed immediately with tap water to reduce the heat in the burn. Client with DX of hyperparathyroidism – The most important symptom to report to the next shift is – Hematuria Note: Hematuria is a sign of renal calculi: 55% of hyperparathyroid clients have renal stones. Note: Dx with multiple sclerosis – most important for the nurse to include in instructions – Is to avoid overexposure to heat and cold – Note: this may cause damage related to the changes in sensation Several days after a client had a myocardial infarction, the physician places the client on a 2-gm sodium diet. Which of the following selections indicates to the nurse an understanding of the diet? – Ans. 1. Scrambled egg, orange slices, and milk, 2. instant oatmeal, toast and orange juice, 3. poached egg, bacon and milk, 4. biscuit, fruit cup and sausage. Note: instant oatmeal has sodium added NOTE: all items are low in sodium with correct answer due to milk is allowed on a salt restricted diet. Instruction about the medication is effective when a pt. on naproxen sodium (Anaprox) (nonopioid analgesics , nonsteroidal anti-inflammatory agents, antipyretics) States “ I should call my doctor if my stools turn very dark” – Note: NSAIDs can cause gastrointestinal bleeding Note:During a dressing change the old dressing should not be saturated with sterile saline before it is removed. The dressing should be removed dry so that wound debris and necrotic tissue are removed with old dressing. Note: Most important for nurse to assess for before administering calcium gluconate 10% 500 mg IV stat – is patency of the vein. If injected into the extravascular tissues, calcium gluconate can cause a severe chemical burn. Note: a child admitted with failure to thrive has just had a positive sweat test. – Nurse anticipates what change in the child’s POC? – ans.Administration of replacement enzymes. Note: positive for sweat test indicate cyctic fibrosis. Note:Best recommendation during discharge for a patient who suffered a mild MI and smokes one pack of cigarettes per day– Ans. Participate in a program such as nicotine avoidance. A pt. has a Sengstaken-Blakemore tube in place. The nurse enters the room and finds the pt. in respiratory distress. Which of the following actions should the nurse take FIRST? – Ans. Cut the balloon ports and remove the tube. Note: Scissors always secured at the bedside: remove tube if observe signs of respiratory distress or airway obstruction caused by upward displacement of esophageal balloon. It is most important for the nurse to include which of the following instruction with prenatal vitamins. – Ans. Take prenatal vitamins with orange juice at bedtime. Note:taking the vitamins with something acidic increases the absorption of iron. Taking them with food at bedtime decreases the possibility of nausea, as the client will be asleep. To promote safety in the environment of a client with a marked depression of T cells, – Ans. Remove any standing water left in containers or equipment. Note: Water should not be allowed to stand in containers, such as respiratory or suction equipment because this could act as a culture medium. Note: proper med administration Carafate (Sucralfate) (anti ulcer agent): should be taken 1 hour ac (before meals) and the Maalox (aluminum hydroxide with magnesium hydroxide) (antacids)1 hour pc (after meals). A client develops severe, crushing chest pain radiating to the left shoulder and arm – BEST PRN med the nurse should administer should be – Ans. Morphine Sulfate IV (Opioid analgesic) Note:This med reduces pain, anxiety and cardiac workload: reduces the preload and afterload pressures. The nurse cares for a client diagnosed with dementia in a long term care facility. Which of the following actions by the nurse is BEST? –– Ans. Direct conversation toward assisting the client to reminisce and talk about important past events in life. Note:geriatric client should be encouraged to talk about his life and important things in the past because he has recent memory loss. Which of the following is the FIRST nursing action that should be implemented for a client after a vaginal delivery? – Ans. Check the patient’s lochial flow. Note:Complication of hemorrhage assessed by observing lochial flow. Note:When recording client’s chief complaint – It should be recorded using the client’s own words. – Ans. “My stomach hurts after dinner every night” A client comes to the nurse’s station for the prescribed antipsychotic medication. The nurse notes that the client has torticollis , an arched back, and rapid movement of the eyes. Which of the following actions should the nurse take first? – Ans. Administer the PRN trihexyphenidyl (Artane) (antiparkinson agents)IM immediately (torticollis definition: Spasmodic contraction of neck muscles causing head to tilt to one side and chin pointing to other side McGraw Hill Nurse’s dictionary 2007) Note:administer Cogentin (benztropine)(antiparkinson agents). or Artane(trihexyphenidyl)(antiparkinson agents). – Assessment, no validation required. Note: a preschool client’s mother reports that the child has freq. abouts of gastroenteritis. Most important quest. To ask “Does the child attend a day care center?” – Note: environments with increased numbers of children (day care) more likely to promote infections due to close living conditions and increased likelihood of disease transmission. Note:Desired response to fluid replacement with a patent DX with hypovolemia. – Ans. CVP reading of 8 cm of water pressure. Note: Normal range of CVP is 3-12 cm water pressure so 8 indicates desired results. Note: - HGB 11 gt, HCT 33% indicates hypervolemia. PH 7.34 indicated acidosis. Client with elevated vital signs, hallucinations and aggressive behavior that are possibly on hallucinogenic drugs – Following action is to decrease environmental stimulation. Note: symptoms will subside with time and decreased stimulation. Note: Early stages of hepatic encephalopathy is – having difficulty describing what he does at work. Note: impaired thought processes is early symptoms. Proper weight gain pregnancy is: -2-5 lbs in the first trimester, -0.66- 1.1 weely in 2nd and 3rd trimester. -So 14 lbs in the fifth month is normal. 5 + 8 = 13. A young adult comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back. The nurse should instruct the client to take which of the following actions? – Ans. Clean the area carefully with soap and warm water every day, and cover them with a sterile dressing. Note:Open Kaposi’s sarcoma lesions should be cleaned and dressed daily to prevent secondary infection. The nurse assesses an infant who had a repair of a cleft lip and palate. The respiratory assessment reveals that the infant has upper airway congestion and slightly labored respirations. Which of the following nursing actions is MOST appropriate? – Ans. Position the infant on one side. Note:will facilitate drainage of mucus from upper airway and will promote adjustment to breathing through the nose. Note:Pitocin(Oxytocin) (misc O/B GYN Agents) should always be a secondary infusion controlled by an IV pump. A client is admitted with a diagnosis of renal calculi and is experiencing severe pain. Meperidine (Demerol)(Narcotic Analgesics) 75 mg IM is given prior to the change of shift. Which of the following symptoms is MOST important for the nurse to report to the next shift? – Ans. Change in the location and character of pain. Note: Location of the pain depends on location of renal stone: character of pain changes depending on location or movement of stone. Note: -Nursing interventions should involve distracting and redirecting behaviors for a bipolar disorder patient in the manic phase. Note: gown gloves and mask are appropriate for rubella (German measles) = droplet precaution. Note: Flagyl shouldn’t be taken with alcohol. It will cause antabuse (Disulfiram)(alcohol antagonist drug)like reactions. Should also be taken with food to decrease gastric upset. Note:4 year old with sickle cell anemia, baby aspirin (SALICYLATES) (antipyretics, nonopioid analgesics) shouldn’t be given for complains of pain. Note: Aspirin(SALICYLATES) (antipyretics, nonopioid analgesics) can cause a hemorrhage during a sickle cell crisis. Which of the following findings indicates to the nurse that a client’s Salem sump tube (nasogastric) was functioning effectively? – Ans. The presence of a hissing sound from the blue lumen tube. Note: Hissing sound is indicative that air is freely exiting the airway; purpose is to provide continuous steady suction without pulling gastric mucosa. The nurse cares for a pt. with deep partial thickness and full thickness burns. The client receives morphine sulfate 15 mg IV(Opioid analgesic). The nurse notes a decrease in bowel sounds and slight abdominal distention which of the following. Actions, if taken by the nurse, is BEST? – Ans. Explore alternative pain management techniques. Note: Morphine (Opioid analgesic) is drug of choice for burn pain management, when side effect becomes apparent, exploration of alternative pain management techniques such as visualization becomes important. Note:How to obtain a throat culture from a client diagnosed with pharyngitis. – Ans. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx. NOTE: height and weight changes in a year Height: at age 6 – 12 children grow about 2 inches (5 cm) a year Weight: gain 4.5 – 6.5lb (3 – 3 kg) a year Height: at age 7 about 44 – 51 inches (111.8 – 129.7cm) Weight: average 39 – 66.5 lb (17.7 – 30kg) A mother brings her 7 year old daughter to the outpatient clinic for a routine check up. The girl weighs 50.25 lb (22.85 kg) and is 48 inches (121.7 cm) tall. The nurse notes that the child has gained 2.5 lb and grown 3 inches in the past year. Which of the following. Responses by the nurse is best?– Ans. “ Your daughter’s height and weight are within normal limits.” NOTE: First 24 hours of TPN – Nurse should evaluate blood glucose level. Note: Total parenteral nutrition (TPN), or hyperalimentation, has a high glucose content important to monitor glucose levels. The nurse receives a phone call from a nursing assistant who states that her 5 year old child has developed chickenpox. It would be MOST important for the nurse to ask which of the following.– Ans. “Have you had the chicken pox?” Note: Need to ascertain if staff has had the disease, if not, Varicella Zoster Immune Globulin (VZIG) can be given, -exclude from patient care from the: 10th day after First exposure through the 21st day after last exposure. Unless Given than 28th day if VZIG given) The nurse knows that which of the following.Plans would be a priority for an infant with a positive PKU blood test? – Ans. Place the infant on Lofenalac formula. Note: Guthrie blood test evaluates neonate for phenylketonuria (PKU). Note: Lofenalac formula is low in phenylalanine but contains minerals and vitamins to provide a balanced nutritional formula. Phenylketonuria definition: Phenylpyruvic acid in the urine. *A recessive hereditary disease caused by the body's failure to oxidize an amino acid (phenylalanine) to tyrosine, because of a defective enzyme. 24 hr after abdominal surgery, which of the following. Plans is a nursing priority to prevent complication of flatulence? – ans. Assist the client to walk in the hall every two hours. Note: Twalking in the hall, this action will increase peristalsis, decreasing the development of flatus. A client admitted with metastatic cancer has received chemotherapy for three months. Lab values include: RBC 3.8 millin/mm3, WBC 3,000/mm3, Hgb 9.3 g/dl, platelets 50.000/mm5 . The nurse expects the patient to exhibit which of the following symptoms? – Ans. BP 120/70, pulse 100, respirations 16. – Note: Increase pulse and respiration are caused by decreased oxygenation of tissues. – The patient will be pale due to anemia, Normal RBC male – 4.3 – 5.9 million/mm3, female 3.5 – 5.5 mill./mm3 Normal WBC 4,000 – 11,000/mm3, Normal Hgb male 13,5 – 17.5 g/dl, female 12 – 16 gt/dl A physician writes an order for an HIV positive infant to receive Inactivated polio (IPV) immunization. Which of the following. Nursing actions is MOST appropriate?– Ans. Administer the immunization. Note: Inactivated polio (IPV) appropriate, contraindications include: anaphylactic reaction to neomycin, streptomycin, or polymyxin- B. A client is placed on cephalexin monohydrate (Keflex) (cephalosporins, First Generation) prophylactically after surgery. Which of the following foods should the nurse encourage?– Ans. Yogurt and acidophilus milk. Note:These foods will help maintain normal intestinal flora, which may be altered by the keflex. Note: A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin Indicates subcutaneous emphysema, which is indication of pneumothorax, observe client for respiratory distress, contact physician. Note:If nurse enters the room to find a tracheotomy tube dislodged. The nurse should immediately replace the tracheotomy tube. Note:a client with sunken eyeballs and fruity breath indicates diabetic ketoacidosis, treatment: with normal saline and regular insulin. Note: HEP–A: is not infectious within a week or so after the onset of jaundice, child can return to school. Activity at that time depends on the child’s energy level. Which finding indicates to the nurse that a client experiencing alcohol withdrawal is in need of more sedation to control the severity of withdrawal symptoms? – Ans. Elevated pulse rate Note:pulse rate is a good indicator of client’s progress through withdrawal, increasingly elevated pulse signals: impending alcohol withdrawal delirium requiring more sedation. A client developed diabetes insipidus following. A craniotomy. The nurse provides discharge instructions for the client and spouse. Which of the following statements, if made by the client indicates to the nurse that further teaching is needed? – Ans. -“I should weigh myself every day -drink less fluid if I gain more than 5 lb over a week”. Note: - desmopressin (DDAVP, Stimate)(hormone) treatment of Diabetes Insipidus nasally or SQ required for remainder of life. During the physical assessment, the nurse determines the need to perform the bulge test. Which of the following statements, if made by the nurse is BEST– Ans. ”Please lie down and extend your legs” Note: Bulge test: confirms presence of fluid in the knee, client’s leg should be extended and supported on the bed. Note:Cromolyn Sodium (Intal, NasalCrom) (misc antiallergy agents) is used to prevent the release of histamine and other allergy-triggering substances. – Correct statement would be “ I will take the medicine before I begin any vigorous exercise”. Note:favorable results from administration of medicationlevothyroxine (synthroid) (harmoe) is increased urine output. Note: Medication increases metabolic processes of body, including glomerular filtration, edema will decrease as water is excreted. NOTE:- Appropriate action in palpating the uterine contractions would be to: place one hand on the abdomen over the fundus, and with the fingertips presses gently. A nurse was sued for malpractice but is proved innocent. Which fact from the case was decisive in determining the outcome? – Ans. No harm was actually suffered by the patient. NOTE: - Required elements of malpractice are: duty breach of duty causation injury Glasgow Scale= A method of assessing neurological condition on a scale 1-15. A score < 8 indicates coma. Eye opening is the most important indicator. The highest score is 15 which is normal. Levels of Consciousness: LOC-----------------------Description Full Awake, alert & oriented, understands & responds Consciousness accordingly. Confusion Disoriented first to time, then place, then person. Memory deficits, restless, difficulties following commands. Lethargy Oriented to time, person and place, but demonstrates slow mental process, sluggish speech. Sleeps frequently, but weakens to spoken word or gentle shake. Maintains wakefulness with sufficient stimulation. Obtundation Extreme drowsiness, responds with one or two word when spoken to, follows very simple commands, requires more vigorous stimulation to waken, and stays awake only for a few minutes at a time. Stupor Minimal movement, responds unintelligibly, and wakens briefly only to repeated vigorous stimulation. Coma Does not respond to verbal stimuli, does not speak. May have appropriate motor response (withdraws from noxious stimuli), nonpurposeful response. Recognizing a Stroke: S-- ask your patient to smile Which cranial nerve would you be testing? T-- ask you patient to Talk and speak a simple sentence coherently i.e. Today is a beautiful day. R--ask your patient to raise both hands Ask your patient to stick his/her tongue out. Which cranial nerve are you testing and what are the abnormal sign you are watching for? A medication that a nurse should question with COPD would be: Propranolol hydrochloride (Inderal)(beta-adrenergic blockers). Rational: – Beta blocker that blocks beta adrenergic impulses to the bronchial tree that cause bronchodilator resulting in increased bronchoconstriction. The nurse performs an ice massage – for a client in chronic pain. The