General Flashcards
everything but meds
What is the maximum amount of time a person can be in restraints on one order based on age?
18+: 4 hrs
9-17: 2 hrs
<8: 1 hr
Which is considered less restrictive, meds or physical restraints?
meds
How often should you offer food, water, and toileting to a restrained patient?
per facility policy
How often should you assess v/s and skin in a restrained patient?
Q 15-30 minutes or per facility policy
If you put emergency physical restraints on a patient, how soon should you get the provider’s order?
ASAP, or within 15-30 minutes of restraints
What are three characteristics of moderate anxiety?
field of perception is increased
learning still occurs
The person can ID the cause of anxiety
use of mild tension-relieving behaviors
If someone has selective inattention and a reduced field of perception and seems anxious, what are some ways to therapeutically deal with this patient?
get a trusted person to help talk them down,
ask what coping mechanisms helped in the past
What is the difference between severe and panic-level anxiety?
severe- feeling of impending doom, loud, rapid speech
panic- loses touch with reality, has hallucinations, shakiness, and fright
What are some interventions for panic and severe level anxiety?
Don’t ever leave them alone, offer self, keep them safe
try gross motor activities like walking
use simple speech and directions
What are some medications to help with anti-anxiety?
benzodiazepines- “-lams”
atypical anxiolytic- buspirone
SSRI- paroxetine
SNRI- venlafaxine
TCA- amitriptyline
MAOI- phenelzine
Antihistamine- hydroxyzine pamoate
B-Blocker- propanolol
Centrally acting A-blocker- prazosin
Anticonvulsant- gabapentin
What are some symptoms of Major Depressive Disorder?
Anhedonia, fatigue, sleep disturbances, changes in appetite, feelings of hopelessness or worthlessness, persistent thoughts of death or suicide, inability to concentrate or make decisions, change in physical activity, psychotic features, Depressed mood most of day
Five A’s of depression
Anhedonia, Angergia, Alogia, Avolution, Affect- flat
SWIGECAPS
Suicide Ideations, with or without attempt
Weight loss sometimes gain
Interest loss/depressed
Guilt/worthlessness
Energy loss/changes and fatigue
Concentration losses and indecisiveness
Appetite loss
Psychomotor issues agitation or retardation
Sleep deprivation
What is the definition of MDD?
History of one or more major depressive episodes
No history of manic or hypomanic episodes
Symptoms interfere with social or occupational functioning or five characteristics for almost every day for 2 or more weeks
What kind of person is most likely to have MDD? and risk factors
Women
anxiety disorders
psychotic
substance use
eating
personality
chronic diseases
What does serotonin control?
Sleep appetite and libido
what does norepinephrine regulate?
Attention and behavior
What is the number one first-line treatment for people with SAD?
Light therapy 20-45 minutes
What are some characteristics of atypical depression?
Individuals experience improved mood when encountering pleasurable events
Episodes can be seasonal
hypersomnia 10 hrs a day
feelings of heavy limbs
increased appetite or significant weight gain
What long might dysthymia patients have depression symptoms and aka?
Persistent depressive disorder Jr light or depression light
Lower levels of depression on most days for at least two years in adults.
symptoms are a consolidation of chronic major depression and dysthymia?
What are some risk factors that increase the likelihood of suicide?
Male, younger than thirty, older than 50, professional, white, no religion, and not married.
What are some areas to assess for a potentially depressed patient?
Affect, thought process, mood, feelings, physical behavior (slow and psychomotor retardation/agitation), communication and religious beliefs and spirituality.
Rule out physical things such as hypothyroidism
Why is it important to consider the patient’s phase of depression?
Patient’s phase of depression may affect their energy level because sleep and appetite. Hopelessness can interfere with functioning and treatment. Acute phase can come with increased risk of suicide
What are some things to consider about how to choose antidepressants?
One antidepressant is not better than another
Consider side effects, ADR, patient history, allergies, previously attempted Rx, family history of Rx taken, cost, residual symptoms after first-line choice, symptom based
How long is a trial period for antidepressant Rx?
3 mos
What are some preop procedures for ECT?
Stop anti-seizure medications before therapy
wait at least 24 hours before signing consent form after presenting information about ECT
keep the patient and PO for at least four hours prior
ask the patient to avoid remove contact lenses accessories and dentures
assess vital signs
What are some medications that are used for ECT?
Robinol (atropine)- stop secretions so they don’t aspirate (one hour prior to ECT)
Brevitol (methohexital) or propofol for anesthesia
Anectine (Succinylcholine) this is used as a muscle relaxant to be able to induce seizure
what are some things to do to the patient after they come out of an ECT session?
Place them lateral recumbent, orient to time place and situation, keep the head elevated, check gag reflex, offer food and drinks and oxygen if needed and headache medication
How many sessions of ECT does a patient usually have?
About three times a week until three treatments have been completed, but is it not a permanent cure
what is ECT? contraindication? SE?
It causes a generalized tonic clonic seizure of about 30-60 seconds for people with depression, acute mania, and suicidal ideation
ICP and recent head trauma
Transient STM loss, HA/nausea
How would you communicate to an MDD patient?
make time to be with the patient
make observations
simple directions
give sufficient time to respond
What are the measurements for a wound?
length, width, and depth in millimeters of centimeters, and tunneling and undermining should be measured separately
difference between friction and shear
friction-skin is rubbed over surface like dragged over sheets
and shear- skin stays in place while underlying structures goes down
what are some ways that can hasten pressure ulcer formation?
improper positioning, like not at 30 degrees
sitting in moisture too much
improper nutrition like prealbumen level less than 19.5
What are the stages of pressure injury?
1- non-blanchable redness
2- partial thickness skin loss with visible injury or fluid-filled blister
3- full thickness tissue loss without exposed muscle or bone and possible undermining
4- full-thickness tissue loss with exposed bone and muscle and sometimes eschar and slough
final- unstageable because eschar or slough obscures wound
How does the Braden Scale work?
grades sensory preception, moisture, activity, mobility, nutrition, and friction/shear.
Scores range from 6-23 with a cutoff of 18 and the lower the score, the greater the risk for ulcer formation
what are the phases of wound healing?
hemostasis, inflammatory phase, proliferative phase, and remodeling phase
What are the characteristics of the inflammatory phase?
skin color changes, heat, swelling, pain, and loss of function to protect body from infection and expedite healing
What happens during the proliferative phase?
new blood vessels form to restore skin integrity and leads to some swelling and granulation (prone to bleeding while healing)
What helps speed up the proliferative phase, and what are some risks?
moist environment helps, but prone to dehiscence and evisceration
Which phase of healing might take more than a year? What happens during this stage?
maturation regorganizes collagen and scars change color
what are some intrinsic factors that affect wound healing?
age- epidermis things, making it more injury-prone
Chronic illness because wound needs an oxygen rich environment
skin with reduced sensation are prone to injury and poor wound healing
Extrinsic factors that affect wound healing
medications, especially those that inhibit platelet action and immunosuppressants
cancer treatment because they cause cell destruction and immunosuppressant
inadequate nutrition without protein and vitamins
stress which release chemical and hormones
length of time for wound healing increases by infection, repeated trauma, and damage to underlying tissues
surgically closed wounds are called what?
primary intention and edges are approximated
What type of wounds heal through secondary intention?
chronic and some acute- wound edges heal by formation of granulation tissue, wound contraction, and epitheliazation
What size syringe should you use to irrigate a wound?
35 mL syringe with 19g catheter for wbout 8 psi
What should you do if a dressing is stuck to a wound?
pour 0.9% sodium chloride over the area or apply petrolatum gauze
why are wet-to-dry dressings not recommended anymore?
take healthy and necrotic tissue
painful when removed
time-consuming to apply
causes maceration of surrounding wound edges
cross contamination as we-to-dry dressing do not provide any barrier to the environment
When are alginate dressings helpful?
provides moist environment for large exudative wounds and packing for deeper wounds
What is the best way to remove staples?
every other staple first to assess skin closure
how far above the wound should you hold irrigating syringe?
at least 1 inch above the wound
What does negative pressure wound therapy do?
removed drainage, reduces bacterial counts, and aids promotes granulation especially a stage IV
When should NPWT not be used
areas of skin cancer, anticoagulant therapy, poosr tissue health, exposed vessels, nerves or organs
what are drawbacks of open drainage systems?
difficult to assess amount of drainage and control micro-organism transmission
What are some additional modalyties to treat pressure wounds?
electrical stimulation for stage 2,3,4 pressure injuries
negative pressure wound therapy for stage 3 and 4
hyperbaric oxygen therapy, growth factors, and US therapy for stage 3-4 pressure injuries
What are different methods for wound debridement?
enzymatic, chemical, shart/surgical, autolytic and biosurgical
autolyitic is using the body’s own mechanisms by trapping moisture beneath it.
Whete would you secure a Jackson-Pratt drainage system?
to the client’s gown
What are some reasons for using DMs?
Automatic coping styles to protect people from anxiety and maintain self-image and ego function by blocking feelings, conflicts, and memories.
What is the difference between repression, dissociation and denial?
repression is when something is traumatic and you push it away to reject reality denial
dissociation- altering consciousness
Projection vs identification
Projection is subconsciously giving a characteristic of self onto another person and identification is taking the characteristics from a group or person onto the self.
Repression vs suppression
Run
Scon
Both are keeping feelings out of awareness, but repression is UNconscious and suppression is conscious
Repression vs dissociation
Dissociation is a disruption of memory or consciousness to protect the whole like putting a memory in isolation or cutting it off like it doesn’t exist and repression is just stuffing a memory away.
Introjection and identification
Introjection is taking on or accepting another’s values and opinions as one’s own for approval usually unconsciously like taking on spouse’s characteristics and lifestyle or internalizing the voices of those around them
Identification is identifying with a person like a son following in their father’s footsteps. Now the person has become the person they are identifying with
Examples of reaction formation
A man who is attracted to men, but whose culture is not supportive of the LGBTQ community, becomes an outspoken opponent of same-sex marriage.
Displacement vs projection (unconscious)
Displacement is transferring emotions associated with a person, object or situation to another nonthreatening person, object or situation, and projection is the unconscious rejection of emotionally unacceptable features and attributing them to other people.
Sublimation examples
Recently divorced woman channels emotions and energy into a home improvement project. (nonmaladaptive use)
for crutches, walkers, and canes, at what angle should the wrists and elbows be?
elbows at 20-30 degrees, and grips at the height of wrist or greater trochanter
summarize 2, 3, 4 point gaits
2-point: lt crutch and rt foot together & rt crutch and lt foot together
3- point: advance crutches and then foot either swing through or swing up to crutches
4- altern. rt crutch, lt foot, lt crutch, rt foot
where should the armpit pads of crutches be?
2 in below axillae to not impact nerves in the axillae
How would you instruct a patient with crutches to sit
back up to chair
move crutches to affected side
feel the chair with the back of the legs
reach back for the arm rest, extend affected leg and sit
What is the tripod position for crutches and canes?
hold six inches to the side or six inches in front
on which side do you hold a cane?
the UNaffected or good side.
how to instruct a patient to use a cane?
move AL and cane together
move UL to the cane
don’t push on walker or cane to get up and use chair to push up
What hormone does the kidney create and what does it regulate?
renin, which regulates blood flow, glomerular filtration, and blood pressure.
It also activates angiotensinogen aka Ang I, which is converted by ACE into Ang II
When are coude catheters used?
for those who have prostatic hyperplasia, which has a curved tip for easier insertion
When would you empty a bag?
about every 8 hrs or per facility policy or about 1/3 full
Where should you take the urine sample in a patient with a catheter?
from the catheter’s tubing between bladder and collection bag, but never the old unclean collection bag
What does a urine dipstick test for?
pH, specific gravity, WBC content, and blood
What does a urinalysis do and where can it be done?
a lab gets the urine from a provider’s order and provides more in depth analysis, but not the type of bacteria
What kind of urine test identifies the type of bacteria?
urine culture and sensitivity
How often should per care be done?
at least once per shift or every 8 hours
How often should suprapubic catheter dressings be changed?
daily, with clean or sterile technique, depending on facility policy
What are common manifestations of UTI?
elevated WBC, urine with pungent odor, increased sediment in urine, ALOC or confusion, change in urination pattern, and fever
What are some common causes of hematuria?
mechanical injury of the urethra, urinary calculi, GU cancers, UTI pyelonephritis, and glomerulonephritis
What is lack of urine return from a foley likely related to?
catheter placement and not size, but don’t push on the distended abdomen, but instead rotate and advance the catheter tip.
when is the only time you can collect urine from a collection bag?
immediately after Foley insertion
for what period of time would an NG tube be appropriate
less than 4 wks.
