general terms Flashcards
urine specific gravity
1.003 to 1.030
- how concentrated the urine is
- low urine = more concentration
normal urine output = 0.5-1 ml/kg/hr or >30 ml/hr
IN PEDS
- greater than 1.5mL/kg/hr is desired in children
OSMOLALITY
- HIGH IS >295
- if you’re retaining pee, the dilution is decreasing
SIADH
most common cause = cancer
MANIFESTATIONS
- HIGH URINE GRAVITY, HIGH URINE OSMOLALITY
- LOW SERUM (BLOOD) OSMOLARITY
- retain water = less pee since all the water in you = causing high blood pressure = hypervolemia
- assess patients mental status
- high osmolality (concentration of dissolved particles/dilution)
- decreased hematocrit
- hyponatremia = why?? fluid overload
TREATMENT
- correct hyponatremia by giving oral salt tablets
- FLUID RESTRICTION
- hypertonic IV solution 3% NaCl delivered in small quantities
- vasopressin
DIABETES ISIPIDUS
- decreased ADH
- polyuria
- polydipsia leading to dehydration due to low ADH
TREATMENT
- desmopressin acetate
HYPERNATREMIA why? = dehydration from the excess urine
- low blood pressure from losing all the fluid
- low urine specific gravity (concentration) from the excess peeing
LOW URINE GRAVITY AND OSMOLALITY
HIGH SERUM OSMOLALITY
cardiac tamponade
fluid collecting in the sac of the heart
- LOW BLOOD PRESSURE
- BULGING NECK VEIN (JVD)
- MUFFLED HEARTBEAT
those 3 symptoms are called the becks triad
OTHER MANIFESTATIONS
- tachypnea, tachycardia (to increase cardiac output)
- pericarditis = if a cleint has this, assess them for cardiac tamponade
PULSUS PARADOXUS - exaggerated fall in systemic BP greater than 10 during INSPIRATION
- the nurse should assess for pulsus paradoxus when cardiac tamponade is confirmed
INTERVENTION
pericardioxentensis = to drain the fluid
tissue plasminogen activator (TPA)
alteplase, reteplase, and tenecteplase
INDICATIONS
- break down clots
- ischemic stroke = must be administered within 4.5 hours from onset of symptoms
MONITOR = BLEEDING
- only used for acute organ/life threatening conditions
COMPLICATIONS
- intracranial hemorrhage
CONTRAINDICATIONS OF TPA
- surgery within the last 2 weeks. why? because TPA dissolves clots and may disrupt the surgical site
- stroke, head trauma IN THE LAST 3 MONTHS
HEPARIN and WARFARIN thins the blood and prevent new clot formation TPA break down the clots
GASTROINTESTINAL BLEED
- upper: melena (black tarry) - ocreotide may be presribed - NPO status may be prescribed - AVOID NG TUBES
- hemoccult test is usally done for melena, when blood is hidden
- lower: hematochezia (bright red stool)
- hemorrhoids: blood present on surface of stool. after hemorrhoidectomy, pain relief is priority because patients might not want to take a shit due to pain which can lead to constipation
first thing to do in acute blood loss = LOWER HEAD OF BED = maintain blood perfusion to the brain and other vital organs
THE 5 A’s of alzheimer
memantine = ease symptoms of severe alzheimer
- encourage patients with mild or early stages alzheimer to make advanced directive before cognitive decline
- agnosia = inability to determine objects or people
- apraxia = inability to perform familiar and purposeful task like clapping, dressing
- agraphia = difficulty writing
- aphasia = impairment of verbal and written language, difficulty finding correct word, reduced words, babbling (simple use of communication like yes or no)
INTERVENTION
- when alzheimer patient becomes agitated = use therapeutic touch
- in clients with unilateral weakness from stroke, TEACH THEM TO WEAR CLOTHE ON THE AFFECTED SIDE FIRST
neuropathy
- diabetic neuropathy- nerve damage as a result of metabolic disturbances (numbness and tingling
- sensory peripheral neuropathy = affects peripheral nervous system and may cause problems with extremities
- autonomic neuropathy =involuntary body funtions such as BP, heart rate, perpiration, sexual fucntion etc = worry about postural hypotension (risk at falls)
MULTIPLE MYEOLOMA
- cancer that forms in a type of WBC called plasma
MANIFESTATIONS
- pathological vertebral column fractures and pain = cancer wakens the vertebrae
caring for patients with Alzheimer disease
- if a client is just diagnosed with a disorder and is crying, as a nurse, you acknowledge it first before saying “we’ll help you make decision for your care”
for of dementia that causes decline in cognitive and physical abilities
if client is agitated and restless, assess for stressors such as pain, problems with elimination, eating
SAFETY PROMOTIONS
- keyed deadbolts
- place a chin lock on the door above or below the client eye level
- medical identification/location devices (bracelets/shoe inserts)
- MEDICATIONS SHOULD BE KEPT OUT PATIENT REACH OR LOCKED AWAY = because they are confused, they may not remmber the day of the week and end up taking more or less than prescribed
- throw rugs and clutters should be removed
- place identifying symbols on the bathroom door
- decreased water heater temperature (HOT and COLD labels on faucets to prevent burns
- provide night light to prevent falls, aid in orientation and decrease illusions
- housheold hazards (gas appliances, rugs and toxic chemicals) removed to prevent injury
- Grab bars installed in showers and tubs
SUNDOWNING
- experienced by clients with dementia in the late afternoon or evening
- acute behavioral disturbances (wandering, confusion and aggression)
- when. aclient is experiencing sundowning, FREQUENTLY REORIENT THEM TO TIME AND ENVIRONMENT
dextrose 5% in water
INDICATIONS
- hypernatremia
- used with insulin for DKA and HYPERKALEMIA
also indicated for hypernatremia cus you lose fluid through polyuria with DKA leading to dehydration and hypernatremia = dehydration
airborne precautions
hand hygiene
fitted n95
private negative room
gown and gloves when need
tuberculosis, rubeola (measles), varicella virus (chicken pox), small pox,
varricella zoster, SARS
- chicken pox activayed in later years by aging is unilateral, linear rash
- calamine lotion is effective for soothing pruritic rashes like varicella(chicken pox)
digoxin range
0.5 to 2.0 = used to treat CHF and Afib
DONT TAKE WITH FOOD
- digoxin causes hyperkalemia
BEFORE ADMINISTERING
- check apical pulse first apical pulse of 60 or more
- in infants hold if pulse less than 90 and less than 70 in older children
- you check blood pressure for CCB and apical pulse for digoxin
LAB VALUES TO MONITOR
- potassium (low potassium increases toxicity) BUT DO NOT INCREASE POTASSIUM INTAKE IF THE QUESTION DOES NOT MENTION OTHER FACTORS THAT DEPLETES POTASSIUM
monitor
- BUN and creatinine = drug is secreted by kidneys
TOXICITY/REPORT
- nausea, anorexia, and other gastro
- visual disturbance, color vision
- vomiting
- bradycardia and heartblock = heart skipping a beat
- confusion and other neuro effects
PAIN in kids
CRIES - newborn
FLACC = 2 to 10 years (pain behavior)
- Face, Legs, Activity, Cry, Consolability
pulmonary embolism
once a thrombus is dislodged, first small vessels it encounters is back of the knee = *HIGH PRIORITY**
post op clients at higher risk
- tachypnea
- dyspnea
- anxiety
- chest pain = priority
- RESTLESSNESS IS A PRIORITY = sign suggesting hypoxia = always check pulse ox first
nursing diagnosis = impaired gas exchange related to ventilation perfusion imbalance
INTERVENTION = always check pulse ox first
- GIVE OXYGEN VIA FACE MASK 8-10 L PER MINUTE
massaging DVT can lead to break of clots leading to pulmonary embolism
people with pulmonary emphysema can eat with nasal cannula to increase oxygen demands
PPE APPLICATION
DONNING (GoM EGL)
- gown
- mask
- goggles
- gloves
DOFFING (GlEy GoM)
- gloves
- goggles
- gown
- mask
herbal supplements that increase risk of bleeding
- feverfew
- garlic
- ginger
- ginkgo biloba
- ginseng
these can cause surgery to be postponed
RECENT OR CURRENT INFECTION IS A CONTRAINDICATION IN SURGERIES
shoulder dystocia
- when the head comes out by the shoulders are trapped inside the maternal symphysis pubis.
- document the time the head was born
frequently associated with macrosomia
MANIFESTATION
fetal head retracting back into the maternal perineum after birth (turtle sign)
INTERVENTION
1. mcroberts maneuver = legs flexed onto abdomen causes rotation of pelvis, alignment of sacrum and opening of birth canal
- suprapubic pressure = pressing downward the symphisis pubis (applying suprapubic pressure)
- pressure is applied to fetal anterior shoulder
MRI vs CT scans
MRI = noninvasive/ NO IODINE USED (gadolinium is used)
- does not require anesthesia so NPO is not required
- can still take meds as normally indicated
-
MRI CONTRAINDICATIONS
- aneurysm clips
- metallic implants such as implantable cardioverter defibrillator (ICD)
- pacemakers, electronic devices, hearing aids
- shrapnel
microwaves ovens are safe to use among clinets with pacemakers
- colostomy is not contraindicated
- transdermal pactches are not contrainidcated but should be removed prior
CT SCAN = NON INVASIVE
- iodine is injected in the veins to enhance image
- iodine contrast = ACUTE KIDNEY INJURY
- DISCONTINUE METFORMIN 24-48 HOURS BEFORE ADMINISTERING IV CONTRAST AND RESTART MEDICATION AFTER 48 HOURS = risk for lactic acidosis
SHELLFISH ALLERGY IS NOT THE SAME AS IODINE
cystic fibrosis
inherited = both parents must be carriers for child to have
- CAUSING EXCESSIVE, THICK MUCUS to build up in the body and causes blockages and trap bacterias = lungs and digestive system
MANIFESTATIONS
- inhibited release of digestive enzymes (amylase, lipase) = POOR APPETITE IS EXPECTED
- inability to break down proteins, carbohydrates and fats
- steatorrhea (fatty frothy stool) = thats why they need high fat
- meconium ileus (obstrcution) in NEWBORNS
- HYPOnatremia = body losing a lot of salt SO YOU NEED LOT OF SALT
- hyperglycemia why?? the blockages blocks the pancreas from releasing insulin
AT RISK FOR
- pneumothorax
- high blood glucose as blockages blocks pancrease from releasing insulin
- ineffective airway clearance
- risk of infection and eventaully chronic lung disease
DIET
- high in fat, calories, proteins AND HIGH SALT
- fruits and vegetables
PANCREALIPASE
- PANCRELIPASE SHOULD ONLY BE GIVEN WITH MEALS because they help absrob fat and other nutrients = DOSE SHOULD BE HELD IF CLIENT NOT EATING
- DO NOT CHEW OR CRUSH
- capsule may be sprinkled on applesauce, yoghurt, acidic foods
- DONT TAKE WITH MILK
- administer IV antibiotic for those that develops a fever
INTERVENTION
- physiotherapy
- encourgae physical activity as tolerated to help remove secretions
- chest tube
- when respiratory status suddenly declines urgent intevention such as chest tube and phsyiotherapy is required
- as a nurse, providing emotional support to the family after a recent diagnosis will be a priority
CHEST PHYSIOTHERAPY
- should be performed at least twice a day
- administered in various ways such as clapping and percussing on chest wall with cupped hands
- do 1 hour before meals or 2 hours after eating
- nebulized bronchodilators are given before or during chest physiotherapy to open airways and mobilize secretions
HIGH FREQUENCY CHEST WALL OSSILATION (HFCWO) VEST
- inflated and deflates rapidly to ease secretions
- rapid vibrations may lead to nausea and vomiting to AVOID FOODS, MEALS, SNACKS 1 HOUR BEFORE or 2 HOURS AFTER to prevent gastro upset
ABDOMINAL AORTIC ANEURYSM
- monitor for peripheral pulses
- monitor renal
- monitor neurologic status
-
medications to be given through endotracheal tube
NAVEL = naloxone, atropine, vasopressin, epinephrine, lidocaine
vasopressin is used to decrease fluid excretion like in diabetes insipidus
atropine = bradycardia
NALOXONE HALF LIFE IS SHORTER THAN MOST OF NARCOTICS so when it is used to reverse narcotics, make sure sure you monitor the client to ensure that the client does not fall again into excessive sedation or respiratory depression
- second dose may be necessary
CONFIRM ENDOTRACHEAL PLACEMENT BY AUSCULTATING LUNGS
- tube can be displaced by movement. in terms of displacement, auscultate lungs
PEDIATRIC: don’t give vasopressin via endotracheal
multiple sclerosis
MULTIPLE SCLEROSIS
- condtion where antibodies attack the myelin sheath of neurons
- AFFECTS CNS ( brain, spinal cord and optic nerve )
EXPECTED SIGN
- bowel and bladder incontinence
MANIFESTATIONS
- blurred vision
- focal weakness
- sensory abnormalities (numbness and tingling
- MEDICATION: BACLOFEN interferons and corticosteroids
INTERVENTION
- walk with feet apart and use cane
Salem sump tube
double lumen used for continuous gastric suctioning
- larger lumen is attached to suctioning and smaller lumen is open to the atmosphere
- its used to decompress stomach so no need to check resdiual volume = you only check that for enteral feedings
INDICATION
- can be used to decompress the stomach in cases like paralytic ileus
INTERVENTIONS TO MAINTAIN GASTRIC SUCTIONING
- place client in smei fowler position (prevent gastric reflux)
if gastric contents refluxes, 10-20 mL of air is injected into the small lumen (air vent)
- provide mouth care every 4 hours
- turn off suctioning briefly during ascultation
- inspect the drainage system for patency
isotertinoin
- oral acne medication derived from VITAMIN A used to treat severe/cystic acnee
COMPLICATIONS
- TERATOGENIC RISk = negative pregnancy tests are required before initiating therapies or prior to refilss
- side effects steven johnson syndrome
- suicide risk
SIDE EFFECTS
- dry eyes, mouth and skin
- lubrication of the eyes may be needed to wear contacts
AVOID
- avoid taking vitamin A supplemts whiles on this medication = can lead to vitamin A toxicity which can lead to ICP, gastro upset, liver damage, chnages in skin and nails
- avoid blood donation is prohibited
- avoid excess sun and tanning
- women of bearing aged should use 2 form on contraceptive
- should not be taken with tetracycline = ICP
uterine inversion
- postbirth complication in which the uterine fundus collapses into the uterine cavity
MANIFESTATIONS
- sudden hemorrhage and hypovolemic shock
TRETAMENT
- manual uterine replacement through the vaginal canal by a hCP. if unsuccessful, emergency laparotomy may be necessary
- initiate large bore line for adequate resuscitation fluids including blood products as needed for hemorrhage
- serial blood pressure monitoring every 3-5 minutes
tocolytics like terbutaline may be needed to assit with uterine relaxation
jehovah witness
AVOID = blood products such as
- RBC
- red cells
- white cells
- plateless, plasma
CAN RECEIVE
- saline
- dextran
- lactated ringers
- hetastarch
hypertension is a contraindcation in erythropoietin
- administer erythropoetin IV or subcue area not IM
blood transfusions
16 or 18 guage IV catheter
- same for large bore IV access and delivering large IV fluids
UAP
- can take vital signs before and after the 15 mins period
INSTRUCTIONS
- ALWAYS CHECK THEM FIRST AFTER A HAND OFF
- HAVE THEM VOID BEFORE SO THAT INCASE OF A REACTION OCCUR, a fresh urine can be obtained
- USE Y TYPE BLOOD ADMINSTRAATING TUBE and should be administered with 0.9 sodium chloride only
- infuse it within 30 minutes of receiving it from the blood bank and must be completed WITHIN 4 HOURS
- not compatible with dextrose run with normal saline ONLY
- nurse must REMAIN with client 15 minutes to monitor for transfusion reactions
COMPLICATION
- hypotention is a reaction
BLOOD TRANSFUSION REACTIONS
1. stop the transfusion
2. admister oxygen
3. take vital signs
4. obtain urine specimen to check for hemolyzed RBCs
TREATMENT OF ALLERGIC REACTIONS TO BLOOD TRANSFUSION
- vasopressors
- epinephrine
- diphenhydramine
- corticosteroids