nurse is most concerned if which of the following is observed? Ans= – Mottling or graying of the tissue. Rational: – Site should be observed every five minutes for: -signs of tissue intolerance, including blanching, mottling, or graying. Complete Heart Block – The nurse should question which of the following orders? Ans= Administrer lidocaine (xylocaine)(antiarrhythmic agent) 50 mg IV push for PVCs in excess of six per minute. Rational = In complete heart block, the AV node blocks all impulses from the SA node, so the atria and ventricles beat independently, because lidocaine suppresses ventricular irritability, it may diminish the existing ventricular response, cardiac depressants are contraindicated in the presence of complete heart block. Manic phase of bipolar disorder – It is most important for the nurses to offer which of the following meals? Ans= Tuna salad sandwich and orange slices Rational = clients with mania need nutritious finger foods; foods contain protein, carbs, and vitamin C and fiber. Urinary Pattern – The nurse should instruct a patient to do what first? Ans= Keep a record of daily fluid intake. Rational: – Client needs to know how much and when he ingests fluid. Ileal Conduit 2 days ago – Most important for the nurse to take which of the following actions? Ans= Apply a close fitting drainage bag to the stoma. Rational = Primary preventative measure to prevent urine from contacting the skin. Note: should be cleaned with soap and water not an antiseptic solution. Intubating a postoperative client – Most appropriate action to take would be to. Ans= Place the intubation blade in a bag, and arrange for gas sterilization. Rational = Sterilization of equipment after exposure to body fluids of a client is protocol. Diet teaching for a client with SCI. – The following meal that is best. Ans= Spaghetti with meat sauce and green beans. Rational – High fiber diet is an important part of bowel program, fiber helps prevent the complication of constipation, includes whole-grain foods, bran, fresh and dried fruits, increased fiber will facilitate defecation, especially with reduction in fat intake. Note: I picked a tuna fish sandwich with orange juice due to the fiber (Spaghetti is white flour and is constipating) NOTE: BIRTH WEIGHT SHOULD DOUBLE IN 5 MONTHS. Client presents with diaphoresis, pallor, and tachycardia – One hour after receiving 7 U of regular insulin. – Action the nurse should take first is Ans= Offer the client milk and crackers. Rational – Onset of action for reg. insulin is 30-60 min; assessment indicates a problem with hypoglycemia, foods such as mild and crackers should be given if blood sugar is around 4060 mg/dl. If orange juice or simple sugaris given, it should befollowed with a meal or with protein intake. Note: It is unnecessary to administer glucagons unless client is unresponsive. Client receiving chlorpromazine (Thorazine) (antipsychotics) 400mg/day for four weeks – Presents with temp. 105 F severe rigidity, oculogyric crisis, and severe hypertension. MOST important for the nurse to take which action? Ans= Hold the chlorpromazine, and notify the medical staff stat. – Rational = Client is experiencing neuroleptic malignant syndrome, fatal in about 15 – 20% of cases, is toxic effect of antipsychotic medication. (HbA1c) of 6% - Results normal, indicates good control of diabetes. Normal heart rate for a two day infant – 120-160 BPM -If a 2 day old infant, lying quietly alert, -heart rate of 185 bpm has tachycardia, and requires further investigation. Graves disease – Nurse would intervene if client drinks Ans= TEA. Rational: = Stimulant that would increase metabolic rate. After the anesthesiologist administers an epidural to a woman – HIGHEST priority would be to Ans= Obtain the blood pressure. Rational: assessment side effect of an epidural is hypotension from the vasodilation that occurs. Note: Assessing the FHR monitor may be done as ongoing management but is not a priority. Ciprofloxacin (CIPRO) (fluoroquinolones) – MOST important for the nurse to include when instructing the client about this medication Ans= “ Drink plenty of fluids” Rational – Prevents crystalluria and stone formation. Spinal Anesthesia – The following is an important nursing implication regarding this anesthesia Ans= Adequately hydrated the client Rational = Important that the client be well hydrated to prevent hypotensive problems after the spinal anesthesia is initiated. Note: unnecessary for client to be NPO for 12 hours A client is diagnosed with a tumor of the pituitary gland and has a transphenoidal hypophysectomy. The nurse plans care for the patient two days after surgery. It is MOST important for the nurse to monitor which of the following? Ans= Specific Gravity of Urine. Note: Lack of ADH from pituitary will cause diabetes insipidus and diuresis with very low specific gravity. NOTE: Clients on hydrochlorothiazide (HydroDIURIL) (diuretic) should be encouraged to eat foods high in potassium – Ex. Dried apricots, bananas every day due to the diuretic causing loss of potassium. NOTE:A LPN/LVN with shingles can care for non-high risk clients as long as lesions are covered. The nurse performs hypertension screening at the local grocery store. It is MOST important for the nurse to complete which of the following tasks? Ans= Take two readings at least five minutes apart. Note: Recognition of adult hypertension should be done after two readings taken at least five minutes apart. NOTE: To confirm a client stating that he thinks he has an ulcer. Nurse should respond by asking “ Do you have a burning pain in the epigastric region?” - Peptic ulcer pain is often referred to as a “boring pain in the back” or a burning gnawing feeling in the midepigastric area. The nurse cares for a client immediately after an abdominal aortic aneurysm repair. Vital signs and blood pressure 100/70, pulse 120 respirations 24, urine output 75 ml during the past three hours. Which of the following is a priority nursing action for this client? Ans= Maintain bedrest, and evaluate for a decrease in CVP readings. NOTE: client is at increased risk for development of hypovolemic shock, vital signs and urine output correlate with the early signs of shock, the nurse should compare the CVP with previous readings. Note: Client with a Harrington rod due to scoliosis, in preparation for the immediate postoperative care, the nurse should include which of the following in a teaching plan – ans. Take 10 deep breaths every 2 hours. Note: Client must be monitored closely for the first 48-72 hours for respiratory problems bowel and urinary problems need to be assessed along with neurological problems in the extremities. Client will have a catheter, may have a nasogastric tube connected to low suction,. No reason to reassign pregnant staff member from taking care of cytomegalovirus patient. – Just need standard precautions. The family members of an 85 year old report to the nurse that they suspect that their father is masturbating. Which of the following responses by the nurse is BEST? Ans= “ This is considered a normal behavior for men” NOTE:Masturbation is an activity performed by some elderly men. The nurse cares for a patient following a right adrenalectomy. During the immediate postoperative period, it is MOST important for the nurse to observe for which of the following? Ans= Blood pressure alteration NOTE: Decrease in blood pressure may indicate shock. When using palpation techniques during the physical assessment of an adult female with abdominal pain, which of the following actions should the nurse take FIRST? Ans= Inform the client to breathe slowly. NOTE: Breathing slowly will enhance relaxation of the abdominal muscles. NOTE: holding a deep breath is done during palpation of the liver. NOTE: It is important for the parents to stroke an infant after surgery. The tactile stimulation is imperative for an infant’s normal emotional development, after the trauma of surgery; sensory deprivation can cause failure to thrive. NOTE: on an EKG stripe if there are 8 QRS complexes in 30 large squares for a 6 second strip. The heart rate is calculated by timeing the QRS complexes by 10. EX (8X10) = 80. 80 is the HR. An order has been received to obtain a stool specimen and test for occult blood. The nurse is MOST concerned if the client makes which of the following statements? Ans= “ I take Feosol every day” NOTE: Iron supplements can cause color of stool to resemble melena. A primipara is admitted in early labor, and her membranes rupture. Which of the following assessments by the nurse is MOST important? Ans= Assess for a prolapsed cord. NOTE: Initial assessment is to check for a prolapsed cord. Note:the mother’s BP is not affected by rupture of the membranes. The nurse prepares a client for a laparoscopic cholecystectomy for treatment of cholelithiasis. It is MOST important for the nurse to ask which of the following questions? Ans= “ Who is going to help you at home during the next couple of days?” NOTE: Cleint usually discharged the day of surgery or the next day: ensure that client has help at home for first 24-48 hours. NOTE: Activity helps reduce frequency and degree of phantom pain on an amputee. An adolescent is seen in the emergency room for an overdose of acetylsalicylic acid (Aspirin)( antipyretics, nonopioid analgesics). Which of the following actions by the nurse is BEST? Ans= Determine when the client took the aspirin. NOTE: Charcoal, if given within two hours, will absorb particles of salicylate. NOTE:Pt. withdrawing from pain or noxious stimuli is a sign of deterioration in pt’s condition. Physicain should be notified. The nurse evaluates care for a client diagnosed with depression. The nurse is MOST concerned if which of the following is observed? Ans= The LPN?LVN administers flurazepam hydrochloride (Dalmane) (sedative hypnotics)15 mg hs. NOTE: Medication that produces dependence should be a last resort, used only if other nursing measures and antidepressant meds have not worked and the client is exhausted. The nurse prepares a client for insertion of a suclavian triple lumen catheter to be used for administration of total parenteral nutrition (TPN). The nurse should position the client in which of the following positions? Ans= Supine with the client’s head low and turned away from the insertion site. NOTE:Produces dilation of the neck and shoulder vessels, making entry easier and preventing air embolus. The nurse cares for a woman with pregnancy-induced hypertention (PIH) treated with magnesium sulfate. The nurse is MOST concerned if which of the following is observed? Ans= Urine output decreaed from 70 to 30 ml/hr. NOTE: is metabolized and excreted by the kidneys; decrease in the urine output can lead to toxicity. The school nurse interviews an adolescent. The nurse is MOST concerned if the adolescent states which of the following? Ans= “ I’m glad I don’t get as sweaty as my friends when I work out.” NOTE: Should have increased sweat production due to hormonal changes. Which of the following questions BEST aids the nurse in assessing the orientation of a client on the psychiatric unit? Ans= “What is your name?” NOTE: Some well-oriented people do not know the answer to(WHO IS THE PRESIDENT OF THE USA?) this question: -depending upon their age, educational level, etc. Which of the following statements by an adult client indicates to the nurse the need for further teaching regarding care of a sigmoid colostomy? Ans= “I’m irrigating my colostomy after each meal.” NOTE: Irrigation of sigmoid colostomy is not necessary more than once a day and sometimes every two or three, if at all. Note:It is possible for many clients to go without a collection bag by performing routine irrigations. The nurse assesses a child diagnosed with cystic fibrosis. The nurse is MOST concerned if which of the following is observed? Ans= The child is expectorating thick, yellow mucus. Note: Thick, yellow mucus is indicative of pneumonia. Note: exertional dyspnea increases during the day and child complains about difficulty breathing is not unusual for a child with cystic fibrosis. The physician prescribes hydrochlorothiazide (Oretic) (antihypertensives, diuretics) 50 mg PO daily for a client. The client also takes dexamethasone (Decaspray) (corticosteroids) 2 sprays in each nostril bid. The nurse should encourage the client to increase the intake of which of the following foods? Ans= Citrus fruits and green, leafy vegetables. Note: Need to increase intake of potassium rich foods because of potassium loss from diuretic medications. NOTE: Client with deep partial thickness and full thickness burns over 30% of the body. Three days ago it is most important for the nurse to report which of the following observations to the next shift? Ans= Gen. muscle weakness and lethargy. Note: Muscle weakness and lethargy are signs of hypokalemia, which can occur on the third day after a burn: hypokalemia is caused by diuresis. A client complains of hearing loss. While the nurse is irrigating the client’s ear to remove cerumen for better observation of the tympanic membrane, the client complains of dizziness. Which of the following actions should the nurse take FIRST? Ans= Warm the irrigant, and resume the procedure. Note: water that is too cool can elicit dizziness when it comes into contact with the tympanic membrane. NOTE: client with Addison’s disease has hyperkalemia. NO need to encourage foods rich in potassium. Cortef (hydrocortisone)(antiasthmatics, corticosteroids)for Addison’s is best taken in the morning. If steroids are taken at night, they may cause sleeplessness. A client returns to the floor following a bronchoscopy. The client complains of thirst and requests ice chips. The physician left an order for the patient to resume a regular diet. The nurse should take which of the following actions? Ans= Touch the back of the client’s throat with a tongue depressor. Note: assessment of patient: a local anesthesia sprayed in throat may interfere with swallowing. Need to check gag reflex. The nurse enters the room and discovers that the client has slurred speech, right-sided paralysis, and unequal pupils. Which of the following actions should the nurse take FIRST? Ans= Assess the respiratory status. Note: Determining LOC is not as important. Ensuring the client has an open airway is the appropriate next step. Further instruction is needed with GoLYTELY (polyethylene glycolelectrolyte solution)(cathartics/laxatives) if client states: Ans= “If I drink it ice cold, it won’t taste as bad.” Note: Golytely can cause hypothermia due to large quantity of solution ingested. In caring for a client with dementia, the nurse should give highest priority to which of the following goals? Ans= Maintain an optimal level of functioning. NOTE: dementia is characterized by severe, prolonged impairment, which is often irreversible; main focus of care is to keep client as healthy as possible for as long as possible. NOTE: it is normal for a neonate; to have apnea for 10 sec. If 15 seconds or longer should be reported to a physician. While checking the patency of a Salem sump tube, the nurse finds stomach contents draining from the air vent. Which of the following nursing actions is MOST appropriate? Ans= Insert 30 ml of air through the air vent. NOTE: Clearing the air vent with air will re-establish proper suction in the Salem sump tube. A 4 month old infant who had a temp. of 103 F following the last DTaP vaccine is seen in the clinic for another immunization administration. Prior to the nurse’s administering the DTaP, which of the following should be the nurse’s priority? Ans= Consult the physician about pediatric DT (diphtheria and tetanus) NOTE: fever over 103 F in first 48 hours after DTaP is a valid contraindication for pertussis vaccine. PT with AIDS – Teaching is effective if the patient takes docusate sodium (Colace) 300 mg once a day. NOTE: Bowel programs, stool softeners, and laxatives reduce intestinal stasis and bacterial overgrowth. The public health nurse cares for a child diagnosed with impetigo. The nurse is MOST concerned if which of the following is observed? Ans= Periorbital edema. NOTE: Indicative of poststreptococcal glomerulonephritis, a possible complication of impetigo periorbital edema. A client receives prochlorperazine maleate (Compazine) (antiemetics, antipsychotics)10 mg IM before repair of a hernia under general anesthesia. The nurse is MOST concerned if which of the following is observed six hours after surgery? Ans. The patient has not voided since surgery. NOTE: Compazine Urine retention is side effect of medication and is caused by general anesthesia. The nurse conducts a class at a senior citizen center on the changes associated with aging. The nurse is MOST concerned if a client states which of the following? Ans= “I’ve been sleeping with fewer blankets over me lately” NOTE: Usually becomes intolerant to cold. NOTE: DX of haemophilus influenzae meningitis – How long child will need to be in isolation. Ans= “Isolation can usually be stopped 24 hours after the start of antibiotic therapy.” NOTE:haemophilus influenzae meningitis