What patients would you use an OG tube?
preemies, mechanical vents, and craniofacial surgery or trauma
What are some things to look for before inserting an NG tube? like a possible contraindication
nosebleeds, nasal polyps, or chronic sinus infections, history of facial surgery, aspiration or anticoag therapy
where do you measure for an NG tube vs duodenal or jejunal placement?
tip of nose to earlobe to xiphoid and add 20-30 cm for duodenal or jejunal placement and use tape or marker to mark length of tube.
What is the pH of gastric content from fasting 4 hrs
1-4 and grassy green and off white, or tan, and intestinal fluid is 7 pH and golden yellow or brownish green
What might have happened if you get a pH of greater than 6 for an NG tube?
you might have hit the lungs
What are the four basic types of enteral formula?
polymeric- milk-based blenderized foods and commercially prepared whole-nutrient
modular- not complete nutrients and single macronutrients 3.8-4.0 kcal/mL
elemental- partially digested nutrients
specialty- liver failure, pulmonary disease, and 1-2 kcal/mL
How often are residual volumes checked?
usually Q4-6 hours for tubes in the stomach
What should you do to a bag of enteral formula before administering it?
Warm the container to room temp, check integrity, and cleanse top of container with alcohol swabs
How much formula should be filled to a feeding bag to prevent bacterial contamination.
only enough to last a 4 hr period, no longer than 12 hours for an open system, and 48 hours for a closed system, and don’t allow feeding bag to empty before refilling
How often should you flush for enteral feed tubing?
30-50 mL of water before and after each intermittent feeding
What is refeeding syndrome?
when malnourished people begin to feed again, the body uses carbs for fuel rather than protein stores. Prevent by making sure electrolyte levels are within range, or start at a slower rate and gradually increase.
What should you do if a patient has abdominal cramping from enteral feedings?
slow the infusion rate, change the formula, bring the formula to room temp
A nurse is providing teaching about risk for aspiration with a client who is receiving intermittent bolus nasogastric feedings. Which of the following findings should the nurse instruct the client to report?
A persistent cough can indicate that the distal end of the nasogastric tube has moved into the respiratory tract. The client should report this finding to the nurse immediately because this is a risk for aspiration.
What are the purposes of NG intubation?
decompression
lavage
treat obstruction
compress bleeding site when endoscopy not available
admin feeds and meds
aspirate contents for analysis
when is gastric decompression indicated?
bowel obstruction, paralytic ileus, and GI/GU post op
When is gastric lavage indicated?
med toxicity for swift removal “pumping stomach”
hyperthermia or hypothermia stabilization for malignant hyperthermia
What is an advantage of a double lumen sump tube?
can be used with continuous suction and feedings
What would you do if the blue lumen of a salem sump becomes occluded?
make sure the blue pigtail is above the client’s stomach,
flush with 10 mL: of air
What is the single lumen good for?
decompression
washing stomach free of toxins other than poison
irrigating stomach to diagnose upper intestinal bleading
withdrawing specimens for diagnostic analysis
What should be the suction mm HG for a Levin tube, and why?
low intermittent suction (25 mmHg) to avoid erosion or tearing the stomach lining.
what is the three lumen tube called and used for?
sengstaken-blakemore tube for upper GI bleeding from esophageal varices in emergencies and short term use only, and a balloon is inflated to compress esophageal varices
Why is intermittent suction used?
reduces the risk of mucosal erosion
How often should you check intake and output from an NG tube?
Q8 hours at least
What are the different types of tubes for decompression?
sengstaken-blakemore
minnesota (4 lumens)
linton-Nachias tube
What should you do to prepare decompression tubes and patient for decompression?
remove air from balloons
label lumens
sit up patient at least 45 degrees or left lateral decubitus position and topical anesthetic
When is gastric lavage indicated?
prep for endoscopic exam
treat injestic toxin other than poison
med toxicity
gastric hemorrhage in emergency situation
which toxins should gastric lavage not be done and what should be done instead?
poison, hydrocarbon, corrosive substance, and absent airway protective reflexes, but instead use antidotes or isotonic polyethylene glycol solutions
What should you check before doing a gastric lavage.
determine client’s LOC before inserting lavage tube, use bite block for unconscious or no gag reflex
What fluids should you lavage the stomach with?
up to 300 mL of room temp water or if large amounts, then use 0.9 Nacl to avoid water intoxication and hyponatremia and don’t leave the patient alone
How and when would you administer activated charcoal?
absorbs toxins when administered one hour after ingestion of the stomach and added to other drink and drunk with straw or through NG tube
administer even after a patient has no more contents coming out of gastric lavage.
most effective one hour after ingestion.
What are some things to remember when removing an NG tube?
flush with 10 mL of Nacl or 30-50 mL of air to clear the tube
provide emesis basin
client will take a deep breath and hold it to prevent risk of aspiration
pinch off tube at naris
How long can PRBC be stored?
frozen for up to 10 yrs.
What does plasma contain and what is it good for?
albumin, fibrinogen, globulins and other clotting proteins
electrolyte imbalance, bleeding and coag disorders, massive burns, liver failure, and replace platelet-aggregating inhbitors for HUS
for how long can plasma be stored and how quickly can it be transfused?
frozen for up to a year and when thawed, transfused rapidly over 30-60 min
What is albumin good for?
maintaining blood volume and blood pressure
What is IgG or immune globulin used for?
those at risk for recurrent bacterial infections like chronic leukemia.
What blood components must be ABO and Rh compatible?
RBC and platelet transfusion, but fresh frozen plasma requires ABO compatibility but not Rh consideration
What blood components don’t have to be ABO and Rh compatible?
Albumin and cryoprecipitate typically, but some people may require more specific testing at a blood bank because they might be resistant or require more specific compatibility testing.
What are alternatives to donor blood? and benefits and disadvantages
autologous transfusion, or donation from the client.
eliminates viral infection and graft-vs-host disease
not everyone is eligible because current medical problems or low weight and hemotocrit
What are some ways to prevent hemolysis?
prime Y-type tubing with 0.9% saline
18 g or larger
warm blood with an approved device
use a sterile, pyrogen-free filter
use larger gauge catheter
maintain separate IV access for other fluids or meds
What is the timing for PRBC?
max 4 hour from bank to patient
transfuse within 30 minutes of issue from blood bank.
What is the recommended rate for the first 16 minutes? and max time and how often to record V/S?
2mL/min for first 15
v/s for first 5-15 minutes, and then record v/s every 1-2 hrs.
What is the leading cause of transfusion-related deaths?
TRALI- s/s start about 6 hrs after transfusion and s/s chills and sudden respiratory distress and lead to respiratory failure.
What are the most common causes of acute intravascular hemolytic reaction and why do they cause the s/s associated with them?
errors in blood-component labeling or client identification resulting in ABO or Rh incompatibility.
hemolysis makes RBC to be excreted through urine and vascular collapse causes hypotension and elevated BP and back pain is caused by kidneys trying to filter the dead RBC.
also sinaled by an increase in temp of more than about 2 degrees F
What would you do after stopping the transfusion after a hemolytic rxn occurs?
support BP and renal circulation, and bleeding as DIC can occur, and collect urine specimens
send blood back to the bank
What might happen if you transfuse large quantities of cold blood? 34-45 degrees
hypotehermia and cardiac rhythms and cardiac arrest
how many units of blood can be transfused through one administration set?
two max usually to reduce risk of bacterial contamination
How fast should you transfuse blood products to older patients?
administer blood slowly, 2-4 hours to reduce risk of fluid overload and dyspnea and use a large Gauge catheter, at least
What’s the definition of cyclothymia?
Milder version of bipolar that you need to have symptoms for at least two years
Hypomania and symptoms of mild to moderate depression
Gender differences of Bipolar I and II
More men have bipolar I and more women have II
What symptoms are present in mania?
Inflated self-esteem or grandiosity (delusions of grandeur), decreased need for sleep and food, pressured speech, flight of ideas, distractibility, psychomotor agitation, involvement in pleasurable activities, psychosis, poor insight/judgment, clown-like makeup
What is the difference between bipolar one and two manic and hypomanic states?
Only in Bipolar one mania do we see hallucinations and delusions of grandeur, and Bipolar II symptoms can only get to the hypomanic level.
What doesn’t a manic patient feel like they need?
Food and sleep
What is the difference between mania and hypomania?
Hypomania is less erratic behavior and no psychotic features
Mania is a more extreme form
What is not present in hypomania?
No psychotic features or cognitive changes
What are some priority considerations for bipolar?
Place them away from the nurse’s station in a quiet place
Give meds like trazadone to sleep
Finger foods so they can keep up with nutrition
Don’t allow them to distract in groups that require a lot of talking, but do activities such as physical activities,
What types of food are good for someone in a manic state?
Finger foods that are portable, not messy, can be consumed whenever and wherever, and not complicated
What room location is good for a person in a manic state?
Away from the nurses’ station in a private room with low stimuli
What are some manic thought processes and speech patterns
Hyperverbal, pressured, and self-destructive sometimes, omnipotent (all knowing, all powerful, and all present), grandiosity
What are some things to assess for with Bipolar?
DTO/DTS, need for protection from uninhibited behaviors, need for hospitalization, medical status (nutrition and sleep especially), coexisting medical conditions, and family’s understanding, sleep, and slef-harm
What is the difference between insight and judgment?
Insight is the patient’s ability to understand their diagnosis
Judgement is the ability to make decisions
What are some medications for bipolar?
mood stabilizers- lithium, anticonvulsants
first gen antipsychotic- chlorpromazine and loxapine
2nd gen antipsychotics- olanzapine, risperidone
antidepressants: SSRI fluoxetine
eWhat are the factors influencing wound healing? “DIDN’T HEAL”
D= Diabetes
I= Infection
D= Drugs
N= Nutritional problems
T= Tissue necrosis
H= Hypoxia
E= Extensive tension
A= Another wound
L= Low temperatures
What kind of cells detect touch especially in the soles of the feet and the palms of the hands?
Merkel cells
Venturi mask flow rates
flow rates in the range of 4 to 10 L/min (24% to 50%).
chronic oxygen toxicity s/s
atelectasis
coughing
dyspnea
pleuritic chest pain
heaviness substernally. However, once oxygen is discontinued, symptoms lessen within 4 hours
when should you do postural drainage?
nefore eating
iff tube fed, then wait 30+ min
position (10-15 min) , percuss and vibrate
chest physiotherapy (CPT) consists of percussion of the what?
chest, vibration, and postural drainage
how t measure OPA and NPA
OPA- corner of mouth to jaw tip
NPA nose tip to earlobe
how long are ET tubes left in? and when are they most likely to dislodge?
usually 14 days, 72 hours
disadvantage of Nasal cannula
dermatitis
dry mucous/headaches for flow rat 4L+
less accurate in terms of what percentage of O2
NC concentration
concentrations of 1 to 6 L/min (24% to 44% of oxygen)
flow rate for partial and NRB
(60% to 75%; 80% to 95%) at flow rates of 10 to 15 L/min
Simple face mask O2 flow
5 to 8 L/min (40% to 60% oxygen concentration)
NRB is not recommended to who?
COPD or respiratory failure for long-term use due to a risk of oxygen toxicity.
Venturi mask flow rates
flow rates in the range of 4 to 10 L/min (24% to 50%).
Oxygen toxicity s/s
dysphoria
ears- tinnitis
nausea in prolonged exposure
generalized convulsions
twitching of the hand muscles
CHESt pain
COugh (nonproductive)
CONvulsions
Paresthesia
Anxious
Nausea
Emesis
Dyspnea
chronic oxygen toxicity s/s
atelectasis
coughing
dyspnea
pleuritic chest pain
heaviness substernally. However, once oxygen is discontinued, symptoms lessen within 4 hours
Any heat source should be kept how many feet away from the oxygen system,
five feet
Oxygen concentrators should be kept how far away from curtains or walls.
several inches
Oxygen tubing should not be longer than how many feet to avoid tripping.
