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
CALCIUM CHANNEL BLOCKERS (CCB)
-DAPINE + cardizem (can be IV continuos) and verapimil = VASODILATORS
CCB
TREATS EVERYTHING WITH “ATRIAL” IN IT NOT VENTRICULAR EXCEPT SUPRAVENTRICULAR TACHYCARDIA
AAAS
sure systolic has to be atleast 100 or up
- antihypertension = relaxes your heart so it relaxes blood vessels as well
- anti-angina = relaxes your heart by decreasing oxygen demand
- anti-atrial-aarhythmia (NOT VENTRICULAR)
- Supraventricular Tachycardia
SVT IS HEART RATE OF 200-300
SUPRAVENTRICULAR TACHYCARDIA = TERMINATED WITH ADENOSIDE but first have them bear down if having a bowel movement/ throw ice bucket on them to slow down HR
- give adenosid eover 1-2 seconds followed by 20 ml bolus
- ADENOSIDE HAS A SHORT HALF LIFE
- SVT is Skinny = NARROW QRS
- suPravebtricular = some sort of P waves
DURING SVT ATTACK (200-300/min
- place ice bag on clients face and instruct client to hold their breathe while bearing down
- stimulating a vagal response like coughin is appropriate intervention for SVT
- DONT USE VALSVA MANEUVER ON ELDERLY
**radiofrequency catheter ablation is indicated for clients with recurrent episodes of SVT
SIDE EFFECTS
- headaches = vasodilates the brain
- hypotension = relaxes cardiac and heart vessels
because they cause vasodilation, client may develop peripheral edema = advised to elevate legs when lying down and use stockings
- REPORT MOOD CHANGES!!
CONTRAINDICATION
- avoid grapefruit = SEVERE HYPOTENSION
- systolic pressure less than 100
** negative inotropic, negative chronotropic, negative dromotropic** = CARDIAC DEPRESSANT
- its like valium to your heart meaning THEY CALM AND RELAX. CARDIAC DEPRESSANT
positive inotropic, postive chronotropic, positive dromotropic = THEY STIMULATE THE HEART AND MAKE EVERYTHING GO UP
peripheral arterial disease
- characterized by affected blood flow to the LOWER EXTREMITIES = fail pinprick test
- hairlessness on lower extremities due to no blood flow down
- ULCER AT GREAT TOE
- worsened pain when elevating legs
- avoid heating pad
- pain extremities when walking ( can be relieved by rest = CLAUDICATION ) = expected of PAD so not a priority
can cause tissue necrosis - keep legs below heart levels
- at risk of developing other vascular disease such as AORTIC ANEURYSM dissection or rupture
- decreased peripheral pulses
DANGLE LEGS WHEN PAIN OCCURS
CAUSES
- smoking
- hypertension
- diabetes insipidus
- hyperlipidemia
MANAGEMENT
- lower the extremities when sitting
- engage in moderate exercise to promote circulation and distal tissue perfusion
- take prescribed vasodilators and antiplatelets
- skin care, applying lotion to prevent skin breakdown
CONTRAINDICATIONS/AVOID
- elevating legs cus we want blood to come down
- heating pad = they have decreased sensation on the ectremities and can lead to brun
- compression/stocking/ted socks
- tight clothings
venous insuficinecy / peripheral vascular disease
leg veins don’t allow blood to flow back up to your heart = risk of developing pulmonary embolism
- ULCER WOUND USUALLY AT THE ANKLE = PAD is ulcer at the toe
- hyperpigmentation of the legs due to stagnant blood
- warm compresses help reduces edema and are safe with DVT
- early ambulation such as walking
- portruding veins in the legs
- edema in legs = elevate legs
- pedal pulses are present
- focus on wound care
+1 is normal in pregancy
MASSAGING IS CONTRAINDICATED = can cause the clot to become disloged and result in life threatening PE
EPHEDRINE are contraindicated
benzodiazipines
- antianxiety meds considered minor TRANQUILIZERS
- have a “ZEP” in name, ALPRAZOLAM
INDICATIONS
other uses of benzos
- pre op to induce anesthesia
- muscle relaxant
- alcohol withdrawal (delirium tremors)
- seizures ( suctioning ) clients with seizures should always be assessed first due to high risk of injury, aspiration and airway obstruction
-a patient that fights a ventilator (relaxes them)
- they work quickly, but YOU MUST NOT take them longer than 2-4 weeks.
preferred time to take is at night
ANTIDOTE: flumanezil
CONTRAINDICATED
- hepatic encelopathy = MUSCLE RELAXANTS ARE METABOLIZED BY THE LIVER
- COPD patients
drowning patients
MONITOR
- defibrillation = attach on cardiac monitor (PRIORITY)
hypothermia is a medical emergency = 95F (35C)
AVOID
- frequent turning = could lead to v fib
MANAGEMENT = focus on airway
- one of the first goals is to warm the client = warmed fluids, blankets
- sometimes they get so cold pulse cannot be detected this is why they say a client is not dead until warm and dead = they might just require prolonged resuscitation
- hypothermia which may lead to organ failure = prone to dysrhytmias so attach to a cardiac monitor
- most client develop acute respiratory distress syndrome
- blood transfusion is not indicated unless trauma had occured during the near drowning incident
heart failure teachings
WEIGHT MONITORING
- measure and record daily weights in same clothing before breakfast BUT after voiding
DIETS TO AVOID
- cold cuts
- canned foods
- broth and stocks
- LIMIT FLUID INTAKE TO 2L
MEDICATION REGIMEN
- examine OTC drugs such as laxative, antacid and other drugs containing sodium
- take own pulse for 1 minute if taking digoxin or beta blocker
- know symptoms of orthostatic hypotension
ACTIVITY
- increase walking or other activities gradually
- plan for rest periods
- consider cardiac rehab
- avoid extremes of heat and cold
REPORT
- weight gain of 3lb in 2 days or 3-5 lbs in a week
- frequent dry, hacking cough especially when laying down
- swelling of ankles, feet,abdomen or face
preffered drug for a fib and vtach
amiodarone = CAUSES LUNGS LIVER AND THYROID ISSUES
- A FIB HAS IRREGULAR PULSE
gold standard for diagnosing VTE
venous duplex ultrasonography
- noninvasive that assess the flow of blood through veins of the arms and legs
normal cholesterol values
VITAMIN FOR CHOLESTEROL: B3 NIACIN
- HDL (good cholesterol): <50
- LDL: <100
- triglycerides: <150
fish oil is good for triglyceride
total is 200
METABOLIC SYNDROME (WBTHG) = presence of 3 or more of the listed below
- We Better Think High Glucose
- Waist cirumference
- Blood pressure
- Triglyceride, HDL
- Glucose (>100)
D dimer = fibring lingaments
myoglobin is released into the circulation within 2 hours after MI
BMI
18.5 to 25
less is underweight
25-30 is overweight
obesity is from 30
what arrhtymias are cardiversions indicated for
atrial fibrillation or atrial flutter
cardioversion delivers a timed electrical current to reset the heart’s electrical activity
- prior to delivery of electrical shock (cardioversion, defibrillation), OXYGEN SHOULD BE TURNED OFF AND MOVE AWAY oxygen is flammable
hypertension treatments
ABCD
- Ace inhibitors ( has “PRIL” in name) = monitor for angioedema (affects areas of the face,lips, tongue) = mostly occurs in african americans
- Beta-blockers ( lol monitor for hypotension)
- Calcium channel blockers ( -DAPINE, verapimil, diltiazem ) = avoid GRAPEFRUIT = severe hypo
- Dieuretics ( hydrochlorothiazide furosemide )
HYPERTENSION DRUGS SAFE FOR PREGGOS
- Hypertensive Mothers Love Nifideipne
- hydralazine
- methyldopa
- labetalol
- nifedipine
FUROSEMIDE SHOULD BE GIVEN SLOWLY TO PREVENT OTOTOXICITY
WHEN TAKING CLONIDINE = ADVISE CLIENT NOT TO STOP TAKING ABRUPTLY = rebound hypertension
- nitroprusside can also be indicated for hypertensive situations and hypertension in heart failure
CLIENTS WITH HYPERTENSION SHOULD AVOID
- OTC meds including antacid, appetite suppresant, cold and sinus meds = THEY CAN INCREASE BLOOD PRESSURE.
HERBAL
- hawthron
RISK FACTORS OF HYPERTENSION
- diabetes 1&2
- african american
- increasing age
CLONIDINE PATCH
- upper outer arm or chest once every 7 days
- rotate sites
- never stop using patch abruptly = rebound hypertension
how to calculate cardiac output
heart rate multiplied by strove volume
CO = HR x SV
if a client comes in the emergency with chest pain what are some measures to establish
it might be acute myocardial infarction (heart attack, CK-MB) so implement the following
- obtain electrocardiogram (ecg)
- establish IV access
- administer nitroglycerin
holter monitor = used to record ecg for 24-48 hours
- keep a diary of activities and any symptoms
- DO NOT BATHE R SHOWER during test period
- enegage in normal activities
difference between decorticate and decerebrate
deCorticate = damage to the midbrain
- flexing of the arms
- arms shaped like a C moving towards the spinal Cord
decerebrate = damage to deep brain structures (pons)
- extension, example toes pointing straight down, arms and legs straight out, head/neck arched back
- INDICATES WORSE, MORE EXTENSIVE DAMAGE
DECEREBRATE = ICP
Hirschsprung’s disease
condition of the large intestine (colon) that causes difficulty passing stool
MANIFESTATIONS
- constipation (they fail to pass meconium so its normal finding)
- feeding intolererance
- vomiting green bile = indicates bowel obstruction
- poor feeding
- ribbon like stools
- abdominal distention
does not respond to medications
REPORT = enterocolitis
- fever
- lethargy
- explosive, foul smelling diarrhea and rapidly worsening abdominal distension
**COLECTOMY/PULL-THROUGH PROCEDURE where the surgeon get rid of that part of the colon and connect the rest of the colon to the anus
meconium = should be passed within 24 hours of birth
tonsillectomy
TONSILITIS = group A strep
REPORT
- TRISMUS = inability to open mouth due to tonic contraction of the muscles = inidcates serious complication of tonisilitis
- deviated uvula
EXPECTED MANIFESTATIONS FEW DAYS AFTER SURGERY
- severe throat pain
- white scabs will form at surgical site
- a low grade fever
- ear pain is expected after adenotonsillectomy due to iritation of the 9th cranial never
- fluid filled exudates in the throat with halistosis (foul smelling breath)
- ear pain = given acetaminophen
MONITOR AND REPORT
- FREQUENT SWALLOWING INDICATES HEMORRHAGE AND SHOULD BE REPORTED
- hemorrage may occur up to 14 days after surgery so avoid strenous activity or contact sport
- potential for bleeding is even higher 7-10 days after post op while sloughing is occuring
- vomiting bring red blood
AVOID
NO HOT, ACIDIC OR SPICY FOODS
FOODS TO GIVE AFTER
- soft foods!