treated with penicillin; IV fluids and isolation for 24 hours after the start of antibiotic therapy to prevent respiratory transmission. NOTE: fetal heartbeat can be heard at 12 weeks; is a positive sign of pregnancy. Best assessment to assist the nurse in determining her expected date of confinement (EDC)? Ans= If client isn’t shure when the last menstruation was. The nurse cares for a client in hypovolemic shock. Which of the following indicates a therapeutic response to volume replacement? Ans= Urine output increases to 40 ml/hour. NOTE: hypovolemic shock: primary objective of fluid replacement is to perfuse vital organs; -increase in urine output to a normal range indicates that kidneys are adequately perfused; other major organs are being perfused also. Note: CVP is an indicator of fluid balance; CVP of 5 cm water is in the low range and does not indicate adequate tissue perfusion. NOTE: During examination of thyroid:drinking water facilitates swallowing. Which nursing action is MOST appropriate when an infant is admitted for fever, poor feeding, irritability, and a bulging fontanel? Ans= Place the client on droplet precautions. NOTE: Implementation; classic signs of meningitis; client should be isolated from other clients. NOTE: If Dr. orders an analgesic to be administered to a woman in labor who is 9 cm dilated and is having contractions every 3 minutes, lasting for 50 seconds. Which of the following nursing actions is MOST important? Ans= Notify the physician regarding the status of contractions. NOTE: Information indicates that woman is in transition phase; analgesics should not be administered during transition phase. NOTE: Extrusion reflex in an infant usually disappears in 3 to 4 months of age. NOTE: dexamethasone (Decadron) (antiasthmatics, corticosteroids)should be taken with breakfast. Note: Oral steroids have ulcerogenic properties -need to be administered with meals; -if ordered daily, administer in morning. A client with urinary frequency, burning, and a temperature of 102 F is instructed by the nurse to collect a urine specimen for culture and sensitivity. The nurse knows that teaching is successful if the client states which of the following? Ans= “I will collect the specimen using an aseptic technique” NOTE: aseptic technique decreases the possibility of contamination with organisms. NOTE:appropriate actvity for a 10 year old female client recovering from a sickle cell crisis? Ans= Collecting pictures of favorite stars from magazines. NOTE:collecting is an activity that is important to schoolaged children. NOTE: after a thyroidectomy a nurse is most concerned with:tension and muscle spasm of the hand when a blood pressure cuff is applied to the are and inflated. -Positive Trousseau’s sign :indicates tetany; surgery may damage parathyroid glands and cause a decrease in serum calcium. The nurse cares for a client with a bleeding duodenal ulcer. The nurse is MOST concerned if the patient reported taking which of the following mediations? Ans= Metoclopramide hydrochloride (Reglan)(antiemetics) 15 mg PO. NOTE: Reglan stimulates motility of upper gastrointestinal tract, contraindicated with possible hemorrhage of gastrointestinal tract; used to treat nausea of chemotherapy. NOTE: heparin(anticoagulants) not transmitted in breast milk; breast-feeding considered safe. NOTE: haldol (haloperidol) (antipsychotics)is particularly effective in reducing assaultive behavior associated with severe anxiety. Symptoms of a Hypertensive Crisis 1) severe occipital headache radiating frontally 2) neck stiffness and soreness 3) nausea/vomiting 4) chills/fever 5) clammy skin 6) dilated pupils 7) palpitations 8) tachycardia and bradycardia 9) chest pain Prevention Definition: 1) Primary prevention= measures that include activities that help avoid a given health care problem. Examples: a) passive/active immunization, exercise and a balanced diet for avoiding diabetes type 2 and high blood pressure b) health protection education such as promoting using a helmet while riding a motorcycle, use of the passenger seatbelt Successful primary prevention helps to avoid suffering, cost and burden of a disease. 2) Secondary Prevention=Identification and treatment of asymptomatic clients who have already developed the risk factors or pre-clinical disease, but in whom the condition is not clinically apparent. 3) Tertiary Prevention= Activities involving the care of a client who has been diagnosed with a disease with the attempt to restore the highest function. Example, speech therapy for a person who had a stroke. feliz Duration: 18-24hrs. Intermediate acting insulin 5) Ultralente (U)=Onset: 30min.-3hrs. Peak: 10-20hrs. Duration: 20-36hrs. Inject thigh fat tissue 6) Lantus= Onset: 60-90 min. No peak time insulin is delivered at a steady level. Duration:20-36hrs. Note: premixed insulins are a combination of specific proportions of intermediate-acting and short- acting insulin in a bottle or in an insulin pen. The numbers following the brand name indicate the percentage of each type of insulin. For example Novolin 70/30. The first number is the percentage of NPH=70, and Regular=30. The second number is 30 which represents the percentage of Regular Insulin in the bottle. feliz3 Aneurism Precautions: 1) Bed rest in a quiet setting is a must for a patient with this condition. 2) Minimize environmental stimuli--keep lights dimmed 3) Any activity that increases blood pressure or impedes venous return to from the brain is strictly prohibited. ABSOLUTELY NO! a) pushing b) pulling c) sneezing d) coughing e) straining---may have to be given a stool softener for avoiding effort of bowel movement--document this-4) stimulants such as caffeine, nicotine---prohibited 5) visitors, radio, TV and reading material---limited or prohibited. The purpose is to avoid increase in intracranial pressure. Signs of infiltrated IV: 1) pallor 2) coolness 3) swelling--IV fluid deposited in subcutaneous tissue 4) IV stops when the pressure of the fluid deposited in the tissue exceeds the pressure in the tubbing. Phlebitis, thrombosis and infection cause the affected skin to feel warm to the touch. Dilantin(phenytoin) is an anticonvulsive that causes gum bleeding and hyperplastic gingivitis (inflammation and enlargement of the gums caused by an increase in the number of cells). An assessment of the mouth while the patient is taking this drug and educating the patient abouNEVER give potassium IV push because it is fatal. Never administer concentrated potassium chloride without first diluting it Potassium chloride (KCL) preparation available in a premixed form a KCL preparation greater than 60mEq/L should not be given in a peripheral vein...what do you think it will happen to the peripheral vein? Administer potassium at an infusion rate than does not exceed 10-20mEq/L For extreme hypokalemia, infusion rates should be no more than 40mEq/hr while the patient is hooked to an EKG. Must monitor cardiac activity. Potassium is excreted by the kidneys, assess kidney function before administering Potassium Use an infusion pump to control the infusion flow rate Infiltrated KCL (KCL going into the subcutaneous tissue instead of the blood circulation system--extravasation causes tissue necrosis-). KCL is extremely irritating as Potassium is a caustic substance. Infiltration(extravasation) Protocol: Signs and Sx 1) coolness to the skin 2) taut skin 3) dependent edema 4) backflow of blood absent 5) infusion rate slowing Tx 1) 2) 3) 4) assess for inflitration and notify physician discontinue catheter apply cool compresses inject, depending on the drug given, an antidote to the site Prevention: 1) Stabilize the catheter 2) Place the catheter in appropriate site 3) avoid antecubital fossa...why? for a patient taking Dilantin. feliz3 feliz3 t the importance of using a soft toothbrush is a must If upper Gi series and lower Gi series ordered: DO lower GI series first- B/C to avoid barium from upper GI –traveling to lower Gi & interfering with results. S/SX irritable bowel syndrome: HA, epigastric pain reieved by food, anorexia, N&V , and periods of both constipation and diarrhea Pain 4/10 after total abdominal hysterectomy: Administer narcotic pain meds, as ordered -B/C there is a “known” etiology for pain… Surgury ! NOT repostion for comfort just B/C pain is 4/10… -Look at pain management S/P ! Regular insulin: Onset: ½ hr (30 mins) Peak: 2.5 to 5 hours NPH insulin: Onset: 1 ½ hours Peak: 4 ro 12 hours Iron (intramuscula): Iron Dextran Add 0.2 ml of air to syringe after drawing up iron med. -ensures an air-lock which which clears excess medicine from the needle -dose to prevent medication irritation and/or -“staining” from leaking in subcutanous tissues & skin surface either or -injection or -withdrawl of needle. Pull the skin and subcutaneous tissue 1 inch to one side of intended injection site & hold it there while inecting iron = Z Track method Wait 10 secounds after injectin the med (iron) -before removing needle, -aspirate first (1M); NEVER massage Z-track in ADULT must ALWAYS DORSAL GLUTEAL: -NEVER DELTOID with Z-Track C/O Red-Haze in his viaual field: Ask “Have you ben see by an Opthamologist?” -should be evaluated by opthamologist -“Red Haze” = vitreous hemorrhage -may be absorbed spontenusly if it does not resolve this way, may need surgury Asthma preventive care (child): DO NOT let child sleep on bottem bunk- have asthmatics sleep on top bunk to avoid dust mites! DO NOT sleep or lie down on upholsterd furniture Sleep on foam pillow & foam mattress- OK with asthmatics Remove child from room & have wear mask when vacuming carpets. Suspension of amoxicillin trihydrate (Amoxil) for a 2 month old infant: -shake med before giving it NEVER PUT IN FORMULA; -give an empty tummy –for maxmuim absorption. Rotating Insuling injection sites: if nurses/ patient are not rotating injection sites… Glucose levels rise temporarily -B/C poor absorption of insulin lends to increase Blood Sugar. ** Post-OP patients are “clean” … -S/P Right pnumonectomy (clean) -contraindicated to be placed with COPDer (dirty) Epoetin Alpha (Procrit) (antianemics): Report to M.D. -if hematocrit rises more than 4% in two weeks (flu-like symptoms normal at first) (ie; from 28% to 33% -Contact M.D. to decrease Procrit –B/C increase risk of HTN & seizures) Fundus- palpate (where) after 8 hours post delivery: -Level of umbilicus (fundus will be here 6 to 12 hrs post (beginning with day 1, fundus descends ~ 1 fingerbreadth per-day TPN completion: hang 10% dextrose in water -hypertonic dxtrose to wean patient, & is similar to TPN! Basal Body Temperature Method: (to determine if patient is ovulating) –client takes temperature every morning before rising -if patient ovulates there ill be a slight drop, and -then rise in temperature B/C of progesterone influence, -temperature will be increase during second-half of cycle. Lumpectomy-of breast? DO NOT EXPOSE TO: HOT or COLD; NO SUNSHINE exposure; NO TAPE, NO CREAMS,LOTIONS, DEODERANTS –wear a loose-fitting bra made of 100% cotton; assess skin for redness, cracking ***Wheezing upon inspiration (18 month-old infant): **Know: wheezing usually occurs on expiration** **-Thus, ask :”was child eating a hotdog or nuts, beans, seeds, chewing gum, “ immediately before -developing (inspiratory wheezing) breathing problems? toddlers (18 months to 3 years) -in DANGER of aspirating large pieces of meat (hotdog), seeds, nuts, beans, chewing gum etc.) Insertion of Central venous catheter: -instruct client to turn her head to the left until the procedure is complete -shave skin at insertion site the right before to allow healing of minor irritations -inform client she will be positioned with her head down (Trendelenberg) during insertion procedure of central venous catheter -Instruct to perform VALSALVA MANEUVER – to prevent EMBOLISM (DO NOT DEEP BREATH) (instead hold breath & bear down Question: Does anybody knows how to create a table in this thread?...this information I'm sending looks better written on a table for clarification purposes, but I have no idea what keys I need to use in order to create a table. feliz3 Normal Blood gas Values: pH----7.35---7.45 Pco2--35-45 mmHg HCO3--22-27 mEq/L Po2----80-100 mmHg O2 sat--95%-100% Note: CO2 is the acidic component of this buffer system HCO3 is the base component of this buffer system Base=Alkaline Buffer= a substance than maintains a given pH A lot of acid in a solution will lower the pH of a solution: acid solution A lot of alkaloids in a solution will increase the pH of a solution: alkaline solution. Metabolic Acidosis: Condition: metabolic acidosis---pH: low ---Paco2: Normal ---HCO3: low Compensated metabolic acidosis---pH: low ---Paco2: low ---HCO3: low How the body compensates for metabolic acidosis: The lungs hyperventilate to blow off excess of CO2 and conserve HCO3. Causes of Metabolic Acidosis: 1)Diabetes Mellitus or diabetic ketoacidosis 2) Excessive ingestion of of acetylsalicylic acid = ASA = aspirin 3) Severe diarrhea 4) High fat diet 5) Insufficient metabolism of carbohydrates 6) Renal insufficiency or renal failure 7) Malnutrition: Improper metabolism of nutrients causes fat catabolism (breakdown) leading to an excess of ketones (by-product of fat metabolism) Assessment: 1) The lungs blowing off the CO2 build up and compensate for the acidosis, hyperepnea or hyperventilating (respiratory rate > 20 breaths/min) with Kussmaul's breathing pattern. Kussmaul's breathing=deep breathing pattern and when it is due to metabolic acidosis, the rate could be fast, slow or normal. 2) headache 3) nausea/vomiting/diarrhea 4) fruity-smelling breath resulting from improper fat metabolism 5) CNS depression: mental dullness, drowsiness, stupor and coma 6) Twitching, convulsions 7) Hyperkalemia--must know this in connection with metabolic acidosis This is it for now, but I will continue discussing the body's reactions to acid-base imbalances, later. feliz3 Fall prevention: Exercise, Tai-chi, -prevents falls or decrease chances of falling -Tai-chi improves balance & coordination -Avoid shoes with thin, nonslip soles are SAFEST -Avoid slippers -Avoid athletic shoes with deep treads!! -Go to eye doctor -Have vision checked -Buy New, Bight Lamps/ lights for home -Remove throw rugs Q bank # 15 TB skin testing with PPD: **10 mm in duration: POSITIVE PPD in otherwise healthy patient. **5 mm in duration: Positive PPD in HIV Positive client and other immunocompromised clients Allergies to sulfa drugs/sulfonamides: if *skin develops a yellow crust* (Jaundice is a sign of liver involvement (may signal metastasis- of cancer cells) Morphine sulfate (MS04) will DECREASE blood return to right side of heart, and decrease peripheral resistance -decreases preload & after load pressures and cardiac workload - Vasodialtes; provides anxiety relief too. -SQ or IM – Wow! Even SQ! Even continuous IV morphine infusion ..ESP if on Hospice. Captopril (Capoten) (ACE inhibitor): Take 1 hour before or 2 hours after meals (NEVER with meals for Captopril always separate!) -Take Captopril at same time every day -Ace inhibitor Treatment for HTN -change position slowly to prevent orthostatic hypotension -S/E: dry hacking cough - Hypotension -taste disturbances (metallic) -Protienuria -DO NOT increase potassium -DO NOT use salt substitute -DO NOT double dose if missed dose -Avoid potassium foods -No Apricots -No Bananas on Captopril Decreased variability: This FHR pattern:.. -will occur if Meperidine (Demerol) 50mg IV is given to client in Labor -irregular fluctuations in the baseline of FHR; -Demerol crosses the placenta & -is a CNS depressant; FHR variability is affected by Narcotic Administration. Early decelerations = occur before peak of contraction –result from fetal head compression (NORMAL) Late decelerations = occur after peak of contraction -from uteroplacental insufficiency (ABNORMAL) Variable declarations = occur any time during uterine contraction -result from cord compression (ABNORMAL) “Casts” in urine = “Renal Disease” Specific Gravity = 1.010 to 1.030 (normal) Blood Urea Nitrogen (BUN) = 10 to 30 mg/ml (normal) Serum creatinine = 0.5-1.5 mg/dl (normal) Permanent Pacemaker: MOST IMPORTANT “Take your pulse every day” -a change in heart rhythm or rate can signal a malfunction of the pacemaker -take pulse x 1 full minute -same time each day & record it in a journal; -also, take pulse if feeling any symptoms!! Acute Glomerulonephritis: -C/O of sore throat, -fever Culture -group A beta-hemolytic streptococcus infection Urinalysis -large amount of protein and -Large # of red blood cells will be found in urinalysis -Instruct client to make an appointment -before leaving the country to determine client’s renal status Anorexia Nervosa: -BEST INDICATOR that goal of balanced nutrition has been met to meet metabolic demand; “MENSTRUAL PERIOD” has returned and is REGULAR” = Balanced nutrition -NOT ideal body weight has been attained… -B/C NO guarantee that underlying metabolism disturbances been corrected. Postpartum Hemorrhage: GREATEST RISK hemorrhage is with: -DISTENEDED BLADDER can cause hemorrhage -this distended bladder will likely displace the uterus to the: LEFT or RIGHT & interferes with uterine contraction *-Episiotomy is NOT a risk for hemorrhage! But can cause discomfort. Abusing Spouse: most appropriate therapy=Group therapy UTI’s : -repeated UTI’s and incontinent -uninhibited bladder: -Perform an intermittent catheterization for residual urine volume -bladder may not empty completely “residual urine can cause UTI” B/C it sits in there and causes infection! First stage of labor (3 phases) Latent Phase: = 0-3 cm; Contractions : 10-30 secs & Contractions 5-30 minutes apart -Mild to moderate Active Phase: =4-7 cm; Contractions: 40-60 secs & Contractions 3-5 mins apart -moderate to strong ***Transition Phase: 8-10 cm Contractions: 45-90 secs & 1 ½ to 2 mins apart Strong ***intense desire to urinate*** -in this phase even ask for help to go to the bathroom! 