50
how many psi for oxygen tank?
2K
What should the psi be to suction without a trach or ET?
100-150mmHG
how long should you suction a throat, and how long to begin suctioning again?
Apply intermittent suction for 10 to 15 seconds, and allow at least 20 seconds before suctioning again. 1 min if an ET or trach
How should you secure a tracheostomy after cleaning?
Gather the twill tape that has been prepared.
Insert one end of tie through the faceplate eyelet and pull the ties behind the client’s head and around their neck to the second eyelet, pulling the ties snugly. Do not remove the old ties until the new ties are in place. Tie the ends of the tracheostomy ties in a double knot, leaving enough space for one or two fingers.
What should the pressure be to suction a trach or ET?
Check that the suction device is functioning and set to 80 to 120 mm Hg for adults and 50 to 100 mm Hg for children. also The nurse should set the suction up to 120 mm Hg for open suctioning and up to 160 mm Hg for closed system suctioning.
How far should the catheter be inserted when the airway is suctioned?
insert until resistance or until they cough. pull back 1 cm and slowly withdraw
Can chest physiotherapy be delegated to a UAP?
Yes, in some situations to trained AP, but the patient must be assessed
Recommended ET cuff pressure
20-25 mmHG
how often to reposition ET tube?
every 12 hr to prevent irritation to the oral mucous membranes
What is the bell of the stethoscope used for hearing?
low-pitched like heart murmurs and vascular bruits
What is the diaphragm of the stethoscope used for hearing?
high-pitched like hear, lung, or bowel sounds
Where should the cones of light be visible in the ear drum?
7 o’clock for left ear, and 5 o’clock for right ear
Where are bronchial breath sounds heard? How does it sound?
anterior over the trachea, loud, high-pitched hollow sound
Where are bronchovescivular breath sounds heard? How does it sound?
mainstem bronchi, medium pitched and quieter but present both anteriorly and posteriorly
Where are vescivular breath sounds heard? How does it sound?
most of lung tissue over lung tissue. Soft, breezy, low-pitched sounds
what are crackles, aka, and when are they heard?
rales, common at the end of inspiration or expiration
What causes wheezing?
usually with asthma, and heard when the airway is constricted
What abnormal lung sound can you hear without a stethoscope?
A stridor, which is a high-pitched crowing sound.
Where is the aortic site vs pulmonic?
2nd intercostal, rt, and left
What would you ask the patient to do if the heart sounds are hard to hear?
ask the patient to lean forward to move heart closer to chest wall or lie on their left side.
Where is Erb’s point found?
3rd INC
How are murmurs graded?
1: difficult to hear
6: very lound, even without touching the chest, associated with a palpable visible thrill
What is thin shiny skin a sign of?
PVD
Whare is the pulse grading? where to start?
start on the very distal ends
0: absent and nonpalpable
+1: diminished and thready
+2: normal pulse, easy to palpate
+3, full and easy to palpate
+4: bounding and very strong
How long do you auscultate before noting no bowel sounds?
5 minutes
deep vs light palpation depth
1 cm vs 2.5-7.5 cm
Muscle strength grading
0: muscle contraction
1: trace contraction of muscle 10%
2: moves muscle when gravity is eliminated, PROM 25% of muscle strength
3: 50%
4: 75%
5: 100% normal muscle strenght
DTR grading
0: no response
1+: sluggish response
2+: expected reponse
3+: slightly hyperactive
4+: hyperactive, exaggerated response.
What does SBAR and SOAP stand for?
situation: client hx and current admission status
background: review of current problem and time of onset
assessment: statement of concern based on PA findings, labs, and dx tests
Recommendation: request for action
Subjective, objective, assessment, and plan
For how long and where should you clean a CVAD port?
2 to 3 inches around with chlorhexidine for at least 30 seconds with a back-and-forth motion. Allow to dry
With how much saline to flush CVAD port
Gently flush with 3 to 5 mL of 0.9% normal saline with 10mL syringe and pulsatile motion
What are the indications for nontunneled CVADs?
short term therapy for IV therapy, blood sampling and central venous pressure monitoring
How often should you flush an implanted VAD?
once a month
When are PICCs contraindicated?
masterctomy or radial artery surgery, hemodialysis graft, or AV
How often does a peripheral IV line have to be replaced vs a PICC line
72-96 hours vs a year
Why would a medication infusing through a triple lumen CVAD have to be clamped before blood sampling?
stop 1-5 minutes before so the lab results won’t be altered by the infusing solutions
What is the difference between tunneled and non tunneled catheters
Tunneled central venous catheters (T-CVCs) are designed for long-term use, while non-tunneled central venous catheters (NT-CVCs) are designed for short-term use. T-CVCs are less likely to cause infections and can be used for years, while NT-CVCs have higher complication rates and are typically used for 2–3 weeks.
What is the recommended dose of Epinephrine during cardiac arrest?
1 mg IVP over 1-3 minutes
According to the Hs and Ts of ACLS, which of the following combinations is not one of the possible causes of PEA?
Hydrogen ion (acidosis), hypokalemia, tamponade
Hypothermia, tension pneumothorax, hydrogen ion (acidosis)
Thrombocytopenia, hypoglycemia, hemophilia
Hypovolemia, thrombosis, toxins
Thrombocytopenia, hypoglycemia, hemophilia
In addition to providing effective CPR, what is the 2ND most important aspect of successfully treating a patient with PEA?
Identifying and treating the underlying cause of the arrhythmia
What are some pacemaker malfuncturions?
failure to pace, failure to capture
You obtain an ECG on a patient and the rhythm is sinus bradycardia with a rate of 52 bpm. Your NEXT nursing action is to?
Assess the patient
A patient is experiencing sinus bradycardia with a rate of 39 bpm and blood pressure of 82/42. The patient reports symptoms of chest pain, has cool and clammy skin, dyspnea, and feels like they may faint. The nurse prepares to administer Atropine per a standing physician’s order for the patient’s symptomatic bradycardia. How will the nurse administer this medication?
1 mg IV push every 3-5 minutes, max dose of 3 mg
Referring back to the previous question, Atropine was ineffective for treating bradycardia. The patient is still symptomatic with a rate of 39 bpm. What other options could be considered for the patient? (Select all that apply)
Dopamine or Epi infusion
Transcutaneous pacing
What is the goal of ACLS intervention in patients with sinus tachycardia?
To identify and treat the underlying systemic causes
A 21-year-old female is seen in the Emergency Department for vomiting and diarrhea for 3 days. Her BP is 94/64 and her EKG rhythm shows that she is sinus tachycardia. The best action for the nurse to take initially is to:
start IV and bolus normal saline per protocol.
The nurse records the ECG of a patient present with dizziness, light headness and palpitations. The ECG shows a absent p-wave and fibrillatory waves. Which of the following invasive approaches are not beneficial in treating this patient’s arrhythmia?
Placement of a pacemaker
Surgical MAZE procedure
AV Node ablation
Radiofrequency catheter ablation
Placement of a pacemaker
The nurse is caring for a client with atrial fibrillation. In addition to an antidysrhythmic, what medication does the nurse plan to administer?
Heparin
When would you use dobutamine in ACLS?
as a second choice in sinus bradycardia after atropine because it is a positive inotrope
A 31-year old patient with no prior health issues presents with heart palpitations. The patient is alert and oriented, with vital signs including a heart rate of 220-230 beats per minute, blood pressure 122/66 mmHg, RR 20 BPM, and SpO2 97%.
Adenosine
Alternative management of patients with SVT may include diltiazem (Cardizem). What is the mechanism of action?
Interrupts the reentry pathways in the atrioventricular (AV) node
A hallmark finding in a First-Degree Heart Block is…
a PR interval >0.20 seconds
The patient is experiencing the rhythm monomorphic v-tach. The patient is presenting with a blood pressure of 70/42, mental status changes, and is clammy and pale. A pulse is present. The nurse preps the patient for…
Synchronized cardioversion
The nurse sees the rhythm v-fib on the ECG. The patient is unresponsive and has no pulse. The nurse calls a code blue and takes what step next?
start CPR
The nurse would expect which of the following to be the first choice to treat a stable patient with ventricular tachycardia?
amiodarone
What should you do in VF/pulseless VT following the first unsynchronized shock?
immediately resume CPR
What would you do for a snake or spider bite?
Assess for tissue edema every 15 to 30 min if bitten by a snake or spider.
administer opioids
What is contraindicated in the first 6-8 hrs after snake or spider bite generally? ITCH
ice
tourniquets
corticosteroids
heparin
When is the rabies vax series given?
days 3, 7, 14
Oxygen saturation expected reference range
95%-100%
Arterial blood gases (ABGs) for hypoxemia and hypercarbia
Hypoxemia (decreased PaO2 less than 80 mm Hg)
Hypercarbia (increased PaCO2 greater than 45 mm Hg)
Considerations for neutropenic precautions?
avoid fresh fruits and veggies, undercooked meat, fish, and eggs; pepper and paprika
avoid yard work, changing litter box
discarding room temp beverage 1hr+
wash toothbrush daily in dishwasher or with bleach
examine mouth daily for lesions
What kind of animal bites do you apply ice to?
black widow bites
What electrolyte do salt substitues increase? Why?
potassium because they contain more potassium
What are some things that indicates latex and propofol allergies? What about CT contrast?
latex allergy- avocado, strawberries and bananas
propofol- peanuts and eggs
hx of asthma has greater risk of reacting to contrast dye in procedure of CT with contrast
What are some causes of high ESR?
infection, inflammation, arthritis, cancers, CKD, anemia, thyroid disease, pregnancy, obesity
What foods can decrease calcium absorption?
spinach, rhubarb, beets, bran, and whole grains
What ares some causes of metabolic acidosis?
Excess production of hydrogen ions
DKA
Starvation
Lactic acidosis: Heavy exercise, Seizure activity, Hypoxia
Excessive intake of acids- alcohol and aspirin
Inadequate elimination of hydrogen ions: kidney failure and pancreatitis
liver failure
diarrhea
What are three examples of situational role changes?
situations other than physical growth and development like marriage, job changes & divorce
illness or hospitalization
resolution- healing in physical, mental, and spiritual realms
What are the first several actions when giving a blood product?
explain procedure
assess V/S and temp
review lab values
verify prescription
obtain consent
obtain samples for compatibility
assess hx
IV
obtain blood
two RN check
What are appropriate amounts of carbs to give with hypoglycemia?
15 to 20 g of a readily absorbable carbohydrate
4 to 6 oz of fruit juice or regular soft drink
glucose tablets or glucose gel
6 to 10 hard candies
1 tbsp of honey
10 g of glucose will increase the blood glucose by 40 mg/dL over 30 min.
What are some patient ed for metformin use?
w/ food to decrease adverse GI effects.
w/ vitamin B12 and folic acid supplements.
No alcohol w/ metformin to reduce the risk for lactic acidosis.
Contact the provider if manifestations of lactic acidosis develop (myalgia, sluggishness, somnolence, and hyperventilation)
What are the initial actions for evisceration and dehiscence?
call for help
stay wth client
cover wound with sterile saline dressing
position client supine with hips and knees bent
observe for shock
maintain calm environment
NPO
What is the difference between gestational hypertension vs mild preeclampsia vs severe preeclampsia vs eclampsia?
gestational hypertension- BP of over 140/90 on two occasions after 20 wks of pregnancy and no proteinuria
mild preeclampsia- w/ of proteinuria of 1+ or 2+
severe preeclampsia- BP over 160/110 on two occasions 6 hr apart
proteinuria more than 3+
visual disturbances
creatinine greater than 1.1
extensive peripheral edemia
epigastric and RUQ pain
hepatic dysfunction
thrombocytopenia
oliguria
eclampsia- seizures
What is HELLP syndrome?
Hemolysis, elevated liver enzymes, and low platelets
What are the complications of preeclampsia for the fetus and newborn?
Premature delivery
intrauterine growth restriction related to decrease in uteroplacental perfusion
low birth weight
Fetal intolerance to labor
Still birth
what are some risk factors for preeclampsia or eclampsia?