- ice chips and applesauce are good
- COOL ICE CHIPS CAN HELP EASE THE THROAT PAIN
- AVOID THE USE OF STRAWS and other pointed objects in mouth
- toddlers can be given magic blankets for pain cus they they are mystical thinkers
- suction equipment should be available but only for EMERGENCY airway obstruction
RHEUMATIC FEVER = streptococcal infection
- temperature alone is not sufficient because because fever is a symptoms of many illnesses not just RF
treated with group A streptococcal
steps for adult CPR
family members may be allowed in the to sit or stand in the area but a staff member should be assigned to stay with them and explain whats going on
- first check level of consciousness
- check for pulse for no longer than 10 second at the carotid artery
- begin chest compression (2inc/5cm deep)
- after 30 high quality compressions, open the airway with the head tilt
- delivery 2 rescue breathes followed by activating rhe emergency response and obtaining automated external defibrillator
if no shock is advised, the nurse should resume chest compressions immediately
100-120 per minute
- center breast bone (lower half of the sternum
in babies less than 1, BRACHIAL PULSE is the most accessible pulse not carotid bc it might not be palpable due to fatty issue around infants neck and shorter necks
- NECK SLIGHTLY EXTENDED = SNIFFING POSITION
- ROLL TOWEL OR BLANKET UNDER NEWBORN SHOULDER
- single person performing infant CPR should use 30:2 and 15:2 when two rescuers are involved
- RADIAL PULSE IS USED IN RESPONSIVE CLIENT over 1 year
malignant hyperthermia
severe adverse reaction caused by certain drugs used for surgery = IT IS INHERITED
- triggering agents leads to excessive calcium released into the muscles
TREATMENT: IV dantrolene
EXPECTED FINDINGS RIGHT AFTER GEN ANESTHE SURGERY
- pinpoint
- difficult to arrouse
- hypo and hyperthermia
- muscle rigidity
MANIFESTATIONS
- hypercapnia (earliest sign)
- generalized muscle rigidity (jaw, trunks, extremities)
- hyperthermia (later sign to confirm suspision of malignant hyperthermia)
REPORT muscles stiffness/rigidity with elevated temperature
MED: dantrolene = relaxes muscles
systemic lupus erythematosus
MONITOR
- URINE SPECIMEN FOR PROTEINURIA
- report BUN and creatinine elevation
- KIDNEY FUCNTIONING
LABS
- postive antinuclear antibody (expected)
- low WBC and plateless, and anemia
- anemia and leukopenia, thrombocytopenia (nurse would report these too but not a priority over abnormal kidney values
MANIFESTATIONS
- butterfly rash (2 wings representing kidneys)
- issues with photosensitivity
- joint stiffness
- recurrent oral ulcers
- can lead to end stahe kidney disease
- use the LOWEST POSSIBLE DOSES of antiinflammatory drugs = cus they may cause creatinine elevation
- skin biopsy test may be ordered
INTERVENTION
- avoid stressful physical and emotional stress
- avoid sun exposure and UV light when posible
- notify hcp when you have fever
- hydrochloroquine can be prescribed to reduce SLE exacerbation but can take several months
- monitor for renal and visual disturbances whiles taking chloroquine
ADHD
INTERVENTION
- when they are being disruptive, offer deep breathing exercises to help them slow down and relax = blowing a ballon
- isolating them is punitive and not therapeutic but instead, remove them from source of anger
MANIFESTATIONS
- inattention = easily distracted
- distractibility
- hyperactivity
can lead to impaired social skills and peer rejecetion = LOW SELF ESTEEM
INTERVENTION
- should be weighed regularly at home or school
- blood pressure and cardiac function
- sugars does not reduce childs symptoms
-
MED = METHYLPHENIDATE = CAN CAUSE GROWTH DELAYS
- drug is a stimulant
- take 30-45 minutes before meals
- MONITOR loss of appetite, weigh loss, increased blood pressure, tachycardia = upper symptoms cus drug is a stimulant
- take med before meals
- drug is a stimulant and can interfere with sleep so dont take it after 6pm to prevent sleep disruption
GROWTH HORMONE
- daily injection under the childs skin
- not lifetime = therapy is stopped when bone growth begins to cease or when the child, parents and provider make the decision
THEY CAN DEVELOP PARANOIA IF THEY TAKE HIGH DOSES OF MED OR MEDICATION MISUSE
how do hypersensitivity (anaphylactic) reactions occur/ EPINEPHRINE EDUCATION
when antibodies are formed through previous exposure to an allergen. (elevated eosinophils are seen in allergy
- wear a medical alert bracelet
- anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces
- **RISK OF HYPOTENTION = GIVE ISOTONIC FLUID (0.9 SODIUM)
fever is not an expected symptom of anaphylactic reaction
MANAGEMENT OF ANAPHYLACTIC SHOCK WHILES ON IV MEDICATION
1. stop the infusion and call for healp
2. ensure patent airway and administer oxygen
3. given epinephrine intramuscular
4. administer adjunctive therapies (bronchidilators, corticosteroids, antihistamines)
FIRST LINE DRUG: parenteral epinephrine
EPIPINE
- always be available and DO NOT DELAY
- can be given through clothes
- GIVE AT MID OUTER THIGH and hold position for 10 seconds to allow the entire contents to be injected
- still go to the emergency after you give epi to monitor for further complications
- REPEAT DOSES WITH 5-15 MINS ALLOWED IF THERE IS NO IMPROVEMENT FROM THE INTIAL DOSE
hip dysplasia peds
FINDINDS
- the presence of extra inguinal or thigh folds
- laxity of the hip joint on the affected side (barlow and ortolani maneuvers)
- affected leg may be shorter than the opposite leg but this is also apparent after age 3 months
Barlow maneuver
- ADDuction with posterior pressure on the hip
ortolani maneuver
- ABDuction with anterior lifting of the hip
TREATMENT: pavlik harness (prevents them from extending legs, kinda put them in a frog position) , proper swaddling
PAVLIK HARNESS INSTRUCTIONS
- should be left on during care activites including diaper change = could be removed for a short bath once a day
- dress child in a shirt and knee socks under the straps to protect the skin = same for boston brace for scoliosis
- lightly massage the skin under the straps daily = promotes circulation
- place diaper under the straps
- regulary assess skin for redness and breakdown but avoid lotion and powders to prevent irritation and excess mositure
goal is to keep hips flexed/bent up abducted and opened as possible and to promot immobilization of the hip = like a frog legs
CONTRAINDICATIONS
- ROM contraindicated
- DONT SWADDLE THEM WITH HIPS EXTENDED AND ADDUCTED
avoid any positioning device, seat or carrier that causes hip extension and knees straight togehter
parkinson disease
- degeneration of dopamine-producing neurons
- damage to dopamin neurons makes it difficult to control muscles
INTERVENTION
- identify times where clients has more energy to provide teachings
- dont exclude ppl with cognitive impairement from plan of care
MANIFESTATIONS
- mask like facial expression
- bradykinesia (delay in initation of movement)
- increased muscle tone (RIGIDITY
- typical parksinson tremors occurs at resting
- shuffling gait
MEDICATION: carbidopa-levodopa = orthostatic hypotension is an adverse effect = tell them to rise slowly
CARBIDOPA-LEVODOPA TEACHINGS
- intedneded effect = imporovement in spontaneous activity
- it decreses tremors but does not elimintae them
- red, brown, black secretions and discolorations are normal
- fall precautions = change positions slowly
- takes several weeks to reach maximum benefit
- dyskinesia (facial/eye lid twitching, tongue protrusion, facial grimacing) may indicate overdose or toxicity
ORTHOSTATIC HYPOTENSION
- whiles measuring, if any position produces decreases systolic by >/20 , decrease diastolic >/10 or more, disconitnue assessment, place client in recumbent postion and noticy HCP
- aslo discontinue further position change if pulse increases by 20 in any new position
hepatitis A vrs Hepatitis B
HEPATITIS A = fecal oral route
- undercooked food
- FECAL ORAL ROUTE (rotavirus)
- contaminated water
sign and symptoms
- pruritus
- abdominal pain
- scleral icterus
HEPATITIS B = body fluids
- blood
- semen
- vaginal secretions
- can still breastfeed newborn as long as nipple is intact
HEPATITIS RISK FACTORS
- alcohol
- OTC meds
- herbal and dietary
HEPATITIS C
- may be asymptomatic
- drug abuse especially IV
- anything needle associated tattos etc
- sexual transmission is RELATIVELY LOW
TREATMENT: no vaccine, antirivals (ribavirin)
OTHER CAUSES
Sexual behavior—high risk sexual behavior
* Drug abuse, especially IV
* Occupation exposure
* Dialysis
* Peritoneal exposure—dialysis
* One peritoneal (peritoneum) and one via blood (hemodialysis)—dialysis
* Blood transfusions before 1992
reduction of IV drug use decreases risk of HEPATITIS C
tuberculosis
HOW TO CONFIRM DIAGNOSIS
- collect early morning sputum sterile specime on 3 consecutive days for an acid-fast bacili (AFB)
- RINSE MOUTH WITH WATER BEFORE OBTAINING SPUTUM SAMPLE = reduce bacteria in the mouth and prevent specimen contamination by oral flora
report if client is taking prednisone = it converts latent TB to active disease
MANIFESTATIONS
- chest pain
- hemoptysis
- low grade fever
- NIGHT SWEATS
- fatigue
TREATMENT (4 drug regimen) = RIPE
RIFAPENTINE = REDUCES EFFICIACY OF ORAL CONTRACEPTIVES = Red secretions
- pyrazinamide
ISONAZID = interferes with the action of vitamin B6 resulting in peripheral neuropathy
- ethambutol = have eyes checked
- RIFAMPIN
- wear eye glasses instead of contact
- red discolration such as urine is expected
ISONAZID = monitor liver = TAKE PYRIODOXINE(VIT B6)
- only antitubercular drug that does not cause red-orange discoloration of bodily fluids
- take pyriodoxine(vitamin b6) to prevent neuropathy
- avoid alumninium contaning antacids within 1 hour of taking isoniazid
EXPECTED SIDE EFFECTS FROM MEDS
- yellow skin = hepatotoxicity
- dark colored urine
- hepatotoxicty is not common with ethambutol but clients taking ethambutol must have baseline and periodic eye exam
- amniglycoside antibitoic may be used for drug resistant TB
- hepatoxicity may occur from treatments (jaundice,fatigue,weakness, nasuea and anorexia)
client taking oral contraceptive will need a non hormonal birth control like iud to prevent pregancy during treatment
STATIN MEDICATIONS
- drugs ends with STATIN TAKE AT NIGHT OR DURING FASTING STATE
EXPECTED SIDE EFFECTS
- insomnia
- abdominal discomfort
- morning headache
REPORT TO HCP
- muscle aches or weaknesses = could be an early sign of rhabdomyolysis
- cause hepatotoxicity
monitor liver function tests prior to the start of therapy
CONTRAINDICATIONS
AVOID GRAPEFRUIT WHILES TAKING THIS DRUG = MYOPATHY
rhabdomyolysis = breakdown of muscle tissue that leads to the release of muscle fiber contents into the blood
HIV
- goal is to increase clients CD4&8 cells and to DECREASE VIRAL LOAD
CANNOT BE TRANSMITTED THROUGH
- sweat
- urine
- saliva
PREGNANCY
- it reduces the risk of transmitting the disease to the fetus
- breastfeeding is contraindicated
-infants born to HIV positive parents should receive antiretroviral therapy for atleast 4-6 weeks after birth
HIV = multiple drug regimen
OPPORTUNISTIC INFECTIONS
- kaposis sarcoma
- tuberculosis
- toxoplasmosis
they take hold once the host immunity declines significantly (immunocompromised)
THESE SYMOTOMS ARE ASSOCIATED WITH HIV!!!