all these drugs increases blood pressure and since hypotension is a complication of blood transfusion, these agents can correct the hypotension by increasing blood oressure
BLOOD GROUP
- O- = universal donor
- AB+ = universal recipient
BLOOD DONATION RULES
- can give to whoever has your letter
- CANNOT receive if they don’t have your letter
causes of metabolic acidosis and metabolic alkalosis
METABOLIC ACIDOSIS = SOIDUM CARBONATE
- starving
- diabetic mellitus
- severe diarrhea
- burns
- renal failure
- salicylate toxicity
- lactic acidosis
METABOLIC ALKALOSIS
- vomiting
- gastric suctioning = losing acid from the stomach = can lead to paralytic ileus
- over the counter antacids ( tums, alka-seltzer ) = these meds neutralize acid in the stomach so it makes sense why they cause alkalosis
TIP
if you don’t know the answer… always answer METABOLIC ACIDOS
radioactive iodine
- treats hyperthyroidism by partially damaging thyroid glad
has a delayed response
CLIENTS SHOULD FOLLOW THE FOLLOWING PRECAUTIONS
- limit close contact and time spent with pregannt women and children
- breastfeeding should be stopped 6 weeks before treatment to prevent agen accumulating in the breasts after treatment
- use separate toilet, flush 2 or 3 times
- use disposables utentils
do not share foods
- If the urine is spilled, they
must call the HAZMAT TEAM = radioactivity is excreted THROUGH URINE
- do not sit near others for. a prolonged time (train, flight travel)
- breastfeeding is not resumed with the current child but can be resumed with future pregnacies
BRACHYTHERAPY = internal radiation
RADIATION THERAPY
- causes dryness of mouth so perform oral hygiene often
mantoux test/ PPD
after the infection, it’s is important to ask the client to follow up in 48-72 hours for results read
RESULTS
- < 5mm i= negative
- > 15 = positive however, a positive response does not indicate the client has TB but has been exposed and developed immune response
report if client is taking prednisone = it converts latent TB to active disease
USED TO CONFIRM
- chest x ray is used to confirm the client has active disease after the positive induration
for all skin test, IT IS IMPORTANT TO MAKE SURE THEY COME BACK FOR THE READING OF THE RESULT
Intracranial Pressure ICP
earliest sign = LOC
HEAD OF THE BED SHOULD BED RAISED
CUSHING TRIAD
1. widened pulse pressure (systolic hypertention) = seen as late sign
2. bradycardia
3. irregular respiration
cushing triad = later sign that does not appear until the ICP is increased and can INDICATE BRAIN STEM COMPRESSION
KIDS
- high pitch cry
- irritable and fever
MONITOR
- decerebrate ( extension ) can indicate worsening
- projectile vomiting
FLUIDS: hypertonic fluid 3%
INTERVENTION = HYPERTONIC FLUID 3% / MANNITOL
- IV mannitol to reduce cerebral edema by pulling water from the cerebral cells into the vasculature
- elevate bed 30-40 degrees
- dim lights
- administer stool softeners
- do not place on abdomen/prone
- maintain strict bed rest. assist with activities
- reduce exertion
- maintain head in midline position to improve jugular venous return to the heart
incident/occurence report
best way in preventing and reducing medication errors
used in health facility to document events that pose unanticipated actual or potential risk to the health or safety of a client, visitor or employee
- if you adminster wrong medication, FIRST THING TO DO IS MAKE SURE CLIENT IS STABLE BEFORE FILING A REPORT
EVENTS THAT REQUIRE REPORTING
1. assault and injury (physical, verbal or sexual in the health care facility)
- client falls with or without injury
- staff and visitor falls regardless of acceptance or refusal of treatment
2. Treatment and intervention
- delayed/inadequate diagnosis and monitoring
- hospital equipment failure
- failure to obtain or intervene requested procedures
- anything that deviates from the norm
- refusing to wear PPE
- tempering with medical devices activating a patients pain controlled analgesia
- falls or injuries
most important outcome of interdisciplinary communication among care givers = reduce number of medical errors
WHEN REPORTING AN INCIDENT, YOU DONT DOCUMENT THE OCCURANCE!!!! = DONT DOCUMENT IT IN THE MEDICAL RECORD OR NURSING NOTES
medical errors should be reported to the state department of health
CRISIS
- unanticipated
- rapid
- can be brief
- can result from actual and perceived threats
assault: threats to do bodily harm to another person
battery: involves touching the person
infiltration vs extravasation
INFILTRATION
- non vesicant in subcue tissue
infiltration intervention
- discontinue
- elevate the affected extremities to decrease swelling
- cold, warm or moist compress
EXTRAVASATION
- vesicant into the tissue surrounding the vein
extravasation intervention
- stop the infusion and diconnect the IV tubing
- use syringe to aspirate the drug from the catheter and remove the iv catheter while aspirating
- elevate the extremity above the heard to reduce EDEMA
- notify HCP to obtain prescription for the
EXTRAVASATION ANTIDOTE = PHENTOLAMINE
- administer it into affected tissues
IV access is restablished onto an unaffected extremity or through a central line
cardiac catherization
- post op, HOB flat or low fowler position with affected extremity straight
- used to assess and diagnose coronary artery disease
- a catheter is inserted through a large artery or vein (femoral) and threaded to the heart
most common complication is bleeding so monitor for hematoma - metformin should be held for 48 hours
HOW TO PREVENT AND CONTROL BLEEDING
- supine and HOB less than or equal to 30
- apply pressure above the insertion site to control bleeding
- affected extremities straight to prevent bleeding from the catheter insertion site
- assess bilateral pulses frequently
radiofrequency catheter abaltion = SVT
- close monitor for a fib
Peripheral pulses may be diminished following cardiac catheterization, but the complete absence of a pulse indicates a serious complication. If unable to palpate the patient’s pulse, the nurse’s priority action should be to attempt to locate it with a doppler.
ensuring proper fit of a sling
used to support a fracture, dislocation, surgery
- elbow flexed at 90 degrees: prevent swelling, relieve shoulder pressure
- hand slightly above the level of the elbow to prevent venous pooling and edema
- bottom of the sling ends in the middle of the palm with fingers visible
- sling supports the wrist joint
clomophine
- infertility drug that works by stimulating ovulation
necessary to engage in frequent sexual intercourse 5 days after completing the medication regimen
SIDE EFFECTS
- INCREASED RISK OF MULTIPLE GESTATION
- may cause mood swings
- nausea
- hot flashes and headaches
INFERTILITY
- failing to conceive after 12 months (women less than 35) of frequent unprotected sex
- in women of 35 or more, it is after 6 months
- IT IS IMPORTANT TO ASSESS THEM FOR ANXIETY AND DEPRESSION. use active listening and open ended questions
INFERTILITY RISK FACTORS
- age 35 and up
- hormonal dysfunction such as lack of ovulation
- STI
- endometriosis
- very low BMI (18-24.9) or very high BMI (24.9 and up)
FERTILITY INTERVENTION
- TEACH ABOUT TIMING OF SEXUAL INTERCOUURSE NEAR OVULATION (FERTILE WINDOW) = OTC pregnancy ovulation predictor kit detects luteinizing hormone for fertile window
- DO THIS BEFORE SUGGESTING ALTERNATIVES AND BEFORE EDUCATING THEM IT TAKES A YEAR TO GET PREGNANT
cholecystitis
- irritation to the diaphragm from inflammed gallbladder
RUQ pain that refers to the RIGHT shoulder
MANIFESTATIONS
- nausea (promethazine suppository is 2nd priority to relief nausea and vomiting to minimize further fluid loss)
- vomiting (prirotiy is NPO if actively vomiting)
- fever
- leukocytosis
- NG tube might be prescribed to prodive gastric decomp and alleviate nause and vomiting and promote bowel rest
green vomit in infants are red flag = CAN INDICATE BOWEL OBSTRUCTION
SIGNS OF CHOLECYSTECTOMY INFECTION
- pneumonia occur when atelectasis (alveolar collapse) prevents clearing of secretions
- surgical site infections = redness, warmth, swelling and purulent drainage
- UTI
- peritonitis = rebound tenderness,GUARDING boardlike abdominal rigidity
POST OP CHOLECYSTECTOMY = low fat diet
- surgical bandages can be removed day after sugery and the client MAY SHOWER AT THIS TIME BUT NOT BATH!!
- baths are not permitted aa they may introduce infection into the surgical sites. once incisions are head, baths may be resumed
clostridium difficile (C.diff)
- overgrowth in intestine when GI flora is destroyed example by antibiotic use
PHARMALOGICAL TREATMENT
- metronidazole and ORAL vancomycin
METRONIDAZOLE
- unpleasant metallic taste is expected
- dark urine (brown, rust colored) is expected
- AVOID ALCOHOL COMPLETELY PRIOR and 3 days after therapy
- although rare, stevens johnson syndrome can occur (rash, skin peeling)
MANIFESTATIONS
- watery diarrhea = hypovolemia and loss of electrolyte imbalance
- nausea
- leukocytosis
- fever
- abdominal pain
LABS
- hyponatremia
- hypokalemia
- HYPER bun = elevated by dehydration
INTERVENTION
- USE SOAP AND WATER not hand sanitizers
- gowna dn gloves at all times
- USE DILUTED bleach solutions ( chlorine ) to disinfect contaminated surfaces
- hand based alcohol products are NOT EFFECTIVE
CONTINUOS IV vs INTERMITTENT INFUSIONS
- CONTINUOS IV INFUSION: can be changed every 72 hours (3 days). this means maximum time it should be left on is 3 days. after that, it needs to be changed
INTERMITTENT FLUIDS (hypertonic,TPN, propofol, blood): needs to be changed more frequent *4-24 hours) due to risk of infection
cystoscopy
- procedure to look inside the bladder
EXPECTED POST OP (48 hours)
- pink tinged urine
- dysuria and urinary frequency
- abdominal disocmfort and bladder spasm = take acetaminophen/ibuprofen and warm tub/sitz bath = warm sitz bath can help you to urinate
COMPLICATIONS
- urinary retention
- hemorrhage
- infection
REPORT
- blood clots
- bright red blood when urinating
- inability to void
- fevers
- chills or severe pain
anticholinergic drugs
tolTERODINE, oxybutynin, , soliFENACIN (TOS), dicyclomine
SIDE EFFECT
- dry mouth (XEROSTOMIA) = sugar free hard candy or gum
- sedation = avoid driving or operating heavy machinery
- dry mouth = INCREASE FLUID
- heat intolerance
- drowsiness
- decreased sweat production = hyperthermia SO AVOID HOT TEMPERATURE
INTERVENTION
- increase fluid intake and bulk forming foods (fruits, veggies) to prevent constipation
CONTRAINDICATIONS
- closed angle glaucoma
- urinary retention(BPH)
- bower obstruction
SJORGREN SYNDROME
- chronic autoimmune disorder in which moisture producing exocrine glands of the body are attacked by WBC
- most commonly affected are the salivary and lacrimal glands leading to dry eyes and dry mouth
- AVOID DECONGETATANS = further dryness
gastric residual volume (GRV)
PURPOSE
- used to check and evakauate absorption from last feeding.
FINDINGS
less than 500 is good and feeding should not be stopped BUT you must verify placement first (x ray or gastric ph) before starting feeding
AVOID BOLUS FEEDING IN RISK OF ASPIRATION PATIENTS + CONTINUAL IS SAFTER
AMOUNT
- safe amount (<500) = reinsert and feeding continues
- unsafe amount = content is discarded and feeding is held until the GRV decreases
MONITOR FOR
- nausea, vomiting
- abdominal distension
- constipation
- abdominal pain
- should be checked first 48 hours of gastric feeding and after that, every six to eight hours
EXPECTED FINDINGS AFTER GASTROSTOMY TUBE IS INSTALLED
- thin, pale, and yellow-green drainage with a sour odor and a small amount of blood
- use cotten tipped applicator dipped in sterling saline to clean
- if client coughs during NG tube, pull back on the tube slightly and then pause to give the client time to recover and breathe before advancing the tube
- coughing and gagging occur when the tube coils in the throat or slips into the larynx
disulfiram (antabuse)
- it is a form of AVERSION THERAPY (gut hatred for something, in this case alcohol)
- does not cure alcoholism so they should continue seeing a therapist
- It’s used in recovery programs that include medical supervision and counseling
PREVENT
- nausea
- vomiting
- death
WEAR A BRACELET ALERTING OTHERS OF BEING ON DISULFIRAM THERAPY
PATIENT TEACHING = avoid all alcohol containing products so AVOID
- mouthwash
- alcohol-based hand sanitizers
- aftershaves alcohols
- perfumes/colognes
- sauces, vinegars and flavor extracts
- insect repellents (mosquitos sprays)
- ANY COUGH MEDS AND OTC MEDS THAT ENDS WITH -ELIXER (robitussin)
- uncooked icings (VANILLA EXTRACTS)
takes 2 weeks for drugs to start working and effect of drug can last 2 weeks after the last dose
acamprosate: decreases cravings for alcohol ( common side effect: diarrhea )
ALCOHOL SCREENING TOOL
- CAGE = CUT down alcohol = Annoyed = GUILTY= EYE OPENER
- TWEAKING = tolerance, worry, eye openers, amnesia
- AUDIT = alcohol use disorder tool
drinking during pregancy = microcephaly, cleft palate
epiglottis
4DS: dysphagia, dysphonia (muffled voice), drooling, and distress
- should be placed in a tripod position
TREATMENT = ENTRACHEAL INTUBATION
COMMON CAUSE: bacterial infection HIB
- sore throat
- abrupt onset
- absence of spontaneous cough due to severe EDEMA
- not wanting to swallow due to pain
- drooling may indicate they’re going into respiratory distress
- DO NOT TAKE ORAL TEMP = can lead to airway obstruction and cause SPASM
- do not open throat to do visual exams or swab throat = can cause obstruction of airway
AIR RAID
- Airway inflammation
- Increased pulse
- Restlessness
- Retractions
- Anxiousness
- Inspiratory stridor
- Drooling
types of therapies
physical therapy = BELOW THE WAIST
- ability to move their body, balance and gait = MOBILITY
- walker training
occupational therapy = ABOVE THE WAIST
- use of assistive device to manage activities of daily living ( fine motor coordinations )
- dressing
- bathing
speech therapy: assess and treat patients with swallowing disorders as well as communication and speech problems that occur following a stroke
orthopedics: dealing with the correction of deformities of bones or muscles
BELL PALSY
FACIAL NERVE DISORDER = unilateral
- STROKE IS CAUSED BY BLOOD CLOTS THAT STOPS BLOOD TO THE BRAIN
INTERVENTION
- chew on the unaffected side = prevents food trapping
- SOFT DIET PREFERRED
- CAREFUL ORAL CARE after every meal to prevent problems from accumulating residual food
DOES NOT AFFECTION VISION, BALANCE, CONCIOUSNESS, EXTREMITY MOTOR FUNCTIONS SO YOU CAN STILL DRIVE
BELLS P =eye stay open so to prevent dryness, apply eye lubricants in the form of artificial tears
- flattening of the nasolabial folds
Blink reflex abnormal
Earache/eye rollsl up
Lower corner of mouth and eye lid
Loss of taste and brow movement
Suddent onset (hours to days)
Paralysis unilateral facial nerve 7
TREATMENT: steroids (prednisone) and antiviral
fracture vs sprain
OPEN FRACTURE
- Assess
- Protect (cover the wound with a clean dressing)
- Apply ice pack
- Elevate
SPRAIN = RICE
- rest: activities and movement should be stopped and limited to promote healing within the first 24 to 48 hours
- ice (cryotherapy)
- compression (ace wrap, splint)
- elevation
*analgesia
*exercise rehab program
IF A PATIENT FALLS AND YOU SUSPECT A FRACTURE
FIRST THING: IMMOBILIZE THE LEG BEFORE MOVING THE PATIENT
- this helps minimizes bleeding, edema, pain and prevents further injury to the tissues and structures surrounding the fracture. This also decreases the patient’s risk for the development of other complications such as fat embolism and shock.