40 year-old: -client compares life’s accomplishments -against goals (potential mid-life-crisis at 40 yr-old) **Enteral line gets disconnected: -patient restless, C/O difficulty breathing -nurse locks the Central Catheter position patient * On left side in Trendelenberg; -institute Oxygen therapy & -Notify Physician ** S/SX: -Air embolism DO NOT place in high fowlers -may go to brain Battery Acid to the eyes: -continue to irrigate his eyes until the pH is within normal limits –removal of acid is imperative -checking pH helps verify if chemical/acid has been removed -this falls within the L.V.N.’s scope of practice! -DO NOT interrupt rinsing of eyes Older client with Emphysema: -becomes restless & -confused -encourage client do “Pursed-Lip Breathing” -B/C prevents collapse of lungs-helps patient control rate/depth of breathing Term Infant Extremities flexed at rest Lanugo (fine-hair over body) Lanugo greatest @ 28 wk gestation Elbow creases contain vernix Nipple bud measures 0.5 to 1 cm Pre-term infant extremities are in extension (preterm) Restraints: -reevaluate the need for restraints every 4 hours -order for restraints are time-limited to 4 hours Prednisone (cortisone)-Long-term use ( 3 yrs. Or more) -leads to osteoporosis S/SX -weakness -muscle wasting -depression, -alopecia -buffalo hump (Cushing Syndrome) -Obesity -Mood swings -slow wound healing Phobia: -e.g. fear of elevators: FIRST allow patient to avoid elevator (NOT encourage to discuss his fear) Nasal decongestant spray: -close one nostril while you breathe in and squeeze the spray into the other -be seated with head erect or -head slightly tilted backward -Tip of spray bottle SHOULD actually be inserted into the nostril! -DO NOT blow nose after spraying medication into nose! -B/C Need to retain the nasal medication! *NEVER label IV bags directly onto PLASTIC with a Permanent Marking Pens -BEST on label instead! -B/C ink can penetrate into IV Solution BAD Suzanne's plan 30 minutes studying Infection Control (from this site, the CDC web site, and another site listed on this forum, also the You Tube flash card review on Infection Control 75 questions on the NCLEX 3500 site -- quite different than my other NCLEX review CD Several pages in my Delegating, Prioritization & Assigning book 30 minutes studying rationales that I had copied & pasted from NCLEX review-type questions from a CD & the NCLEX 3500 site 30 minutes studying medications 30 minutes (minimum) going over the Facts Throwing site THROWING?? Re: Anyoone up for random FACT Hello guys, So heres some stuff i worked on, and hope it will help you guys. It's random facts. Feel free to correct any mistakes... Food ok to give to infant during first year of life 0-4 mos - breast milk or formula 4-6 mos - pureed fruits, rice cereal, strained veg., ground meat 1 yr - whole milk may be introduced Post-op care for a pt underwent surgical repair of Detached retina - approach pt from left side (to avoid startling the pt) - discourage bending down, coughing and deep breathing - orient pt to his environment -administer stool softener to discourage straining during defacation leads to increase IOP - Pt should lie on his back or on the unaffected side to decrease IOP on the affected side LEFT SIDED HEART FAILURE - backward failure of the LEFT ventricle causes congestion of the pulmonary vasculature. S/S - dyspnea on exertion (in severe case dyspnea at rest) - rales or crackles - pleural effusion - pulmonary edema - orthopnea - dizziness - confusion - cool extremeties at rest - gallop rythm - heart murmur RIGHT SIDED HEART FAILURE - backward failure of the RIGHT ventricle leads to congestion of systemic capillaries. S/S - peripheral edema - jugular vein distention - hepatomegaly - ascites - hepatojugular reflux - nocturia Tx for both left and right sided failure is focused on improving symptoms and preventing progression of the dse. ST JOHN'S WORT (SJW)- most widely known as herbal treatment for major depression. - extracts are usually in tablet or capsule form it can also be in teabags or tincture form. SJW is is generally well tolerated but has some adverse effects like : - dizziness - GI symptoms - confusion - tiredness and sedation - in some cases hair loss also has been noted Note: SJW may interact with birth control pills and may reduce the effectiveness of oral contraceptives by 50%. St John's wort may also contribute to serotonin syndrome in combination with other drugs which may elevate serotonin levels in the CNS. Drugs which may contribute to serotonin syndrome with St John's wortClassDrugsantidepressantsMAOIs, TCAs, SSRIs, mirtazapine, venlafaxineopioidstramadol, pethidineCNS stimulantsphentermine, diethylpropion, amphetamines, sibutramine5-HT1 agoniststriptansillicit drugsmethylenedioxymethamphetamine (MDMA), lysergic acid diethylamide (LSD), cocaineothersse legiline, tryptophan, buspirone, lithium, linezolid, dextromethorphan, 5-HTP ERYTHEMA INFECTIOSUM ( 5th disease) - also called as slapped cheek syndrome - 5th dse derived its classification as the 5th of the classical skin rashes on children called exanthems. Note: in japan it is called " apple disease or ringo- byou " S/S - bright red cheeks ( defining sign that there may an infection) - red lacy rashes on the rest of the body - rash can last up to 2 days (in some cases can last up to several weeks) - pts are no longer infectious once the rash has appeared. Note: In pregnant women - infection had been linked to hydrops fetalis causing spontaneous abortion. Re: Anyoone up for random FACT THROWING?? This one is going to be short and sweet for I am preparing for Susanne's plan which is actually quite good...I am having fun with it. feliz3 Scale measuring Pulse Strength: 0 = Absent 1+ = Pulse is diminished, barely palpable, easily to obliterate 2+ = Easily palpable, normal pulse 3+ = Full pulse, incresed 4+ = Strong, bounding pulse, cannot be obliterated Lung conditions and Expected Sounds: Type: Description: Pneumonia & consolidation = Broncovesicular or bronchial breaths sounds over the affected area. Rales may be present on late inspiration. Rales/crackles = Discontinuous bubbling noises heard on auscultation of the lungs during inspiration. Pneumothorax = Decreased or absent breaths sounds. No adventitious sounds present. Adventitious sounds = a breath sound that s not normally heard such as a rale/crackle, gurgle or a wheeze. It may be superimposed on normal breaths sounds. Tumor = Decreased or absent breath sounds over an area the lungs. Emphysema = Bronchial breaths sounds with prolonged expiration and and decreased intensity. Fine rales often present during late inspiration; occasional rhonchi. Rhonchi = an abnormal sound heard during the auscultation of an airway obstructed by thick secretions, muscular spasm, neoplasm (abnormal cell growth) or external pressure. This is like a continuous rumbling sounds which are more pronounced during expiration and clears on coughing. The person with emphysema coughs a lot an easily get out of air. Pleural effusion = Decreased or absent breaths sounds. A pleural friction rub may be heard. Pleural friction rub = pleuropericardial rub An abnormal coarse, grating sound heard on auscultation of the lungs during late inspiration and early expiration. Asthma = Broncovesicular breaths sounds. Wheezes or sibilant rhonchi usually present. Atelectasis = Vesicular breaths sounds. rales may be heard in late inspirations. Bronchitis = Vesicualr breaths sounds. Rales and sibilant rhonchi (wheezes) present. Best, feliz3 Re: Anyoone up for random FACT THROWING?? Atropine - cyclopegic - temporary paralysis of the muscles of accommodation to maintain pupillary dilatation. Exopthalmos - fluid and fat accumulation in the areas behind the eyeballs forces the eyes forward, out of their sockets. SIADH – d/t extracellular fluid expansion, serum osmolality decreases; sodium levels decline (as a result of being diluted), leading to hyponatremia. Cold insulin - increases tissue hypertrophy; all extra bottles may be stored in the refrigerator, but the bottle currently being used should remain at room temperature, and the insulin should be injected at room temperature. Non-insulin-dependent diabetes mellitus (NIDDM), or type 2 diabetes, - is due to insulin resistance, insulin deficiency, and inappropriate glucose production by the liver RAI uptake - increases in hyperthyroidism and decreases in hypothyroidism Diabetic foot care - no foot soaks; macerate the skin and can increase the risk of breaks in the skin. Diabetes - leading cause of end-stage renal disease (ESRD), the result of chronic kidney disease; in both type 1 and type 2 diabetes, the first sign of deteriorating kidney function is the presence of small amounts of albumin in the urine, a condition called microalbuminuria Addisonian crisis – an acute episode adrenal insufficiency, which can be a life-threatening emergency; weakness, often accompanied by pain in the back, abdomen, or legs, along with severe manifestations of glucocorticoid and mineralocorticoid deficiency including hypotension (particularly postural), tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, hyperpyrexia, and confusion Immed post-op of diabetic clients - the blood sugar frequently fluctuates, therefore, insulin sliding scale is used Post ablation therapy (RAI) - it frequently takes several weeks before the production of thyroid is sufficiently decreased for the blood pressure to return to normal so that beta adrenergic blockers are used to maintain the client’s blood pressure and pulse rate until the RAI has sufficiently decreased the output of the thyroid hormone. Regular insulin (a short-acting insulin) peaks in 2 to 4 hours NPH insulin (an intermediate-acting insulin) peaks in 6 to 12 hours. Metformin (Glucophage) - taken with meals to minimize gastrointestinal effects; adverse effects are abdominal bloating, diarrhea, nausea, vomiting, and an unpleasant metallic taste SILICOSIS - is a chronic fibrotic pulmonary dse caused by inhalation of silica dust (crystalline silicon dioxide particles). Exposure to silica and silicates occurs in almost all mining , quarrying and tunneling operations. S/S - hypoxemia - severe airflow obstruction - right sided failure - edema may occur because of the cardiac failure Management: - Theres is no specific Tx for silicosis, because the fibrotic process in the lung is irreversible. - Supportive therapy is directed at managing complications and preventing infection. - Testing is performed to rule out other lung dses like TB, LUNG CANCER AND SARCOIDOSIS. Note: If TB is present , it is agressively treated and additional therapy might include OXYGEN, DIURETICS, INHALED BETA-ADRENERGIC AGONISTS, ANTICHOLINERGICS, and BRONCHODILATOR THERAPY. TEACHING PTS SELF-CARE FOR CARDIAC PT's The most effective way to increase the probability that the pt will comply with selfcare regimen after discharge is to provide adequate education about the dse process and to facilitate the pt's involvement with the cardiac rehabilitation program. EXPECTED OUTCOMES - experiences relief of pain - shows no signs of respiratory difficulties - maintains adequate tissue perfusion - is less anxious - complies with self care program - avoids complications Levothyroxine (Synthroid) – toxicity include cardiovascular collapse, dysrhythmias, and tachycardias; should not to take the medication if pulse is greater than 100 beats/min and to notify their physician of headaches, nervousness, chest pain, palpitations, or any unusual symptoms. Glipizide (Glucotrol) - sulfonylureas reduce the blood glucose level by stimulating insulin release from the pancreas. PTU – (for hyperthyroidism) report fever, sore throat which are earliest indications of agranulocytosis; most serious toxic effect of the medication. Addison’s disease - should always wear a medical alert ID bracelet and should carry an emergency kit, which should include 100 mg of IM dexamethasone and directions for its injection; the physician’s phone number; and the client’s diagnosis and medication schedule Sliding scale - with the blood sugar level at 200 mg/dl, no additional regular insulin needs to be given. Thyrotoxic crisis, or thyroid storm - an acute condition that can be life threatening; treated with high doses of potassium iodide or strong iodine solution, which inhibits the synthesis of triiodothyronine and thyroxine (T3 & T4) and blocks the release of these hormones in the circulation Somatrem (Protropin) – growth hormone; given at bedtime Vitamin D toxicity - nausea, vomiting, poor appetite, constipation, weakness, and weight loss; raises blood levels of calcium, causing mental status changes such as confusion. Glyburide (Micronase) – is a second-generation sulfonylurea whose primary action is to stimulate the release of insulin from the pancreatic islet cells According to the American Diabetic Association, it is acceptable practice to reuse disposable needles and syringes. Rapid-acting insulins - lispro (Humalog) and insulin aspart (NovoLog), - usually administered within 15 minutes of beginning a meal. Glipizide (Glucotrol) – sulfonylureas; may increase sensitivity to sunlight, resulting in sunburn.; wear sunscreen and to avoid excessive exposure to sunlight Intermediate-acting insulin - Lente, should be given 30 to 60 minutes before a meal. Uptake of fat soluble vitamins - decreased in children with Cystic Fibrosis. Digoxin - increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. Chlamydial infections - one of the most frequent causes of salpingitis or pelvic inflammatory disease. leaking cuff on ET tube - a leak in the cuff would allow air to pass through the trachea and vocal cords, allowing the client to make a noise — to speak. major purpose of oxygen therapy is to decrease the workload of the heart in clients with chronic pulmonary diseases and to assist in preventing right heart failure. croup - causes upper airway obstruction, inspiratory stridor is a predominant symptom. autosomal recessive inheritance pattern occurs with cystic fibrosis; parents are not affected, but each parent carries the trait; there is a 25% chance that with each pregnancy the child will have the condition. Flail chest care - turning, coughing, and deep breathing represent the most appropriate airway care. Acute asthma attack - doing a slow, prolonged exhalation will allow the client to exhale a greater volume and this will facilitate increased oxygenation. CF diet modification - the lack of pancreatic enzymes leads to malabsorption of fats and therefore deficits of the fat-soluble vitamins; these vitamins are administered to the client in a water-soluble form. clavicle puffy and “crackling”noise upon palpation - after thoracic trauma, air in the pleural space (pneumothorax) dissects through soft tissue, causing subcutaneous emphysema; air in the tissues causes the crackling noise. paradoxical respirations may occur with multiple rib fractures. Re: Anyoone up for random FACT THROWING?? OK, this is another short one, dear friends, Dysfunction: ... it is about the Assessment of Thyroid Gland Hyperthyroidism: increased body metabolism nervousness/restlessness tachycardia HR >100 bpm and bounding heart sounds increased blood pressure reduced vital capacity skin warm, moist, and smooth hair fine, nails soft weakness and fatigue demineralization of the bones hypercalcemia---if calcium is high what do you think would be phosphorous level? brisk reflexes increased appetite and weight loss muscle wasting diabetes worsens increased stools increased libido decreased fertility-no period for women higher body temperature exosphtalmus (bug out eyes)--- Graves Disease is a result of hyperthyroidism Thyroidectomy: Removal of a hyperactive thyroid gland post-op critical for patient may BLEED often blood collects behind the neck being pulled by gravity if the patient is lying on his/her back place patient in semi-Fowler's position for avoiding tensionon the suture line assess airway due to potential swelling from the wound vocal chords may be swollen assess frequently for noisy breathing and increased restlessness---very important assess for vocal changes: increased hoarseness--may be indicative of laryngeal edema assess for normal wound healing--avoid infection Note: A patient with this type of surgery gets into