what infectious diseases should be reported to the health department
- HIV
- Hepatitis A
- Syphylis = treated with IM penicillin for primary, secondary etc
- chlaymydia
- gonorreha
- ifluenza
- rabies
- pulm tuberculosis
- chicken pox
Aspirin indications
TIA
- Transient Ischemic Attack
- Ischemic stroke
- Acute coronary syndrome
elevated BP in the presence of acute ischemic stroke is an expected findings and may be a protective measure to maintain tissue perfusion
TIA MANIFESTATIONS
- expressive aphasia = inability to express spoken words
occurs in the frontal and temporal lobe
emergency bites of venomous animals
- DO NOT APPLY TOURNIQUETS why = impedes arterial blood flow and we don’t want want the poison being concentrated at one spot = it will rapidly destroy cells in that area so allow it to spread to be diluted
- DO NOT APPLY ICE PACK
- immobilize the affected extremities to decrease absorption of the venom
- estbalish IV access
- collect lab values such as ptt, pt/inr, platelets and CPK
lyme disease
MONITOR
- neurological and cardiac = HALLMARKS
- artrioventricular heart block
MANIFESTATIONS
- neuropathy
- red rash
- fatigue
- bulls eyes
- lymphadenopathy
- bulls eye rash
- flu like symptoms (headache, malaise, sore throat) = REPORT
- arthritis
- myalgias and joint issues
MEDICATION: doxycycline
INTERVENTION
- tick should be removed carefully with a tweeezer
- dont cover ticks on the skin with a petroleum jell or nail polish
anthrax
- breathing in bacterial spores
- ingestion of RAW/CONTAMINATED ANIMAL PRODUCTS
- through open wound or scratch on the skin
ANTIDOTE OF ANTHRAX: Ciprofloxacin
IT IS NOT SPREAD PERSON TO PERSON
RADIATION CONTAMINATION (CHEMO)
- oral mucusa ulcerations
- gastro (vomiting/nausea)
- bone marrow (RBC WBC ETC)
-
herpes simplex virus type 2
- also known as genital herpes
- lesions are vesicular and painful
MED: acyclovir = shorten duration and severity of active lesions
MANAGEMENT
- warm water with mild soap
- when applying topical medications to herpes lesions = use gloves to prevent spreadin
- keep the lesions clean and dry = hair dryer on a cool setting
- sitz bath and oatmeal baths to provide comfort and relief of itching and burning
- avoid sexual activity when lesions are present. barrier contraception like condoms are not sufficient during an outbreak
- continue to use condom in the absence of active lesions = transmission is still possible in future sexual encounters
EPISTAXIS intervention
- epistaxis is nose bleed
- sit them upright whiles leaning forward and pinching the nose togehter
- humidifier or nasal spray to keep the nose moist redcues risk of nosebleeds
- client should also be asked about aspirin, bleeding disorders, nasal surgeries/injuries an anticoagu use
in peds, PRIORITY is to keep them calm and quiet = crying can exacerbate the bleed
risk factors of breast cancer
- nulliparity (never being preggo)
- early menarche
- late menopause
- family history
- overweight or obesity
- white women are more likely to develop breast cancer but BLACK PEOPLE ARE MORE LIKELY TO DIE
BRCA 1&2
POST MENOPAUSE
- consider dietician
- spotting or bleeding after menopause is most common symptoms of endometrial cancer
- cholesterol monitoring
- weight bearing exercise regimen
- green, leafy veggies and dairy products
- support group to cope with any emotional symptoms
iron tends to increase with agin so avoid iron pills in old age
chemotherapy
WAYS TO PREVENT NAUSEA
- serve small meals
- provide meals best eaten at room temperature
- BRUSH TEETH IN AFTERNOON rather than in the morning
- when they begin experiencing nausea and vomiting, MOST IMPORTANT THING TO DO = evaluate the onset, frequency and severity of the nauseas and vomiting
REPORT
- low grade fevers in these patients
risk for developing testicular cancer
- HIV
- family history
- cryptorchidism (undescended testicles) = normal in newborns
TESTTICULAR TORSION = priority and can result in testicular ischemia from inadequate blood supply
septic care
- packed rbc when needed
- offering stool softners to avoid constipation
- preventing the use of harb objects and basiclly anything that can cause bleeding
- mouth sponge is preferred over toothbrush
ALL OF THESE ARE MEASURES TO BE TAKEN FOR PATIENTS WITH CLOTTING DISORDERS
if injected, apply pressure on the site for like 30 mins to prevent further bleeding cus these ppl have clotting disorders
spinal cord compressions
- lower back pain
- decreased ROM
- reduced tendon reflexes
- URINARY RETENTION due to inability to contract the bladder
NORMAL RESIDUAL VOLUME: 50-100
residual urine volume of 100 mL or more on a bladder scan may indicate urinary retention
superior vena cava syndrome
invasion by a tumor
OBSTRUCTS VENOUS CIRCULATION or DRAINAGE OF HEAD,NECK,ARMS AND THORAX
- trouble breathing
- puffy neck/face
- nasal congestion
- raspy voice
SUPINE HYPOTENSION IN PREGNACY/ AORTOCAVAL COMPRESION
- when mom is laying supine, it causes the uterine to fall on the aorta and vena cava
- treatment is elevation/tilit and support = moves the uterus to the side
tumor lysis syndrome
both calcium phosphate and uric acid are deposited into the kidneys causing renal injury
LABS
- HYPERkalemia
- HYPERphosphatemia binds to calcium leading to HYPOcalcemia
- HYPERuricemia
- HYDRATE!!!! hydration prevents TLS
MEDICATION = allopurinol
- used to decrease hyperurecemia caused by TLS
albumin indication
3.5-5.5
- depleted plasma protein
- blood volume expansion
indicated
- thermal burns ( greater than 10% = priority is assessing for respiratory status
- third spacing
fresh frozen plasma
THEY CONTAIN ABUNDANCE OF CLOTTING FACTORS
coagulopathy (clotting deficiency)
- deficiency of certain clotting factors
- TO BE INFUSED OVER 15-30 mins
packed red blood cells TO BE INFUSEd over 2-4 hours
may be used for warfarin toxicity along with vitamin K
primary preventions
PRIMARY
PREVENT THE ONSET OF THE DISEASE
EDUCATION AND IMMUNIZATIONS
- seatbelts
- eliminating alcohol
- surveying a home to identify fall risk
SECONDARY
- screening
- HEALTH FAIRS
- early identification of the disease
- makes it possible to treat the disease early and increases chances it will be cured
- colonoscopy
- pap smears = early detection of cervical cancer
PAP SMEARS
- 21 years and up only. no adolescent
- 21-29 years should be screened every 3 years
- no testing after 65 years
TERTIARY PREVENTION
- already developed the disease
- participating in recovery programs
- PREVENTION IS NO LONGER AN OPTION
- rehab to prevent disease progression
- treats the disease and prevent further complications
nutritional education for someone with CHF
obstructive sleep apnea (OSA)
- repeated episodes of partial or complete airway obstruction during sleep = CONITINUOS AIRWAY PRESSURE (CPAP)
MANIFESTATIONS
- excessive daytime sleepiness
- morning headachques
- snoring
- witnessed episodes of apnea
AVOID
- sedative medications
- eating at bed time
- stimulants
- alcohol
INTERVENTION = CPAPA
- continuos positive airway pressure
- increasing exercise and weight loss
- KEEPS THE PHARYNX AND TONGUE FROM COLLAPSING BACKWARDS AND OBSTRUCTING THE AIRWAY
- check to see the tightness of the straps and mask BECAUSE ITS the main cause of sudden drop in O2 levels whiles sleeping
direct coombs test
- measures maternal antibodies present on the infant RBC
those antibodies puts the infant at risk for erythroblastosis fetalis
indirect coombs test = test to see of the mother is at risk for Rh immunization
For a client to be discharged following a surgery, the following criteria must be met:
client that underwent surgery with general anesthesia with low O2 levels should do head tilt to open airways FIRST = this opens up airway
➢ Return to baseline neurological status
➢ Adequate urinary output (30 mL/hr)
➢ Return of reflexes (cough, gag, swallow)
➢ Bowel sounds present in all four quadrants
➢ Ability to ambulate
➢ Vital signs within normal limits
➢ Ability to tolerate oral fluids
➢ Minimal nausea and vomiting = PRIORITY DUE TO ANESTHETIC SIDE EFFECT OF DECREASED GASTROINTESTINAL MOTILITY = HIGH RISK OF ASPIRATION DUE TO THEIR ALTERED LOC
➢ Adequate pain control
catheters
urine flow is deoendent on gravity so the draining bag should hung below the level of the bladder to maintain gravity flow
INDWELLING CATHETER = STERILE
- insert int point of bifurcation (two branch on the catheter)
- drops of urine may just mean theres urine in the urethra so further put in until theres full urine. after that is when you inflate the ballon