monitor ppl with fractures for fat embolism which is a priority
MANIFESTATIONS OF FAT EMBOLISM
- PRIORITY IS MINIMIZING MOVEMENT OF THE INJURED EXTREMITY
- repiratory distress
- mental status changes
-petechaie on chest
- parestheisa and pressure in extremity is compartment syndrome
- petechiae is small pinpoint red/purple spots on mucus membrane or skin
HIP FRACTURE
- extremities externally rotated
- muscle spsm
- shortening of the extremity
- ecchymosis
acute glomerulonephritis
NORMAL GFR RATE: 120 ml per minute
fluid retention
- HIGH BLOOD PRESSURE = HIGHEST PRIORITY
MANIFESTATIONS
- tea/pink or cola colored urine
- headaches can indicate encelopathy and should be taken serious
- periorbital and facial/generalized edema
- hematuria
INTERVENTION
- avoid salt in the diet
- conserve energy
ACUTE PYELONEPHRITIS
- dull, constant and maximal at the costovertebral angle area
- severe bacterial infection
- requires aggressive IV fluids and IV antibiotic to stop progression of infection and kidney scarring SO PATENT IV IS THE PRIORITY
- even though administering IV antibiotic is the priority, BLOOD AND URINE CULTURES MUST BE OBTAINED BEFORE INITIATING ANTIBIOTIC THERAPY WHENEVER POSSIBLE
infectious mononucleosis
- epstein-barr virus
CAUSES
- sharing drinks
- kissing
or other exposure to saliva
MANIFESTATIONS
- fatigue
- fever
- sore throat
- splenomegaly
- swollen lymph nodes
- MONITOR FOR RUPTURED SPLEEN
REPORT
- sudden onset severe abdominal pain* in the left upper quadrant
- airway obstruction = stridor, difficulty breathing
INTERVENTION = hydration, rest, pain control and reducing fever as necessary
- SORE THROAT IS TREATED WITH SALINE GARGLES or ANESTHETIC TROCHES
- avoid contact sports like soccer to prevent injury to the spleen or liver
- its a viral infection so antibiotic is inappropriate = TAKING IT CAN CAUSE A RASH
acute otitis media
- INCREASED RISK WIH PACIFER AND DRINKING FROM BOTTLE WHILES LYING DOWN
- blocked eustachian tube which leads to buildup of purulent fluid and inflamation in the ear
- infant are at more risk due to horizontal, shorter and narrower
MANIFESTATIONS
- refusal to eat
- red, bulging tympanic membrane, inner ear pressure
- pulling of ear indicates ear infection
- nausea
vomiting
- rhinorrhea
OTITS EXTERNA
- retracted tympanic membrane
- severe pain with pressure on the tragus
AVOID DECONGESTANTS
ASSESSMENT
- in toddlers (1-3), wait until end of the assessment to perform otoscopic exams especially when pain is present = can lead to distress
- examine traumatic procedures ears, eyes and mouth near the end of assessment
- insert speculum only as far as the outer cartilage not into the bony interior
- inspect tympanic membrane for infection
RECOMMEND
- flu and pneumococcal conjugate vaccine
TREATMENT: AMOXICILLIN
- PRIORITY = administer acetaminphone espcially if febrile and pulling ears
- antibiotic eardrops not effective. systematic like amoxicillin may be used
- heat and cold packs may be used
- side lying may be used to drain fluid from ear but its not a priority
- if symptoms do not improve by 48-72 hours of amoxillin therapy = return for further assessment
asthma
- NSAIDS and BETA BLOCKERS CAUSES MORE PROBLEMS IN ASTHMA PATIENTS
- begins early in life
- symptoms worse at night
- usually occur in obese ppl
- hypersensitivity
- swimming is s good exercise or aerobic exercises
MANIFESTATIONS
- tachycardia (120 or up)
- tachpnea (30 per minute)
- saturation less than 90
- use of accessory muscles
- elevated eosinophils is associated with allergy
administer oxygen followed by albuterol by nebulizer
- bronchodilator should be given before chest physiotherapy
RESCUE EMERGENCY DRUGS: albuterol, ipratropium nebulizer every 20 minutes
acetylcysteine does not work with airway clerance and can cause or worsen bronchospasm
ALBUTEROL SIDE EFFECTS
- diffculty sleeping
- palpitations
- tremors
- nausea/vomint
TRAFFIC SIGNAL COLORS/PEAK FLOW (rate <50 of personal best needs emergency medical care)
- GOAL OF FLOW METER USAGE IS TO EXHALE AS QUICKLY AND FORCIBLY AS POSSIBLE
- green zone (peak flow of 80 and above: asthma under control ( no worsening symptoms)
- yellow zone: means caution. even on a return to the green zone after rescue meds, further medication or change is still needed
- RED ZONE: medical alert. NEED FOR IMMEDIATE TREATMENT **IF levels does not return to yellow immediately after taking recue meds*
- best reading is attained over a 2 week period when asthma is in control
- peak flow meter is used after a short acting bronchodilator rescue not after corticosteroids
LONG TERM
- montelukast
- salmeterol
- BECLOMETHASONE: long term, first line drug to control chronic airway inflammation. taken on a regualr schedule. should not be omitted if SABA is effective
- rinse mouth to prevent candida infection (thrush)
when using both, take the SABA albuterol first to open airways - wash only the mouthpiece with warm water 1-2 times a week cus deposits can prevent full dose of medication from being dispended
RELIEVES
- wheezing, breathlessness, chest tightnness associated with asthma
- sleep High or semi-Fowler’s position
INTERVENTION
- deteremine the severeity of clients condition before impleneting intervention
teach to avoid triggers but if the patient is present with symptoms, ASSESS PEAK EXPIRATORY FLOW FIRST!!* or assess respiratory rate and lung sounds
WORSENS ASTHMA SYMPTOMS
- problems with the perception of the disease
- frequent visits to the hospital
- recent withdrawal from corticosteroids
lithium therapy
0.6-1.5 = above 2 is toxicity
INDICATION
- anti-mania drug for bipolar = TAKES ABOUT 3 WEEKS TO START WORKING
- stabililizes nerve cell membranes
SALT LEVELS
- low sodium = makes lithium MORE TOXIC
- high sodium = makes lithium ineffective
- SODIUM level must be NORMAL for LITHIUM TO WORK
EXPECTED SIDE EFFECTS
- weight gain
- dry mouth
- drowsiness
INTERVENTION
if pt is sweating/manic - do NOT give them water; give Gatorade/POWERADE
MANIFESTATIONS = 3Ps
- PEEing
- POOPing
- Paresthesia (numbness & tingling) because that’s the early sign of ALL electrolyte imbalance
YOU can still GIVE lithium with these S/S; just tell the DOC when they come in
- hyperactivity and audiotry hallucinations are still expected when lithium therapy starts because it may take 3 weeks to become effective
TOXIC EFFECTS = hold dose and call doctor
- tremors
- metallic taste & severe diarrhea
CAUSES OF LITHIUM TOXICITY = dehydration from stomach flu or diarrhea
- hyponatremia
- severe renal dysfunction = lithium is cleared renally
- thiazide diuretics
- NSAIDS (acetaminophen will be betteer for pain relief
- ACE inhibitors
blood levels should be monitored frequently for therapeutic lithium levels and toxicity
about half of the patients on long term lithium therapy will develop HYPOTHYROIDISM
- can cause leukocytosis
Implantable cardioverter-defibrillator (ICD)
- lead system placed in the endocardium via subclavian vein
- cannot sense or treat pulselessness so CPR is needed if there’s no pulse
EXPECTED MANIFESTATIONS
- firing of the ICD may be painful
- clients describe it as a blow to the chest
clients should take ICD identification card and list of medications while travelling
POST OP TEACHINGS
- refrain from lifting the affected arm above shoulder including brushing hair, doing hair
impending respiratory failure
clients with respiratory failure has repiratory acidosis
- paCO2 ≥ 45 = hypercapnia
- paO2 ≤ 60
- paradoxical breathing = use of respira muscles
- mental status change
- absence of wheezing and silent chest
- single word dyspnea = inability to speak 1 word before pausing to breathe
- MARKED DECREASE OR INCREASED WORK OF BREATHING
PEDIATRICS
- nasal flaring
- head bobbing
- GRUNTING = mostly in c section babies
NORMAL RESPIRATION IN PEDS
- 30-60 with less than 20 periodic pauses
in neonates, rectal temp of >100.4 or less than 96.8 is a RED FLAG**
Carotid endarterectomy
- surgical procedure that removes atherosclerotic plaque from carotid artery
WATCH OUT FOR
there are at increased risk for TIA and stroke BECAUSE BLOOD CAN LEAK INTO THE BRAIN
MONITOR
- monitor blood pressure during the first 24 hours
-hypertension may strain the surgical site and trigger hematoma formation = leading to hemorrhage or airway obstruction
- neurological fucntion = STROKE
INTERVENTION
-ensure systolic blood pressure is MAINTAINED 100-150 to ensures adequate cerebral perfusion and avoidance of hemorrahe. or stain*
meniere’s disease
disorder in the ear (excessive fluid in ears) leading to vertigo, tinnitus and sensorurineural hearing loss
- FALL RISK ASSESSMENTS SHOULD BE DONE WITHIN 2 HOURS OF ADMISSION
- FEELING LIKE YOU ARE SPINNING = initiate fall risk measures
reduce stimulation by not watching televison and not to look at flickering light
MANAGEMENTS
- REDUCE DIETARY SODIUM, CAFFEINE INTAKE = reduces attacks
- they should use earphones
- initiate fall risk measures by raising side rails BUT NOT ALL SIDE RAILS BECAUSE THAT IS CONSIDERED A RESTRAIN
HOW TO MINIMIZE VERTIGO
- quiet, dark room
impaired hearing = speak at normal volume
SEVERE MENIERE = nausea and vomiting
TREATMNET: diuretics, antiemetics, low sodium and antihistamines
meningitis hallmark
HIGHLY CONTAGIOUS life threatening medical emergency so initially priority is IV antibiotics
COMPLICATION TO MONITOR = hydrocephalus
- assess for bulging and tense fontanels
- access for increasing head cicumference
- access icp
MANIFESTATIONS
- fever
- neck stiffness(nuchal rigidity)
- photophobia = so avoid pupillary light response
- altered mental status
- nausea
- vomiting
suspected meningitis, priroity is placing on droplet precaution
INTERVENTIONS
- head of bed 10-30 degrees to increase blood perfusion from the brain and reduce ICP
- if menigitis is suspected, diagnostic testing (Lumbar punch and immediate antibiotic therapy are critical and need
- FLUID RESUSCITATION IS PRIORITY
- NURSE SHOULD PERFRIM GALSGOW COMA SCALE AND - TAKE ORAL TEMPERATURE
- precautions can be discontinued 24 hours after beginning antibiotic therapy
- KERNIG SIGN= positive sign is when client complains of pain when his knee is extended with hip flexed
- Brudzinski’s sign positive when severe neck stiffness occurs after the neck is flexed towards the chest, causing the patient’s hips and knees to flex.