Nulliparity
Younger than 19 or older than 35
obesity
Multiple gestation
Family history of preeclampsia
Preexisting hypertension or renal disease
Previous preeclampsia or eclampsia
Diabetes mellitus
lupus
How much fluid restriction for preeclampsia?
100-125mL/hr
what are antihypertensive medications for preeclampsia? and which should you not give?
Hydralazine vasodilator
Methyldopa
labetalol beta blocker
Nifedapine- CCB
contras- ARBS and ACE-I
What might be some initial side effects of mag sulfate?
flushing, heat, sedation, diaphoresis, and burning
what are some signs and symptoms of magnesium toxicity?
Decrease or loss of DTRand ALOC
respiratory depression
oliguria or urine output less than 30 mL/ hour
chest pain
EKG changes- dysrhythmias
what are the symptoms of Group B streptococcus?
Usually asymptomatic carriers but can include abnormal vaginal discharge urinary tract infections
Chorioamnionitis
sepsis
why is delaying a pregnancy by 72 hours via tocolytics better than delivering immediately?
It gives several days for the corticosteroids to work and treat any Group B strep infections
When is GBS screened?
35 and 38 weeks
If a mother tests positive for GBS, what would you give them? and is allergic to penicillin?
Penicillin bolus and then intermittent IV bolus and then ampicillin
Cefazolin
difference b/w polyhydramnios and oligohydramnios
poly- excess of 1,500-2,000, which can is related to chromosomal disorder and GI, cardiac or neural tube disorders
oligo- less than 500 mL or 50% reduction, which can cause renal and congenital problems
What are some medications for syphilis?
Penicillin is first line, but also doxycycline or tetracycline
what are the symptoms of chorioamnionitis?
Fever
Fetal and maternal tachycardia
Sore or painful uterus
Bad smell from amniotic fluid
What are the fetal effects of toxoplasmosis?
Severity varies with gestational age and congenital infection, and incidence is low
Spontaneous abortion
Low birth weight
And panel splenomegaly
Icterus
Anemia
Chorioretinitis
Neurological disease
What are the effects of toxoplasmosis?
Mostly asymptomatic but can cause fatigue, muscle pains, pneumonitis, myocarditis and lymphadenopathy
What and when is the treatment for toxoplasmosis
Treat with sulfadiazine or pyrimethamine after the first trimester
what are some ways to prevent rubella infection
rubella immunization three months before getting pregnant or postpartum
what are some effects of rubella on the fetus?
Deafness, eye defects, CNS abnormalities, and severe cardiac malformations
what are some ways rubella or German Measles are transmitted?
Nasopharyngeal secretions and transplacental
what are some maternal symptoms of rubella?
Erythematous maculopapular rash, lymph node enlargement, slight fever, headache, malaise
which torch infection does not have a treatment?
Cytomegalovirus
what are some maternal symptoms of cytomegalovirus?
Mostly asymptomatic but 15% may have mononucleosis like syndromes
what are some effects on the fetus of cytomegalovirus infection?
Depends on which trimester the mother was infected.
May result in low birth weight
IUGR
Hearing impairment with microcephaly
CNS abnormalities
which torch infection does not have a treatment?
how does herpes simplex virus get passed on?
Contact at delivery and ascending infection
What disease is the most common cause of meningitis, pneumonia, and sepsis
GBS
what are the symptoms of chlamydia?
Usually there are none but may have burning on urination or abnormal vaginal discharge
how would you manage chlamydia infection?
Antibiotics such as amoxicillin, azithromycin, and erythromycin
Can lead to PID
Treat all infected partners and retest in three weeks
what can syphilis cause in fetuses and infants?
Preterm birth
Physical deformity
neurological complications
Still birth
Neonatal death
what is the treatment for trichomonas?
Metronidazole
What kind of STI will cause a fishy odor and vaginal discharge?
Bacterial vaginosis
What are some ways HIV/AIDS can be transmitted?
Trans placental
Intraparietal
Breast milk exposure
What are some stages of syphilis?
primary-chancre
secondary- lrashes like maculopapular on palmar surface of hands and feet
tertiary- damage to internal organs incuding difficutly coordingatin muscle and blindness
patient education for rubella vaccination received postpaertum
avoid pregnanc for four ks after receiving vaccine
What are some meds to treat genital warts?
imiquimod and podophyllin
What is some recommended treatment for trichomoniasis? and what other condition do you use for this med?
recommended treatment is metronidazole or tinidazole except first trimester of pregnancy
bacterial vaginosis
What are some contributing factors of gestational DM?
obesity, maternal age older than , family hx of DM, previous delivery of LGA or stillborn
What are some risks of gestational DM to the fetus?
infections b/c increased glucosuria and decreased resistance
hydramnios
ketoacidosis- diabetogenic effect of pregnancy
hypoglycemia
hyperglycemia
When are pregnant women tested for gestational DM?
24-28 wks
levels for 1 hr GTT and 3 hr oral GTT
eat 50 g of oral glucose with or without fasting and if more than 130-140, then move on to OGTT
fast overnight and avoid caffeine and smoking 12 hrs
take 100 g of glucose and if two or more serum glucose tested 1>180, 2>155, 3>140 , then GDM dx made
What are some medications for hyperemesis gravidarum?
IV of LR
pyridoxine (vit b6)
doxylamine
metoclopramide (antiemetic)
coricosteroids for refractory vomiting
What are the lab findings for iron-deficiency anemia in pregnant people?
Hgb less than 11 mg/dL in first and thrid trimesters
less than 10.5 mg/dL in 2nd
Hct: less than 33%
blood ferritin less than 12 mcg/L with low Hgb
What is the recommended iron intake for pregnant clients?
27 mg/day
What are some risk factors of ectopic pregnancy?
STI
IUD
previous tubal surgery
previous ectopic pregnancy
What are some s/s of ectopic pregnancy and which are some scary signs?
unilateral stabbing pain,
tenerness in LAQ or shoulder
hypotension** bleeding and shock
scant daerk red or brown vaginal spotting 6-8 wks after last normal menses.
what are some treatments for ectopic pregnancy?
prevent rupture
methotrexate- inhibit growth of embryo and dissolves pregnancy (cancer drug)
Salpingostomy to salvage fallopian tube if not ruptured
laparoscopic salpingectomy- removal of tube after rupture
What should you tell a client taking methotrexate?
avoid vitamins containing folic acid to prevent a toxic response to the med and use protection against the sun
What is the name of the test that can detect fetal blood in maternal circulation?
Kleinhauer-Betke test
What are some s/s of spontaous abortion?
heavy, bright red vaginal bleeding
elevated temp w/ or w/o foul smelling vaginal discharge
rupture of membranes
dilation if cervix
what are some therapeutic procedures of spontaneous abortion?
D&C
prostaglanding and oxytocin to induce uterine contractions and expulse products of conception
D&E
broad spectrum abx
Rho D immune globulin
What are some physical assessment findings of gestational trophoblastic disease?
often brown bleeding or
bright red with vesicles for a couple days to weeks
anemia from blood loss
preeclapsia findings before 24 weeks gestation
How often would serum hCG be anaysed following a molar pregnancy and what to do about contraceptives and any other follow up tests?
weekly for 3 weks
montly for 6 mos-yr
use reliable contraception and avoid IUD
save clots or tissue for evaluation
chemotherapeutic meds for malignant choriocarcinoma
When should an HIV+ pt get a c-section?
If their viral load is more than 1,000 at 36, prepare for c-section at 38 wks.
What are some s/s of false labor?
contractions decrease with walking or position changes and eating or drinking like braxton hicks
no bloody show
fetus not engaged or cervix is not dilated or effaced
What are some s/s of true labor?
timing of contractions is regular
radiating pain doesn’t go away usually in lower back
unable to relieve pain with activity
exam changes of cervix and presenting part engaged in pelvis
What are the stages of labor and the cervical dilation and contractions?
first stage-
latent (0-3) irregular Q 5-30 min for 30-45 sec, talkative and eager
active (4-7) more regular Q 3-5 min for 40-70 sec, anxious and restless
transition(8-10) strong Q 2-3 min for 45-90 sec, tired and restless, nurse to push,
Second stage- 30 min to 5 hr pushing and full dilation
third stage- 5-30 min and delivery of neonate
fourth stage- achievement of vital sign homeostasis after placental deliver
What are the 6 p’s of the L& D process
psyche- mother’s psychological response to labor
powers- mother’s uterine contractions
passenger- fetus and placenta (includes fetal presentation and lie, attitude, and station)
presentation- what’s coming out of the pelvic inlet first
position- relationship of presenting part like occiput, mentum, sacrum to the maternal pelvic inlet
passageway- birth canal, pelvis, ceervix, pelvic floor and vagina
at what location would the baby be when at station 0?
the narrowest diameter the fetus must pass through a vaginal birth
Which is better, cephalic or breech presentation? occiput anterior or occiput posterior?
cephalic because the head at the pelvic inlet.
occiput anterior so the bony part of the baby’s head is not pushing against the mother’s sacrum
How often should you check maternal v/s if membranes are ruptured?
every 2 hrs.
How often should FHR be assessed during the second stage?
Q 15 minutes
What are some physical and psychological effects of alcohol?
Slurred speech, lack of coordination, unsteady gait, blackouts, nystagmus, flushed face, sense of floating and anorexia
Euphoria, mood lability, impaired judgement, sexual inhibits, decreased concentration, and aggressive behavior
What are some withdrawal effects of alcohol?
Anxiety, agitation, irritability, tremors, tachycardia, hypertension, diaphoresis, hallucinations, N/V diarrhea, DT, easily startled
When do delirum tremens start and look like? How many people die from it?
shaking, vomiting, increased BP, HR, temp, sweating, halucinations 2-3 days after last drink. About 10% of DT patients die
Wernicke-Korsakoff syndrome causes what? And what is W-K caused by?
Drinking heavily and consistently can results from a vitamin B/thiamine deficiency, which causes severely impairs cognitive functioning through peripheral neuropathy, cerebellar ataxia, confabulation and myopathies
Alcohol withdrawal can happen how long after the last drink?
4-12 hours after the last drink and peaks at 24-48 hrs.
What are some signs of alcohol withdrawal?
Anxiety, tremor, insomnia, increase BP and pulse, shaky, startled easily, dry heaves, diaphoresis, disoriented and clouding of sensorium, tactile disturbances, auditory and visual disturbances, headaches
If someone had their last drink on Wednesday @ 0200, when do you get withdrawal symptoms? DT?
Wed 0600 to 1400
DT: Thurs 0200 to Friday 0200
What are the four CAGE questions?
Have you ever felt you should cut down on your drinking
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever had a drink first thing in the morning to steady nerves or get rid of a hangover (eye-opener)?
What is a “good” and “bad” CIWA score?
8-10 minimal to mild so continue with benzos and monitor
20+ is bad so give them everything go to ICU
What is the best score on the RASS?
They are alert and calm with a zero
What is the CIWA used for?
To recognize the process of withdrawal before it progresses to more advanced stages by listing and grading 10 signs and symptoms.
What does a -4 RASS vs +4 RASS mean?
There’s no response to verbal stimulation and there is either eye opening to physical stimulation in -4 or nothing in -5
It means you are combative. Attempt to calm them down, use meds, and restraints if needed
What are some types of benzos to use for alcohol withdrawal?
Diazepam, Clorazepam, and chlordiazepoxide
What might be used for patients to stop their chronic alcohol abuse and how does it work?
What might be used for patients to stop their chronic alcohol abuse and how does it work?
What are some patient teachings when someone is on disulfiram?
There can be no alcohol in the system when starting. Avoid alcohol hand sanitizer, perfumes, vanilla extract, mouthwash, cough/cold meds, and huffing paints, stains, and stripping compounds.
What are some physical effects of opiate use?
opiates
pinpoint pupils
impared cognition
anorexia and anxiety
temporary madness (delirium)
euphoria
skin picking & sleepiness
Think: human bats sleeping in caves without light
What are some withdrawal effects of opiate use after using Narcan?