lower abdomen or upper thigh to prevent urethral injury
- they should be minimized during hospitilization = SHOULD BE REMOVED POST OP AS SOON AS CLIENT IS AWAKE AND ALERT
APPROPRIATE USE OF INDWELLING CATHETER
- urinary obstruction or retention
- perioperative use
- prolonged immobilization
- to impove end of life comoft
- facilitate healing
INAPPROPRIATE USE OF INDWELLING CATHETER
- convenience or replacment for nursing care (urinary incontinence)
- for obtaining urine culture
- post op for prolonged periods
- should be secured with an adhesive device
- the device should be removed gently with an alcohol swab to avoid shearing injury to the skin
CONDOM CATHETER
- if uncircumscined, DO NOT RETRACT FOREKSIN BEFORE APPLYING CONDOM CATHETER=. can lead to paraphimosis (when foreksin cannot be returned to its orignal postion after being pulled back. can lead to permanent damage)
- drainage tube is attached to leg collection bag in a mobile client to enable ambulation, prevent tube kinking and facilitate gravity drainage
**leave 1-2 inch(2.5-5cm) space between the tip and end of the condom to prevent irritation and pooling of urine in the condom
- if not adhessive, elastic adhessive is used in spiral fashion to secure the device to the penis. adhessive tape may cause irritation/injury and should not be used
eye surgery post op care
- approach client from the good eye
- avoid bending down
- avoid coughing and deep breathing that can lead to increased ICP
- orient cilent to environemnt
- obtain prescription for stool softener
smoking cessation drugs
- varenicline
- buspirone = smoking cessation properties
NICOTINE WITHDRAWAL
headache
nervousness
poor concentration
anger
hunter and restless
BURPOPION is used in treatment of depressive disorders but MAY BE USED IN MANAGEMENT OF NICOTINE ADDICTION
endotracheal suctioning
- immediate post op priority goal for a client with new tracheostomy is to prevent dislogment. = check the tightness of ties and allowing 1 finger to fit under these ties
disloged tracheostomy = open the airways with a curved hemostat and insert a new tracheotomy with an OBTURATOR
- should be performed only when clinically indicated
DON’T SUCTION IF ARTERIAL BLOOD GAS IS ORDERED BECAUSE SUCTIONING DEPLETES OXYGEN LEVELS AND WILL GIVE INACCURATE TEST RESULTS
- USE STERILE technique
- administer 100% oxygen prior to suctioning
- apply suctioning WHILE WITHDRAWING catheter from airway not when inserting
- LIMIT SUCTION TO LESS THAN 10 seconds each suctioning
- SUCTION PRESSURE SHOULD BE SET TO 100-120 for adults and 50-75 for children
AVOID
- frequent endotracheal suctioning but provide oral care and ORAL SUCTIONING every 2 hours`
- HUMIDIFICATION IS CRUCIAL = it keeps the secretions thin and reduces formation of mucus plugs so do not remove it if theres too much secretions because that is the intended effect
fenestrated tracheostomy: person can still speak
cleints with tracheostomy should always carry two spare tubes (ONE SAME SIZE, ONE SIZE SMALLER) = to ensure tube can be replaced quickley and effectively
- if tube is meeting resistance = small tube should be used
TRACHEOSTOMY AND FEEDING
- cuff is inflated in clients who are at risk for aspiration
- deflate cuff if patient can eat
retina detachment
sudden and painless = bright flashes of light, hairnet, cobweb, gnats floating dark spots, curtain drawing over eyes
CAUSE
- aging, ocular injury
- restrict activity
- apply eye patch on the affected eyes
NEEDS SURGERY
MACULAR DEGENERATION
- CENTRAL BECOMES DARK but peripheral(sides) vision remains intact
TUNNEL VISION = GLAUCOMA
- opposite of macular degeneration
- glaucoma
CATARACT = blury vision/ cloudy appearance
if patient calls reporting constipation = PRIROTY cus its gonna lead to increased ICP
INTERVENTION AFTER CATARCT SURGERY
- sleep on opposite side
- sleeping on the affected side increases IOP, swelling and bleeding
- increase fluid and high fiber diets to prevent constipation
- may take 1-2 weeks before visual acuity is improved
THERE SHOULD NOT BE REDUCTION IN VISION AFTER EYE SURGERY. if they experience this after surgery?? = EMERGENCY REPORT TO SURGEON
SNELLEN TEST
used to test for visual acuity
IN PEDS = position child 10 ft instead of 20 as in adults
myopia = near sight, squinting
hyperopia = far sight
blind patients
FIRST: Orient the patient to their room
- when ambulating a blind client, the nurse uses sighted-guide technique by walking SLIGHLY AHEAD (half step ahead) with the cleint holding the nurses elbow
- elbow for guidance
- clock face orientation to decribe the location of items
eye drop administration
- tilt head back
- pull down lower eye lid
- administer med in center of lower eyelid
- ask patient to close eyes
oral contraceptive
contains combined doses of estrogen and progesterone that stops ovulation
- 99% effective when taken consistently
- increase risk of hypertension and thrombophlebitis
- estrogen:- creates thick endometrium wall to protect implanted fertilized egg
- legitimizing hormone(LH): releases of an ovum from the ovary
CONTRAINDI
- history DVT
- family history of cerebrovascular accidents
- smoking
if a woman misses there or more oral contraceptives in a row, they should throw out the rest of the pack and start a new pack the following sunday. USE A NEW FORM OF CONTRA FOR THE NEXT 7 days with the new pack
PROGESTIN ONLY PILLS
- oral contraception that works by thickening cervical mucus and thining endometrium to hinder implantation
-if pill is takenafter 3 hours, a second barrier method is needed until pill is taken correctly for 2 days
- contact HCP if you experience leg pain or swelling
- irregular bleeding and spotting between menses are common side effects of combined OCPS
- breast tenderness is a common side effect too
- do not smoke while taking combined contraceptives
- seek immediate medical treatment if you experience vision loss
preeclampsia
PRE
- Proteinuria
- Rising BP (140/90)
- Edema
MED: magnesium sulfate to prevent seizure
MANIFESTATIONS
- blurred vision
- hypertension
- generalized edema
- proteinuria
CAN LEAD TO PLACENTAL ABRUPTION
AVOID IN PREECLAMPSIA
- bright lights = lights should be minimized to decrease risk for seizures
- overstimulations
-
HYPERTENSIVE DISORDERS
- HEADACHE AND FACIAL EDEMA
HELLP
form of preeclampsia
- Hemolysis
- Elevated Liver enzymes
- Low Plateless
MANIFESTATIONS
- hypertension
- RUQ pain
- nausea/vomiting
- possible headache and vision loss
vasectomy
- no protection against STIs
- if recently gotten, another type of birth control should be used until sperm count is 0
- outpatient surgery with low risk
- although reversible, it is often difficult
- ONCE SPERM COUNT IS 0, no need for follow up exams
colposcopy
basically like colonoscopy but for the vagina
- semi-lithotomy
- dyspareunia = painful intercourse = occurs after a colposcopy
- used to detect an array of gynecological conditions
- does not require NPO or due
- VAGINAL INTERCOURSE IS NOT ADVISED 48 hours after colposcopy = SEX MAY BE PAINFUL AND LEAD TO POST PROCEDURE BLEEDING
halo vest
- clean pin sites using sterile water
- don’t adjust pins ONLY DOCTROS CAN DO THIS
- neck exercises such flexion and extension is contraindicated. USE STRAWS
- place small pillow under the client head when supine to reduce pressure on the device
- pin care should be implemented (NO LOSE PINS)
- WRENCH taped to the front of the vest incase it needs to be taken off DURING EMERGENCY like CPR
- avoid driving/bicycle
- when getting out of bed, roll to the side and push on the mattress
- AVOID GRABBING THE DEVICE FRAME WHEN MOVING OR POSITIONING THE CLIENTAS THIS MAY CAUSE SCREWS TO LOOSEN OR ALTER DEVICE ALIGNMENT
- wear cotton t shirt under to absorb any mositure
- use blow dryer on cool setting to dry the vest when wet
non-pharmological pain-management for newborns and infants
- administer oral sucrose solution. to newborn during circumcision
- during painful procedures like the heel stick, apply WARM (not cold) on the heel to facilitate blood flow
- offering nonnutritive sucking (pacifiers) which can help calm and distract them
- swaddling
types of pain
preferred way to administer analgesic = oral route
- somatic: noncicpetive = BONE SKIN MUSCLES
NEUROPATHIC PAIN - phantom pain
shoulder pain radiating down the arm after an amputation may indicate MYOCARDIAL ISCHEMIA
NEUROPATHIC PAIN MEDS
- pregabalin
- amitriptyline
- duloxetine
rheumatoid arthritis.