Deep Venous Thrombosis (DVT)
high priority problem because clot can disloge and cause life threatening complicatipn pulmonary embolism
RISK FACTORS
- RECENT SURGERY - priority
- pregnancy
- birthcontrol use
- long travel
- age
DIAGNOSTIC TEST = HOMANS SIGN
- positive homan sign = pain in the calf when the leg is flexed (dorsiflexion) and the knee is kept extended
homan sign is unreliable so as a nurse, assess the calf for pain, swelling and warmness before concluding on DVT
INTERVENTION
- elevate legs, dorsiflex the feet
- limit alcohol and caffeine
- resume exercise program
client do not need to avoid travelling but should use preventive measure like wearing compression socks,
walk every hour
** don’t cross legs, stop smokin**
PREVENTION
- anticoagulant therapy not aspirin
dental avulsion
- tooth separated from the mouth of a permanent tooth. its an emergency
PRIORITY: rinse the tooth with sterile water and reinsert the tooth into the gingival socket and hold it in place until stabilized by a dentist
- reimplantation within 15 minutes reestablishes blood supply increasing probability of tooth survival
if reimplantation is not possible, the tooth should be placed in commercialy prepared solution, cold milk or sterile water
DONT
- place fallen tooth in water = will lyse the cells killing the tooth
- sterilize gauze = will dry out teeth
NYSTATIN = ORAL CANDIAL INFECTIONS
- assists clients who weat dentures to remove and soak in nysatatin susoension = DENTURES OFTEN BECOMES A RESEVOIR FOR INFECTION
- swish the suspension in the mouth for several minutes and then swallow the medication to allow treatment of esophageal candida
- avoid missing dose and shake well
drug class for heart failure
- ACE inhibitors (-pril)
for clients that cannot tolerate ACE, use ARBS that ends in -SARTAN - measure potassium levels prior to ACE inhibtors AVOID POTASSIUM AND SALT SUBSTITUTES
docusate sodium can be precribed to reduce straining which increases workload of the heart
- straining can also cause bradycardia due to vagal resoonse
SIDE EFFECT
- ortho hypotension
- dry hacking cough = this cough will not be relieved by cough suppressants
- temporary increase in serum creatinine
- REPORT ANGIOEDEMA
ANGIOEDEMA
- most common in african american
- swelling of face, lips and aireaysetc
ACE INHIBITORS AND ARBS ARE BOTH CONTADINCATED IN PREGANCY
- nitroprusside is indicated for hypertension in heart failure. can lead to severe hypotension so priroity is checking blood pressure
DRUGS TO AVOID IN HEART FAILURE
- NSAID cus they contribute to sodium retention and therefore leading to fluid retention
insulin types
continuos pumps of insulin
- delivers more accurately than injections so client will experience fewer swings in blood glucose levels and hypoglycemic episodes
- a bolus might still be adminstered manually at mealtime to cover carbohydrate intake
- still check glucose 4 times a day
SHORT ACTING (LAG) peak 30 minutes-3 hrs
- lispro
- aspart
- glulisine
- used with sliding scale
- take 30 mins before meals
REGULAR peak 2-3 hrs
- best IV use (DKA)
- RAPID short acting
- used with sliding scale
- take 30 minutes before meal
- only insulin that can be given IV
INTERMEDIATE ACTING (NPH) = PEAK 12-18 hrs
- TWICE DAILY morning and evening
- peak 12-18 hours
- when taking at night, eat bedtime snacks containing complex carbs and protein (cereal with milk, crackers with peanuts)
AVOID RAPID AND SHORT ACTING INSULINS BEFORE SURGERIES because they’re supposed to be given with meals and if person is NPO = will cause hypoglycemia
LONG ACTING (DDG)
- determir
- degludec
- glargine
- ONCE DAILY
cast care and compartment syndrome
CAST CARE
- avoid exposure to water
- if exposed to water, DRY THOROUGHLY IMMEDIATELY or with hair dryer
- plastic wrap is not complety occlusive to prevent water into the cast area
- dont insert any foreign object under cast
- AVOID HEAT APPLICATIONS= cause vasodilation and swelling
ITCHY CAST?? = apply a cool air under the cast with blow dryer
cast on leg = elevate the leg on pillows continuosly
cast on arm = elevate arm above shoulder
COMPARTMENT SYNDROME
numbness and tingling for hours or days after a cast is applied.
don’t remove cast without a physicians order
- Pain with passive motion and loss of sensation are early signs of compartment syndrome
7 Ps - paresthesia = earliest sign = tingling, numbness, burning
- pain
- pallor
- pulseless
- pressure
- poikkilothermy = cool skin temp
- paralysis = late sign
itching is not alarming due to heat and sweat under the cast = can be relieved by blowing hair under the cast with blow dryer - INABILITY TO EXTEND FINGERS IS A HIGH PRIROTY = CAN INDICATE VOLKMANN CONTRACTURES
bulimia nervosa
- overeating followed by means to avoid weight gain such as purging, laxative abuse, exercisive exercise, prolonged fasting
- THEY OVEREAT AS A COPPING MECHANISM BUT THEY DONT WANNA GAIN WEIGHT
- sit with client for like an hour to prevent self induced vomiting as a way to prevent weight gain
- they often has a healthy body weight but has concerns about personal appearance and others perception of them and their desire to be in control of their bodies
PRIORITY: ASSESS FOR DEPRESSION
NURSING INTERVENTIONS
- readiness to change maladaptive behaviors such as purging
- monitor client during and after meals atleast an hour to prevent = after eating is more important
- enocurage journal about feelings associated with food
- initiate structured meal schedule
- document the amount of food consumed on a calorie count form for the dietician to evaluate
- monitor for electrolyte imbalances
anorexia nervosa
REFEEDING SYNDROME = DECLINE in PPM (potassium, phosphorus, magnesium)
- fatal complication of nutritional rehabilitation in chronically malnourished clients (anorexia nervosa, chronic alcoholism)
monitor potassium, PHOSPHATE and MAGNESSIUM during the first few days of nutrional replenishment
MANIFESTATIONS OF ANOREXIA NERVOSA
- cold intolerance
- they are still allowed to refuse food
- WEIGHT 25% BELOW NORMAL WEIGHT
- disturbed body image and may see themselves as being fat or overweight DESPITE being severely underweight
strive for perfection exhibiting obedience
Many of these patients see someone in the mirror who weighs more than their desired weight. Despite being too thin, this client will not eat in hopes of getting the perfect body.
PHSYSIOLOGICAL ANOREXIA
- when high metabolic demands of an infancy slows down
- toddlers become very picky and eat small amount of food
- decreased appetite
INTERVENTION OF PHYSIOLOGICAL ANOREXIA
- small feedings
- offer the child 2 or 3 choices of food
- INTRODUCE THEM TO NEW FOODS overtime
- schedule for meals and snacks
- avoid distractions like watching tv when eating
INTERVENTION
- assist the client to reflect triggers of disordered eating = encourage discussion about dysfuntional
- maintain strict documentation of dietary and calorie intake
- remain with client for the duration of each meal
- weight client each morning prior to any oral intake
- limit exercise
FINDINGS
- hypothermia cus of lack of subcue fat
- hypotension why? dehydration
- continuous dieting
- altered electrolyte imbalance
addisons disease (addrenal insufficient)
MANIFESTATIONS
- bronze HYPERpigmented (tanned)
- insufficient sodium so HHYPONATREMIA
- salt craving
- cant tolerate stress = purpose of stress response is to raise glucose and blood pressure.
- vitiligo
since these ppl do not have the adrenal cortex to carry out the stress response, when they undergo stress, they go into SHOCK = MAY NEED MORE STEROIDS DURING STRESS
- DOESNT TAKE MUCH TO PUT THEM INTO SHOCK Anything
from a tooth filling at the dentist or a minor fender bender can cause these.. people to stress out
& die.. TICKING TIME BOMB!
LABS
- D sodium
- I = Potassium
- D glucose
TREATMENT = ADDisson = ADD A SONE
= prednisone, dexamethasone &
hydrocortisone
- prednisone should not be taken with nsaid = GI BLEEDING
- ORAL CORTICOSTEROIDS SHOULD BE TAKEN WITH FOOD TO LESSN THE LIKELIHOOD OF GASTRIC IRRITATION
- side effect: WEIGHT GAIN
- LONG TERM CORTICOSTEROIDS USE CAUSES IMMNUNOSUPRESSION SO REPORT ANY SIGN OF INFECTION
**STEROIDS MAKES BLOOD GLUCOSE GO UP EVEN IF YOU ARE NOT DIABETIC so lookout of people with diabetes
cushing disease
- puffy moon face
- hirsutism (facial hair)
- trunkal/central obesity (big body)
- gynecomastia
(female breast on men) - buffalo hump
- excess acnes
- menstrual irregularities
- skinny arm & legs (muscles waste away)
- retain sodium
& water; losing potassium - striae (stretch marks)
- hypertension
- bruising
-“I’m mad; I have an infection = grouchy/irritable & immunosuppressed
LAB TESTS
- 24 hour urine collection = tested for free cortisol. results 80-120 confirms cushiony syndrome is present
TREATMENTS
- HYPERsecreting of the adrenocortex so = ADRENALectomy
BUT IF YOU DO A BILATERALECTOMY?? = ADDISON = so they might need steroids again making them look like CUSHman again = FRAUSTRATING)
24 hour urine is collected and evaluated for cushing
circumcision
RISK FOR
- hemorrhage
- infection
- voiding difficulties
EXPECTED FINDINGS AFTER PROCEDURE
- glans should appear dark red
- after 24 hours, a yellow exudate = PARENTS SHOULD BE TAUGHT THIS IS A NORMAL HEALING PROCESS
CIRCUMCISION CARE
- ONLY WARM WATER (no soap or alcohol based wipes)
- diapers should be changed every 4 hours to keep area clean
- petroleum gauze or ointment should be applied at every diaper change (unless plastibell used) to prevent sticking)
- diapers should be secured loosely to minimize pressure agaisnt the healing circumsicion site
- hypospadias =urethra underside of the penis
- no urine output for 2 hours is a red flag
INFECTION
- redness
- swelling
- odor discharge
HIATAL HERNIA
gastric problem where part of the stomach slide back into the diapgram (weakening the diaphram)
may be asymptomatic and commly associated with GERD
everything needs to be (HI) FOR (HI)ATAL HERNIA except for protein and fats
INTERVENTION
- elevate head of bed approx 30 degrees
- high fluids =
- Avoid lifting or straining
- high carbs
- avoid caffeine
- small frequent meals
avoid wearing girdle or tight clothes that increases intabadominal pressure
- lifestyle changes such as smoking cessation
- AVOID ACTIVITIES THAT PROMOTES STRAINING LIKE WEIGHT LIFTING = INCREASES ABDOMINAL PRESSURE
LOW PROTEIN and FAT
if unrelieved, surgery might be recommended
dumping syndrome
gastric problem, usually follows gastric injury
- gastric contents dump too quickly into the duodenum ( yes they are suppsoed to go into the duodenum but in this case TOO FAST )
- moves in the
right direction, but at the wrong rate
avoid very hot and cold foods, sugars, soda, cakes, sweets
TREATMENT
we want to sLOW everything
- Eat with head low & turned to the side
- low fluids with meal
- low carb content
in the meals. - HIGH PROTEIN!! HIGH FAT
Diabetic ketoacidosis / diabetic coma (TYPE 1 DIABETES)
- HIGH BLOOD GLUCOSE ONLY IN TYPE 1 generally due to lack of insulin
- another name for type 1 is ketosis thats why. type 2 we know is non ketosis
MANIFESTATIONS
- dehydration
- ketones in blood/ kussmaul breathing (deep and rapid)
- K (potassium) up
- Acidosis (metabolic)/ acetone breath, anorexia due to nausea
client with DKA may initally develop kyperkalemia despite losing potassium from urinary loss but as DKA is being corrected, it might result in HYPOKALEMIA SO GIVE POTASSIUM
CAUSES
- too much food
- not enough medication
- not enough exercise
TREATMENT (DIE)
- diet (least important)
- insulin (most important)
- exercise
- acute illness in clients with type 1 diabetes may trigger release of stress hormones = increased blood glucose AS A RESULT, YOU STILL GIVE INSULIN EVEN IF THEY DO NOT EAT
KUSSMAUL BREATHING
- deep and labored breathing pattern asscoiated with severe METABOLIC DISORDER particulary DKA but also kidney failure
you can have ketones in your urine and not have DKA but ketones in blood means you have DKA
MONITOR AND REPORT
- lethargy
- abdominal pain
- uirne ketones
MANAGEMENT = HYDRATE
- IV fluids fast 200ml/hr
- insulin (most important)
- regular insulin normal saline with dextroseD5 whyD5?? =
doesn’t stay in veins; goes into the tissues and wont cause hyperglycemia(D10 and D50 will cause hyperglycemia
NOTE!
hypokalemia often occurs when acidosis is being corrected so you still admnister potassium even if the clinet has normal potassium levels to prevent hypokalemia
#1 CAUSE OF DKA IN PEDS IS = acute viral upper
respiratory infections within the last 2 weeks)
CAUSES FLUID VOLUME DEFICIT = thready pulse, tachypnea and ortho hypo
LONG TERM COMPLICATIONS OF DIABETES
- poor tissue perfusion
- peripheral
neuropath
if they ask you, diabetic has renal failure, what will this be due to?? poor tissue perfusion
DKA, HHNK, HYPOGLYCEMIA = theyre are acute
24 hour urine collection
INSTRUCTIONS
- use dark jug containing powder to protect urine from light and preserve the urine and adjust its acidity
- start time and then empty bladder and discard 1st urine
- collect for 24 hours and keep in the fridge or ice chest with secure lid
- exactly 24 hours after start time, empty bladder once more into the collection container
USE STERILE TECHNIQUE WHEN COLLECTING A URINE SPECIMEN
REGULAR URINE COLLECTION
- discard first sample
- collect midline of the urine = less likely to be contaminated
- if the bladder is completely drained (anything over 800 mL = spasm)
DO NOT COLLECT FROM CLLECTION BAG
PERINEAL HYGIENE IS PERFORMED USING SOAP AND WATER ONLY not aseptic
trichomoniasis
STI that may cause frothy, maldorous, yellow green vaginal discharge
inform partners to be treated to avoid reinfection
MED: metronidazole = dark color urine is expected
metronidazole can cause metallic state
MED INSTRUCTION
- abstain from sexual intercourse until infection is cleared
- avoid alcohol for 3 days = can cause nausea, vomiting and severe abdominal pain
theophylline
airway anti-spasmodic. range 10-20
- NOT a bronchodilator
- used when all bronchodilators fails to work
- does not work right away so it should not be used in sudden SOB
MONITOR = seizures and arrhythmias
when a bronchodilator
doesn’t work in an acute airway problem, = GIVE THEM AMINOPHYLLINE, then give the bronchodilator
- caffeinated products as they increase risk. ofadverse effects
SIGNS OF TOXICITY = avoid cimetidine and ciprofloxacin ciprofloxacin interactions leads to toxicity and cimetidine decreases absorb option
- nausea
- vomitting
- restlessness
- anorexia and insomnia
phenytoin (Dilantin)
ELECTROCONVULSIVE THERAPY
- NPO prior
- do not drive during the course of ECT
- temporary confusion is common immediately after treatment
stop feeding for 1-2 hours before and after adminstering
used for seizures
range: 10-20 toxic levels: 20 and above
MANIFESTATIONS
- gum hypertrophy = but does not indicate toxicity
- increase in body hair
- folic acid depletion
TOXICITY = CNS
- horizontal nystagmus
- gait unsteadiness
- ataxia
MONITOR FOR stevens johnson syndrome which starts with flulike symptoms = discontinue drug use is SJS occurs
- clients with seizure should avoid driving
INTERVENTIONS
- decreases effectiveness of oral contraceptives and warfarin
- stop feeding for 1-2 hours before and after adminstering it
- products containing calcium, andtacid can decrease absorption
- enteral feeding decreases absorptions too
COMMON SIDE EFFECTS
- gum problems = instruct them on proper dental hygiene
- drowsiness that improves
OTHER SEIZURE DRUGS
- valproate
- levetiracetam
REPORT THE FOLLOWING WHEN USING AN ANTICONVULSANT
- new or increased agitation, anxiety and or depression = associated with suicidal ideation
- report new rash
nephrotic syndrome
hypoalbuminemia due to losing alot of protein in urine
MANIFESTATIONS
- massive proteinuria
- edema in abdomen, face and perineum
- HYPERLIPIDEMIA
HOW TO COLLECT URINE FOR URINALYSIS TO MONITOR FOR PROTEINURIA
- place cotton balls in dry diaper and later squeeze urine onto a dipstick
- avoid urine dipstick in clients diaper
CAUTION
loss of immunoglobins = increased susceptibility to infection = MAKE SURE TO PREVENT ANYTHING THAT CAN LEAD TO THIS including limiting visitors, playdates
MANAGEMENT
- low sodium diet
- fluid restriction for severe edema
- monitor weight gain and proteinuria to detect relapse
acute kidney injury
causes: hypotension = lack of blood flow to the kidney, medications and trauma, hyperkalemia
symptoms: oliguria
urolithiasis
- kidney stone , the presence of calculi (stones) in the urinary tract.