Lacrimation, rhinorrhea, excessive sweating, yawing, tachycardia, fever, insomnia, muscle aches, craving, N/V dilated pupils, and chills. Like a flu diarrhea
Think: rhino sick and sleepy with the flu
What are three types of defense mechanisms of neurocognitive disorders?
denial- refuse to believe the changes and loss that are taking place
confabulation- patient makes up stories that they do not remember unconsciously to preserve self-esteem
perseveration- avoid answering questions by repeating phrases or behavior
What is a major difference between dementia and delirium?
Onset- dementia is insidious and there is no change in consciousness
What is some cognitive support for those with neurocognitive disorders?
compensatory memory aids- clocks, daily calendars, photos, memorabilia
consistent daily routine and caregivers
no mirrors
encourage physical activity throughtou day
adequate lighting in the bathroom at all times
What is some physical support for those with neurocognitive disorders?
skin integrity, nutrition, vital sign, incontinence monitoring
promote sleep
What is some communication support for those with neurocognitive disorders?
positively worded phrases
rinforce reality and time, place, and person
eye contact with short, simple sentences
reminiscence about happy times
limit choices when eating or dressing
address the client by name
encourage family to visit
What are the stages of Alzheimer’s?
Stage 1-3: mild- memory lapses loss, but able to perform ADL
losing or misplacing items, difficulty concentrating and organizing, STM
Stage 4-5: moderate, forgetting one’s own history,
forgets address and dates, and common words
difficulty with planning tasks and organizing like managing money, arithmetic
behavioral changes- sleep patterns, getting lost, incontinent perhaps
Stage 6-7: Severe, lose ability to convers with others, only remembers own name
ADL assistance, incontince, walking, sitting and swallowing
eventually loses all ability to move and develps stupor and coma
losing awareness of one’s environment
can’t recognize others
What should you give to an 8 y.o. with updated immunizations for a deep puncture injury?
Td b/c it is recommended in children ages 7 and older and every 10 yrs after 18 y.o.
What kind of play is good for a four-month-old?
splashing in a bath because it provides tactile stimulation
rattles
bouncing in the guardian’s lap
playing with brightly colored toys.
How would you used the Snellen chart?
place heels on 10 foot mark
wear glasses if needed and keep both eyes open
cover one eye and start at bottom
4/6 right to advance to next
cover other eye and start at top and move down
If someone had 20/30 vision, what does that mean?
The person is able to see something at 20 feet what a normal person could at 30
Why should you palpate the abdomen of an infant with unrepaired myelomeningocele??
they might have a neurogenic bladder, so assess for bladder distension and retention
feeding a cleft lip only vs cleft palate lip tips
only lip-
brest feeding
wide-based nipple for bottle feeding
squeeze cheeks together
both- upright
one-way valve with special nipple
burp frequently
syringe if necessary
When should the birthweight of an infant double and then triple? Quadruple?
doubled 5 mos
Tripled at 12 mos
quadrupled at 30 mos
nutritional guidelines for 2 y.o.
about 1,000 cal /day
2 oz of protein/day
no more than 24 oz, or 3 cups of milk/day
8 ox or 1 cup of veggies /day
What is the difference between night terrors and nightmares?
nightmares are scary dreams that people wake up from , which can cause kids to be scared of falling asleep
night terrors occur just within the time people are dreaming, and they will thrash around, moan, and scream that go away when they awake
Both might be have daytime fatigue, concentration impairment, and impulsive behaviors
What ais the WBC range for a child under 2 yrs?
6.2-17
what should the Hct for a 2-8 wk old be?
39-59%
Total Bilirubin for newborn
0.3-10 mg/dL
What do measles or rubeola spots look like and what are some s/s of impending rash?
3-4 days prior- mild to mod fever, conjunctivitis, fatigue, cough, runny rose, red eyes, sore throat
koplik spots appear in mouth 2 days prior to rash that comes with fever
Red or reddish-brown rash beginning on the face spreading downward
What happens before the rash of fifth disease, and then what happens?
fever, rhinitis, and h/a few days before rash
rash on face from days 1-4
Maculopapular red spots symmetrically distributed on upper and lower extremities progressing proximal to distal surfaces through 1 week
Secondary itchy rash that can appear on rest of body, especially on the soles of the feet
Nutritional guideline for preschooler
1200 to 1400 kcal/day
13 to 19 g/day of protein (2- to 4-oz equivalents)
700 to 1000 mg/day of calcium and19 to 25 g/fay of fiber.
Total fat should be 30% of total
5-2-1-0 framework, which includes that preschoolers have 5 servings of fruits and vegetables per day, 2 hr or less of screen time, 0 servings of sugar-sweetened beverages, and 1 hr of physical activity per day
What are the four T’s of postpartum hemorrhage?
Tone (uterine atony)
Tissue (retained placenta)
Trauma (injury to the birth canal)
Thrombosis (clotting problems)
What is a mental status exam used for and what are some questions?
to determine a client’s current ability to use cognitive processing or to re-evaluate the ability during and after treatment.
information about time
orientation
thinking and recall
ability to follow verbal and written direction
language use
concentration
spatial understanding
proverb interpretation
What kind of antiseptic should be used to clean a peripheral IV cath?
70% alcohol or chlorhexidine
What are some types of complicated grief?
resentment, changes in sleep and withdrawal fromothers
delayed or inhibited- not normal grief process and cultural or societal norms can influence development of grief
distorted or exaggerated- unable to perform ADL and remain in anger stage and develop clinical depression with somatic effects
chronic/prolonged- remain in maladaptive response and in denial stage and affect performance of daily living
disenfranchised grief- not able texpress loss publically such as suicide and abortion
Characteristics of borderline personality
unstable affect, identity, and relationships
splitting, manipulation
fear of abandonment, and self-injurious and suicidal
chronic emptiness
Think Malificent
what personality typ is characterized by emotional detachment, disinterest in close relationships, and indifference to praise or criticism; often uncooperative
schizoid (detached like Golem)
What personality type is characterized by odd beliefs leading to interpersonal difficulties, an eccentric appearance, and magical thinking or perceptual distortions that are not clear delusions or hallucinations
schizotypal (Magical and hallucinations with no close firends like trelawney from Harry Potter)
What personality type is characterized by seductive behaviors; nonadherence to traditional morals and values; verbally charming and engaging?
antisocial- disregard for others with exploitation, lack of empathy, repeated unlawful actions, deceit, failure to accept personal responsibility; evidence of conduct disorder before age 15
Think Joker
Different between ASD and PTSD?
ASD: Exposure to traumatic events causes anxiety, detachment and other manifestations about the event for at least 3 days to 1 month following the event.
PTSD: Exposure to traumatic events causes anxiety, detachment, and other manifestations about the event for longer than 1 month following the event. Manifestations can last for years.
What are some expected findings of ASD and PTSD?
Intrusive flashbacks/involuntary flashbacks
night time dreams related to event
avoidance of tirggers that remind the pt of the event
avoidance of the event
anxiety, anger, decreased interest in activities, guilt, detachment from others
inability to experience positive emotional experiencesdissociateive manifesations
inability to concentrate
hypervigilance
What therapy involved cognitive-behavioral therapy for clients who have a personality disorder and exhibit self-injurious behavior?
dialectival behavior therapy for gradual behavior changes and provides acceptance and validation for these clients.
What are some interactions with cholinesterase inhibitors for alzheimers duch as donepezil?
Concurrent use of NSAIDs (aspirin) can cause gastrointestinal bleeding.
Antihistamines, tricyclic antidepressants, and conventional antipsychotics (medications that block cholinergic receptors) can reduce the therapeutic effects of donepezil.
Late adverse effects of SSRI?
After 5 to 6 weeks of therapy: Insomnia, headache, and sexual dysfunction
weight changes
GI bleeding
hyponatremia- with diuretics usually
Serotonin syndrome
Bruxism
withdrawal syndrome
postural hypotension
SI
What character has and avoidant personality disorder and what are they like??
Charlie Brown or a bit like Adrian Monk
Avoid responsibility, promotion, intimate relationships for fear of rejection and failure
Feelings of inadequacy and fear an no confidence
the
What type of personality disorders are at a higher risk for danger to self? what about others?
borderline personality disorder are at a higher risk for danger to self.
anti-social personality disorder are at a higher risk for danger to others
What is conversion disorder?
aka functional neurological symptom disorder
There is an internalization that turns into externalization and there are deficits in voluntary motor or sensory functions
What are some common symptoms of conversion disorder?
Paralysis, blindness, movement and gait disorders, numbness, paresthesia, loss of vision or hearing
What is the mindset of conversion disorder patients?
anxiety and distress in some clients while others can exhibit a lack of emotional concern (la belle indifference).
What do people with illness anxiety disorder worry about
Hypochondriacs are overconcerned for health and preoccupied with symptoms and there is extreme worry and fear like extreme worry and fear
Risk factors for illness anxiety disorder
First-degree relative with disorder
previous loss with intense feelings
childhood trauma
MDD/anxiety
stressors
low self-esteem
What are some examples of factitious disorders?
Self-directed other-directed and malingering behaviors, but malingering is conscious and factitious is a mental illness
What personalities are grounds for factitious disorder?
Dependent personality
Borderline personality disorder
B/w delirium and neurocognitive disorder, which has a fluctuatiing LOC?
delirium and a
What are some things to ask an altered client during discharge to ensure safety
Will the client wander out into the street if doors are left unlocked?
Is the client able to remember their address and name?
Does the client harm others when allowed to wander in a long-term care facility?
What are CBT for anorexia nervosa?
Cognitive reframing
Relaxation techniques
Journal writing
Desensitization exercises
What type of food planning could you do with anorexic patients?
consider food preferences
structured and inflexible eating schedule at start of therapy
small frequent meals
liquid supplement
high fiver
low sodium
limit high-fat and gassy food and no caffeine
admin multivitamin and mineral
What are some cultural assessment categories?
Environmental control- eenvironment can be mastered to affect health status will actively engage in health promotion, disease prevention, and treatment/ predetermined
Time orientation- Individuals who focus on the past or present can have little interest in health promotion behaviors, which are described as having benefit in the future.
social organization- decisions about a client’s health might be made by an individual other than the client, or by the group
Health beliefs and practices
Biological variations in health
What are five agent factors of assessing susceptibility to work-related illness?
Biological agents: viruses, bacteria, fungi, blood-borne, airborne pathogens
Chemical agents: asbestos, smoke, lead, mercury, cadmium, nickel, zinc, and antineoplastic drugs
Enviromechanical agents: musculoskeletal or other strains from repetitive motions, poor workstation-worker fit, lifting heavy loads, slippery floors, cluttered work areas
Physical agents: temperature extremes, vibrations, noise, radiation, lighting
Psychosocial agents: threats to psychological or social well-being resulting in work-related stress, burnout, violence, interpersonal relationships
What is the general definition of sentinel event and two classifications?
Unexpected death, major physical or psychological injury, or situations where there was a direct risk of either of these
Major loss of function or death that was not expected with the client’s medical condition
Client-attempted suicide during round-the-clock care, hemolytic transfusion reaction, wrong site or wrong client surgical procedures, rape, infant abduction, or discharge to the wrong family
How many minutes should a yellow tag be delayed care, and what does it involve?
Urgent or delayed
Second-highest priority is given to clients who have major injuries that are not yet life-threatening and usually require treatment in 30 min to 2 hr.
How many minutes should a green be delayed care, and what does it involve?
Nonurgent or minimal
The next highest priority is given to clients who have minor injuries that are not life-threatening and can wait hours to days for treatment.
How many minutes should a black be delayed care, and what does it involve?
Expectant
(CLASS IV, BLACK TAG)
The lowest priority is given to clients who are not expected to live and will be allowed to die naturally. Comfort measures can be provided, but restorative care will not.
How many minutes should a red be delayed care, and what does it involve?
Emergent or immediate
(CLASS I, RED TAG)
Highest priority is given to clients who have life-threatening injuries but also have a high possibility of survival once they are stabilized.
What about a kid’s anatomy makes them vulnerable to common respiratory illnessess?
Age- b/w after 3-6 mos makes them more at risk due to decrease of maternal antibodies until 5 y.o.
Anatomy- short narrow airway: edema, short respiratory tract: infections travel faster, middle ear problems
Decreased resistance- weak immune system, anemia, allergies, nutritional deficiencies, chronic conditions, second-hand smoke
Seasonal variables- asthma increase risk of RSV and pneumoniae.