- pain is a priority
- systematic and BILATERAL
- low grade fever
- SLEEP AND REST IN FLAT NEUTRAL POSITION = elevating legs leads to development of contractures
- serum rheumatoid factor (not for osteoarthrtis)
- low grade factor (not for osteoarthritis)
TREATMENT: prednisone, METHOTREXATE (bone marrow suppression, hepatoxicty, gasto irritation)
- take med even if joint not hurting
- prednisone should not be taken with nsaid = GI
NON PHARMALOGICAL INTERVENTIONS
- taking a warm shower/bath or applying heat first thing in morning helps with stiffness and increases flexibility
- ROM exercises are more effective after warm shower
- ROM is encourgaed to prevent loss of function
OSTEOARTHRITIS = TOPICAL CAPSAICIN =apply to hands and wait atleast 30 minutes before washing them
- unilateral (herbeden nodels
- noninflammatory
- nonsystemic disorder
- occasional OA inflammation is limited to affected joints
DMARDS - methotrexate, hydrochloriquine, leflunomide, sulfasalazine (dehydration, elevated urine gravity due to cystal formation in the kidney)
- methotrexate is also used for psoriasis
- can cause oral candidiasis which is expected
- TERATOGENIC = folate antimetabolite
- hepatotoxic so avoid alcohol
- suppresses the immune system so avoid anything that can lead to infection
total hip replacement/ athroplasty
an hour after post op, check for drainage in suction drainage device = blood loss/hemorrhage
PERFORM RANGE OF MOTION!!
DISCHARGE TEACHING
- elevated toilet seats
- head of bed greater than or equal to 60 degrees. 90 degrees promotes excessive hip flexion
- DONT PUT PILLOW BEHIND THE KNEE CUS IT CAUSES JOINT FLEXION WHICH INCREASES THE RISK OF CONTRACTURE
- cold packs may be applied to reduce post op swelling and pain
- use continual passive motion deice if prescribed
- perform leg exercises to strenthen muscles around the hip and avoid excessive hip flexion when sitting, dressing and toileting
- perfrom isometric quads, gluteal setting, leg raises and ABDUCTION EXERCISES from supine and standing positions
- client should use a toilet riser or bedside commode chair with arms to prevent excessive hip flexion when getting on and off the toilet seat
SLEEP ON BACK WITH PILLOW/ wedge BETWEEN LEGS
- no internal or external rotation of hip
USE TROCHANTER ROLL, AVOID CROSS OF LEG - NO ADDUTION OF HIP (abduction pillow might be used to prevent dislocation of the joint)
TOTAL KNEE ARTHROPLASTY
- place on continuos passive ROM exerciser for 6-8 hours a day
- ROM HELP WITH CONTRACTURES AS WELL
- may increase risk of VTE = TAKE ANTICOAG
- Maintaining joint flexion is high priority
- DO NOT DANGLE FEET = can cause dislocation
osteoporosis
- if they fall, assess for capillary refill and sensation first
- weight bearing exercises
- increase calcium and vitamin d (sun)
- take calcium supplement with food
calcium absorption is impaired if taken in excess of 500 mg or more per dose
MED:
alendronate = take early morning and before food. DO NOT LAY FOR 30 MINS AFTER TAKING IT
- irritate esophagus
AVOID
- PPI (prazole) = decrease absorption of calcium
colles fracture = dinner fork characterisic of the wrist
rotator cuff injury = shoulder pain with arm abduction
contractures
- ROM exercises of the extremities help prevent contractures
- too many pillows under head can cause neck flexion contracture
- flexion contrations more common
- SPLINTING MIGHT HELP
Recognize those who are at risk. These would be individuals recovering from a burn, stroke, or any neurological impairment inhibiting range of motion.
Collaborate with other disciplines such as physical and occupational therapy.
Apply splints to the hands and feet.
Reposition the client frequently
Avoid positioning the client that has extremities in extreme flexion.
Perform range of motion exercises of all extremities
GOUT
- buildup of uric acid deposited in the joints that causes pain and inflammation
- abnormal metabolisms of purines(proteins)
FOODS TO AVOID
- adhere to low purine diets but does not need to avoid protein foods
- red meat (liver, kidney, brain , seafood, sardine, shellfish)
- beans
MEDICATION
- allopurinol is used to prevent gout by preventing uric acid depositis in joints
ALLOPURINOL INSTRUCTIONS
- can take several months to become effective (colchicine is used in gout attacks)
- can be taken with or after food to prevent gastric upset
- take with glass of water and increase fluid intake to prevent kidney stones = MOST IMPORTANT TEACHING
- REPORT any form of rash = stop taking med and CALL HCP
- nausea can be prevented by taking medication with food
CONTRAINDICATIONS
- ROM can aggravate the pain in gout
- partial weight bearing on the affected extremities not FULL
- sunlight photosensitivity
suspicison of spinal injury
- ensure patent airway
- STABILIZE THE CERVICAL SPINE to prevent further damage including applying HARD COLLAR
- place on firm and rigid surface
- use log rolling technique as a unit (requires precense of a nurse)
upper back injuries should be treated like spinal injury which means you should stabilize the back on a backboard util the spine is appropriately assessed
best away to visualize and open airway = jaw-thrust maneuver IN SUPINE POSITION ON A BACKBOARD
ASSESS FOR
- abdominal breathing
- increased work of breathing may indicate impending loss of airway and require rapid sequence intubation
movement of the neck/upper extremities should be avoided until cervical injury is ruled out with imaging
JAW THRUST VS HEAD TILT
- jaw thrust = when spinal injury is suspected
- head tilt chin lift = open airways of unconscious patient
pagets disease
- disrupts the replacement of old bone tissue with new one
- accelerated bone remodeling
BURNS
burns over 10% = hyperkalemia
- vascular dehydration
- HEMATOCRIT and BUN goes up
- hyperglycemia due to the stress
- metabolic acidosis
- hemoconcentration
FLUID CHOICE FOR BURNED CLIENT = LACTATED RINGERS because it remains in the intravascular space longer than other solutions
- stabilizes blood pressure and avert shock
LABS OF A BURN PATIENT
- epinephrine
- aldosterone
- anti diuretic
LAB VALUES OF BURN INJURIES
MONITOR FOR HYPERKALEMIA
- hemoglobin and hematorcit levels go up
- hyponatremia and hypovolemia
FLUID CHOICE FOR BURNED CLIENT = LACTATED RINGERS because it remains in the intravascular space longer than other solutions
- stabilizes blood pressure and avert shock
TYPES OF BURNS
daily application of water based lotion is necessary to minimize scar formation and alleviate itching
- Superficial-partial - partial burns: blister formation, exudation
- superficial - redness of the skin, only epidermal
- deep-partial - wound appear moist and pale white, sluggish cap refill
- full thickness - deep to muscle, bone
unstageable
- slough or eschar (yellow and black)
- slough appears yellow or tan
- returned pulses distal to the site.
deep tissue injury = intact skin
- area of dark purple or maroon discolaration
- clean with sterile, gentle solution like normal saline and pat dry with gauze
- clean wound with hydrophilic(water loving) dressing that absorbs moisture
electrical burns = place on electrocardigram
STAGE 1: nothing is lost, just reddened
hydrocolloid = protect shallow ulcers
PHOTOTHERAPY(sunlight) helps with psoriasis
BURNS CALCULATIONS
PARKLAND FORMULA
- 4mL x body weight(kg) x total body surface area burned ( % TBSA)
- first 8-hr fluid administration = 50% total fluid requirement
- remaining 16- hr fluid administration = 50% total fluid requirement
MONITOR FOR HYPERKALEMIA
RULE OF NINES (just anterior)
- head: 4.5% x2
- torso: 18% x2
- left arm: 4.5% x2
- right arm: 4.5% x2
- perineal = 1%
- left leg = 9% x2
- right leg = 9% x2
should add up to 100
don’t priortize clients with burns 60 or up = expected to die
THERMAL BURN
Assess airway patency
Administer supplemental oxygen, as indicated
Keep the client NPO
Initiate IV line and telemetry monitoring
Provide prescribed fluid resuscitation
Keep the burns covered with sterile dressings
age-related skin changes include
Decreased epidermal thickness
Increased epidermal permeability
Decreased dermal blood flow
Thinning subcutaneous layer
Degeneration of elastic fibers
- increased growth of facial hair
PHOTOTHERAPY(sunlight) helps with psoriasis
types of wound drainage
- serous = clear watery
- sanguineous = BRIGHT RED
- seroanguineous = pink mixture of red and clear
- purulent = thick yellow, FOUL ODOR
serosanguineous is expected 2 hours after surgery but sanguineous (bright red) indicates excess blood loss = hemorrhage
DURING WOUND CHANGE
- contaminated dressing should be placed in impervious plastic/glove or paper bag before disposable into household trash = paper towels are not effective as the dressing content can seep through into other items
- unused sterile supplies should be throwed out
ovarian cancer
symptoms are often subtle and condition is often not discovered until advanced stage
MANIFESTATIONS
- bloating and pelvic pressure
sentinel event
event that has reached the patient and caused harm like death or serious physical or psychological injury
adverse event:
- injury to a client caused by medical management rather than clients underlying condition
- no harm event: reaches the patient but no harm is caused
- close call/near miss/ good catch: patient safety event that did not reach the patient
pressure ulcer
- moisturize skin using zinc oxide, good
- use emollient and barrier creams on dry surfaces
- avoid bed at 90 degrees. 30 degrees or less is fine
- avoid donut pillows
- do not use hydrogen peroxide and iodine agents
- EAT PROTEIN enriched foods
- repositions every 2 hours
- don’t massage bony prominence
cerebral palsy
MANIFESTATIONS
- head lag after 6 months is associated with cerebral palsy
- abdnormal brain development often before birth
- spasticity/clonus is an expected finding
- congenital disorder of movement, muscle tone and posture = head lag after 6 months
- ELEVATE HEAD OF BED AT 60-90 when feeding to prevent aspiration
- ROM is good to prevent contractures
- lowering bed to lowest position is good to decrease risk of injury incase of a fall
glasgow coma scale
EYE OPENING (1-4)
- 4 eyes
VERBAL RESPONSE (1-5)
- jackson 5
MOTOR RESPONSE (1-6)
- V6 engine
8 or less = INTUBATE THEM cus its considered a coma
INTUBATION
- drop in oxygen saturation = confirm tube placement by AUSCULTATE LUNG SOUNGDS BILATERALLY
- ausculating lung sounds is necessary to confirm tube placement before suctioning
- maintain endotracheal cuff pressure
CAMATOSE CARDIAC ARREST PATIENTS
- perform an induction of therapeutic hypothermia
- induction of hypothermia is indicated for camatose patients or clients who do not follow commands after resuscitation
- after 24 hours, the client is slowly rewarmed
- improves neurologic outcomes
hydrocephalus
- macewen sign = (percuss temporal side. crack pot or hyperresonant sound means hydrocep is present)
MANIFESTATIONS OF ICP IN CHILDREN
- increased head circum
- setting sun eyes (sundowning eyes) = sclera visible above the iros
- bulging fontanels
- irritable
- high pitched cry
TREATMENT = ventriculoperitoneal shunt
COMPLICATIONS OF VP SHUNT
- high risk of seizure
- stopping seizure activity is first priority during status epilepticus
- blockage and infection leading to ICP and cushing triad
MALFUNCTION OCCUR WITH INCREASED ICP
- vomiting
- headache
- vision changes
- chnages in mental status
- early intervention decrease risk to the brain tissue
SHAKEN BABY SYNDROME
- type of abusive head injury from violent shaking of an infant by the arms, legs or shoulders
- external signs are usually absent on physical examination with SBS
- causes bleeding with the brain or the eyes
S/S OF SHAKEN BABY SYNDROME
- vomiting
- lethargy
- irritability
- inability to suck or eat
- seizures
- inconsolable crying
myelomeningocele
most serious type of spina bifida. BUMP AT THE BACK FILLED WITH FLUID.