common condition associated = dehydration
KIDNEY STONES/RENAL CALCULI
INTERVENTION
- strain all urine for the prescence of stone
- encourage fluid intake up to 3L/day
- administer analgesic at regularly scheduled intervals
- frequent ambulation and mobilization facilitate passage of calculi
- do not massage the flank but heat therapy would be acceptable
renal calculi include hematuria (blood in urine), renal colic (unilateral pain spasms in flank), and severe radiating pain, which can cause nausea/vomiting, sweating, and elevated blood pressure
Preexposure prophylaxis (PrEP)
- preventive strategy in which antiretroviral therapy is prescribed for those at high risk of contracting HIV
emtrucutabine/tenofovir is a commonly used combination therapy for high risk individuals
HIGH RISK INDIVIDUALS
- IV recreational drug users
- sexual partners with HIV
- men who have sex with men
hiv can be transmitted through needlestick injury but risk is low, therefore standard precautions are sufficient to prevent HIV transmission in healthcare workers
transuretheral resection of the prostate (TURP)
- urinary catheter will remain in place
- removal of only the enlarged portion of the prostate
- blood tinged urine, small clothes are expected
- PAINFUL BLADDER SPASMS ARE EXPECTED AFTER TURP AND CATHETER PLACEMENT = tretaed with oxybutynin
MONITOR
- priority = hemorrhage
- can have altered urinary elimination too
- monitor post op hematocrit and hemoglobin
- AFTER TURP, continuos bladder irrigation is recommended 24-36 to flush out small clots and prevent obstrcution**
- assess the urine in the continuous irrigation drainage bag
REDDISH-PINK DRAINAGE IS EXPECTED IN THE IMMEDIATE POSTOP PERIOD
urinary incontinence
TIMED VOIDING
have them in a time scheduled voiding
- goal is to prolong the time interval
- void every 2 hours
- have them wait for 20-30 seconds after voiding and then attempt to void a second time to help empty residual urine
FLACCID BLADDER: perform the crede maneuver or valsalva maneuver (bearing down) before catherization BECAUSE IT IS NON INVASIVE METHOD
- SELF CATHERIZATION = intervention for flaccid, spastic or urinary retention
- lossing excess weight is good to reduce pressure on the pelvic floor
NORMAL RESIDUAL VOLUME: 50-100
residual urine volume of 100 mL or more on a bladder scan may indicate urinary retention
FECAL INCONTINENCE
- provide perianal skin skin care with barrier cream
Total Parental Nutrition (TPN)
-
central line is preferred
TPN IS THE SAME AS HYPERALIMENTATION - contains dextrose, amino acids and electrolyes ofc
central lines ONLY = highest risk of infection
SUSPECTED AIR EMBOLISM
- clamp catheter
- position on left, tredelenburg position
- administer oxygen
- notify hcp
- stay with client
AFTER TUBE IS PLACED
** confrim placement with chest xray before starting the infusion**
INDICATIONS
- indicated for high risk for aspiration patients
- indicated for GI track obstruction
have 10% in water IV solution is available to prevent hypoglycemia
APPROPRIATE ACTIONS
- attach filter to the IV tubing
- monitorbaseline blood glucose level and fingerstic BG every 6 hours. maintain at 140-180
- incorrect placement of a subclavian central venous catheter can result in pneumothorax or hemothorax
10-mL syringe is preferred for flushing of central venous catheter =use push-pause method
DO NOT
- piggyback or add medication to TPN
- do not abruptly stop even if its almost done = pacrease will continue to secrete increased a ounts of insulin in anticipation = rapid-onset hypoglycemia
IF TPN ABRUPTLY STOPs
- assess for signs of hypoglycemia and have blood glucose measured IMMEDIATELY!!
COMPLICATIONS
- infection
- fluid overload
- hypo/hyperglycemia HYPO IF ABRUPTLY STOPPED
- embolism (failure to clamp IV properly)
- pneumothorax (accident puncture of the lungs)
WHEN PERFORMING DRESSING CHANGE
- use sterile technique (central line)
- during injection cap and tubing = hold the breath to prevent air from entering = air embolism
- have client TURN THE HEAD AWAY from picc site to prevent contamination**
when removing contaminated dressing = use clean rather than sterile gloves
PARENTAL NUTRITION
- delivers nutrient to the body via bloodstream rather than GI tract
- WHERE ABSORPTION IS IMPAIRED
thoracentesis
INITIAL POST OP MONITORING
- level of alertness
- lung sounds
- O2 stat
- respiratory pattern = cus you just drained alot of fluids from the pleural space which may have been pressing against the lung
most common complication = COLLAPSED LUNGS ( pneumothorax)
LATER MONITORING (after 72 hours)
- infection (temperature)
**urine output should not be affected by thoracentesis or the drugs administered for the procedure
- preferred position procedure: sitting up leaning forward
aucultating fine crackles in base of lung is common 1 day post op and its usually related to atelectasis casued by hypoentilation especially in a client who has not yet ambulated
COPD
- cough suppresants should be avoided cus if cough reflex is suppressed, it can lead to accumulation of secretions
- usually develops later in life - they usually run high on the CO2 and low on the O2
RISK FACTORS
- tobacco smoke active/passive
- occupational exposure
- air pollution
- gentics
- tiotropium is a capsule but it is put in a special inhaler to be inhaled NOT SWALLOWED
- they are not resuce drugs except ipratropium
- difficulty breathing during sleep = orthopnea which can be as a result of sleeping style, pillow etc
- COPD patients that can’t sleep at night should be asked how many pillows they sleep with
INTERVENTIONS
- pursed lips effective when CO2 slightly above normal like the 50s = inhale for 2 sec through nose and exchale for 4 seconds
- COPD patients should also be allowed to sleep in recliners which can facilitate better breathing
BIPAP THERAPY
- in worse cases where CO2 levels are up the roof like 80 = BIPAP therapy is effective to decrease CO2 levels
- nebulizer treatment
- BIPAP machines are able to deliver nebulizer treatment while providing positive pressurized oxygen
- AVOID INCREASING OXYGEN IN COPD because it can increase CO2 retention causing further respiratory failure
- steroid therapy
SEEK MEDICAL HELP FOR
- increased sputum
- fever
- worsening dyspnea
VACCINES
- obtain influenza and pneumococcal vaccines to prevent exacerbations
LAB VALUE OF COPD
- plycethemia (increased RBC) so taking iron pills can be harmful
- RBC is produced more to carry out oxygen as a way of compensating for the low oxygen levels
MEDICATIONS: TIOTRAPIUM inhalers
- tiotropium is a capsule but it is put in a special inhaler to be inhaled NOT SWALLOWED
- they are not resuce drugs except ipratropium
AVOID MORPHINE AND BENZODIAZEPINES = worsen CO2 retention
positve end expiratory pressure (PEEP)
- prevent small aveoli or airways from collapsing (keeps them open)
- usually kept at 5cm h20
INDICATION
- high levels can be used to manage ARDS
- helps reduce
COMPLICATION = barotrauma
- HIGH LEVELS (10-20 CM H20) = can lead to overdistension and rupture of alveoli (BAROTRAUMA)
BAROTRAUMA
- air from ruptured alveoli can escape into the pleural space causing pneumothorax and emphysema
- causes increased pressure in the throacic leading to REDUCED venous return and HYPOTENSION
use of lower FiO2 = reduces the risk for oxygen toxicity
pneumonectomy post op care
- closed chest drainage system to collect the blood and drainage and to prevent it from accumulating in the chest
- high fowler position
- deep coughing and splinting are encouraged during post op period to promote expansion of the lung
- lie on affected side so that the drains don’t drain into the good lung
but for pneumonia, lay on the good side to promote proper blood flow
prostatectomy / masectomy
AVOID
- suppositories or enemas
- straining
clients who go home with indwelling catheter should learn how to clean around urinary meatus with warm water and soap to prevent infection
INTERVENTION TO PREVENT CONSTIPATION
- fluid intake
- at risk of devloping DVT and pulm embolism so AMBULATION IS IMPORTANT and will reduce comnstipation
MASECTOMY POST OP CARE
- removal of part of the titty
- massage tecqnuique to mobilize fluid (decongestive therapy)
- perform isometric exercises
- tingling, numbness and itching are common at the surgical site
place client in semi fowler position with the affected side arm on several pillows = promotes draininage and prevents venous and lymphatic pooling
- avoid supine position
- never place client in HIGH FOWLER position immediately after anesthesia = MIGHT DECREASE BLOOD PRESSURE and cause dizziness
MOST COMMON QUADRANT OF BREAST CANCER = upper quadrant = BREAST TISSUE THERE ARE THICKER (GLANDULAR TISSUE)
autonomic dysreflexia (hyperreflexia)
SPINAL INJURY AT T6 OR HIGHER
- FULL/DISTENTION OF BLADDER OR RECTUM IS COMMON CAUSE (pressure ulcers could also be)
- leads to high blood pressure and REDUCED HEART rate
- sudden headache = analgesic needed. headache is corrected after blood pressure is solved
- flushed skin above the level of the spinal cord injury (T6 or above)
- piloerection = goosebumps
INTERVENTION
- elevate head of bed, high fowler
- removing tight clothing
- correcting cause of bowel or bladder distension
INSERT INDWELLING CATHETER TO RELIEVE but first palpate the bladder first
intrauterine device (IUD)
- not hormonal so does not raise risk for breast cancer, thromboembolism or cardiovascular disease
- they have immediate effect
- REPORT CHANGES IN STRING LENTH = CAN INDICATE DISPLACEMENT
- does not cause bone demineralization (unlike depot shot)
- adverse effect: increased bleeding and cramping within first 6 months
- menstrual cycles may be more heavier due to cramping
CERVICAL CAP
- used with sperimicide
- remain in place >6 hours after sex BUT SHOULD NOT EXCEED 48 HOURS
- alternative should be used during menstruation = can lead to toxic shock syndrome
- insert several hours before sex
**clients with intrauterine fetal demise are at risk for dissemninated intravascular coagulation (DIC) = obtain baseline lab test for fibrinogen and complete blood count with platelets
VAGINAL RING
- wear for 3 weeks then remove it for 1 week
- hormones from the ring are absorbed into the bloodstream through vaginal mucosa
- if accidently removed, rsine and place back within 3 hours**
jaundice
yellowin, bilirubin in the skin
- normal: 9.9 and less
- elevated levels: 10-20
- toxic level: 20 and above ( GOES INTO KERNICTERUS = bili in brain )
COMPLICATIONS (billi levels around 20)
- kernicterus = when billirubin is on the blood and occurs when bilirubbin is at highest levels
- Opisthotonus = the position assumed when there is high bilirubin in blood/brain leading to HYPEREXTENSION. place baby on their side
PHOTOTHERAPY = treat high bilirubin
- low heat setting
- babies should. befully exposed except for diaper
- cover eyes with patches to prevent retinal damage
- avoid lotions and ointments = can absorb heat and cause burns
- don’t interrupt parent feeding child
- adequate hydration
kids who undergo phototherapy are prone to DEHYDRATION so promote human milk or infant formula (not water)
breast engorgement vs mastitis
MANAGEMENT IF CLIENT IS NOT BREASTFEEDING
- apply ice pack to both breast for 15-20 minutes every 3-4 hours to reduce blood flow and swelling
- apply chilled, fresh cabbage leaves on both breast
- avoid manual milk expressin and breast massage cus they stimulate milk production
- maintain firm breast support (supportive bra, breast binder) until milk flow is diminished
- take analgesic as directed to reduce pain
BREASTFEEDING
- if i need to reposition my baby latch, i will use my clean finger to break the suction first in the newborns gum before unlatching = do same if baby needs to be removed from breast
- 15 to 20 minutes oer breast
brest feeding is supply and demand process meaning massaging or manually expressing milk stimulates more milk to be produced so if client chooses to stick to just fomula, they should avoid such behaviors
BREASTFEEDING POSITIONS
- cradle hold
- cross craddle hold
- football hold
- lying down
- tummy to tummy
MASTITIS
INTERVENTION
- apply WARM compresses to the breast (for engorgement you apply COLD compresses)
- increase oral fluid intake
- take ibuprofen as needed for pain
- massage
- dont discontinue breastfeeding
- antibiotic therapy
AVOID
- tight fitting bra as much as possible ( do this in breast engorgement care )
central venous catheter
POSITION = bear down or exhale, air occlusive dresing
- supine trendelenburg position = this is to prevent air embolism
CARE = non sterlirle gloves
- should be changed every 7 days
- scrub the hub with alcohol or chlorhexideine for 10-15 seconds using friction to the veniouncture site
- ** THE LUMEN HUB SHOULD BE CLEANED THOROUGHLY WITH ANTISEPTIC PRIOR TO DRUG ADMINSTRATION**
- distal port largest lumen should be used for cvp monitoring
- most CVC require IV heparin flushes to maintain patency and prevent clotting 10 units/ml are standard care. dose of 1000-10000 is given for cases of thromboembolism
- in events of catheter occlusion,reposition the patient
normal central venous pressure (CVC) = 2-8
- normal pulmonary artery wedge pressure (pawp) = 6-12
- high fowler might worsen respiratory distress
diverticulosis
- small herniations in the large bowel = COMMON CAUSE IS LOW FIBER DIETS = 50% of ppl over the age of 65 will have this
- adhere to high fiber diet like scrambled eggs, white toast
INTERVENTION FOR DIVERTICULITIS
- main goal is allowing the BOWEL TO REST = maintain NPO and bed rest
- IV pain meds and antibiotics
- prevent abdominal pressure
- avoid laxatives
- AVOID RECTAL TUBES
- any procedure or treatment that increases intrabdominal pressure may cause rupture
- in severe cases of abdominal distention, nausea and vomiting, NG suction may be prescribed
RECTAL TEMPERATURE CONTRAINDICATIONS
- people who are post MI bc it can slow the heart rate by stimulating the vagus
- hemorrhage
FOODS TO AVOID AFTER
- red meat
- high fat foods
enteral feedings
GI tract functions is normal and food goes to your stomach, large and small intestines
-preferred during times like stress ulcers
- LOWER RISK OF INFECTIOUS COMPLICATIONS THAN TPN
- maintains intergrity of the gut, prevent ulcers and help prevent translocation of bacteria into the blood stream
- ## initoate slowly and advance to a prescribed rate
OBSTRUCTION/ CLOGGED TUBE DURING FEEDING
- flush and aspirate the tube with warm water
- digestive enzyme may help if warm water is not effective
myathenia gravis
- impairs acetylcholine
- impair facial, eye, chewing, swallowing and respiratory muscles
- skeletal muscles tend to be stronger in the morning and weaken throughout the day
MANIFESTATIONS
- diplopia
- ptosis
- respiratory failure = have ambu-bag by bedside
- facial and oropharyngeal muscle weakness
- difficulty swallowing indicate need for immediate intervention
MYASTHENIC CRISIS =
- infection
- undermedication
- stress
HOW TO PREVENT MYASTETHENIC CRISIS
- eat semi solid food to prevent choking
- get annual flu vaccine
- take acetylcholine inhibitors (pyriodostigmine) before meals so that the peak effects of the medication help the cleint to eat and swallow
TREATMENT: pyridostigmine = increases acetylcholine
Atrial fibrillation (Afib)
- represents P wave
CAUSES
- overactive thyroid glad (hyperthyroidsim)
PRIORITY
- keeping ventricular rate under control to less than a 100 to prevent stroke
- CCB, beta blockers (metoprolol) and digoxin is used for ventricular rate reduction
TREATMENT = AMIODARONE (also for v tach-stable with a pulse)
- ABCD
- beta blockers ( -LOL ) (side effects: headache, hypotension) no asthma
- calcium channel blockers (avoid grapefruit)
- digitalis (digoxin same as lanoxin)
before administering beta blocker, apical pulse has to be atleast 60 beats per min
SYNCHRONIZED CARDIOVERSION
- used to convert tachyarrthmias (SVT, v tach) (sometimes a fib with rapid vtach response) with a pulse to stable cardiac rhythm
- SYNCHRO CARDIOVERSIONS ARE LAST RESORT FOR ATRIAL DISORDERS
V TACH
- unstable with pulse = synchronized
- stable with pulse = amiodarone
- if client becomes pulseless, the synchronize function should be turned off and defib should be started
- TURN OFF OXYGEN PRIOR TO DELIVERING!!