What are some non patho related risk factors of AOM?
not breast fed
exposed to 2nd hand smoke
large number of kids like day care
cleft lip or palat
noncompliance with vaccines
down syndrome
What can trigger otitis media?
bacteria infection of respiratory tract like Haemoph influenzae, strep pneumoniae
What is the course of abx for otitis media?
only for children over 6 months with fever more than 102.2F and increase pain for more than 2 days
80-90 mg/kg/day in two divided doses usually for 10 days in children younger than 6 or less in older children
How long does a myringotomy take?
15 min under general and discharge in one hour
8-18 months for tubes to fall out on own
client education for myringotomy post op?
limid activity for a few days post-op
avoid getting water in ears
breathing pattern for active vs transition phase
active- deep cleansing breaths before and after modified-paced breathing
transition phase- rapid pant-pant-blow pattern
How often should the v/s, contractions and FHR be assessed in the first stage?
latent- every 30-60
active- every 30 min for v/s and 15-30 min for contraction and FHR
transition- 15-30 min of v/s and FHR and 10-15 for contractions
How often would you check v/s in the fourth stage of labor?
15 minutes for the first 1-2 hours and then 30 minutes for the next and per hospital protocol
temp should be Q 4 hours
What are the types of pain each of the stages of labor?
first- visceral back and leg from cervical stretching, distention of lower uterus, and contractions
second- somatic with fetal descent and expulsion, pressure and distention of vagina and perineum- burning, splitting, and tearing from lacerations
third stage- placental expulsion and pressure of pelvis
fourth- distention and stretching of the vagina and perineum
What analgesics would you give in the first vs. second stage of labor?
first- opioids, epidural block(analgesic), combo spinal-epidural analgesia,
nitrous oxide
2nd- not opioids, but epidural analgesia, CSE, nitrous oxide, local infiltration anesthesia, pudendal and spinal block
What are some cutaneous stimulation strategies for labor pain?
effleurage of abdomen/ sacral counterpressure of back/ accupressure
walking/rocking
TENS
heat/cold
hydrotherapy
maternal position changes
When is a good time to have an epidural block, and what are some nursing considerations?
at least 4 cm dilated, remain side-lying to prevent supine hypertension, and bolus IV fluids and possibly IV vasopressor
help them up when start to salk after delivery
What conditions are a spinal block used for in labor and when should it be administered?
for cesarean or vaginal birth, but eleminates all sensation from feet to nepples
NOT for labor, but can be given in second stage or before c-section
How often to check v/s after angiography?
Q 15 min, 1 hr
Q 30 min, 2 hr
Q 1 hr, 4hr
q 4 hr thereafter
What are some discharge instructions pre-angiography? post?
NPO at least 8 hrs
hold metformin 48 hrs prior due to possible acidosis
post:
maintain bedrest 4-6 hrs after
no metformin 48 hrs after angiography
leave dressing for first 24 hrs
avoid lifting more than 10 lbs, bending at the waist
what are some complications of angiography?
artery dissection,
cardiac tamponade
hematoma formation
allergic rxn to contrast
external bleeding of insertion site
embolism
restenosis of treated vessel
retroperitoneal bleeding
AKI
What must you hold and give before an elective cardioversion?
hold metformin 48 hours before and after surgery
anticoag therapy for 4-6 weeks prior
At what weeks would an external cephalic version be done?
37-38 weks
what are some risks to external cephalic version?
Placental abruption, umbilical cord prolapse, ROM, stillbirth, fetomaternal hemorrhage, severe variable decelerations, emergent cesarean, multifetal gestation
what is the medical management for external cephalic version?
US, informed consent,
tocolytics for relaxation of the uterus for easier manipulation,
neuraxial analgesia,
NST or BPP,
cesarean services must be readily available
Rho gham has ben administerd at 28 weks if mom is Rh-
What are the criteria for Bishop score?
cervical dilation, effacement, consistency, position, and station
What is the leading indication for primary cesarean birth in the US?
Labor distocia
What is the test used for cervical status and maternal readiness? and what is a good score at 39 weeks? not a good score?
Bishop score- 8 is great, 6 is not
Pharmacological methods of cervical ripening
cervidil (dinoprostone insert)
misoprostol PGE1 (cytotec)
How long after using dinoprostone gel would oxytocin be delayed?
6-12 hours after
How long after misoprostol should oxytocin be delayed?
At least four hours
How long after cervidil removal can the woman be given oxytocin?
30-60 minutes (dinoprostone insert)
How many times can you use a dinoprostone gel?
0.5 mg gel Q 6 hours max 3 doses
How long should the woman lay recumbent after a dinoprostone gel vs. insert?
30 minutes after gel and 2 hrs after cervidil
What are the four risks for amniotomy
variable decelerations
bleeding
umbilical cord prolapse
intraamniotic infection
Prior to elective induction, fetal maturity must be confirmed to be _____ weeks or greater by the following:
39
1. Ultrasound before 20 weeks’ gestation confirms gestational age of 39 weeks or greater.
2. Fetal heart tones have been documented as present by Doppler for 30 weeks.
3. It has been 36 weeks since a positive serum or urine pregnancy test was confirmed.
What are nursing actions for a Category II or Category FHR pattern from oxytocin induction?
■ Discontinue.
■ Change maternal position to lateral.
■ Initiate IV hydration of at least 500 mL LR
■ Administer O2 by nonrebreather mask at 10 L/min.
■ Consider terbutaline if no response
■ Notify the provider and request evaluations for Category III abnormal FHR.
What is the desired contraction pattern to maintain the dose of oxytocin?
contraction frequency of 2-3 min
contraction duration of 80-90 sec
intensity of 40-0 mmHg
uterine resting tone of 10-15 mmHg
cervical dilation of 1 cm/hr
reassuring FHR between 110-160
When would you discontinue oxytocin?
uterine tachysystoe
More than 5 UCs in 10 minutes over 30-minute window
Series of single UCs lasting 2 minutes or longer
UCs occurring within 1 minute of each other
contraction intensity pressure greater than 90 mmHg
no relaxation of uterus b/w contractions
What are some things to confirm before vacuuming?
Cervix fully dilated and retracted
Membranes ruptured
Engagement of the fetal head
Position of the fetal head has been determined
Weight estimated
Adequate anesthesia
Pelvis is adequate
Fetus older than 34 wks, engaged head, and at least 0 station*
Vacuum cup should not be on the fetal head for longer than ____
15-20 minutes
Forceps risk for newborn
facial lacerations
facial nerve palsy
corneal abrasions and external ocular trauma
skull fracture
intracranial hemorrhage
What are some advantages of vacuum over forceps?
Easier application
Less anesthesia required
Less maternal soft tissue damage
Fewer fetal injuries
Complications and client ed after vacuum-assisted delivery?
laceration, cephalophematoma
caput succedaneum - this will disappear usually within 3-5 days
What are indications of a c-section from a high-risk pregnancy?
HIV+
hypertensive disorder
DM
active genital herpes lesions
What are VBAC indication?
One or two prior low transverse cesarean births with no other uterine scars
Clinically adequate pelvis
Physician and OR team immediately available to perform emergent cesarean birth.
Contraindications of VBAC
Prior vertical (classical) or T-shaped uterine incision or other uterine surgery
Previous uterine rupture
Pelvic abnormalities
Medical or obstetric complications that preclude a vaginal birth
Inability to perform an emergent cesarean birth if necessary because of insufficient personnel such as surgeons, anesthesia, or facility
Preprocedure considerations for C-section
US/FHR
SCD
informed consent
NPO
Rh-factor test
IV catheter and fluids
Post-procedure considerations for C-section
monitor for excessive bleeding, firmness, lochia, and endometritis
encourage splinting, turn, cough, and deep breathe
early ambulation
urination
Over how much time does platelets need to be administered?
15-30 min with a small filter
Over how much time does plasma transfusion need to be transfused?
200 mL of FFP over 30-60 min through a regular Y-set
What is the max gauge for an older adult?
19 g
Aspiration of meconium results in what complications?
Results in respiratory distress that can be life-threatening.
It induces hypoxia via four major pulmonary effects:
airway obstruction
surfactant dysfunction
chemical pneumonitis
pulmonary hypertension
What are some risk factors to meconium in the amniotic fluid?
Umbilical cord compression and hypoxia can stimulate the vagal nerve
What are some actions for dysfunctional labor?
fetal scalp electrode or IPC
amniotomy
regular voiding to empty the bldder
position changes to scoot fetus into pelvic outlet
ambulation if not on epidural drip
hydrotherapy
counterpressure
prepare for forceps and vacuum
what are some risk factors for dystocia?
Congenital uterine abnormalities such as bicornuate uterus
male presentation of a fetus such as occiput posterior or face presentation
cephalopelvic disproportion
tachysystole the uterus with oxytocin
Maternal fatigue and dehydration
Administration of analgesic or anesthesia early in labor
Extreme maternal fear or exhaustion which can result in catecholamine release interfering with contractility
Complications of fetal dystocia are:
■ Neonatal asphyxia related to prolonged labor
■ Fetal injuries, such as bruising
■ Maternal lacerations
■ Cephalopelvic disproportion (CPD)
what are some nursing actions for hypertonic uterine dysfunction?
Promote rest to break the pattern of contractions
administer demerol or morphine to promote sleep and prevent exhaustion
hydrate
warm shower or tub bath
Quiet environment
Waiting for spontaneous labor and avoiding use of ____ and ___ reduces the risk of _____.
prostaglandins and oxytocin
uterine rupture
Medical Management of shoulder dystocia
Downward traction may be applied to the fetal head w/ suprapubic pressure
Extend the midline episiotomy to obtain room for maneuvers.
McRoberts maneuver initially
Woods corkscrew maneuver
Deliver the posterior shoulder by sweeping the posterior arm across the fetus’s chest followed by delivery of the arm.
What is the McRoberts maneuver?
Two assistants, each grasp a maternal leg and then sharply flexes the thigh back against the maternal abdomen
Causes cephalad rotation of the symphysis pubis and flattening of the lumbar lordosis that can free the impacted shoulder
Risks Associated With Shoulder Dystocia
Delay in delivery of the shoulders results in compression of the fetal neck by the maternal pelvis, which impairs fetal circulation and results in possible increased intracranial pressure, anoxia, asphyxia, and brain damage.
Brachial plexus injury and clavicle fracture in the neonate can also occur.
Maternal complications include lacerations, infection, bladder injury, or postpartum hemorrhage.
What are some risk factors of uterine rupture?
congenital uterine abnormaliy
uterine trauma from accident or surgery like c-section
overdistension of the uterus from an LGA
tachysystole
external or internal fetal version
forceps
multigravida
What is anaphylactic syndrome?
amniotic fluid that contains fetal cells, lanugo, and vernix enters the maternal vascular system and results in cardio respiratory collapse
amniotic fluid may enter the maternal circulation in what three ways
(1) through the endocervix following rupture of amniotic membranes
(2) at the site of placental separation
(3) at the site of uterine trauma, often lacerations that occur during normal labor, fetal descent, and birth (placental abruption for example)
anaphylactoid reaction leads to what complications
Acute pulmonary hypertension
Rt and lt. ventricular failure
Acute respiratory failure
DIC
For which condition would you monitor for signs of maternal hemorrhage or postpartum hemorrhage?
Precipitous labor, and uterine rupture
how would you categorize rapid cervical dilation that labor is less than three hours?
precipitous labor
What are some risks to the fetus of precipitous labor?
Hypoxia and risk for CNS depression
intracranial hemorrhage
What are some risk factors of precipitous labor
younger age (teens)
hypertension
oxytocin hypertonic uterus
multiparous client
preterm delivery
SGA
placental abruption
What are some risks to the fetus of precipitous labor?
lacerations
tissue trauma
uterine rupture
amniotic fluid embolism
postpartum hemorrhage
What is the difference between capital and operating budget
capital budget involves planning for spending related to equipment and major purchases that have a long life of use.
An operating budget is separate from the budget for large expenditures and reflects expenses that change in response to the volume of service (e.g. supplies, electricity).