trouble, he/she can lose the airway fast. Have a TRACHEOTOMY SET readily available for opening the airway, pronto. Swelling occludes the airway, so frequent assessment for that is a must. Lab value that must be watched carefully: a) calcium levels--parathyroids glands may have been accidentally removed with the thyroid. As you know, parathyroid glands help in maintaining the blood calcium concentration, low levels of calcium will trigger another medical emergency. Therefore, it is necessary to have calcium gluconate readily available in case the serum calcium level goes below its normal limits. Best, feliz3 Early clubbing: -Seen in client with: pallor, fatigue, weakness & dyspnea on exertion angle between the nail plate & Proximal nail fold is straightened to 180 degrees (normal is 160 degrees) └ indicates “early” clubbing” - sign of hypoxia - “nail base” is also “spongy” on palpation - There is normally a 160 degree angle between nail plate & proximal nail fold, & nails shape is normally convex (straightening or flattening beyond 180 degrees= late clubbing) Halo vest traction-MOST CONCERN if: “It hurts when I chew” -If pain occurs with jaw movement in halo traction, -24-48 hours after halo traction has been applied, -it may indicate that skull pins have slipped onto the thin temporal plate -notify physician immediately (Halo vest its normal to have a headache) Acute pancreatitis: -use Meperidine HCL (Demerol) - is drug of choice [Contraindicated is MSO4—B/C it causes spasms of sphincter of Oddi] Intravenous pyelogram: X-ray taken at intervals after dye is injected; -requires bowel perquisite; -NPO after Mid-Night; **Assess for allergies to: -Shellfish, (shrimp) iodine, chocolate, eggs, milk (B/C potential Anaphylaxis!) chronic lung disease - decreased breath sounds caused by the decrease in air movement through the lung fields; increase in the A-P diameter of the chest and there is a prolonged expiratory phase chronic lung disease – most common complication is pneumonia pulmonary embolus - priority is to relieve chest pain and restore oxygenation. chronic bronchitis - history of productive cough and dyspnea. Acute respiratory distress syndrome - a form of pulmonary edema that is characterized by labored respirations and low pO2 in spite of a high Fi02; consistent decline in the p02, regardless of the Fi02 cystic fibrosis - stools are large, bulky, and foul smelling (steatorrhea) low pressure alarm sounds – begin manual mechanical ventilation; the first priority is to ensure that the client is receiving adequate ventilation; usually, the low-pressure alarm sounds when the machine cannot deliver the tidal volume because of a leak or break in the system Important indication of how clients with cystic fibrosis are doing is appetite; poor appetite and weight loss are indications that an infectious process may be occurring three normal breath sounds - vesicular, bronchovesicular, and bronchial Vesicular breath sounds - soft, low-pitched, gentle, rushing sounds that are heard in all of the lung areas, except the major bronchi. Bronchovesicular breath sounds - medium pitch and are heard anteriorly over the main stem bronchi on either side of the sternum and posteriorly between the scapulae. Flail chestproduces paradoxical respirations, which means the affected or flail part of the lung will be sucked in during inspiration (mediastinal shift to uninjured side) and bulge out on expiration (mediastinal shift to the injured side). Chronic bronchitis – teach client to use diagphragmatic breathing to increase lung expansion and maximize ventilation ARDS - PEEP is used to increase Pa02 without raising Fi02; allows lower Fio2 below 60%. Adrenalin - vasoconstriction is a primary effect; throbbing headache, tremor, and increase in blood pressure also occur. Theophylline - N is 10 to 20 mcg/ml; restlessness, tachycardia, insomnia, nausea, and vomiting are indicative of side effects of theophylline at a toxic level. Albuterol (Proventil) by metered-dose inhaler - to be most effective, there needs to be a 1-minute time lapse between the two puffs of medication; the first puff will open the upper airways & will allow more effective penetration of the lower tract with the second puffof medication Processed fruits and vegetables have a higher sodium content than fresh fruits and vegetables. The salicylic acid contained in aspirin and ibuprofen is strong enougho irritate the gastric mucosa, especially in patients diagnosed with peptic ulcer disease. The elderly have a decreased need for calories due to decreased activity. After abdominal surgery, expect bowel sound to return with 12-24 hours. Before a barium enema study, the patient's large intestine must be completely cleaned for a clear view of the colon. During a nasogastric tube feeding the head of the bed needs to be elevated for 30 minutes for facilitation of the absorption process. Drainage from a chest tube should not exceed 100 ml/hour, if the drainage is more than that, or if the drainage becomes bright red or increases, suddenly--call the doctor When to call the doctor: a) if the patient has been injured b) if the patient suddenly experiences adverse effects or an unexpected turn for the worse c) when the patient experiences a negative side effect from a medication d) if the patient refuses a prescribed treatment e) if the prescribed medication is not working When urine output from urethral or nephrostomy tubes is < 30ml/hr or there is no urine output for 15 minutes, call the doctor immediately. Best, fel Re: Anyoone up for random FACT THROWING?? Hi to all of you from sunny California! I want to start a new thread related to Fact Throwing, but is specific to a particular situation. I want to call it: "You call the doctor when"... and we all share our contributions about legitimate reasons to call the doctor. I want to do this because while preparing for the NCLEX some of the questions more often than not there is one alternative "call the physician" and actually that has been the wrong answer for several scenarios presented that I would have chosen to call the MD. It will work like this: You call the doctor when... questioning the safety of a prescription given such as prescribing a dextrose solution to a diabetic the prescription order is illegible or needs clarification on the particular dosage to be given and or the route If you agree to this please follow the format or any other you prefer. Thanks, feliz3 Description of COPD: a) slowly progressive dyspnea b) relatively mild cough later c) increased dyspnea upon exertion d) dyspnea is relieved by rest though it may become persistent e) cough with scant mucoid sputum Note: The drive to breathe for a COPD patient is not getting rid of CO2 as people with healthy oxygen exchange do. COPD patients drive to breathe is apnea. Therefore, a COPD patient cannot be given more than 2-3 liters of Oxygen during an apnea episode. Giving a COPD patient more than 2-3 liters of O2 would affect his center of respiratory reflexes (medulla oblongata) in the brain. Giving a COPD patient O2 at higher rates will knock down the COPD patient's ability to breathe. Best, feliz3Condition pH PaCo2 HCO3 How the body compensates? Metabolic acidosis low normal low With compensation low low low Hyperventilation to blow off excess CO2 and conserve HCO3 Metabolic alkalosis high normal high With compensation high high high Hypoventilation to increase CO2 Kidneys keep H+ and excrete HCO3 Respiratory acidosis low high normal With compensation low high high Kidneys conserve HCO3 And eliminate H+ to increase pH Respiratory alkalosis high low normal With compensation high low low Kidneys eliminate H+ to decrease pH Post aortic femoral bypass graft - after ambulation, it is important to determine the continued integrity of the graft, which is done by checking the pedal pulse of affected leg severe forms of chronic venous disorders - lower extremity edema is the usual initial complaint; pitting edema may be seen at first, but as the edema becomes more chronic, the skin and subcutaneous tissues are replaced by fibrous tissues, resulting in thick, hardened contracted skin. chronic venous insufficiency - leathery, brawny appearance from erythrocyte extravasation to the extremity, persistent edema, stasis dermatitis, and pruritus. venous stasis ulcers - characteristically form near the ankle on the medial aspect with wound margins that are irregularly shaped with tissue that is a ruddy color. Gangrenous wounds and diminished peripheral pulses are associated with arterial occlusive disease. first few hours after femoral bypass graft surgery - greatest risk for graft occlusion; a dramatic increase in the level of pain; loss of a palpable pulse or pulses distal to the operative site; extremity pallor or cyanosis; decreasing ankle-brachial index measurements; numbness, tingling, or a cold extremity temperature may indicate occlusion of the bypass graft and should be reported immediately; pulses have usually returned to normal strength in the operating room after revascularization ankle-brachial index (ABI) – normal resting is 1 or 1.1. ; means that the blood pressure at the ankle is the same as or greater than the pressure at the arm and indicates that there is no significant narrowing or blockage of blood flow. Shock progresses – narrowing pulse pressure Inderal - primary action is to slow the cardiac rate, therefore decrease in cardiac output; effective in the treatment of hypertension or dysrhythmias that result in tachycardia Low therapeutic dose dopamine - support renal perfusion when administered in low doses in the initial stages of shock by dilatation of renal arteries “statin” drugs - for hyperlipidemia are hepatotoxic; liver enzyme levels should be determined as a baseline before administration of the drug is started and periodically throughout therapy. Mannitol – increased tubular excretion of water; is an osmotic diuretic Dopamine IV - increases blood pressure to increase the adequacy of cardiac output; will increase renal perfusion and increase the urinary output. Dopamine (Intropin) - at low doses increases renal perfusion; at intermediate doses, it increases myocardial contractility, which increases cardiac output and oxygen delivery; at high doses, it causes vasoconstriction and ventricular dysrhythmias. Dobutamine (Dobutrex) - usually given in conjunction with dopamine because it has a vasodilation effect, improves cardiac output, and is less likely to cause dysrhythmias. Hypovolemic pt should receive adeq fluid replacemt first - before the initiation of a potent vasopressor, such as Levophed; otherwise the intense vasoconstriction effect will lead to a further reduction in tissue perfusion Condition pH PaCo2 HCO3 Metabolic acidosis With compensation low low normal low low low Metabolic alkalosis With compensation high normal high high high high How the body compensates? Hyperventilation to blow off excess CO2 and conserve HCO3 Hypoventilation to increase CO2 Kidneys keep H+ and excrete HCO3 Respiratory acidosis With compensation low high normal low high high Respiratory alkalosis With compensation high low normal high low low Kidneys conserve HCO3 And eliminate H+ to increase pH Kidneys eliminate H+ to decrease pH Cor pulmonale - jugular vein distention with the client in a sitting position, or with a 45-degree head elevation, is indicative of an increase in the central venous pressure. First-degree heart block - can only be evaluated with an ECG or monitor tracing because the distinguishing factor is a prolonged P-R interval PVCs - irritable foci occurring in the ventricles, which are indicators of cardiac irritability; frequently precede the development of ventricular tachycardia pulmonary artery diastolic pressure increase – strongly suggests left-sided heart failure central venous pressure increase - would indicate right-sided heart failure MAP & CR - increased in heart failure Post central line insertion – check for bil breath sounds to determine whether a pneumothorax has occurred as a complication of the insertion procedure Pedal edema – weigh client to det fluid retention Femoral arteriogram – local anesthetic given to lessen discomfort acute rheumatic fever - carditis, fever, chorea, migratory polyarthritis, erythema marginatum (rash), and subcutaneous nodules. Sinus or atrial tachycardia - heart rate at or above 100 beats/min, the presence of P waves for each QRS complex, a PR interval below 0.20, the T wave should be present after each QRS complex, and the rhythm should be regular cyanotic heart defect – cyanosis, irritability, clubbing of the digits, shortness of breath, crouching or squatting, heart murmur, respiratory tract infections that recur excessively, and stunted growth Nitroglycerin – vasodilator; dilates the coronary arteries, thereby increasing myocardial blood supply PVCs – drug of choice: lidocaine Diltiazem (Cardizem) - calcium channel blocker; reducing heart rate, which will decrease chest pain as well as decrease and blood pressure in the treatment of hypertension Normally, functional closure of the ductus arteriosus occurs by about 15 hours of life in healthy infants born at term. IV indomethacin (Indocin) was the conventional therapy to promote closure of PDA in preemies, but indomethacin affects blood flow to organs such as the kidneys and so may lead to complications such as renal failure Ibuprofen -(the active ingredient in Advil, Motrin, Medipren, and Nuprin) has been found to work as well as indomethacin in treating PDA in preterm infants with respiratory distress syndrome and is less likely to impair kidney function appendicitis – position of comfort is on the side with the legs flexed against the abdomen; the head of the bed should remain slightly elevated to decrease the upward spread of infection in case the appendix ruptures continent Kock’s ileostomy - catheter is placed in the stoma during surgery and is irrigated every 2 to 4 hours postoperatively; catheter may be left in place for about 46 days; client is taught how to catheterize his stoma every 2 to 4 hours to remove any drainage or urine Creutzfeldt-Jakob disease (CJD) is a very rare and incurable degenerative neurological dse. that is mostly fatal. Among the types of transmissible spongiform encephalopathy found in humans it is the most common. S/S - rapidly progressive dementia that leads to memory loss - personality changes and hallucinations - speech impairment - jerky movements (myoclonus) - balance and coordination dysfunction (ataxia) - changes in gait - rigid posture - seizures Note: The duration of the dse varies sporadic CJD can be fatal within months or even weeks . Some pt's sypmtoms can continue for years. It usually affects people aged 45–75, most commonly appearing in people between the ages of 60–65. The exception to this is the more recently-recognised 'variant' CJD (vCJD), which occurs in younger people. INFECTION CONTROL CONTACT PRECAUTION: MRSA Croup Hepatitis A Imetigo C. Diff. DROPLET PRECAUTION: Adenovirus Influenza Parvovirus B19 Streptococcus pharyngitis Diptheria STANDARD PRECAUTION: Lyme dse. Herpes zozter (localized) Meningococcal pneumonia Non contained cellulitis Haemophilus Influenza pneumonia AIRBORNE PRECAUTION: Varicella Tuberculosis Measles This is it for now guys have a lovely weekend pls. feel free to correct any mistakes .... Gastric Ca - achlorhydria, an absence of free hydrochloric acid in the stomach Peritonitis - abdominal pain & distention caused by fluid leaking into the peritoneal cavity, fever, nausea, vomiting, and altered bowel habits (inability to pass gas and feces) Pyloric stenosis - infant should be weighed daily and placed on his or her right side to prevent aspiration after feeding TEF - elevate infant's head 30 degrees decreases gastric reflux into the trachea. Post cleft palate repair - on the side with head slightly elevated to prevent pooling of secretions in the oropharynx; positioning on the back can lead to aspiration of pooling secretions; repair is begun at 6 to 18 months, after some development of the affected area has occurred. Cleft Lip repair – done at 3 mos If w/ s/s of appendicitis - should avoid ambulation so that peristalsis is prevented or activities that increase pain, such as walking; and activity would increase risk of rupture NGT post colon resection or colostomy - to prevent abdominal distention in the client who has had bowel surgery until after peristalsis has returned, bowel sounds are evident, and the colostomy begins to function PUD - “gnawing, burning, or boring” pain right shoulder pain - describes diaphragmatic irritation, most often caused by free air in the abdominal cavity, which is a common postoperative complication perforation- usually preceded by sudden sharp abdominal pain indigestion - heartburn and substernal discomfort bowel obstruction - bowel sounds proximal to the obstruction are frequently hyperactive; bowel sounds distal to the obstruction will be hypoactive Bowel sounds are considered absent if they are not detected after listening to all four quadrants for a total of 5 minutes. placement of a central line - very easy to cause a