- make sure “sync” feature is engaged to prevent delivery of asynchronous shock (not for v fib)
cardioversion may be done for ATRIAL FIBRILLATION = shock is delivered to client
CARDIOVERSION = there has to be a pulse
paracentesis
- HAVE THEM SIT HIGH FOWLER
- draining fluid from the abdomen due to accumulation, ascites
- HAVE CLIENT VOID BEFORE
- maintain client on BED REST!!
worry about hypovolemic shock cus it can take out large fluids. tachycardia is a rapid response to hypovemia
- WORRY ABOUT RESPIRATORY, ARE THEY NOW BREATHING BETTER?? are they less short of breath? cus you taking the fluid out and the fluid is no more pressing on their lungs
CLIENTS WITH CIRRHOSIS AND ASCITES
- cirrhosis = cholestyramine = take 1 hour before other meds
- position in semi fowler or fowler postion why?? we dont want the pressure exerted on abdominal ascites on the diaphrapgn which restricts lung expansion
hypothyroidism
-
elevated thyroid stimulating hormone
hypometabolism so signs and symptoms reflects name = give them thyroid hormones: levothyroxine (synthroid)
MANIFESTATIONS
- obesity
- **cold intolerance (hypo = always cold)
- heat tolerance
- low BP and pulse
- menstrual irregularity
WHEN CARING FOR HYPOTHYROIDISM PATIENTS
- do not sedate them because they are already have slow vitals and
- If the patient is supposed to be NPO make sure you question that they still get their morning levothyroxine
pill!! = they NEED it (might die on the table due to body been too low already from the anesthesia)!
MYXEDEMA = severe form of hypothyroidism
- hyponatremia
- hypoventilation which causes respiratory acidosis
- HYPOTHERMIA
- HYPOGLYCEMIA (calcium gluconate available)
TREATMENT FOR MYXEDEMA = levothyroxine and hydrocortisone
LEVOTHYROXINE = low levo increases TSH, increased levo is needed to lower TSH
- avoid taking in the evening
- AS PREGNANCY ADVANCES, DOSES MAY NEED TO BE INCREASED
- take same time each day BEFORE BREAKFAST
- follow up to check tsh and t4 levels
- report signs of excess thryoid hormones such as heart palpiations, tachycardia, weight loss and insomnia
ulcerative colitis
- sores in large abdomen = stools containing blood and mucous
keep a symptom journal
EXPECTED FINDINGS
- elevated temp
- abdominal cramping
INTERVENTION
- manage pain
- assess fluid balance
- continue SULFSALAZINE even after resolution of symptoms
- take daily vitamins (calcium) and supplements
- increase fluid to 2000 ml per day
- small frequent meals with HIGH CALORIES AND PROTEINS
- AVOID COFFEE and other triggers
peptic ulcer disease (PUD)
- sucralfate should also be taken 1 hour before meals to protect stomach
ulceration in the protective layer(mucosa) of the stomach
- leads to perforation and bleeding
RISK FACTORS
- H pyloris infections
- genetic prediposition
- prolonged NSAID use
- stress
- lifestyle choices
INTERVENTION
- amoxicillin, clarithromycin and OMEPRAZOLE for 14 days
AVOID
- meals or snacks before sleeping
- taking NSAIDs without prescription
- caffeine = cola, tea, coffee
- smoking and alcohol
-
FIRST LINE MEDICATIONS = PROTON PUMP INHIBITORSENDS IN -PRAZOLE
- SHOULD NOT BE TAKEN WITH FOOD. TAKE BEFORE MEALS
- may decrease absorption of calcium and promote osteoporosis
- LONG TERM USE: osteoporosis, C. difficile and pneumonia
Pancreatitis
MOST COMMON CAUSES
- cholelithiasis
- alcoholism
MAJOR GOALS
- NPO status
- IV fluids
- NG tube
-clients often position themselves in knee chest position to alleviate pain
- semi fowler to decrease tension on the abdomen
CULLEN SIGN ( C = calcium also)
- the discoloration (bruising) of the abdomen and periumbilical area
HIGH RISK OF DEVELOPING ARDS = MOST SEVERE COMPLICATION
MANIFESTATIONS
- severe, continuos, piercing or penetrating pain in the mid epigastric area or left upper quadrant radiating to the back
- steatorrhea
- fatty, yellow, foul smelling stool
COMPLICATIONS
- increased risk of third spacing, ARDS due to systemic infla response and hypocalcemia
manifestations of appendicitis
INTERVENTION
FLUID RESUSCITATION IV CRYSTALLOIDS(normal saline, lactated ringers) is priority in appendicitis
CAUSE
result of viral or infectious diseases more common in males
- high carbs are risk factors
MANIFESTATIONS
- pain from mid epigrastric / left upper that radiates to the back
- if they’re feeling pain and suddenly stops = RED FLAG IT COULD BE A RUPTURED APPENDIX
-
PAINS
- Pain (RLQ)
- Anorexia
- Increased temperature and WBC
- Nausea
- Signs (mcburneys, psoas)
caput succedaneum vrs cephalohematoma
CAPUT SUCCEEDANEUM
- normal edema of soft tissue of the scalp that Crosses Sutures (symmetrical) = look at their initials CS
- develops due to prolonged pressure of the presenting part against the cervix = resolves in few days
- It appears
as a lump or a bump on their head. This condition is caused by prolonged pressure from the
dilated cervix or vaginal walls during delivery.
CEPHALOHEMATOMA = does not cross suture lines
- traumatic subperiosteal bleed under the skin
VAGINAL HEMATOMAS
- formed following trauma to the tissues (vaccum or forceps assisted, episiotomy)
- severe vaginal pain with fullness but fundus is midline
-
benign prosthetic hyperplasia (BPH)
- abnormal porstate enlargement normally in clients over 50
- the prodtate enlarges and comresses the urethra causing voind problmes
MANIFESTATIONS
- urinary urgency
- urinary frequency
- urinary hesitancy
- symptoms are similar to UTI with the exception of burning sesnation and cloudy/foul smelling urine = REPORT THOSE!
- urine dribbling
- nocturia
increased risk for UTI because of incomplete bladder emptying and urine retension
INTERVENTION
- voiding schedule
- avoidance of caffeine an antihistamines
MED = finasteride
- inhibits further grwoth of the prostate
- takes several months of therapy to see appreciable differences in prostate size
- as a result, missing 3 doses will not cause immediate or long term adverse effects
saw palmetto is recommended by many urologist to treat bph
AMINOGLYCOSIDES
DRAW A TROUGH LEVEL PRIOR TO ADMINISTERING = about 15-30 minutes
- powerful class on antibiotics. BIG GUNS OF ANTIBIOTICS
ends in -mycin without the “thro” in middle
- NOT GIVEN PO (poorly absorbed),
PREFFERED ROUTE
- ONLY IM OR IV (central venous catheter preffered
- peripheral IV may be used for short term therapy
PERIPHERAL IV ARE PREFERRED AT THE DORSAL SURFACE OF THE HAND TO REDUCE RISK FOR INFECTION
WHEN ORAL AMINOGLYCOSIDES ARE INDICATED
1. hepatic coma (liver coma) = amonia levels are too high = lactulose and neomycin
2. pre op bowel surgery to sterilize the bowel = NEOMYCIN, and KANMYCIN
GIVE SLOWLY OVER 60 MINUTES
- if given too fast can cause facial flushing but facial flushing is not an indicative of allergic allergic.
- wheezing and hives indicates allergic reaction
INDICATIONS
- life threatening
- resistent
- gran negative (TB)
MONITOR
- anaphylaxis (red man syndrome, laryngeal edema, wheezing)
- observe site every 30 mins for pain, redness and swelling cus they are considered vesicants and can cause thrombophlebitis, extravasation and tissue necrosis
- MONITOR BUN AND CREATININE LEVELS!!
- monitor blood pressure
- respiratory status
TOXIC EFFECTS
- nephrotoxicity elevated creatinine levels
- ototoxicity (hearing loss, vertigo/balance, tinnitus)
- toxic to cranial nerve 8
administer them every 8 hours too
- MUSCLE CRAMPING IS NORMLA AND DOES NOT REQUIRE INFUSION TO BE STOPPED
crutches
canes should equal the distance from the greater trochanter to the floor
- 2-3 finger widths below the anterior axillary fold to a point lateral to and slightly in front of the foot
-
hand grip = elbow flexion should be about 30
degrees - basic crutch stance = 6 inches front and side
REPORT HAND AND WRIST WEAKNESS = CRUTCH PARALYSIS
- if any of the answers says AXILLA OR MEAUSURE TO YOUR FOOT (any landmarks on your foot) , THEY ARE WRONG
GOING ON STAIRS
- ASCENDING (up) = lead with stronger leg (weak leg and cane,crutches should move together)
- DESCENDING ( down ) = lead with affected leg crutch might go first but affected leg should follow right after
2 POINT GAIT CRUTCHES
- two things are moving together
- MOVEMENT: 1 crutch/opposite foot.. other crutch/other foot = RIGHT CRUTCH WITH LEFT FOOT. LEFT FOOT WITH RIGHT CRUTCH SIMULTANEOUSLY
3 POINT GAIT CRUTCHES
- MOVEMENT: moving 2 crutches & the bad leg together at the same time
- odd leg (1 leg affected)
4 POINT GAIT CRUTCHES
- for severe bilateral weaknesses
- MOVEMENT: move everything separately similar to wlaking
- weight bearing on both legs
SWING THROUGH CRUTCHES
- NON-weight bearing, amputations
- MOVEMENT: plant the crutches & swing through past where the crutches are placed
RESIDUAL LIMB CARE FROM AMPUTATION
- RESIDUAL LIMB SHOULD NOT BE ELEVATED!!