Which STI’s are reportable
chancroid.
chlamydia.
gonorrhea.
hepatitis B (acute or chronic) A&C too
HIV.
syphilis
reportable childhood diseases
Measles, Meningitis, Mumps,
Rubella,
Diphtheria,
Tetanus, Pertussis,
Poliovirus infection, RSV, varicella
reportable GI diseases
Cholera
Cryptosporidiosis
Shiga toxin-producing Escherichia coli (E. coli) (STEC)
Giardiasis
Hepatitis A
Salmonellosis
Shigellosis
Typhoid fever
reportable respiratory diseases
COVID-19
Flu
RSV
rhinovirus
human parainfluenza virus
metapneumoviruses
reportable vector-borne diseases
lyme
west nile dengue
chikungunya
zika
rocky mountain spotted fever
tularemia
typhus
best type of chair for pain in rheumatoid arthritis
straight backed chair with elevated seat
What is the first step in disaster response strategy for a hospital?
hazard vulnerability assessment to identify the possible causes of disaster to anticipate potential and actual threats to a community
how long should someone with impteigo stay home and what are the treatments?
stay home for 24 hrs after treatment initiation of triple antibiotic oitment and soaking the crusty sores in warm saline
towels should be washed separately
for which patients is advanced carb counting good for, and why?
DM I with a pump because it is based on insulin to carbs and calculating the appropriate insulin dose to predict how much is needed
What are some nutrition/ feeding guidelines for heart failure infants?
feed every 3 hours because they need rest, but not too much in between feedings
limit bottle time to 30 min
add corn oil to fortify supplement
hold at 45 degree angle during feedings and never place prone
what are some ways to get a patient with urinary rention to pee?
try to void again after urine flow stops
dip hand in water,
Crede maneuver with primary care provider direction
run faucet water
protein intake guidelines for hemodialysis pt
1.2 g of protein per kg of body weight
take phosphate binders
increase complete proteins
increase protein intake by 50% of RDA because amino acids are lost in dialysate
How much should a patient advance a walker and how?
they should lift the walker and advance it 6 in
if there is a weaker leg, move walker with weaker leg first.
otherwise, walker first and then feet
Name some foods high in potassium
avocado, apricots, kiwi, beans, beets, banana, brussel sprouts, cantaloupe, fish, oranges, potatoes with skin, dried apricots, spinach, and tomatoes.
Low potassium foods: apples, blueberries, cauliflower, cabbage, corn, cucumber, grapes
How should sarin be decontaminated?
large amount of mixed 5% bleach and water
What is the purpose of antivirals in HSV?
they diminish symptoms of latent infection, but they still remain infectious during recurrent episodes during active and latent period.
decreases viral shedding and increases the risk for AIDS
with how much should an NG tube be flushed with adults vs children?
15-30 and kids 5-10mL
What should patients with hearing aids do if they hear squealing or shrill sounds?
lengthen the wearing time each day until client has adjusted
how long to seal unwashable items infested with lice?
at least 14 days
what diagnostic test confirms syphillis infection?
Treponema pallidum hemagglutination assaytassium
What sleep stage do people dream?
REM- 90 min/night
damage to what nerve will result in wrist drop?
radial nerve
what is silent aspiration?
no coughing when food enters the airway, due to things like neurogenic disorder
What are some things that magnesium is essential for?
dietary sources?
protein synthesis, muscle contraction
use of ATP
nerve conduction
blood clotting
Dietary sources of magnesium include dark chocolate, nuts, whole grains like quinoa, avocados, legumes, leafy green vegetables, bananas, and tofu
What does CYP3A4 do?
an enzyme that metabolizes many drugs and other substances in the body. It’s found in the liver and small intestine.
what is the recommended temperature for cooked beef?
160F
What are some manifestations of celiac disease?
steatorrhea, foul smelling
anorexia, cachexia, anemia, abdominal distention
uncooperative, emotionless, ill tempered
What types of foods should nopt be given to those with celiac disease?
no gluten
no fiber because decreased absorption leads to inflamation
What are some foods that those with calcium oxalate stones should avoid?
avoid high sugar such as fruit punch or juice and bran that is high in oxalates
1 lb of body fat is equivalent to how many calories
3,500 calories
What statin drug can be taken with grapefruit juice?
Pravastatin can be taken with grapefruit juice because it is not affected by CYP3A4 Inhibitors
Why should older females take adequate folic acid? Where is it found?
Reduces homocysteine levels and lowers heart disease.
Found in foods such as orange juice, beans, legumes, and green leafy vegetables and enriched foods like breads and pasta
how to put on SCD
Assess circulation and skin
Measure around the largest part of the thigh to determine the stocking size.
Apply the sleeves to each leg. Position the openings at the client’s knees.
Attach the sleeves to the inflator.
Monitor circulation and skin after application.
Remove every 8 hr for assessment of calves.
Document the application and removal of the stockings.
how often to do ROM?
hourly while wake
ankle pumps
foot circles
knee flexion
How long should a newborn feed on one breast?
five minutes to promote milk production
What are some feeding methods for an infant with cleft lip?
burp several times throughout feeding
use a one way valve bottle
use high flow rate nipple to help them achieve a good seal
squeeze cheeks together
How many cups of fruits and veggies should an adult eat a day to lower cancer risk?
eat at least 2.5 cups
Why should people with IBS take peppermint oil?
peppermint relaxes the smooth muscle of the GI tract and decreases the manifestations of IBS.
When to use FLACC scale?
FLACC: 2 months to 7 years
Pain rated on a scale of 0 to 10.
Assess behaviors of the child.
Faces
Legs
Activity
Cry
Consolability
When to use the Oucher pain scale
3 to 13 years
Pain rated on a scale of 0 to 5 using six photographs.
Convert to the 0 to 10 scale.
Have the child organize the photographs in order of no pain to the worst pain; ask the child to choose a picture that best describes how they are feeling.
When to use FACES scale?
FACES: 3 years and older
Pain rated on a scale of 0 to 5 using a diagram of six faces.
Substitute 0, 2, 4, 6, 8, 10 for 0 to 5 to convert to the 0 to 10 scale.
What pain scale to use if pt is noncommunicating?
Non-communicating children’s pain checklist: 3 years and older
Subcategories: Activity, body and limbs, facial, physiological, social, vocal
What is Stokes-Adams syndrome?
aka Adams-Stokes syndrome or cardiac syncope- a sudden, brief loss of consciousness from a large drop in cardiac output. This happens because of an abnormal heart rhythm and a change in heart rate, causing fainting/dizziness.
why are bolus feedings contraindicated for NJ tube feedings?
Bolus feedings are delivered directly into the stomach; they are contraindicated for tubes placed into the jejunum or duodenum. They can be poorly tolerated and can cause dumping syndrome.
Volumes range from 250 to 400 mL
how to insert a rectal temp probe?
more accurate than axillary.
Sims, side or prone.
lube probe and expose area, spread cheeks
insert max 1.5 in toward belly button
Use the rectal site to verify the temperature for any reading obtained through another site that is greater than 37.2º C (99º
Which patients should not get a rectal temp generally?
Those w/ diarrhea, bleeding precautions (those who have a low platelet count) or rectal disorders.
The American Academy of Pediatrics recommends not measuring rectal in infants younger than 3 months.
levels of mild dehydration in infants and children
Moderate and severe
mild: 3%-5% in infants, 3-4% in children
moderate: 6-9% in infants, 6-8% in children
severe: 10%+ in infants, 10% in children
s/s of mild dehydration in kids
everything within normal, but
cap refill 2+ and possible slight thirst
s/s of moderate dehydration in kids
cap refill b/w 2-4 sec
Increased: pulse, BP, RR
decreased tears, skin turgor, mucus membrane dry,
normal-sunken anterior fontanel
s/s of s dehevereydration in kids
ten%, tachycardia, thirst (extreme), tenting
hyperpnea
dry mucous membrane
no tear
sunken anterior fontanel
oliguria/anuria
think shriveled skeletal pirate
what type of dehydration would you useoral rehydration?
mild and moderate cases
mild: 50 mL /kg w/in 4 hrs
moderate: 100 mL/kg w/in 4 hrs
diarrhea losses: 10 mL/kg of stool
why should hypertonic dehydration not be remedied with bolus or rapid fluid?
risk of cerebral edema
Defects that decrease pulmonary blood flow
Tricuspid atresia
Tetralogy of Fallot
What is tricuspid atresia and some s/s
A complete closure of the tricuspid valve that results in mixed blood flow. An atrial septal opening needs to be present to allow blood to enter the left atrium.
Infants: Cyanosis, dyspnea, tachycardia
Older children: Hypoxemia, clubbing of fingers
What is Tetralogy of Fallot and some s/s
Four defects that result in mixed blood flow: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
Cyanosis at birth: progressive cyanosis over the first year of life
Systolic murmur
Episodes of acute cyanosis and hypoxia (blue or “Tet” spells)
Obstructive defects
Pulmonary stenosis
aortic stenosis
coarctation of the aorta
Pulmonary stenosis? what and s/s
A narrowing of the pulmonary valve or pulmonary artery that results in obstruction of blood flow from the ventricles
Systolic ejection murmur
Asymptomatic (possibly)
Cyanosis varies with defect, worse with severe narrowing
Cardiomegaly
Heart failure
Aortic stenosis- what and s/s
A narrowing of the aortic valve
Infants: Faint pulses, hypotension, tachycardia, intolerance to food
Children: Intolerance to exercise, dizziness, chest pain, possible ejection murmur
Coarctation of the aorta
what and s/s
A narrowing of the lumen of the aorta, usually at or near the ductus arteriosus, that results in obstruction of blood flow from the ventricle
Elevated blood pressure in the arms
Bounding pulses in the upper extremities
Decreased blood pressure in the lower extremities
Cool skin of lower extremities
Weak or absent femoral pulses
Heart failure in infants
Dizziness, headaches, fainting, or nosebleeds in older children
Patent ductus arteriosus (PDA)
what and s/s
normal fetal circulation conduit between the pulmonary artery and the aorta fails to close and results in increased pulmonary blood flow (left-to-right shunt)
Bounding pulses
Wide pulse pressure
Rales
Asymptomatic (possibly)
Systolic murmur (machine hum)
Heart failure
Atrial septal defect (ASD)
what and s/s
A hole in the septum between the right and left atria that results in increased pulmonary blood flow (left-to-right shunt)
Systolic murmur and a fixed split second heart sound may be present
Heart failure
Asymptomatic (possibly)
Ventricular septal defect (VSD)
what and s/s
A hole in the septum between the right and left ventricle that results in increased pulmonary blood flow (left-to-right shunt)
Loud, harsh murmur auscultated at the left sternal border
Heart failure
Many VSDs close spontaneously early in life
Defects that increase pulmonary blood flow
Defects with increased pulmonary blood flow allow blood to shift from the high pressure left side of the heart to the right, lower pressure side of the heart.
Increased pulmonary blood volume on the right side of the heart increases pulmonary blood flow.
These defects include manifestations and findings of heart failure.
VSD, ASD, PDA
What does the New Ballard Score indicate?
A newborn maturity (higher=more mature) rating score used to assess neuromuscular and physical maturity in categories of
physical: skin, lanugo, plantar creases, breast tissue, eyes and ear, genitalia development
Neuromuscular Maturity: posture, square window, arm recoil, popliteal angle, scare sign, heal to ear
difference between caput succedaneum and cephalohematoma
caput suCCadaneum Can Cross suture lines and soft, and usually doesn’t require treatment and 3-4 days to resolve
cephalohematoma is bloody filled from pressure and forceps, but doesn’t cross suture lines, appears in the first 1-2 days and resolves in 2-8 weeks.
what are some newborn signs of down’s syndrome
more than one-third the distance across both eye
Ears that are low-set
A protruding tongue
Absence of head control can
bilirubin levels of newborns
24 hr: 2 to 6 mg/dL
48 hr: 6 to 7 mg/dL
3 to 5 days: 4 to 6 mg/dL
glucose for newborns
Glucose: greater than 40 to 45 mg/dL
WBC count for newborn
WBC count: 9,000 to 30,000/mm3
Sucking and rooting reflex
Expected finding: stroke cheek or edge of mouth. The newborn turns its head toward the side that is touched and starts to suck.