pneumothorax; immediate evaluation of the breath sounds is important. A chest x-ray film should also be obtained after the procedure is completed; the placement of the line should be verified before beginning administration of the hyperalimentation solution Daily irrigations are not indicated for an ileostomy and would cause a loss of digestive enzymes, fluid, and electrolytes. Misoprostol (Cytotec) - protects the lining of the stomach by stimulating the secretion of mucous and increasing the bicarbonate production; a gastric antisecretory agent Metoclopramide - is a GI stimulant and should not be given in situations where an intestinal obstruction is suspected severe hepatic disease – diet aimed in reducing ammonia levels through consumption of low-protein foods and simple carbohydrates Referred shoulder pain - common response after a laparoscopic cholecystectomy. The laparoscopic procedure uses carbon dioxide to expand the peritoneal cavity for better visibility, while the gallbladder is removed through a tiny incision; activity and walking will help to absorb the carbon dioxide Referred Pain = Pain perceived as coming from an area different from that in which the pathology is occurring. An example of this would be the perception of left arm or jaw pain in a person having a myocardial infarction. This is the attachment...I put some notes on picture for guiding me feliz3 Please, click on the picture to see bigger. Thanks, feliz 3 PS this would not have been possible without the kind assistance of super moderator Silverdragon102. I want to thank her publicly. I do not know why is so hard just to put a simple attachment on this page. Please, bear with me I just sent a message to silverdragon102, supermoderator about having difficulties attaching the picture. feliz3 Levodopa – (parkinsons) first side effect to be noticed may be gastrointestinal problems like anorexia, N&V. ; taking medication with meals may alleviate these symptoms. Most CSF leaks resolve spontaneously; child should be maintained on bed rest until drainage ends. early symptom of Parkinson’s disease - slowness of movements in all normal activities of daily living Parkinson’s – mood fluctuations Irritability and vomiting are common signs of increased intracranial pressure in the infant; the symptoms are often delayed in the infant because of the open fontanels Done to pts w/ increased ICP - hyperventilation causes respiratory alkalosis, which results in cerebral vasoconstriction; this decreases the circulating cerebral blood volume and thus decreases intracranial pressure MS early signs - include difficulty with fine motor movement, especially of the head and neck; often, visual disturbance / diplopia is the most ominous sign Tonic-clonic or generalized seizure - loss of consciousness and involvement of all the major motor muscles cerebral palsy – in infant, feeding difficulties because of poor sucking ability and persistent tongue thrust cerebral palsy - often occurs as a result of hypoxia during labor and delivery; it is more likely with a premature, small child (1500 gm) or with a difficult labor and delivery (C5) level of injury - intercostal muscles and diaphragm can be affected; high risk for development of respiratory compromise Pupillary checks - pupils are checked for the reaction to light and accommodation, which is controlled by cranial nerve III (oculomotor) post lumbar puncture - increase oral intake to facilitate the body’s replacement of the cerebrospinal fluid that withdrawn MS - prevention of constipation and urinary tract problems is important in the health promotion; keeping cool, not warm, is associated with improvement of neurological function bed to a wheelchair transfer - should move his upper body to the wheelchair first and then move his legs from the bed to the wheelchair myelogram- sensation of flushing is a typical response to radiopaque dye when it is injected intravenously simple partial seizure - unilateral paresthesia, numbness and tingling, and spastic movement of the extremities (old term is Jacksonian seizure); no loss of consciousness or incontinence of bowel or bladder myasthenic crisis - respiratory muscles are affected and aspiration is a concern; compromises respirations and may result in infections, aspiration and respiratory insufficiency myelomeningocele usual complication – hydrocephalus; rapid increase in head size (increase in frontal occipital circumference), irritability, suture line separation, and bulging fontanels; eyes appear to look downward only, with the cornea prominent over the iris (sunset sign) osteoarthritis - gradual onset and affects weight-bearing joints with pain that is more pronounced after exercise herniated lumbar disk pre-op - movement and sensation should be evaluated before surgery to have as a base for evaluation during the postoperative recovery period balanced suspension traction with a Thomas splint - check the groin area where the thigh is supported Osteoarthritis and gouty arthritis – unilateral Crepitus - associated with osteoarthritis. hip dysplasia - help stabilize the hip, a Pavlik harness is used Denis Browne - splint is used to correct talipes equinovarus Harrington rods - surgically inserted to treat scoliosis post lumbar laminectomy - bladder dysfunction may occur after surgery because of impaired innervation to the bladder from the lumbar area; client should be checked every 2 to 4 hours for bladder distention. menopausal or post menopausal women, prolonged steroid intake and hyperthyroid intake have all been associated with the development of osteoporosis Pickup Walker use - arms are flexed 30° when standing in the walker, the walker is advanced and the client steps into the walker with the affected leg first, bearing weight on the walker as the client moves forward Acetylsalicylic acid (aspirin) - DOC and is the most effective in the early treatment of rheumatoid arthritis H2 blockers – like Zantac, are not effective in preventing ulcerations caused by nonsteroidal antiinflammatory drugs (NSAIDs); if the client is using NSAIDs to control the pain from arthritis, the nurse should notify the health care provider to consider changing the medications First sign of toxic shock syndrome - rapid onset of high fever TX for wernicke's encephalopathy - thiamine IV Pap smear classification of CIN grade III - highly suggestive of malignancy post abdominal hysterectomy – observe for decreased UO; low back pain and decreased urine output are serious symptoms that may indicate accidental intraoperative cutting of the ureter Gonorrhea in men - urethritis, dysuria, and purulent drainage fluorescent treponemal antibody absorption test - identifies the spirochete treponema pallidum, which causes syphilis Up to 100 ml of serosanguineous fluid would be an acceptable amount of drainage over a 24-hour period in a client who has had a mastectomy. BPH complication - flank pain and hematuria may be indicative of an infection or a ureteral obstruction causing increased pressure on the renal pelvis postcoital bleeding - common symptom of cervical cancer Depo provera - irregular menses and edema are common; administered by IM injection every 3 months tetracyclines and ampicillins - may decrease the effectiveness of the oral contraceptives serious side effects of OCs - thromboembolic problems; increased risk for a stroke, an MI, or a pulmonary embolism Rapid instillation and removal of dialysate fluid along with accumulation of the fluid under the diaphragm can lead to pain and discomfort indications for dialysis - volume overload, weight gain, hyperkalemia, metabolic acidosis, and rising BUN (normal is 8-25 mg/dl) and serum creatinine (normal is 0.6-1.3 mg/dl) levels, along with decreased urinary creatinine clearance disequilibrium syndrome - decrease in blood pressure, confusion, and sometimes seizures OHAs - not usually recommended for breast-feeding mothers RhoD - given to all Rh-negative women in the twenty-eighth week of gestation negative rubella titer (serologically a titer of 1:8 or enzyme immunoassay [EIA] level of 0.8) - indication that the woman needs to be vaccinated; women must understand that they must practice contraception to avoid pregnancy for 2 to 3 months after being vaccinated because of risks associated with side effects and teratogenic effects of the live vaccine ruptured fallopian tube - causes a sharp, sudden, stabbing pain. Symptoms of shock (decreased BP, increased pulse, and respirations) occur as the client’s condition quickly becomes a surgical emergency Board-like abdominal rigidity is often noted with abruptio placentae. In the last two trimesters of pregnancy, the insulin needs should steadily increase as a result of the insulin antagonism from the placenta and the fetus; lack of an increased need for insulin may be a sign of placental insufficiency Women over 35 years old - routinely scheduled for amniocentesis to determine presence of fetal genetic defects Post amniocentesis - damage to the membranes is a possibility and a high-priority situation; without the protective barrier of the amniotic membrane, the mother and the baby are susceptible to infection; should refrain from sexual intercourse because of the possibility of introduction of pathogens; bathing would also be a hazard because of the possibility of contracting an infection from the bath water diaphragm - predisposes many women to UTIs; some women are sensitive to the contraceptive cream or jelly; has been associated with toxic shock syndrome; hence, its use should be avoided during menses, and it should not be left in place longer than 6-8 hours Depo-Provera - frequently associated with menstrual cycle changes; irregular bleeding is the most commonly cited reason for discontinuation RhoGAM or RhoD - given with and after each pregnancy, including an abortion of an Rh positive fetus Chorionic villi sampling - performed at 8 to 12 weeks' gestation to detect genetic disease; performed early to give the client the option of terminating the pregnancy if genetic defects are present Re: Anyoone up for random FACT THROWING?? Hegar’s sign - (softening of the lower uterine isthmus) may be present at 6 to 8 weeks' gestation, along with Chadwick’s sign, a bluish-purple discoloration of the vaginal walls When a laboring client is at +3, delivery is imminent priority nursing measure to correct a variable deceleration - to change the mother’s position; problem may be caused by pressure on the umbilical cord, and a position change will help to relieve it abruptio placentae - prone to the development of disseminated intravascular coagulation after delivery, which is characterized by abnormal fibrinogen and coagulation studies Epidural anesth- left lateral (Sims') position with legs flexed and shoulders parallel to readily expose the lumbar spaces; or the client may be in a sitting position with her shoulders resting on the bedside table Urine retention - common cause of uterine atony and can lead to postpartum hemorrhage; urine retention causes a distended bladder to displace the uterus above the umbilicus and to the side, which prevents the uterus from contracting nurse should assess an episiotomy for presence of edema and approximation of the incision; swelling in the perineal area causes more tension on the suture line and increases pain; although the perineal sutures may be difficult to visualize, the suture line should be intact contraction of 60 seconds in duration and occurring every 2 minutes is too strong and too frequent; pitocin infusion must be either stopped or slowed to prevent uterine rupture Before the administration of magnesium sulfate, the total urine output should be above 30 ml per hour, respiratory rate should be >12 breaths/min, and deep tendon reflexes should be 2+ Close monitoring of frequency (q15mins) and length of contractions is critical for a client receiving oxytocin before delivery; FHR should be monitored on an almost a continuous basis in clients receiving oxytocin Within 12 hours, the fundus may be approximately 1 cm above the level of the umbilicus Post cleft lip repair – supine head turned to side; it is important that the child be positioned in such a manner that he does not traumatize the incisional area and that the airway is maintained It is not necessary to cover the neonate’s eyes with use of the fiberoptic blanket; feedings and fluids should be encouraged to promote excretion of the bilirubin Post circumcision - whitish-yellowish exudate around the glans penis is granulation tissue and is normal; it will usually disappear within 2 to 3 days; it is not an infection Grunting creates a “back-pressure” in an attempt to keep alveoli from collapsing; if the alveoli are kept open, the functional residual capacity will increase, the lungs will be better ventilated, and the Po2 will increase Post cicumcision - petroleum jelly should be applied as a moisture barrier to the head of the penis; this should be done after each diaper change; a dry dressing should not be used In clients diagnosed with gouty arthritis, encourage intake of large amounts of water (2,5003,000) to prevent the precipitation of ureate(uric acid salts) in the kidneys. validation is the process of double checking questionable findings during assessment, for example double-checking an unusually high blood pressure before writing it down on the progress notes. Compartment syndrome results from accumulation of fluid within a muscle compartment, which decreases the blood flow to tissues and can lead to neuromuscular deficiency and tisue death. It is usually seen in long bone fractures. HgbAIc provides useful information about how well diabetes has being controlled for the past 3 months. The normal valueof Hgb A1c is 7.5 or less. A mild transient fever is expected after a surgery. A high sustained fever indicates complications such as atelectasis(collapse of a lung area) within the first 48 hours after surgery; infection of the wound withing 1 week; urinary tract infection within 5 days and thrombophlebitis within the first week. What to do? insentive spirometry 5-10 every hour-atelectasis; carefull assessment of wound and strict handwashing--infection and for thrombophlebitis support stockings. Best, feliz3 Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation From 24-34 weeks gestation, fundal height correlates with # of weeks of gestation. Example: At 26 weeks gestation, fundal height measures approximately 26 cm. If an immunocompromised child who has not had chickenpox is exposed to someone with varicella, the child should receive varicella zoster immune globulin within 96 hours of exposure. Psoriasis - occurs equally among women and men, although the incidence is lower in darker skinned races and ethnic groups Epididymitis from urinary tract infection should decrease intake of acidic foods and increase fluid intake to flush the urinary system. Because organisms can be forced into the vas deferens and epididymis from strain or pressure during voiding, the client should limit the force of the stream Blurred central visionoccurs with macular degeneration; changes in peripheral visual acuity most often occurs with glaucoma; glare from bright lights is a common complaint in the client with a cataract post pneumonectomy - client should be instructed to perform arm and shoulder exercises two or three times a day; should expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks Black cohosh produces estrogen-like effects. Zinc stimulates the immune system and is used for its antiviral properties. Echinacea stimulates the immune system and ginger is used for nausea and vomiting. Total nutrient admixture (TNA) is a solution that combines dextrose, amino acids, and lipids in one solution; 1.2-µm filter or larger filter should be used because the lipid particles are too large to pass through a smaller (0.22- or 0.10-µm) filter; 0.22-µm filter is used for 2-in-1 solutions containing only dextrose and amino acids Parenteral nutrition solution should be changed every 24 hours because the PN solution is a high-concentrate glucose solution and is a medium for bacterial growth. Infection control is also aided by use of aseptic technique with bag and tubing changes. Most agencies recommend that tubing be changed every 24 hours along with the bag Optimal weight gain on PN is 1 to 2 lb/week If the client has a temperature higher than 100° F, the unit of blood should not be hung until the physician is notified and has the opportunity to give further orders. post surgery - temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately AKA - amputated limb is supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema; after the first 24 hours, the amputated limb usually is placed flat on the bed to reduce hip contracture Residual amounts more than 100 mL require holding the feeding Obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. Pitocin - goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period; uterus should return to resting tone between contractions, and there should be no evidence of fetal distress hydrocephalus - if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown Acute