- lie prone several times each day and avoid sitting in a chair for more than an hour
- phantom pain is a priority
- lying prone will prevent flex flexion contractures
- avoid alcohol, lotion, powder
- wash with soap and water
- perform range of motion exercises to improve muscle strenth and mobility
REMEMBER
- odd for odd
- even for even
celiac disease
immune reaction to eating glutten, a protein found in wheat
- need to be on a glutten free diet for the rest of life
- if client does not experience relief after being on a gluten free diet, = ASK THEIR LAST MEAL
MANIFESTATIONS
- dirrhea
- foul smelling stools
AVOID = BROW = barley, rye oats and wheat
french fires
- wheat
- rye
GLUTEN FREE OPTIONS
- eggs
- potatoes
- fish
- vegetable
- corn
- rice
- milk
- red meat
- chicken
peritoneal dialysis
insufficient outflow results most often from CONSTIPATION
INTERVENTION FOR INSUFICIENT OUTFLOW
- dialysate bag should be installed using a sterile technique
- assess for abdominal distention and constipation
- examine fir kinks and obstructions
- place in side lying position
stool softenrs may be prescribed
MONITOR AND REPORT = they are signs of peritonitis
- cloudy outflow (effluent) = infection
- brown outflow = perforation
- respiratory distress AND CRACKLES
- low grade fever
- tachcardia
avoid beta blockers or anything that brings down pressure prior to dialysis cus one of the complications of dialysis is hypotension
HYPOGLYCEMIA
GLYBURIDE = LOWERS BLOOD GLUCOSE
- bad cross sensitivity with sulfa containing drugs
- severe risk and prolonged hypoglycemia in geriatric population
- cross sensitivity with diuretics
- even foods labeled as diabetic, sugar free or sugarless may still contain carbs such as honey, sugar and corn syrup which all can elevate blood sugar
HYPOGLYCEMIA 70-110 is normal
- not enough food
- TOO MUCH INSULIN/MEDS
- too much exercise
OVER MEDICATION IS THE NUMBER 1 CAUSE OF HYPOGLYCEMIA
- they can all lead to permanent brain damage
SIGN AND SYMPTOMS
- drunk in shock (how drunk ppl behave and they also look like they are in shock)
epinephrine is one major hormone released during hypoglycemic reaction
HYPOGLYCEMIA MANIFESTATIONS
DRUNK
- staggerin’ gait
- slurred speech
- impaired judgemnt
- delayed reactions
- labile ( EMOTIONS ALL OVER THE PLACE)
- loud/obnoxious
diaphoresis
trembling
SHOCK
- (vasomotor) low BP
- tachcardia
- tachypnea
- pale, cold, clammy, mottled skin
if a client is demonstrating hypoglycemia signs and symptoms, FIRST THING CHECK BLOOD GLUCOSE BEFORE GIVING THE SUGAR
UNRESPNSIVE CLIENTS OR CLIENTS WITH DYSPHAGIA
- 1 mg of glucagon IM int deltoid muscles
ASYSTOLE vs V FIB
both lethal arrhythmias with no cardiac output (pulse) = no brain perfusion = dead = THEY WILL KILL YOU IN 8 MINUTES OR LESS
ASYSTOLE = NO DEFIB
- always confirm electrodes are placed first do not take electrode off during shower
- continuous high-quality CPR, oxygenation and epinephrine are priority
- lacks QRS
defibrillation is not indicated for asystole because it LACKS electrical activity (flat line)
- atropine can be given too but EPI first
- defib is not effective for pulseless electrical activity either
VENTRICULAR FIBRILLATION (v-fib)
- defib, shock with CPR in between
- DEFIB PADS, RIGHT UPPER CHEST AND LEFT LATERAL STERNAL BORDER = for 8 years and older
- less than 8 years = place one pad on chest and the other at back
- V FIB = defib and shock with cpr in between
what those two have in common, no cardiac output (pulse) = no brain perfusion = dead = THEY WILL KILL YOU IN 8 MINUTES OR LESS
- V FIB responds to defibrillation NOT CARDIOVERSION
ATROPINE is also given for bradycardia
ICDS CANNOT SENSE OR TREAT PULSELESSNESS SO CPR SHOULD BE INITATED IN PULSELESS CLIENTS WITH ICD
duchenne muscular dystrophy (DMD)
- xlinked rexcessive disorder due to lack of protein called DYSTROPHIN
- muscle tissued being replaced by connective tissue = lower extremities weakness
MANIFESTATIONS
- frequent trips and falls at home
- places hands on the thighs to push to stand = GOWER SIGN
- walks TIPTOES and has disproportional large calve
respiratory and cardiac problems are the leading causes of mortality
DIET
- whole grains, fruits and vegetables to maintain a bowel fuction to reduce risk for conspitation from IMMOBILITY
INTERVENTION
- no effective cure = die by 20-30 years from respiratory failure
- avoid floor clutter, throw rugs and prevent falls/injury
- gentle exercise and swimming to avoid disuse atrophy and social isolation
- most might require a wheelchair due to how they can easily fall
SCLERODERMA
- overproduction of collagen that causes tighthening and hardening of the skin and connective tissue
- MONITOR FOR RENAL CRISIS THAT CAUSES MALIGNANT HYPERTENSION
Internal Arteriovenous (AV) fistula
created to provide vascular access for hemodialysis with kidney disease
maturing the fistula requires hand performing hand exercises such SQUEEZING A RUBBER BALL = increases blood flow to the vein
- cerebral arteriovenous malformation is a contraindication in thrombolytic therapy
PATENCY
Ensure patency of AV fistula = BRUITS (hear) or THRILL (feel) = teach patient how to feel them
o Auscultate for bruit/thrill = loud swooshing sound
o No BP where fistula is
o Not to wear bracelets—may restrict blood flow to arm
o Do not carry bags—use shopping cart = NO PRESSURE ON ARM WITH FISTULA
o Do not sleep on the affected side
ARTERIOVENOUS MALFROMATION
- tangle of veins and arteries
- blood pressure control is prioty
- avoid anything that can increase bleeding
hyperthyroidism
hyperthyroidism = hypermetabolism therefore
MANIFESTATIONS
- weightloss but avoid high fiber foods cus they increase GI symptoms
- increased appetite
- high pulse & BP
- Atrial fibrillation
- irritable
insomnia
- heat intolerance
- cold tolerance
- exophthalmos
(bulging eyes) - lightly tape eyes shut if can’t close at night - raise head of bed
- GRAVES disease (running yourself into the grave)
- PRIORITY OUT OF ALL THE MANIFESTATION IS AGITATION AND CONFUSION
TREATMENT
1. radioactive iodine = patient needs to be by themself for 24 hours (restriction of
visitors)
CLIENTS RECEIVING RADIOACTIVE IMPLANTS
- long handled forceps and lead lined container should be present at bed side
- in cases of dislogment = use forceps to place the implant in a lead container to contain radiation exposure
- Propylthiouracil (PTU) = Puts Thyroid Under
- CANCER drug = immunosuppression (monitor WBC) - thyroidectomy (most common way) = total or subtotal thyroidectomy
most important thing before answering a thyroidectomy question is if its a total (complete) or subtotal (partial)
HYPERPARATHYROID = elevated calcium TREATED BY FUROSEMIDE
- avoid THIAZIDE CUS IT CAUSES CALCIUM LEVELS TO INCREASE MORE
thyroidectomy
- 1st 12 hours: PRIORITY = airway and hemmorhage (neck edema, irregular breathe, prevent swelling)
TOTAL THYROIDECTOMY = 12-48 hours
- Total = Tetany (TT) = muscular spasms in larynx: can cut off airway) due to LOW calcium
- RISK FOR LOW CALCIUM
SUBTOTAL THYROIDECTOMY
- Subtotal = Storm (SS)
- DOES NOT REQUIRE LIFELONG HORMONE REPLACEMENT but now at risk for thyroid storm
- after 48 hours: INFECTION ( NEVER choose infection as a PRIORITY in the first 72 hours for
anything!!! ONLY CHOOSE it after the first 72 hours )
MONITOR AND REPORT THYROTOXICOSIS
- chills
- fevers
INTERVENTION
- HOB 30-45 degrees
- have trach kit, suction and oxygen by bedside at all times
ASSESS FOR
- voice strength and quality to monitor for laryngeal damage
REPORT IMMEDIATELY
- report noisy breathing = indicates airway obstruction
- stridor and difficulty breathing should be reported immediately
- SIGNS OF HYPOCALCEMIA = trousseu and cvostek signs
OTHER SIDE EFFECTS TO MONITOR
- elevated blood pressure
- low oxygen saturation (common in postoperative clients so its not much of a priority)
incomplete vrs complete spinal cord injuries
INCOMPLETE
1. BROWN-SEQUARD SYNDROME
- being stabbed. orshot
- damage to ONE SIDE ONLY
- cover the wound with petroleum gauze taped on three sides
- CENTRAL CORD SYNDROME
- most common form of incomplete SCI characterized by HYPEREXTENSION AND HYPERFLEXION
- AFFECTS THE UPPER EXTREMITIES than the lower
COMPLETE SPINAL CORD INJURY (PARAPLEGIA)
- also called leg paralysis
- total loss of motor function and sensations below the level of injury
BOTH SIDES ARE EQUALLY AFFECTED
1st generation antipsychotic drugs
- also called phenothiazines
ALL ENDS IN AZINES + haloperidol - Chlorpromazine
- Haloperidol = can be given to pregnant women
- Fluphenazine
they are considered major TRANQUILIZERS BIG GUNS!!
out of them all HALDOL IS THE ONLY ONE THAT CAN BE SAFELY GIVEN TO PREGNANT WOMEN
they do not cure psych diseases, they just reduce the symptoms. targets psotive symtpoms but no effect on negative
IN LARGE DOSES = they are ANTIpsychotics
IN SMALL DOSES = they are ANTIemetics
aminoglycocides are to antibiotics,
like phenothiazines are to tranquilizers* = they’re both the BIG GUNS! = you pull them out when nothing else is gonna work
HALPERIDOL
- the ONLY MAJOR antipsychotic tranqulizer that CAN be given to pregnant
women!
- safety CONCERNS related to the side effect
- has a “decanoate” form; LONG acting IM
BENZTROPINE
- anticholinergic used to treat extrapyramidal symptoms
- side effects = dystonia (abnor muscle movem) and parkinson symptoms
- contraindicated in clients with urinary retention and acute glaucoma
SIDE EFFECTS OF HARIPERIDOL
A = anticholinergic (dry mouth) Nursing dx: risk for injury
B = blurred vision Nursing dx: risk for injury
C = constipation
D = drowsiness
E = EPS (extrapyramidal symptoms); like Parkinsons = associated with metocloropramine and treated with benztropine
F = Fotosensitivity (photosentivity)
aG = agranulocytosis (LOW white count; immunosuppressed)
Nursing dx: risk for injury
DECANOATE DRUGS
- IM DRUGS
2nd generation antipsychotic
USED TO TREAT SEVERE SCHIZOPHRENIA
-zapine
-idone
CLOZAPINE
- has an advantage by not having side effects A, B, C, D, E or F
BUT HAS THE SIDE EFFECT OF AGRANULOCYTOSIS = low white count = TRASHES BONE MARROW
- However, aG doesn’t always happen with everyone; so some people can take this
drug & some people can’t
BEFORE STARTING CLOZAPINE
- ** obtain a complete blood count and ANC**
- ECG cus they prolong QT interval
- blood pressure = orthostatic hypotension is a side effect
agranulocytosis poses more significant danger to the client
REPORT sore throat (flu-like symptoms) because it can indicate infection due to neutropenia
- Remember: with any of your ATYPICAL ANTIpsychotics,
WHITE count is a BIG DEAL
ZIPRASIDONE
- has a BLACK BOX WARNING (FATAL drug situation
- it prolongs
the QT interval & can cause sudden CARDIAC arrest = do NOT use with heart problem pt’s
Selective serotonin reuptake inhibitors (SSRIs) antidepressant
- first drug or choice FLUOXETINE (PROZAC)
SERTRALINE (zoloft) - citalopram
- escitalopram
- INCREASES RISK OF SUICIDE ESPECIALLY IN YOUNG ADULTS 18-24 so a client who reports increased in energy without change in depressive feeling needs to be assessed and monitored
DO NOT TAKE WITH ST JOHN WORT
side effects
A = anticholinergic (dry mouth)
B = blurred vision
C = constipation
D = drowsiness
E = euphoria
- frequent headaches
- weight gain
- gastro disturbances
- sexual dysfunction
FLUOXETINE (PROZAC)
- ** causes insomnia so give it before noon, DONT GIVE AT BED TIME**
- when CHANGING the DOSE in adolescents/young adults; watch for increased suicidal
risk! = wont be a risk of dose are kept the same
SERTALINE
- monitor for serotonin syndome - diarrhea and fever
- causes insomnia just like fluoxetine (prozac) but you can give this one at bedtime
- interferes with cytochrome p450 system in the liver which is responsible for breaking down and deactivating the
drugs in the liver
- sertraline makes it easier for other drugs to reach TOXICITY
** MOST CONCERNING SIGN IN SUICIDAL CLIENTS: sudden positive outlook. THE NURSE SHOULD ASK ABOUT THE PLAN**
“risk of suicide” is the nursing diagnosis for people who have attempted suicide are at more risk of suicide
RISK FOR SUICIDE
- significant life stressor such as unemployment, difficulty finding new job
- access to devices firearms
- history of substance abuse
- feelings of hopelessness
Serotonin and norepinephrine reuptake inhibitors (SNRIs) antidepressants
ATYPICAL
- Venlafaxine
- Desvenlafaxine
- Duloxetine = has pain reliving effects
SEROTONIN SYNDROME
- upper symptoms
- diaphoresis
- agitation
- tachycardia
SHOCK
IV catheter = large bole = 14 gauge
- BP go down
- rates go up
- pale, cold and clammy (in neurogenic shock, skin is warm and dry)
decreased central venous pressure normal: 2-8
MANIFESTATIONS
- dysonea
- lightheadnesses
- skin rash hives)
- wheezing
PLACING SpO2 on FOREHEAD rather than finger gives more accurate readings
NEUROLOGICAL SHOCK = heart rate decreases
- bradycardia
- skin is warmed and flushed
POSITION: trendelenburg position ( supine with head kinda pointed down )
as shock progresses, kidneys decrease filtration and increase reabsorption to correct BP
INTERVENTION
- FLUID RESUSCITATION = IV boluses of isotonic fluid to increases intravascular volume and perfusion DO NOT DELAY IV
- norepinphrine is a vasopressoror to increase stroke volume. titrated to maintain MAP 65 or up
lumbar punch
- lateral recumbent position or sitting upright
- needle is inserted L3/4 or L4/5
AFTER PROCEDURE
- lie flat with NO PILLOW for atleast 4 hours
- increase fluid intake
- INCREASE FLUID IF PATIENT COMPLAINS OF HEADACHE
- headache not a priority
- headaches happen as a result of CSF fluid leaked
- ask the client to void prior
- DOES NOT REQUIRE NPO
- dextrose testing is used to test for the presence of leaked CSF but make sure there’s no presence of blood cus it can skew results. why? because blood contains glucose
heparin vrs WARFARIN (COUMADIN)
-WARFARIN is given only PO
- takes few days to week to work
- CANNOT BE GIVEN TO PREGNANT WOMEN
- can be given rest of your life
- antidote = vitamin K (FRESH FROZEN PLASMA can be used for rapid reversal)
eat the same amount of food high in vitamin K (dark, green, leafy vegetables) when taking warfarin - avoid aspirin
VITAMIN K RICH FOODS
- brocolli
- liver
spinach
OFTEN USED IN CLIENTS WITH
- atrial fibrillation to prevent clot formation and reduce the risk of stroke
- DVT, pulmonary embolism
- mechanical heart valves to prevent clot formation on valves
MECHANICAL HEART VALVE INR = 0.6-1.2
MONITOR
- PT(INR) (coumadin = 8 letters; count on hand; 2 fingers left (PT)
- vitamin K intake should be consitent cus too much vitamin k makes warfarin ineffective and too little increases effectiveness placing client at high risk of bleeding
DONT DELIVER WARFARIN IF INR OVER 4
AVOID
- cranberry and grapefruit
- green tea
atonic vrs tonic-clonic seizure
- atonic = sudden LOSS OF MUSCLE MASS
TONIC CLONIC
- stiffening and contraction of the muscle
- normal to wake up confused and then back to sleep for few hours
levetiracetam is used to prevent seizures also
PHASES OF SEIZURE
- prodromal phase = warning signs that precedes the seizure
- aural phase: period before the seizure when client may experience visual or sensory changes
- ictal phase: period of the active seizure activity
- postictal recovering from the seizure, confusion, headache , syncope
KEY CONCERN OF SEIZURES = have suctioning by bed side
DELIRIUM TREMENS SYNDROME DIFFERENCES IN CARE
- NPO/clear liquids (seizures)
- private/near nurses station
- restricted bed rest
- bed pans/urinals
- restrained (VEST or 2 point locked leathers) = 1 arm and opposite legs
MAKE SURE IV ACCESS HAS BEEN ESTABLIHSED
- oxygen at bed side
- suctioning available
CAUSES OF DELIRIUM
- medications (opiods, anticholinergic)
- electro imbalance (hyponatremia)
- hypoxia
- acute infection (fever, positive culture)
- lack of sleep
- dehydration or malnutrition
- metabolic disorders (hypoglycemia)
SAFETY IS A HIGH PIRORITY IN DELIRUM CLIENTS = close observation and one on one supervsision
MED TREATMENT
- antihypertensive pills
- TRANQUILIZER
- MULTIVITAMIN B1 TO PREVENT WERNICKE-KORSAKOFF SYNDROME
- THIS IS BEACUSE SINCE THEY ARE GOING THROUGH WITHDRAWAL, EVERYHTING GOES UP AND THE BP PILL WILL KEEP EVERYTHING DOWN
RESTRAINTS CARE
- not as needed = based on behavior
- release one at a time
- 45 degrees and up
- avoid supine or prone
- never put 4 rails up because it is considered a restraint
basillar skull fracture
- raccons eyes (periorbital hematomas)
- battle sign (postauricular)
CSF leakage is an indication of this and can be evidenced by conjugated blood surrounded by CSF
CSF TESTING
- dextrose testing but only when there is no presence of blood because blood contains glucose also
CONTRAINDICATIONS
- NG tube should not be used when basically skull fracture is suspected
- morphine
SUCTION CONTROL CHAMBER CHEST TUBE
chest tube installing : have client raise arm above the head when placing a chest tube
GOOD FINDINGS: continuous and gently bubbling
- amount of suctioning is controlled by water in the chamber NOT by the wall suctioning.