Expected age: Usually disappears after 3 to 4 months but can persist up to 1 year
Palmar grasp
Expected finding: Elicit by placing examiner’s finger in palm of newborn’s hand. The newborn’s fingers curl around examiner’s fingers.
Expected age: Lessens by 3 to 4 months
Plantar grasp
Expected finding: Elicit by placing examiner’s finger at base of newborn’s toes. The newborn responds by curling toes downward.
Expected age: Birth to 8 months
Moro reflex
Expected finding: Elicit by allowing the head and trunk of the newborn in a semisitting position to fall backward to an angle of at least 30°. The newborn will symmetrically extend and then abduct the arms at the elbows and fingers spread to form a “C.”
Expected age: Complete response seen until 8 weeks, body jerk only until 8 to 18 weeks, absent by 6 months
Tonic neck reflex (fencer position)
Expected finding: With newborn in supine, neutral position, examiner turns newborn’s head quickly to one side. The newborn’s arm and leg on that side extend and opposing arm and leg flex.
Expected age: Birth to 3 to 4 months
Stepping Reflex
Expected finding: Elicit by holding the newborn upright with feet touching a flat surface. The newborn responds with stepping movements.
Expected age: Birth to 4 weeks.
s/s of heroin withdrawal in neonates
Small for gestational age (SGA)
Manifestations of neonatal abstinence syndrome
Increased risk of sudden infant death (SUID).Methadone withdrawal
Manifestations of neonatal opioid withdrawal syndrome (NOWS): Increased incidence of seizures, sleep pattern disturbances, stillbirth, SUID, higher birth weights (compared to with heroin exposure
Increased incidence of seizures, sleep pattern disturbances, stillbirth, SUID, higher birth weights (compared to with heroin exposure)
What are some complications of preterm birth?
RDS- decreased lung surfactant
bronchopulmonary dysplasia
aspiration
aspiration
intraventricular hemorrhage
rtinopathy
DA
necrotizing enterocolitis
Infection, hyperbilirubinemia, anemia, hypoglycemia, and delayed growth and development
what might happen if a baby has continued jaundice?
Kernicterus is an irreversible, chronic result of bilirubin toxicity. The newborn demonstrates many of the same manifestations of bilirubin encephalopathy with hypotonia, severe cognitive impairments, and spastic quadriplegia
Acute bilirubin encephalopathy is when the bilirubin is deposited in the brain w/ bilirubin 25+. dystonia and athetosis, upward gaze, hearing loss, and cognitive impairments.
________ jaundice is typically visible after 24 hours of life
Physiological
appearance of physiologic jaundice vs pathologic
Pathologic jaundice appears before 24 hr of age or is persistent after day 14. In the term newborn, bilirubin levels increase more than 0.5 mg/dL/hr, peaks at greater than 12.9 mg/dL, or is associated with anemia and hepatosplenomegaly.
physiologic- increase in unconjugated bilirubin levels 72 to 120 hr after birth, with a rapid decline to 3 mg/dL 5 to 10 days after birth.
how often to feed, turn, take temp, remove, and see therapeutic benefits of phototherapy in newborn
Reposition the newborn every 2 hr to expose all of the body surfaces
Remove the newborn from phototherapy every 4 hr, and unmask the newborn’s eyes
axillary temperature every 4 hr
Feed the newborn early and frequently, every 3 to 4 hr
benefits: 4 to 6 hr after starting treatment.
What skin findings are normal with phototherapy
Bronze discoloration: not a serious complication
Maculopapular skin rash: not a serious complication
3 ed points for taking care of hearing aids
The lowest setting allows hearing without feedback.
Use mild soap and water for mold while keeping the hearing aid dry.
When the hearing aid is not in use, turn it off and remove the battery to conserve power
Main way cochlear implant works
Convert sounds into electric impulses, and electrodes that are attached to the auditory nerve.
three things to remember post op cochlear implant surgery
the speech processor is programmed 2 to 6 weeks after surgery, and not turned on immediately
avoid MRI’s
how to treat Ménière’s
relieves pressure points by inserting tympanostomy tube by displacing fluid of the inner ear
expected findings of Ménière’s
episodic vertigo
tinnitus,
unilateral sensorineural hearing loss
pressure and fullness in the ears
usually bw 40-60
During wound care, when should we use aseptic surgical vs medical?
medical for taking off dressing and asepsis when cleaning and putting on the dressing
What is the Hep B vaccine schedule like for adults who haven’t had it at all?
same as infants- get a series of 3 within 6 mos.
What are some contraindications for propranolol?
hypersensitivity
pulmonary edema
uncompensated HF
cardiogenic shock
sick sinus syndrome
heart block
After surgery in the PACU, how often after surgery should you check vitals sign
Q 15 min
After a gastric sleeve, what vitamin needs to be included in the diet?
Vitamin B12, E and K
iron, selenium, and zinc
what kind of sugar imbalance is associated with furosemide and thiazide diuretics?
hyperglycemia
What are the different types of hypersensitivity reactions?
Type I- IgE from allergens binding with free IgE that binds to basophils and mast cells
Type II- rxn ABO blood incompatibility- mediated by IgG and IgM- can lead to hemolytic anemia
Type III- formation of antigen-antibody complexes in serum, including drug fever and vasculitis
Type IV- delayed rxn up to several days and mediated by T cells and can include transplant rejection
Irrigation liquid should be poured at the height of what into a sterile field.
a height of 4-6 inches above the sterile field.
how does abdominal compartment syndrome occur, and what happens?
after surgery, the cavity is filled with fluids and gas and the pressure goes from 5 mmHg or less to more than 15, resulting in hypotension, reduced CO, and oliguria.
when to take dimenhydrinatefor motion sickness?
might cause dizziness, so don’t take before driving, but about 30 min to 1 hr before traveling
How long whould you have a PEG or jejunostomy for?
longer than 6 wks
What does the MSE look for?
psych status
physical heatlh
well-being
mental impairment
via
cognitive level- count backwards
mood
appearance
physical behavior
speech
nonverbal communication
though process
What are some things that the geriatric depression scale looks for?
questions r elating to difficulty sleeping, incontinence, falls or other injuries, depression, dizziness, and loss of energy.
include family and significant others
obtain detailed medication history
assessment of role and life changes
What is Program of All-Inclusive Care for the Elderly (PACE)?
comprehensive care program that provides all Medicare and Medicaid-covered services, and additional services deemed necessary, to older adults who would otherwise need nursing home care, allowing them to remain in their homes and communities. like aging at home
What kind of immunity does colostrum provide?
igA
What color should newborn stool be during breastfeeding?
loose, pale, and or yellow
what are some OTC or medications that help milk production
herbal products (fenugreek, blessed thistle) and prescription medications (metoclopramide)maybe
how long can breast milk be stored?
Room temperature: up to 4 hr.
Refrigerated in clean bottles or bags for use within 4 days
Frozen in clean containers in the freezer compartment of a refrigerator: up to 6 months.
Deep freezer-12 months.
temperature for newborn
Normal temperature ranges from 36.5° C to 37.5° C (97.7° F to 99.5° F), with 37° C (98.6° F) being average.
When does caput succedaneum resolve vs cephalohematoma
CAPUT SUCCEDANEUM- 3-4 DAYS
appears in the first 1 to 2 days after birth and resolves in 2 to 8 weeks.
what shouls the O2 saturation levels be in COPD
88-92%
nutrition for hepatitis
high-carbohydrate, high-calorie, moderate-fat, and moderate-protein diet after nausea and anorexia subsides, and small, frequent meals to promote nutrition and healing.
what are the levels of liquid consitencies
evel 0 (Thin/TNO): can flow like water through a straw to Level 4 (Extremely thick/EX4): smooth with no lumps can be eaten with a spoon
Food levels range from levels 3 to 7 and include:
3-Liquidized (LQ3)- can be eaten with a spoon or drunk from a cup
4-Pureed (PU4)-no coarse textures w/ foods that are pureed in blender with extra gravy, sauce, milk
5-Minced and moist (MM5) moistened and softened and easy to chew
6-Soft and bite-sized (SB6)-soft, bite-sized, tender and moist. No mixed textures of foods/liquids.
7-Easy to chew (EC7) -tender and soft texture, may include thin and thick textured foods and liquids
7-Regular (RG7) all foods and liquids
how often should you urinate when trying to prevent UTI?
Q3-4 hrs
What are some nursing interventions for NMS?
stop med
monitor v/s
apply cooling blankest and antipyretics
increase fluid intake
administer diazepam to control anxiety
dantrolene and bromocriptine for muslce relaxation
treat dysrhythmias
ICU
wait 2 weeks before resuming antipsychotic therapy
nursing actions for tracheostomy care
oral care Q 2 hrs
remove soiled dressings and secretions
clean stoma site and trach plate
place fresh slit gauze dressing
replace ties if wet or soiled
change Q 6-8 wks
Stages of Lewin’s change theory for planned changes
Unfreezing: Need for change is identified or created.
Change/Movement: Strategies (driving forces) that overcome resistance to change (restraining forces) are identified and implemented.
Refreezing: change is integrated, and the system is re-stabilized.
Lewin’s theory of change model for individual change
Precontemplation: No intent to change is present or has been considered.
Contemplation: The individual considers adopting a change.
Preparation: The individual intends to implement the change in the near future.
Action: The individual implements the change.
Maintenance: The individual continues the new behavior without relapse.
stages of team formation
Forming: Members of the team get to know each other. The leader defines tasks for the team and offers direction.
Storming: Conflict arises, and team members begin to express polarized views. The team establishes rules, and members begin to take on various roles.
Norming: The team establishes rules. Members show respect for one another and begin to accomplish some of the tasks.
Performing: The team focuses on accomplishment of tasks.
What are some things that happen in the orientation phase of a therapeutic relationship?
discuss limits, confidentiality, frequency, duration, date of termination, and goals
How often and how long are intermittent tube feedings?
4-6- times/day with 30-45 feeding infusions and unused portion can be refrigerated up to 24 hrs and bag should be discarded every 3 hrs, extension tubing changed every 24 hrs
how often are bolus feeinds?
5-15 every 3-4 hrs
one word to describe each of the four:
somatic
illness anxiety
conversion disorder
factitious
somatic symptom disorder- anxiety
illness anxiety disorder- hypochondriasis
conversion disorder- functional neurologic disorder
factitious disorder- Munchausen
A client has immunosuppression and has a continuous IV infusion, how often would you assess the IV, check WBC, monitor mouth, and change IV tubing?
assess the IV- Q4hr
check WBC-Q 24 hr
monitor mouth-Q8 hrs
change IV tubing- Q 24 hrs
What is tumor lysis syndrome?
TLS occurs when cancer cells die quickly, releasing large amounts of intracellular contents like potassium, phosphate, and nucleic acids (which break down into uric acid) into the blood.
emergency!
What are client teachings for Kawasaki Disease?
irritability can last 2 mos
tender skin
do pROM in bath
avoid live immunizations for 11 mos
avoid smoking
if coronary abnormalities, continue aspirin therapy indefinitely
How much sterile fluid should be in the water seal chamber?
up to 2 cm
What are two reasons for cessation of tidaling in the water seal chamber?
lung re- expansion or obstruction like kink or clot
What are some preprocedure fro chest tube?
admin pain and sedation,
supine or semi-Fowler’s
povidone iodine
How to remove chest tube?
pre-medicate
semi-fowler
instruct client to deep breathe, exhale, and Valsalva- reduces air emboli
apply airtight sterile petroleum dressing
What are some risks factors of diabetes insipidus?
head injury, trauma, meningitis, small cell lung cancer
What do vasopressnates do to ADH?
vasopressin breaks down ADH to prevent the body from holding on to fluids like water
What is the osmolality of DI?
300+
normal: 275 to 295 mOsm/kg
How much fluid should SIADH patients be getting a day to prevent hemodilution?
500-1,000 mL/day plus hypertonic sodium chloride IV to alleviate neurologic compromise
What are some drugs for SIADH?
tetracycline- to increase blood sodium/osmolarity and decrease urine sodium
vasopressin antagonist (tolvaptam/ conivaptan)- get rid of ADH levels
loop diuretic- increase water excretion