MANIFESTATIONS OF SPINA BIFIDA
- small tuft of hair at the base of the spine
- hemangioma = bright red birthmark
- nevus = mole
- dimple along the base of the spine
- cover the sac with sterile, moist, non adherent dressing to the sac
- can cause constipation
phenylketonuria
impaired metabolism of an essential amino acid phenylalanine found in PROTEINS
- hypopigmentation of hair, skin, irises
COMPLICATIONS
- intellectual disability by intefering with brain growth and development
INTERVENTION
- low-pheylanine diet is required before and during pregancy
- elimination of diary, meat, eggs and any food with protein
- protein substitutes should replace meat eggs etc
- AVOID HIGH PROTEIN foods**
- eat mostly fruits and veggies
-adequate milk intake after birth is important to ensure the screening test for PKU is accurate
- avoid aspartame
- restriction of tyrosine might not be necessary
- lifetime dietary restrictions are recommended for optimal health
- infants should be given special fomrulas
- irritability
- nausea and vomiting
nocturnal enuresis
bedwetting = establish and maintain a voiding diary for the child
meds like desmopressing and tricyclic antidepressant (IMIPRAMINE=tofranil) may be prescribed
Sudden infant death syndrome (SIDS)
- dress newbordn in no more than one layer of clothing than adults. DRESS THEM IN WEARABLE BLANKET, SLEEP SAC this keeps the newborn warm and prevents head from being covered during sleep
- hard mattress is preffered soft can confrom to their face and suffocate them when they’re rolling
- overheating might be a cause
- BACK-TO-SLEEP IS SAFEST POSITION FOR INFANT
- no stuffed animals = risk of suffocation
- kids sleeping with adults contributes to SIDs = avoid cosleeping with their infants
bronchitis vs bronchiolitis
- bronchitis = inflammed large airways ( trachea and bronchi which are in the lower part of respi tract)
bronchiolitis
- inflammation of the small airways (bronchioles)
- RSV is most likely the cause = use saline nose drops and suction the nares with bulb syringe prior to feeding
LUNG SOUNGS
- laryngotracheobronchitis (croup) = stridor/ seal like cough
- pleurisy = granting sound rubbing together
- bronchitis = thick secretions causing resembling in moaning or snoring
- pneumothroax = diminished or absent
down syndrome
ASD,VSD
- trisomy 21
- artrioventricular canal
- atrial septal defect (ASD)
- ventricular septal defect (VSD)
- simian crease = single line inside the palm
floppy muscles
- intellectual disability
INTERVENTION
- genetic screen and echocardiogram are scheduled
- surgery is conducted when neonate grows in size and can tolerate invasive procedure
MARFAN SYNDROME = tall and thin = aortic root disease
- affects connective tissue
- cardiovascular manifestations = PRIORITY
- avoid contact sports = risk of cardiac injury
- ocular problems
- scoliosis (wear t shirt under the boston brace at all times. remove for bathing and exercise)
- overcrowind of teeth
- high risk of maternal mortality = use a reliable form of birth control
**TRISOMY 18 (EDWARDS SYNDROME)
- affects multiple organs
- many fetuses affected by this condition die in the utero
- of the children that survive birth, HALF DIE IN THE FIRST WEEK and most do not make it to their first
heart failure in pediatrics
- small frequent feedings
- feed for a max of 30 mins
- increased calorie formula
MANIFESTATIONS
- tachypnea
- tachcardia
- pale cool extremities
- diaphoresis
- puffiness around the eyes
- weight gain
- POOR FEEDING/ LOSS OF APPETITE
- fatigue
- rhonchi on ausculatation is not part
late sign
- oliguria = reduction in wet diapers
- hypoxia
Aortic regurgitation
- increases preload in the left ventricle
- causes decreased cardiac output
- increases left ventricle end diastolic pressure.
MITRAL VALVE REGURGITATION
- may bar asymptomatic and may eventually turn to heart failure so report any sign of fatigue
- decrease cardiac output
impetigo
- highly contagious
- common bacterial skin infection 2-5 years
- usually not systemic
- contact precaution
- common around nose, mouth, hand and feet
- lesions
NO LONGER CONTAGIOUS AFTER 24 HOURS OF ANTIBIOTICS
DECREASE TRANSMISSION
- handwashing
- isolate infected person clothing and linens and washing them in hot water
- keep fingernials short to prevent bacteria from collecting under them and to deter scraching
- avoid close contact with others for 24-48 hours
MANIFESTATIONS
- burning
- pruritus
chicken pox/varicella-zoster virus
- varicella
- airborne and contact precaution
- can go back to school after sores are crusted. this happens in about a week
- apply diphenhydramine / antihistamines cream to lesions after bathing because the rashes are usally itchy
- acetaminophen for pain and fever
-
cool oatmeal baths also helps with itching
vaccine is not indicated for those that has already developed immunity and recovering from it - keep giving your child acyclovir (antiviral therapy) to fight the virus
reyes syndrome
- acute from of encelopathy/CEREBRAL EDEMA
- increased ICP
LAB = elevated ammonia
RISK FACTORS
- viral illness like flu and varicella (chicken pox)
- metabolic disorders
- ASPIRIN AND SALICYLATE USE DURING INFLUENZA OR VARICELLA INFECTION
INTERVENTION
- acetaminophen is appropriate antipyretic to reduce risk of syndrome
ASPRIN?ACETYLSALICYCLIC OVERDOSE OR TOXICITY = ACTIVATED CHARCOAL
- after the activated charcoal, IV sodium carbonate is an appropriate treatment
PEDS INGESTING SOMETHING
- first assess the clients condition = mental, physical, mental status and behavior
- based on the condition, the nurse can provide guidance and instructions
pyloric stenosis
- opening between the stomach and duodenum(small intes) is hardend and almost closed
- projectile vomiting without visualized blood especially after feeding
- olive shaped mass
- weight loss NOT anorexia
ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA = ASPIRATION GREATEST RISK
- eso phagus and the trachea does not properly separete or develop
- frothy saliva, chocking
- client may also develop apnea and cyanosis
CHOKING INTERVENTION = HEIMLICH MANEUVER
- under 1 year = back blows and chest thrust
- over 1 year = abdominal thrust
encopresis
- voluntary or involuntary fecal incontinence in children over age 4 who were previously trained
intussusception
part of the intestine slides into an adjacent part of the intestine
TREATMENT
- can successfully treated without surgery using hydrostatic (saline) or pneumatic (air) enema
MANIFESTATIONS
- sausage shaped stools
- red, currant jelly stools
- bilious vomiting
- stools mixed with blood and mucus
- intermitten pain drawing up of the knees
- non projectile vomiting
MONITOR FOR =
REPORT
- notify HCP if there is a passage of normal stool = indicates reduction of the intussuception = plans of surgery should be stopped and the plan of care should be modified
suitable activites after abdominal surgery in pediatrics
- blowing bubbles
- giving them a pinwheel to blow
= THEY FACILITATE LUNG LUNG EXPANSION AND PREVENT RESPIR PROBLEMS
- such activities can serve as incensitvive spiromer
omphalocele
intestines, liver and other organs OUTSIDE of the abdomen IN A SAC
- umbilical cord at apex
GASTRISCHISIS
- eviscerated bowel with no covering membrane
- umbilical cord to the left of defect
INTERVENTION
- maintain NPO
- administer ceftrixone due to the abdominal contents being exposed
- d5W
- DO NOT APPLY PETROLEUM JELLY TO THE BOWEL
- cover with nonadherent dressing plastic bowel bag, sterile, saline soaked gauze covered by loose plastic
wilms tumor/nephroblastoma
cancer that affects renal cells/kidneys (usually one kidney)
MANIFESTATIONS
- unusal bulding/contour abdomen on one side of the abdomen
- hypertension due to excess production of renin
- if tumor metastized, adventitious sounds may be present
INTERVENTION
DONT PALPATE ABDOMEN should be placed at bedside
- palpating can disrupt the tumor and cause dissemination of tumor cells
leukemias
- if temperature is elevated, PRIORITY is the establish an IV access because they are immunocompromised and antibiotics needs to be started right away
- neutropenic and bleeding precautions
LAB VALUES
- decreased platlets
- decreased neutrophils
- increased blast percentage
- decrease in RBC/erythrocytes = anemia
sickle cell
- both parents gotta have sickle cell to make it a 100% for child to inherit
- if one parent has sickle cell and the other is a carrier = 50%
- monitor of ischemic stroke = prirotiy
INTERVENTION
- HYDRATE!!