BAD FINDINGS: intermittent bubbles which indicates suctioning is not high enough. go to the dial on the wall and turn it up until bubbling is continuous
turning up wall will cause vigorous bubbling but DOES NOT increase suctioning = check water level and add sterile water if necessary to prescribed levels
COLLECTION CHAMBER
- where the drainage from client accumulate
- 50-500ml for the first 24 hours is expected
- REPORT drainage of 100 or more an hour
- assess amount and color of the fluid and record as output
bucks (skin) traction vs skeletal traction
BUCKS(SKIN)
APPROPRIATE ACTIONS
- keep supine or HOB in semi fowler (max 30 degress)
- maintain limb in straight neutral position
- lose the velcro straps if the boot is too tight = can impair neurovascular status
- provide fracture pan to minimize client movement (they can move to the bathroom but better if in bed)
- avoid side to side repositioning of the client
- weights should be free hanging at all times and should never be placed on bed or touch floor
SKELETAL TRACTION
- used to immbobilize
- **NEVER REMOVE WEIGHTS = CAN CAUSE INJURY and unless there is a life threaning situation
NURSING INTERVENTIONS
- Temperature
- Ropes hang freely
- NO weigh on bed/floor
- Alignment
- Check circulation by nurse
- Type and location of fracture
- Overhead trapeze to lift self up during bed change etc
overhead trapeze for both and perform assessment of affected extremities in tractions
RN CAN DELEGATE THE FOLLOWING TASK TO UAP
- assist with passive ROM
- notify the nurse of pain, tingling etc
- remind client to use incetive spirometer
- maintain proper use of pneumatic compression devices
guillain barre syndrome
destroy the nerves of the peripheral nerves
MANIFESTATIONS
contribute
- numbness and tingling = diabetic neuropathy
- assending paralysis
paresthesia
decreased reflexes
MOST COMMON COMPLICATION = rate and depth of respiration
- at risk of paralytic ileus due to immobility or nerve damage
ITS IMPORTANT TO ASK ABOUT RECENT RESPIRATORY AND GASTRO TRAC INFECTIONS cus GBS usually start few days or weeks after
- have INTUBATION TRAY AT BED SIDE
Billroth II surgery (gastrojejunostomy)
- part of the stomach is removed and shortened leading to client experiencing
DUMPING SYNDROME MANIFESTTIONS
because they demonstrate dumping syndome, apply same interventions for this!! = LAY DOWN AFTER EATING TO SLOW GASTRIC EMPTYING
MANIFESTATIONS
- sweating
- tachycardia
- hypotension
- abdominal pain, N/V. dizziness
molar pregnancy
gestational trophoblastic disease that results in abnormal fertilization
- rapid growing of trophoblastic tissues
- MONITOR HCG LEVELS!!
TROPHOBLASTIC CELLS MAY CONTAIN GENETIC MATERIAL THAT EXORESSES THE RH FACTOR THEREFOR RHOGAM IS REQUIRED FOR CLIENTS WITH RH NEGATIVE BLOOD TYPES
AFTER EVACUATION OF MOLAR PREGNANCY
- hcg hormone will continue. toincrease
- AVOID PREGANNCY to allow HCP to closely monitor rising hcg levels which may indicate malignant gestational trophoblastic neoplasia
POST PARTUM HEMORRHAGE RISK FACTORS
- polyhydramnios (excess amniotic fluid). OLIGOHYDRAMNIOS IS NOT ASSOCIATED WITH PPH
- dytocia = prolonged and painful labor
UTERINE ATONY = most common - preeclampsia and ecampsia
- placenta previa = painless = cervix covering cervix
- twins
- multifetal gestation
- macrosomia = infant larger than average/birth weigh 8lbs or more
- use of meds like mag sulfate
UTERINE ATONY = soft boggy uterus
- after they gave birth and they’re bleeding, ITS MOST LIKELY DUE TO UTERINE ATONY SO MASSAGE THE FUNDUS!!
- inability of the uterine muscle to contract** adequately following birth, leading to vaginal bleeding and/or postpartum hemorrhage = meds: misoprostol
- boggy uterus
- soaked perineal pads
- SOFT FUNDUS= massage the fundus until its FIRM
NORMAL FINDINGS 24 HOURS POSTPARTUM
- elevated temperature (fever)
- elevated WBC (leukocyte)
OPERATIVE VAGINAL BIRTH USING VACCUM EXTRACTOR OR FORCEPS
- never apply fundal pressure = can lead to uterine rupture
kawasaki disease
- swelling in the arteries througout the body
- PRIORITY OF TREATMENT AND PRIMARY GOAL IS TO PREVENT HEART DISEASE
PRIORITY MANIFESTATION
- MONITOR FOR GALLOP AND HEART SOUNDS AND DECREASED URINE OUTPUT
MANIFESTATIONS
- acute febrile HIGH FEVER
- administer ASPIRIN or immunoglobin to prevent coronary artery aneurysms
- soft food and clear liquids
- irritability is expected and can last up to 12 months
- temp joint pain and other arthritis are expected = ROM exercises and warm baths will help reduce symptoms and minimize discomfort
- skin peeling
- lymphadenopathy/ sleep enlargement
- obtain 12 lead electrocardiogram
- this ASPIRIN can lead to reye syndrome
IV IMMUNOGLOBULIN
- since they are receiving a lot of fluid can lead to fluid overload, heart failure, decreased urine cus the fluid is being retended
ONCE DISCHARGED
- check temp every 6 hours for the first 48 hours
- strawberry tongue
- bright, red swollen lips
- blood shot eyes
- red palms and soles of feet
hypercyanotic tetralogy of fallot
- occurs more often during stressful situations or on waking so sleep should not be interrupted
Place the infant in the knees to chest position = improves pulm blood flow
FOR TOF, REPORT INCREASED RBC
THE CHILD SHOULD BE FIRST PLACED IN KNEE CHEST POSITION = flexion of the legs relief dyspnea and improve oxygenation
HOW TO REDUSE HYPERCYANOITC SPELLS
- encourage smaller, frequent feedings
- offer a pacifier when the infant begins. to cry
- promote calm environemnt
- swaddle infant during procedures
MEDICATION: MAGNESIUM SULFATE and MORPHINE
OTHER INTERVENTION
- Administer 100% oxygen
- Administer morphine sulfate
- Administer an IV fluid bolus
- Document the event
have oxygen available during infant vax. vaccinations make them cry and crying uses alot of their energy
tracheoesophageal fistula = cyanosis
when giving oral medication to kids
- have them in semi reclining position
- use oral syringe
- direct liquid towards the back and inside of the infants cheek
diabetic foot care
some diabetic patients may not feel the ache of a blister or the sting of a cut on their feet due to DECREASED PERFUSION
- wash feet everyday in WARM water
- don’t put feet in hot water, don’t use heating pads or hot water bottles
- don’t try to remove corns, calluses
- don’t wear tight, elastic, thick bulky socks
- use mild foot powder on perspiring (sweating) feet
- we want to keep the feet clean, dry and free from irrtation
- dont walk barefoot
- creams or lotion can be applied on the tops and bottoms of feet to keep them from crackling.
- dont cut nails laterally
LOTIONS SHOULD NOT BE APPLIED BETWEEN TOES = between the toes should be kept dry
fifths disease/ parvovirus
viral illness caused by parvovirus that mainly affects school aged children
MANIFESTATIONS
- rash on cheek = slapped face
- only communicable prior to onset of symptoms
- spreads via respi secretions
- general malaise and joint pain = well controlled by NSAIDS
- recover in like 7-10 days
pneumonia
- left sided pneumonia should be placed on their OPPOSITE SIDE (right)
- good lung down to increase blood flow to the lung most capable of oxygenating blood = blood flow in the lungs are partially influenced by gravity
RISK FACTORS
- advanced age (over 65)
- young age (less than 2)
- CNS depression
- decreased level of conciousness
MANIFESTATIONS
- fever
- chills
- fatigue
- crackles
- sputum production
- hemoptysis = usually sig amount that is not concerning
- lung abscess
- bronchiectasis
small amounts of blood tinged sputum are normal after brochoscopy, frank bleedings or clots be reported
INTERVENTION
- obtain sputum for gram stain and culture testing because administering med before can skew results
- MED LEVOFLOXACIN
COMPLICATIONS
- pleurisy (pleural friction rub) = caused by inflammed parietal and visceral pleurae rubbing together
REPORT = pleural friction rub (pleurisy)
- stabbing pleuristic chest pain that increases on INSPIRATION
DISCHARGE TEACHING
- avoid the use of oTC cough suppressant
- schedlue follow up with HCP and chest xray
- keep cool mist humidifer in your bedroom at night = keeps membranes mosit
- continue incentive spirometer
- infleunza and pneumonia vaccinations
FETAL MONITORING
GOOD FETAL MONITORING PATTERNS
- high fetal heart rate of 110-160 (if above 160 for 10 or more minutes = fetal tachycardia = concerning findings)
- High baseline variability = when babies heart is always changing
- Early deceleration = when heart slows before or at end of contraction
BAD FETAL MONITORING PATTERNS
- Low fetal heart rate (less than 110)
- Low baseline variability = babies heart stays the same and does not change
- Late deceleration = babies heart slows down near end or after contraction = fetal oxygen is compromised = c section
- Variable (VERY BAD) deceleration
INTERVENTIONS FOR BAD FETAL MONITORING
- LION but stop oxytocin first if its running
- Left side
- IV (increase IV)
- O2
- Notify doctor
amniofusion = used to correct fetal heart rate
VEAL CHOP
- Variable = Cord compression due to loss of amniotic fluid (oligohydramnios)
- Early deceleration = Head compression
- Acceleration (high fetal heart rate = Okay
- Late deceleration = Placental Insufficiency
- KNEE CHEST FIRST!! then amniofusion is indicated to give room for cord to float
ALWAYS CHECK FETAL HEART RATE = WHEN IN DOUBT, PICK THIS AS THE ANSWER!
Left ventricular failure vs right sided heart failure
BNP (brain natriuretic peptide) = BEST INDICATOR for Congested Heart Failure**
- left ventricular presence/severity of heart failure
BNP LAB
- should be under 100
HEART AND NOT HIGH PRIORITY??? = cus it indicated chronic condition and not an acute (acute beats chronic)
- should not call the doctor middle of the night just watch them for CHF
LEFT SIDED HEART FAILURE = congested heart failure/ systolic heart failure
- s3 gallop = NORMAL IN CHILDREN
- any symptom lungs related
- inability of the left ventricles to pump blood leading to pulmonary congestion (CRACKLES)
- fluid backs up into the lungs making it difficulty to breathe = patient will cough as a result of that
RIGHT SIDED HEART FAILURE = diastolic heart failure
- everything is being retained leading to swelling
- elevated central venous pressure can indicate fluid overload = 2-8 is normal
- s4 gallop is heard
- jugular vein distention
- peripheral edema
- oliguria
- weight gain
ANGINAS
LAB = CPK-MB
VARIANT ANGINA
- occurs at the same time everyday USUALLY AT REST including sleeping
UNSTABLE ANGINA : myocardial infarction (MI) = shortness of breath and muscle weakness
- avoid isometric exercises such as weight lifting because it can increase the workload on the heart
CHRONIC STABLE ANGINA
- DONT EXERCISE ON A FULL STOMACH - preferably, 2 hours after eating**
- aerobic exercises such as walking, swimming or cycling are GOOD
STABLE ANGINA
- relieved by rest = RELIEVED BY NITROGLYCERIN TABLETS
NITROGLYCERIN TABLET INSTRUCTIONS
- lie down before taking tablet cus it can cause dizziness from possible orthostatic hypotension
- MONITOR FOR HYPOTENSION = dizziness and lightheadness = PRIORITY! PRIORITY ALWAYS MEAN SAFETY
- CAN WEAR NITROGLYCERIN PATCH IN SHOWER
- keep tablests in original container and store way from light and heat sources including body heat and cars
- 1 tablet or spray taken sublingually EVERY 5 MINUTES for a maximum of 3 doses
- relieves pain in about 3 minutes and lasts 30-40 minutes
side effect of headaches are expected form the vasodilation and can be treated with acetaminophen
- if symptoms are unchanged or worse 5 minutes after first dose, call emergency
- they should be made assessible at all time
CONTRAINIDCATIONS OF NITROGLYCERIN
AVOID: use of erectile dysfunction drugs (ends in -AFIL) when taking nitroglycerin tablets = can lead to severe hypotension
- dont give if blood pressure is already low
STEMI vs NSTEMI
STEMI
- goal is to reduce cardiac workload and improve myocardial oxygenation to prevent mycocardial necrosis
- should undergo an immediate angiography with PCI = IF IMMEDIATE PCI IS NOT AVAILABLE = administer fibronylitics ( ends in PLASE )
- they should NOT have chest pain after PCI
NSTEMI
- perform an angiography with 28-48 hours
MONAB
Morphine
Oxygen
Nitroglycerin
Aspirin
Beta blockers = fatigue is a side effect
ventricular bigeminy following a myocardial infarction is a PRIORITY = can lead to v fib
CLIENT CAN RESUME SEXUAL ACTIVITITIES AFTER THEY ARE ABLE TO CLIMB 2 FLIGHT OF STAIRS OR WALK 1 BLOCK WITH NO SYMPTOMS
monoamine oxidase inhibitors (MAOI’s)
antidepressants
DRUGS (-ine)
- Tranylcypromine (PARnate)
- Isocarboxazid (MARplan)
- Phenelzine (NARdil)
- Selegiline
- interacts with many drugs such as antidepressants so should be prevented 2 weeks of eachother to prevent adverse reactions
AVOID TYRAMINES
- to PREVENT severe acute, sometimes fatal HYPERtensive crisis:
- they are allowed all fruits and veggies except NO, BAR (bananas,avocados,raisins (any dried fruits)
- Grains are fine; cookies, bread, pies :)
- NO ORGAN meats; liver, kidney, tripe (sheep’s stomach), etc.
- NO PRESERVED meats smoked, dried, cured, pickled*
- NO hot dogs or certain processed lunch meats; they contain “other assorted parts”
DAIRY: NO cheeses except cottage cheese & mozzarella
- NO ALCOHOL or CHOCOLATE (caffeine), NO YOGHURT
FOODS TO AVOID
- yogurt
- no cheese except cottage and mozzarella
- broad beans
- beer
- red wine
- choclate
- avocado
Teach the pt’s NOT to take over-the-counter meds when they are on a MAOI
- give in morning with food, ensure adequate fluid
SIDE EFFECTS OF MAOI
A = anticholinergic (dry mouth (XEROSTOMIA)
B = blurred vision
C = constipation
D = drowsiness