otitis media -child is positioned on his or her affected side to facilitate drainage; a soft diet is recommended during the acute stage to avoid pain that can occur with chewing. Status asthmaticus - inhaled aerosolized short-acting β2 agonists are quick relief medications and recommended for clients with status asthmaticus after epinephrine has been administered aortic stenosis - shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods of time early signs of congestive heart failure (CHF) - include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress Intussusception - sausage-shaped mass at RUQ Complication after surgical treatment of scoliosis is superior mesenteric artery syndrome - is caused by mechanical changes in the position of the child’s abdominal contents, resulting from lengthening of the child’s body; results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain; although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important; these exercises do not involve joint movement Petechial red, pinpoint spots occurring on the soft palate are characteristic of rubella (German measles). Coal tar - used to treat psoriasis and other chronic disorders of the skin; suppresses DNA synthesis, mitotic activity, and cell proliferation; has an unpleasant odor, frequently stains the skin and hair, and can cause phototoxicity Mafenide acetate - a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis;clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation); if this occurs, the medication should be discontinued for 1 to 2 days A side effect specific to etoposide is orthostatic hypotension; should be administered slowly over 30 to 60 minutes to avoid hypotension; blood pressure is monitored during the infusion Water intoxication (overhydration) or hyponatremia is an adverse reaction to desmopressin; early signs include drowsiness, listlessness, and headache Oral doses of levothyroxine (Synthroid) should be taken on an empty stomach to enhance absorption; dosing should be done in the morning before breakfast The client who is taking an antihypocalcemic medication should be instructed to avoid eating too much spinach, rhubarb, bran, or whole-grain cereals because they decrease calcium absorption Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese Propantheline bromide - antimuscarinic anticholinergic medication that decreases gastrointestinal secretions; should be administered 30 minutes before meal Magnesium citrate - available as an oral solution and is used commonly as a laxative in preparation for or after certain studies of the gastrointestinal tract. Magnesium citrate should be served chilled and not be allowed to stand for prolonged periods, which would reduce the carbonation and make the solution even less palatable Prochlorperazine is a phenothiazine - type antiemetic and antipsychotic; assess the client for blurred vision as a frequent side effect of prochlorperazine; other frequent side effects include dry eyes, dry mouth, and constipation TB - one of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum Carbon dioxide narcosis - condition that results from extreme hypercapnia, with carbon dioxide levels in excess of 70 mm Hg With a rapid drop in carbon dioxide levels, the kidneys are unable to excrete bicarbonate ions at the same rate. The client can experience rebound metabolic alkalosis, with resulting seizure activity Pulmonary sarcoidosis - can lead to cor pulmonale (or failure of the right side of the heart), characterized by distended neck veins, elevated central venous pressure, full bounding pulse, weight gain, engorged liver, and peripheral edema Terbutaline (Brethine) - bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics; should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, or hyperthyroidism, and a history of seizures; may increase blood glucose levels Zafirlukast - used with caution in clients with impaired hepatic function; liver function laboratory tests should be performed client taking adrenergic bronchodilators may experience paradoxical bronchospasm, which is evidenced by the client’s wheezing; this can occur with excessive use of inhalers; further medication should be withheld, and the physician should be notified Thiazide diuretics such as hydrochlorothiazide - sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction; WOF risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia Post renal biopsy - if pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected trimethoprim (TMP)-sulfamethoxazole (SMZ) (Bactrim) - should be informed about early signs of blood disorders that can occur from this medication such as sore throat, fever, and pallor, and the client should be instructed to notify the physician if these symptoms occur Bethanecol Cl (Urecholine) - toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension Amphotericin B deoxycholate, erythromycin, and ketoconazole can elevate cyclosporine levels; when any of these medications is combined with cyclosporine, the dosage of cyclosporine must be reduced to prevent accumulation to toxic levels Epoetin alfa (Epogen, Procrit) - client should be instructed not to shake the bottle; should be refrigerated at all times; should not be frozen Parkinson’s disease - should exercise in the morning when energy levels are highest; should avoid sitting in soft deep chairs because they are difficult to get up from; can rock back and forth to initiate movement; should buy clothes with Velcro fasteners and slide-locking buckles to support the ability to dress self Stress ulcer - can be detected by Hematest-positive nasogastric tube aspirate or stool Baclofen - a skeletal muscle relaxant and frequently causes drowsiness, dizziness, weakness, and fatigue; also can cause nausea, constipation, and urinary retention Pentam 300 - frequent side effects of this medication include leukopenia, thrombocytopenia, and anemia; should be monitored routinely for signs and symptoms of infection adverse effect of PTU - agranulocytosis; needs to be informed of the early signs of this adverse effect, which include fever and sore throat Post cervical radiation - foul-smelling vaginal discharge is expected and will occur for some time following removal of a cervical radiation implant Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation From 24-34 weeks gestation, fundal height correlates with # of weeks of gestation. Example: At 26 weeks gestation, fundal height measures approximately 26 cm. If an immunocompromised child who has not had chickenpox is exposed to someone with varicella, the child should receive varicella zoster immune globulin within 96 hours of exposure. Psoriasis - occurs equally among women and men, although the incidence is lower in darker skinned races and ethnic groups Epididymitis from urinary tract infection should decrease intake of acidic foods and increase fluid intake to flush the urinary system. Because organisms can be forced into the vas deferens and epididymis from strain or pressure during voiding, the client should limit the force of the stream Blurred central visionoccurs with macular degeneration; changes in peripheral visual acuity most often occurs with glaucoma; glare from bright lights is a common complaint in the client with a cataract post pneumonectomy - client should be instructed to perform arm and shoulder exercises two or three times a day; should expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks Black cohosh produces estrogen-like effects. Zinc stimulates the immune system and is used for its antiviral properties. Echinacea stimulates the immune system and ginger is used for nausea and vomiting. Total nutrient admixture (TNA) is a solution that combines dextrose, amino acids, and lipids in one solution; 1.2-µm filter or larger filter should be used because the lipid particles are too large to pass through a smaller (0.22- or 0.10-µm) filter; 0.22-µm filter is used for 2-in-1 solutions containing only dextrose and amino acids Parenteral nutrition solution should be changed every 24 hours because the PN solution is a high-concentrate glucose solution and is a medium for bacterial growth. Infection control is also aided by use of aseptic technique with bag and tubing changes. Most agencies recommend that tubing be changed every 24 hours along with the bag Optimal weight gain on PN is 1 to 2 lb/week If the client has a temperature higher than 100° F, the unit of blood should not be hung until the physician is notified and has the opportunity to give further orders. post surgery - temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately AKA - amputated limb is supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema; after the first 24 hours, the amputated limb usually is placed flat on the bed to reduce hip contracture Residual amounts more than 100 mL require holding the feeding Obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. Pitocin - goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period; uterus should return to resting tone between contractions, and there should be no evidence of fetal distress hydrocephalus - if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown Acute otitis media -child is positioned on his or her affected side to facilitate drainage; a soft diet is recommended during the acute stage to avoid pain that can occur with chewing. Status asthmaticus - inhaled aerosolized short-acting β2 agonists are quick relief medications and recommended for clients with status asthmaticus after epinephrine has been administered aortic stenosis - shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods of time early signs of congestive heart failure (CHF) - include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress Intussusception - sausage-shaped mass at RUQ Complication after surgical treatment of scoliosis is superior mesenteric artery syndrome - is caused by mechanical changes in the position of the child’s abdominal contents, resulting from lengthening of the child’s body; results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain; although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important; these exercises do not involve joint movement Petechial red, pinpoint spots occurring on the soft palate are characteristic of rubella (German measles). Coal tar - used to treat psoriasis and other chronic disorders of the skin; suppresses DNA synthesis, mitotic activity, and cell proliferation; has an unpleasant odor, frequently stains the skin and hair, and can cause phototoxicity Mafenide acetate - a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis;clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation); if this occurs, the medication should be discontinued for 1 to 2 days A side effect specific to etoposide is orthostatic hypotension; should be administered slowly over 30 to 60 minutes to avoid hypotension; blood pressure is monitored during the infusion Water intoxication (overhydration) or hyponatremia is an adverse reaction to desmopressin; early signs include drowsiness, listlessness, and headache Oral doses of levothyroxine (Synthroid) should be taken on an empty stomach to enhance absorption; dosing should be done in the morning before breakfast The client who is taking an antihypocalcemic medication should be instructed to avoid eating too much spinach, rhubarb, bran, or whole-grain cereals because they decrease calcium absorption Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese Propantheline bromide - antimuscarinic anticholinergic medication that decreases gastrointestinal secretions; should be administered 30 minutes before meal Magnesium citrate - available as an oral solution and is used commonly as a laxative in preparation for or after certain studies of the gastrointestinal tract. Magnesium citrate should be served chilled and not be allowed to stand for prolonged periods, which would reduce the carbonation and make the solution even less palatable Prochlorperazine is a phenothiazine - type antiemetic and antipsychotic; assess the client for blurred vision as a frequent side effect of prochlorperazine; other frequent side effects include dry eyes, dry mouth, and constipation TB - one of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum Carbon dioxide narcosis - condition that results from extreme hypercapnia, with carbon dioxide levels in excess of 70 mm Hg With a rapid drop in carbon dioxide levels, the kidneys are unable to excrete bicarbonate ions at the same rate. The client can experience rebound metabolic alkalosis, with resulting seizure activity Pulmonary sarcoidosis - can lead to cor pulmonale (or failure of the right side of the heart), characterized by distended neck veins, elevated central venous pressure, full bounding pulse, weight gain, engorged liver, and peripheral edema Terbutaline (Brethine) - bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics; should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, or hyperthyroidism, and a history of seizures; may increase blood glucose levels Zafirlukast - used with caution in clients with impaired hepatic function; liver function laboratory tests should be performed client taking adrenergic bronchodilators may experience paradoxical bronchospasm, which is evidenced by the client’s wheezing; this can occur with excessive use of inhalers; further medication should be withheld, and the physician should be notified Thiazide diuretics such as hydrochlorothiazide - sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction; WOF risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia Post renal biopsy - if pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected trimethoprim (TMP)-sulfamethoxazole (SMZ) (Bactrim) - should be informed about early signs of blood disorders that can occur from this medication such as sore throat, fever, and pallor, and the client should be instructed to notify the physician if these symptoms occur Bethanecol Cl (Urecholine) - toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension Amphotericin B deoxycholate, erythromycin, and ketoconazole can elevate cyclosporine levels; when any of these medications is combined with cyclosporine, the dosage of cyclosporine must be reduced to prevent accumulation to toxic levels Epoetin alfa (Epogen, Procrit) - client should be instructed not to shake the bottle; should be refrigerated at all times; should not be frozen Parkinson’s disease - should exercise in the morning when energy levels are highest; should avoid sitting in soft deep chairs because they are difficult to get up from; can rock back and forth to initiate movement; should buy clothes with Velcro fasteners and slidelocking buckles to support the ability to dress self Re: Anyoone up for random FACT THROWING?? Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation From 24-34 weeks gestation, fundal height correlates with # of weeks of gestation. Example: At 26 weeks gestation, fundal height measures approximately 26 cm. If an immunocompromised child who has not had chickenpox is exposed to someone with varicella, the child should receive varicella zoster immune globulin within 96 hours of exposure. Psoriasis - occurs equally among women and men, although the incidence is lower in darker skinned races and ethnic groups Epididymitis from urinary tract infection should decrease intake of acidic foods and increase fluid intake to flush the urinary system. Because organisms can be forced into the vas deferens and epididymis from strain or pressure during voiding, the client should limit the force of the stream Blurred central visionoccurs with macular degeneration; changes in peripheral visual acuity most often occurs with glaucoma; glare from bright lights is a common complaint in the client with a cataract post pneumonectomy - client should be instructed to perform arm and shoulder exercises two or three times a day; should expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks Black cohosh produces estrogen-like effects. Zinc stimulates the immune system and is used for its antiviral properties. Echinacea stimulates the immune system and ginger is used for nausea and vomiting. Total nutrient admixture (TNA) is a solution that combines dextrose, amino acids, and lipids in one solution; 1.2-µm filter or larger filter should be used because the lipid particles are too large to pass through a smaller (0.22- or 0.10-µm) filter; 0.22-µm filter is used for 2-in-1 solutions containing only dextrose and amino acids Parenteral nutrition solution should be changed every 24 hours because the PN solution is a high-concentrate glucose solution and is a medium for bacterial growth. Infection control is also aided by use of aseptic technique with bag and tubing changes. Most agencies recommend that tubing be changed every 24 hours along with the bag Optimal weight gain on PN is 1 to 2 lb/week If the client has a temperature higher than 100° F, the unit of blood should not be hung until the physician is notified and has the opportunity to give further orders. post surgery - temperature higher than 37.7°C (100°F) or lower than 36.1°C (97°F) and a falling systolic blood pressure, lower than 90 mm Hg, are usually considered reportable immediately AKA - amputated limb is supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema; after the first 24 hours, the amputated limb usually is placed flat on the bed to reduce hip contracture Residual amounts more than 100 mL require holding the feeding Obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. Pitocin - goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period; uterus should return to resting tone between contractions, and there should be no evidence of fetal distress hydrocephalus - if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help prevent skin breakdown Acute otitis media -child is positioned on his or her affected side to facilitate drainage; a soft diet is recommended during the acute stage to avoid pain that can occur with chewing. Status asthmaticus - inhaled aerosolized short-acting β2 agonists are quick relief medications and recommended for clients with status asthmaticus after epinephrine has been administered aortic stenosis - shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods of time early signs of congestive heart failure (CHF) - include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress Intussusception - sausage-shaped mass at RUQ Complication after surgical treatment of scoliosis is superior mesenteric artery syndrome - is caused by mechanical changes in the position of the child’s abdominal contents, resulting from lengthening of the child’s body; results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain; although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important; these exercises do not involve joint movement Petechial red, pinpoint spots occurring on the soft palate are characteristic of rubella (German measles). Coal tar - used to treat psoriasis and other chronic disorders of the skin; suppresses DNA synthesis, mitotic activity, and cell proliferation; has an unpleasant odor, frequently stains the skin and hair, and can cause phototoxicity Mafenide acetate - a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis;clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation); if this occurs, the medication should be discontinued for 1 to 2 days A side effect specific to etoposide is orthostatic hypotension; should be administered slowly over 30 to 60 minutes to avoid hypotension; blood pressure is monitored during the infusion Water intoxication (overhydration) or hyponatremia is an adverse reaction to desmopressin; early signs include drowsiness, listlessness, and headache Oral doses of levothyroxine (Synthroid) should be taken on an empty stomach to enhance absorption; dosing should be done in the morning before breakfast The client who is taking an antihypocalcemic medication should be instructed to avoid eating too much spinach, rhubarb, bran, or whole-grain cereals because they decrease calcium absorption Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese Propantheline bromide - antimuscarinic anticholinergic medication that decreases gastrointestinal secretions; should be administered 30 minutes before meal Magnesium citrate - available as an oral solution and is used commonly as a laxative in preparation for or after certain studies of the gastrointestinal tract. Magnesium citrate should be served chilled and not be allowed to stand for prolonged periods, which would reduce the carbonation and make the solution even less palatable Prochlorperazine is a phenothiazine - type antiemetic and antipsychotic; assess the client for blurred vision as a frequent side effect of prochlorperazine; other frequent side effects include dry eyes, dry mouth, and constipation TB - one of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum Carbon dioxide narcosis - condition that results from extreme hypercapnia, with carbon dioxide levels in excess of 70 mm Hg With a rapid drop in carbon dioxide levels, the kidneys are unable to excrete bicarbonate ions at the same rate. The client can experience rebound metabolic alkalosis, with resulting seizure activity Pulmonary sarcoidosis - can lead to cor pulmonale (or failure of the right side of the heart), characterized by distended neck veins, elevated central venous pressure, full bounding pulse, weight gain, engorged liver, and peripheral edema Terbutaline (Brethine) - bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics; should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, or hyperthyroidism, and a history of seizures; may increase blood glucose levels Zafirlukast - used with caution in clients with impaired hepatic function; liver function laboratory tests should be performed client taking adrenergic bronchodilators may experience paradoxical bronchospasm, which is evidenced by the client’s wheezing; this can occur with excessive use of inhalers; further medication should be withheld, and the physician should be notified Thiazide diuretics such as hydrochlorothiazide - sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction; WOF risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia Post renal biopsy - if pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected trimethoprim (TMP)-sulfamethoxazole (SMZ) (Bactrim) - should be informed about early signs of blood disorders that can occur from this medication such as sore throat, fever, and pallor, and the client should be instructed to notify the physician if these symptoms occur Bethanecol Cl (Urecholine) - toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension Amphotericin B deoxycholate, erythromycin, and ketoconazole can elevate cyclosporine levels; when any of these medications is combined with cyclosporine, the dosage of cyclosporine must be reduced to prevent accumulation to toxic levels Epoetin alfa (Epogen, Procrit) - client should be instructed not to shake the bottle; should be refrigerated at all times; should not be frozen Parkinson’s disease - should exercise in the morning when energy levels are highest; should avoid sitting in soft deep chairs because they are difficult to get up from; can rock back and forth to initiate movement; should buy clothes with Velcro fasteners and slide-locking buckles to support the ability to dress self Stress ulcer - can be detected by Hematest-positive nasogastric tube aspirate or stool Baclofen - a skeletal muscle relaxant and frequently causes drowsiness, dizziness, weakness, and fatigue; also can cause nausea, constipation, and urinary retention Pentam 300 - frequent side effects of this medication include leukopenia, thrombocytopenia, and anemia; should be monitored routinely for signs and symptoms of infection adverse effect of PTU - agranulocytosis; needs to be informed of the early signs of this adverse effect, which include fever and sore throat Post cervical radiation - foul-smelling vaginal discharge is expected and will occur for some time following removal of a cervical radiation implant This I attached chart helps to find the right answer NCLEX –PN, I am practicing based on this chart it is helped me, good critical thinking practice 1SEFETY All answer must be implementations Try to answer based on knowledge if you cant What will cause the client the least amount of harm 2-MASELOW Recognize the answer are both physical & psychosocial Eliminate psychosocial answers “Does this make sense?” ABC 3-THERAPEUTIC COMMUNICATION Eliminate don’t worry’ Eliminate ‘explore answer Don’t ask “why?” Eliminate “authoritarian” answer Eliminate “focus on the nurse” answer 4-COLLECT DATA Vs IMPLEMENT Recognize both data collection and implementation answers Read stem to decide whether to collect data or implement. Select best data collection or implementation 5-EXPECTED OUTCOME What is expected out come? What is the best action for expected out come. 6-REAL WORLD Don’t use the real world experience to answer NCLEX-PN exam questions. You have time the staff and the equipment Take care of the client first The NCLEX –PN exam tests the LPN judgment 7-POSITIONING Are you try to prevent or promote What are you trying to prevent or promote Think A&P 8-QUESTION Read the stem one time Read answer choice for clues to topic Reword question using clues from answer choices. 9-ANSWERS Read the stem Identity the topic Read the answer choices Identify the nursing concept contained in answer choice. Idiopathic thrombocytopenic purpura (ITP) is having low platelet count (thrombocytopenia) of no known cause (idiopathic). Although most cases are asymptomatic, very low platelet counts can lead to bleeding diathesis and purpura. Usually, ITP patients suffer from bruising; petechiae, nosebleeds and bleeding gums may occur if the platelet count really low. Not Ready, Ready Now": Air into NPH Air into Regular Draw up Regular Draw up NPH If it is help Urinary incontinence is associated with a risk for, fractures, pressure ulcers, and depression. When skin break dowen related with incontinence, the care giver implied, Keep the skin clean and dry, Assess for signs of breakdown, Apply protective barrier creams and implement bladder retraining program. Signs of Aspiration: sudden onse of coughing and shortness of breath (SOB) while eating, drinking or regurgitation tachypnea, dyspnea, cyanosis, decreased breath sounds tachycardia, bradycardia crackles and rhonchi (usually on the right lung, but it could be bilateral) altered mental status fever chest pain(pleuritic) Immediate Intervention: elevate the head of the bed (HOB) to upright position and help the client to expectorate provide supplemental Oxygen suction oropharynx encourage coughing when client is out of danger call the doctor and document doctor's response to the report given Focused Assessment: assess client's ability to clear airway and effort to breathe assess airway for secretions or foreign objects assess effectiveness of measures to clear the airway assess oxygenation status: level of consciousness(LOL), Oxygen saturation, presence of circumoral (area around the mouth) and nailbed cianosis assess hear rate, blood pressure, respiration rate, rhythm, effort and work of breathing auscultate lung fields Note: Continue to monitor airway and respiratory function. Symptoms of Dehydration: increased respirations increased heart rate decreased central venous pressure (CVP) normal CVP = 4-11 cm water weight loss poor skin turgor dry mucous membranes decreased urine volume increased specific gravity normal specific gravity = 1.016-1.022 (depending on laboratory) CVP= the pressure under which blood is returned to the superior vena cava and right atrium Specific Gravity = Urine test that measures the kidney's ability to concentrate urine. Note: Decreased specific gravity occurs with increased fluid retention. Could you guess, why? feliz3 Hi you all, I want to add more information to the subject of dehydration. Now I want to add the possible Causes of Deficient Fluid Volume (another name for good old dehydration) feliz3 Causes of Dehydration: 1) diarrhea 2) conditions that cause increased respiration such as vigorous exercising 3) conditions that cause increased urine output such as diabetes insipidous 4) insufficient IV fluid replacement 5) draining fistulas 6) ileostomy 6) colostomy 7) use of hypertonic fluid for replacing isotonic fluid loses--do you know why is this? Why you cannot replace fluid for isotonic dehydration with a hypertonic fluid? think about it, and if you do not come up with the right answer lets discuss it if you like to do so. Hypertonic Fluids: NS= Normal Saline NACL = Sodium Choride a) 5% Dextrose in Lactated Ringer's solution b) 5% Dextrose in 45% NS c) 5% Dextrose in 9% NS d) 10% Dextrose in Water e) 3% NACL USING THESE CAN INCREASE BLOOD SUGAR: "TOTE BAG" T -THIAZIDES/DIURETICS O -ORAL CONTRACEPTIVES T -THYROID MEDS E -ESTROGEN B -BRONCHODILATORS A -ADRENALINE G -GLUCOCORTICOIDS feliz3 USING THESE CAN DECREASE BLOOD SUGAR: "MATABA" (that means fat in Tagalog) M -MAOI A -ANTICOAGULANTS T -TETRACYCLINE A -ASA (ASPIRIN) B -BETA BLOCKERS A –ALCOHOL Treatment For Chf U-upright Position ( 45 To 90) N-nitrates ( Dilates Vessels, Stops Pain) L-lasix ( Check Potassium) O- Oxygen A-aminophylline (dilates) D-digoxin (acute) F- Fluids (decrease) A-afterload ( Decrease) S- Sodium Restriction ( Decrease) T- Test ( Dig. Level, Abg's, Potassium Level) Unload Fast Re: Anyoone up for random FACT THROWING?? Thank you for everyone! I love this thread. Here are some of mine to you: The adverse effects of ANTI-phschotics can be remembered using this: SHANCE S-SUNLIGHT SENSITIVITY(use hat and sunscreen) H-HEPATOTOXICITY(monitor LFT) A-AGRANULOCYTOSIS(characterised by fever and sore throat) N-NEUROLEPTIC MALIGNANT SYNDROME(characterised by fever and musclar rigidity) C-CIRCULATORY PROBLEMS(leukopenia and orthostatic hypotension) E-EXTRA PYRAMIDAL SYMPTOMS(administer anticholinergics and antiparkinsonian agents) An endotracheal tube cuff should not be inflated > 20 mmHg fluid oscillation in the tubing of a chest drainage system indicates that the system is working properly a positive tuberculin skin test is an induration of 10mm or greater at the injection site, if the patient is HIV+ it is less than 10mm. Intermittent claudication (pain during ambulation or other movement that is relieved by rest) is a classic symptom of arterial insufficiency in the leg. Passive immunization is the administration of antibodies that were preformed outside the body. Active immunization is the formation of antibodies within the body in response to vaccination or exposure to a disease, and the length of immunity is longer than at passive immunity. When a patient is having bleeding esophageal varices, pressure against the esophageal veins must be applied in order to control the bleeding. If the client has ulcerations in the esophagus, necrosis or has had previous esophageal surgery, then pressure against the esophageal veins is contraindicated. A client who has a Sengstaken-Blakemore tube (a triple lumen gastric tube with an inflatable gastric balloon) should be placed on Fowler's position (upright) in preparation for the incertion of the tube. The gastric balloon compressess the esophageal varices, and the balloon should be inflated to 25-45mmHg. Metabolic Acidosis occurs in conditions such as 1) 2) 3) 4) 5) 6) 7) 8) diabetes mellitus diabetic ketoacidosis Excessive ingestion of aspirin(ASA) high fat diet insufficient metabolism of carbohydrates malnutrion renal insufficiency or renal failure severe diarrhea Metabolic Alkalosis occurs in conditions such as: 1) 2) 3) 4) 5) 6) 7) diuretics excessive vomiting excessive gastrointestinal suctioning hyperaldosteronism excessive ingestion of bicarbonate excessive infusion of bicarbonate (HCO3) massive transfusion of whole blood Respiratory Acidosis occurs in diseases that cause obstruction of the airway or a defect in the lung function such as: 1) asthma (spasm resulting fr)om allergens, irritants or emotions) 2) atelectasis (collapsed alveolar sacs) 3) brain trauma 4) bronchiectasis(dilated bronchi as a result of inflammation) 5) CNS depressants (opioids, sedatives and anesthetics) 6) emphysema (loss of elasticity of alveolar sacks) 7) hypoventilation (retention of CO2) 8) pulmonary edema( extracellular fluid accumulated in pulmonary tissue) 9) pneumonia( excess mucus production and lung congestion) 10) pulmonary emboli (undissolved material that causes an obstruction in the lungs) Respiratory Alkalosis occurs in conditions that cause overstimulation of the respiratory system such as: 1) 2) 3) 4) 5) 6) fever hyperventilation hypoxia hysteria pain overventilation by mechanical ventilators Allen's Test is done prior to the collection of an arterial blood gas specimen for determining the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the client's hand if damage to the radial artery occurs with the arterial pucture. A nurse who fails to perform the Allen's test and as result of that action the client develops tissue necrosis... is an example of negligence or malpractice? You tell me...felix3 Before performing the Allen's test assess the factors that may affect the accuracy of the results such as: 1) changes in the Oxygen settings 2) suctioning within the last 20 minutes 3) client's activities Usually is the Respiratory Therapists who draws the arterial blood, but the nurse performs the Allen's test and assists with the specimen draw by preparing a heparinized syringe. After the blood is taken must apply pressure to the puncture site for 5 minutes if the client is on anticoagulants, then it must be for 10 minutes. Allen's Test: 1) Apply direct over the client's ulnar (directcly below the last finger) and radial ( directly below the first finger) arteries simultaneously. 2) While applying pressure ask the client ask the client to open and close the hand repeatedly. The hand should blanch. 3) Release pressure from the ulnar artery while compressing the radial artery and assess the color of the extremity distal to the pressure point. 4) If pinkness fails to return within 6 seconds, the ulnar artery is insufficient, indicating that the radial artery should not be used for obtaining an arterial blood specimen. Best, feliz3