- follow high calorie and high protein diet
- they are at high risk of CVA so if they complian of headache = assess neuro status
- drink extra fluids if going on a plane
- avoid extreme cold/hot temps. high latitudes, mountains
- SEVERE PAIN IN THESE CLIENTS COULD INDICATE VASOOCLUSION AND TISSUE ISCHEMIA AND NEEDS TO BE ADDRESSED = may lead to irreversible tissue damage
- daily aerobic exercise is helpful but avoid strenous exercises
- they have lower immunity so advise them to take annual influenza vaccine
- continuos PCA is recommended rather than a prn
males can develop priapism
- priapism is a side effect trazodone
DURING CRISIS, AVOID
- action game = too exciting and can increase oxygen expenditure
- avoid activity rooms = too stimulating
- MAINTAIN BED REST DURING CRISIS
- crisis also affects joints so will be hard to use hand dexterity in playing game
AVOID
hemophilia
the blood does not clot properly = administer SUBQUE clotting factors
MEDICATION: desmopressin = stimulates the release of factor VIII
LONG TIME COMPLICATION = JOINT DESTRUCTION (HEMARTHROSIS)
- the most common site of bleeding are the joints especially the knee
HOW TO ADMINISTER MEDICATIONS
- use smallest guage
- vaccines are adminstered subcutaneously whenever possible to prevent IM hematoma
AVOID
- NSAIDs (ketorolac, ibuprofen, indomethacin, naproxen)
- avoid warm compress to the injection site. use ice
- avoid massaging
ACETAMINOPHEN IS RECOMMENDED FOR PAIN RELIEF
LAB VALUES
- normal PT/INR
- abnormal PTT
- normal thrombin time
trust vrs mistrust
infant (birth to 18 months)
- sooth by high pitched voice
- communication is nonverbal through touch, patting etc
- crying as means of communication
- separation anxiety
- pincer grasp should be present by age 10 months
- palmar grasp = 10 months
industry vs inferiority
grade school (6-11)
solid foods: 4-6 months
- requires 9-12 hours of sleep
- experience slower growth rates and require decrease hours of sleep
- NO ACTIVE PLAYTIME BEFORE BED. quiet and restful activities like coloring and reading prior to bed will promote restful sleep
identity vs role confusion
adolescent (13-18)
- peer!
SEXUAL MATURATION IN BOYS
- first manifestation is testicular enlargement
- followed by pubic, axillary, facial, body hair and voice changes
intimacy vs isolation
young adult (18-40)
generativity vs stagnation
middle age adult (40-65)
integrity vs despair
older adult (65+)
average number of hours of sleep over 24 hours that are expected for developmental age groups
- neonate: 16 to 18 hours of sleep each day
- infant: 14 to 15 hours of sleep
- pre school: 11 to 13 hours of sleep
autism
- strong genetic components
- not liked to old parents age
INTERENTION
- structured routine and consistency
- they will be stimulated if you give them too many choices
- place in private room away from the nurses station ( they may be hyper or hyposensitive to sound, lights, movements, touch, taste, smells
- maintain calming environemt
- have family bring in patients toys
- dim lights in the room
- maintain constant care givers
- low noise
head lag remaining after 6 months can be associated with autism
vaccines are NOT risk factors
piaget stages of cognitive development
- sensorimotor stage (0-2 years)
- preoperational stage ( 2 to 7 years)
- concrete operational (77 to 11 years)
- formal operational (11 to adulthood)
RhoGAM
- only effective if the mother HAS NEVER DEVELOPED ANTIBODIES
- given IM within 72 hours after birth
- ONLY WHEN MOM IS RH NEGATIVE, BABY IS RH POSTIVE
- prevent sensitization to the RH factor in an Rh negative woman with an infant who is Rh positive
- additional dose might be given if excessive fetomartenal hemorrhage is required
placental abruption vs placental previa
severe complication by preeclmapsia
- dark red bleeding
- hypotension
- rigid abdomen
PLACENTA PERVIA MANAGEMENT
- placenta covers cervix, painless bleed
- transvaginal ultrasound to confirm (also confirms ectopic preggo)
- DONT assess cervix for dilation
- blood draw for type and screen
- initiate 2 large bore IV catheters
- pelvic rest
- c section prior to onset of labor
BLOOD DRAW
- after 2 attempts to draw blood and still unsuccessful, dont try again. contact a phleotomist or a different nurse to complete blood draw
reflexes in infants
- moro/startle reflex: infant startle and strecthes out their extremities in response
- absencne of moro refelx = underdeveloped or damaged brain/spinal cord
- babinski sign: plantar flexion when inside of the feet is stroked. positive is when the toes flexes UP. positive is normal in newborn up to 1 year = DISSAPEARS AT 1 YEAR
in adults positive babinski (toes goin up) = indicates brain or spinal cord lesion - rooting reflex: the newborn turns his/her head to the side on which the cheek is stroked
ectopic pregnancy
- when fertilized ovum implants outside the uterine cavity
MANIFESTATIONS
- unilateral abdominal pain (lower quadrant abdominal pain on one side)
- referred shoulder pain
- hypotension (dizziness, tachycardia)
RISK FACTORS
- recurrent STIs
- IUDs
- pelvic pain
- vaginal bleeding
- positive preggo test
NO fever
NO dysuria
PELVIC INFLAMMATORY DISEASE
- most common cause is untreated STI
- multiple sex partners
- history of PID
- history of STI
- age 15-25
- lack of consitent barrier contraceotion use
amniocentesis
ultrasound-guided test used in the detection of fetal abnormalities
- may be conducted in patients with high risk
- may tell the gender of the baby
- will receive IV sedation
Ultrasounds typically require a full bladder as the fluid moves the uterus upward and assists with visualization
physiological chnages during pregnancy
- increased in heart size ( heart shift upwards and to the left
- increased BMI
- reduced renal threshold for glucose
- decrease gastric motility
WBC elevates even in the absence of infection
AVOID NSAIDS (ibuprofen, indomethacin, naproxen
gestational diabetes
- glucose in the urine
oral glucose challenge test for clients with gestattional diabetes. abnormal is 130 and higher
- causes elevated hematocrit levels in kids
chronic kidney disease
retension of potassium and phosphurus (restrict them)
fluid restriction
the kidneys regulate fluid volume and blood pressure
MANIFESTATION
- uncontrolled hypertension and hypertensive emergencies
MONITOR FOR AND REPORT
- hypertensive encephalopathy = nausea, vomiting and headache
ALLOWED FOODS
- apples
- pears
- grapes
- pineapple
- black and blue berries
plum
AVOID NSAIDS
- ibuprofen
- indomethacin
- ketorolac
- naproxen
AVOID NSAIDS IN PREGNANCY
ALSO AVOID
- salt substitutes
- high phosphorus
- high fluids (popsicles)
- high potassium
they retain electrolytes such as potassium and excess potassium often results in dysrhythmias
- avoid high sodium foods such as cured meats, pickeld foods, canned soups, salad dressing
NSAIDs
antitiotic
statins
prazoles
bisphosphonates
ends in NATE
- DRINK EXTRA WATER AND SIT UPRIGHT FOR 30 mins after taking them
premature babies
- high risk of cold stress due to decreased brown adipose tissue
- INABILITY TO GENERATE HEAT BY SHIVERING
- cold stress can lead to hypoglycemia
IMPORTANT PROBLMES OF PRE TERM NEW BORNS
- cold stress and hypoglycemia
SIGNS AND SYMPTOMS OF COLD STRESS
- decreased temperature
- altered mental status
- bradycardia
- hypoxia
- weak cry and suck
in elderly clients, acute altered mental status may indicate infection(urinary tract)
malnutrition
- first assess for unintentional weight loss
- after that, contributing factors such as functional status, mood alteration, diet
if a person is not eating, UNINTENTIONAL WEIGHTLOSS IS A PRIORITY OVER DEPRESSION
failure to thrive
- under tuition and inadequate growth in infants = weight less than 80% of ideal for age
- children are not at risk based on birth order or number of siblings
SOCIOECONOMIC CAUSES
- poverty
- notional isolation
- cognitive and mental disorders
- lack of nutritional education
domestic violence
- negative attitude towards food
PRIORITY = OBSERVING CLIENTS FEEDING
PHYSIOLOGIC FACTORS
- pre term babies
- breastfeeding difficulties
- gastroesophagral reflux
- cleft palate
END OF LIFE CARE
- they may have unfinished business that needs to be completed which may motivate the client to become anxious or INSIST ON DISCHARGE
- ask them to tell you more about their need to leave the hospital
- end stage organ failure must be motivated and educated on organ transplants rules such as abstaining from alcohol etc
PAIN MED AT END OF LIFE
- advocate it as a nurse even if the side effects can lead to death
PALLIATIVE VRS HOSPICE
PALLIATIVE CARE
- provides relief from symptoms associated with chronic illnesses
- can be provided at any time
- focuses on quality of life on the client and their families
- provided by multidisciplinary team
HOSPICE CARE
- only started when client decides to do without curative treatment
clubfoot
- mother can still cradle baby to encourage bonding and attachment
- place infant in supine. PRONE INCREASES SIDS
- recasting needs to be done ever 5-8 weeks
- monitor for circulation ( make sure toes is pink and warm )
- keep the cast dry to prevent skin irritation or infection
post partum urinary retention
- epidural causing decreased bladder sensation
- urinary retention can cause bladder distention which can lead to displaced or body uterus
MANAGEMENT: self limited condition and INTERMITTENT CAUTERIZATION
phlebostatic axis
- 4th intercostal space, midway point of the AP diameter of the chest wall
this is where you accurately measure continual arterial and or pulmonary artery pressure - lower will make the BP reading too high
- upper will make the BP reading too low
AUSCULTATING HEART VALVES
APETM
aortic (2nd RIGHT sternal border)
pulmonic (2nd LEFT sternal border)
erbs point (3rd LEFT sternal border)
tricuspid (4th LEFT sternal border)
mitral (5th mid clavicular line) apical pulse!
infant apical pulse is at 4th intercostal space
botulism
- gastrointestinal absorption of the neurtoxin produced by C botulism
MAIN CAUSE: imporperly canned or stored foods.
- in infants = RAW WILD HONEY
- results in muscle paralysis DESCENDING FLACCID PARALYSIS STARTING FROM THE FACE dysphagia and constipation (smooth muscle paralysis
- discard canned food with bulging ends
children under one year should not be given honey due to their immature gut system = makes them prone to botulism
when a client questions a drug “ this is a pill i havent seen before”
FIRST CHECK THE PRESCRIPTION TO VERIFY THE 6 RIGHT OF MED ADMIN
- this confirms the right patient.
- ONLY TEACH THE PURPOSE OF THE MEDICATION AFTER YOU HAVE VERIFIED IT FROM THE HCP PRESCRIPTION MEDICAL RECORD
if the lab calls for a critical lab value and the nurse is busy, what should the nurse do
- instruct the caller to have the CHARGE NURSE RECEIVE THE REPORT
- if UAP reports to the nurse whiles shes caring. for another patient that a client wants them = tell them to tell the charge nurse the needs of the client
critical lab results should be verbally communicated
transcutaneous pacing vs cardioversion
cardioversion = used to restore FAST beating arrhythmias to normal
trans pacing = used to correct SLOW arrhythmias to normal
INCISION CARE leg incision from CABG
- wash daily with soap and water and gently pat dry
- itching, tingling and numbess around the site may be present for several weeks due to damage of the local nerves
- avoid tub baths = infection
- dont apply powders or lotions on incisions as they trap bacterials into the incision
- wear supportive elastic hose on the legs, elevate when sitting to decrease swelling
- incisions may take 4-6 weeks to heal
Carbon monoxide poisoning
- toxic inhalants that enters the blood and bind. to the hemoglobin (carboxyhemoglobin)
- pulse oxi reading often appears normal because such devices cannot differentiate between CO and oxygen = THIS IS WHY IT IS DEADLY!!
- a serum carboxyhemoglobin is needed to confirm diagnosis. < 5 in non smokers, < 10 in smokers
TREATMENT: immediate 100% oxygen to correct hypoxemia and eliminate CO from the blood
= SMOKE INHALATION IS THE LEADING CAUSE OF DEATH IN BURN CLIENTS = KILLS FASTER AND IS ALWAYS A PRIORITY
neonatal abstinence syndrome
- withdrawal from opiates due to maternal drug use
Manifestations
-neurologic: irriatability, hypertonia, jittery movements, seizures(rare) = swaddling can be an intervention for those
- gastro: dirrhea, vomitting, feeding intolerance
- autonomic: sweating, sneezing, pupillary dilation, nasal congestion, frequent yawning, sneezing, tachypnea, sweating
TREATMENT: opiod therapy (methadone and morphine)
- methadone has a long half life
itching is an expected side effects of narco’;/;tics
FETAL ALCOHOL SYNDROME
- microcephaly
- thin upper lips
- smooth philtrum
- short palpebral fissures flat midface
INTELLECTUAL DISABILITY IN CHILDREN
- down syndrome
- hypothyroidism
- fetal alcohol syndrome
- phenylketonuria
OPIOD OVERDOSE = NALOXONE
- EVERYTHING GO DOWN
- slurred speech
- respiratory depression
- hypotension
- drowsiness
- constricted pupil
GASTRIC LAVAGE: = stomach wash
- Performed through probate if tube to remove ingested toxins and irrigate stomach
- prepare intubation and suction at the bed side incase of aspiration and respiratory distress
OPIOID DISORDER DRUGS
- - natrexone
- methadone
- buprenorphine
better if combined with appropriate counseling
teratogenic agents (alcohol, cytomegalovirus, valproic acid)
- microcephaly
- cleft palate
plagiocephaly = flattening of the skull = when infants spends a lot of time in the same position (supine)
cellulitis
- inflammation of subcue tissues
CAUSES
- insect bites
- abrassion
- open wound
MANIFESTATIONS
- redness
- edema
- pain
- fever
daily marking and dating of reddened and edema assist with monitoring improvement
INTERVENTION
- elevate legs to promote circulation and reduce edema
- warm compresses
tumor necrosis factor inhibitors
- infliximab, adalimumab and etanercept
- clients should be tested for TB before
- no traumatic procedures (initation of IV sites, IM injection) should be performed unless absolutely necessary due to risk of bleeding
- any sign of infection, avoid taking these drugs = because they suppresses the immune system
- avoid live vacciness BUT SHOULD RECEIVE INFLUENZA
CONTRAINDICATIONS
- CLIENT WITH CURRENT, RECENT OR CHRONIC INFECTION SHOULD NOT TAKE TNF INHIBITOR
-
antibiotics
- nausea and vomiting are expected
MACROLIDES
- mycin antibiotics with “thro” in it = they prolong QT interval
- ecg should be monitored for any sudden changes
CLIENTS THAT SHOULD RECEIVE PROPHYLACTIVE ANTIBIOTICS PRIOR TO DENTAL PROCEDURES (this is to prevent infective endocarditis
- cardiac transplantation recipients who develop heart valve disease
- prothestic heart valve
- previous infective endocarditis
- unrepaired cyanotic
- ineffective endocarditis require IV antibiotic for up to 4-6 weeks
- persistent temperature elevature may indicate that the therapy is ineffective or complications have developed
BLOOD CULTURES
- always obtain blood cultures before you administer antibiotics because it can lead to false negative results
when patients have fever chills, rash, blood cultures should be done before antibiotics is administered
what drugs prolongs QT interval
- amidarone
- sotalol
- haliperidol
- ziprasidone (second gen antidepressan)
- clozapine
- they can hepatotoxic so monitor for liver function test
it’s priority even if it’s expected cus it can lead to cardiac arrest and other lethal arrhythmias such as TORSADES DE POINTES
TORSADES DES POITES
- caused by low magnesium
treated with magnessium sulfate
pregnant adolescent clients
- increased risk of complications
DURING ENCOUNTER AS A NURSE
- discuss emotional response
- family/social support systems
- nutritonal habits and subtance abuse
pregnancy food
- AVOID
- liver = rich in vit A and can be teratogenic
- deli meats, hot dogs
- avoid unpasteurized milk products
- unwashed fruits and veggies
- raw fish or fishes high in mercury
EAT
- folic acid (fortified cereals, bread, pasta)
- green and leafy veggies
postpartum psychosis
- rare but serious perinatal mood disorder = psychitric emergency
- signs appear 2 weeks after birth and include hallucinations, delusions and paranoia
delirium that someone wnna hurt the baby
POSTPARTUM DEPRESSION
- assess parent and ask question about depression and feeling of hopelessness
live attenuated vaccines like influenza vaccine
INCLUDE MMR (measles-mumps-rubella), varicella-zoster, rotavirus
- a child less than 12 months can and should receive MMR when they contract it
- safe for healthy 2-49 years including breastfeeding women
MMR CONTRAINDICATIONS
- HIV with CD4 less than 200
- history of guillain baire syndrome
- pregnant women
- immunocompromised (leukemias)
- corticosteroids therapy
- chemotherapy
- AVOID pregancy for atleast 1-3 months after MMR immunization is given
- chicken poxed
- less than 2 years
- leukemia
best way to administer MMR vaccine to a nonimmune client is postpartum period just prior to discharge
if a client calls that that they are seeing rash and having mild = ask them what their temperature is. FEVER AFTER MMR CAN LEAD TO FEBRILE SEIZURES
INACTIVATED VACCINESS RECOMMENDED FOR PREDNACY
- TDAP
- tetanus
- dipthertia
- pertussis
CONTRAINIDICATED VACCINES FOR PREGNANCY
- MMR
- HPV
- live attenuated influenza
- varicella
FLU TREATMENTS ( flu last for about a week)
- antiviral meds like oseltamivir are given to clients with symptoms within the last 48-72 hours = can shorten duration of the illness
- annual vaccine
- droplet precaution
- wear mask when being transported out the room
MISCONCEPTIONS ABOUT IMMUNIZATIONS
- penicllin allergy
- mild illness (with or without an elevated temperature)
- mild site reactions (swelling, erythema, sorness)
- recent infection exposure
- current course. ofantibiotics
THESE PEOPLE CAN STILL RECEIVE IMMUNIZATIONS
Ebola
- extremly contagious viral disease with high mortality
- standard, contact and droplet precautions
- placed on single client airborne isolation
- maintain log of everyone in and out the clients room
- keep client door closed at all times
client does not require n95 HOWEVER all other individuals entering the room must don approprate ppe - visitors prohibited unless necessary like parent visiting an infected child
PPE REMOVAL PROCESS
- requires strict monitoring by a trained observer
- outer gloves are first cleaned with disinfectant and removed
- inner gloves are wiped between removal
somatic symptom disorder
- psychological disorder that develop from stress and disrupt daily life
- unexplained physical symptoms like abdominal pain
NURSING INTERVENTION
- DONT DISPUTE = disputing the validity of the client symptoms may increase the clients stress level and make everyhting even worse
- clients symptoms are real despite the lack of diagnostic findings
CONVERSION DISORDER
- diagnosis that acknowleges that your symptoms are real even if there isnt a physical cause
misoprostol (cytotec)
IDICATION
- prevent stomach ulcers (can still take nsaid cus that’s the point of the medication, it reduces the effects of nsaids)
- can take with food if stomach irritation occurs
- cervical ripening that occurs before onset of labor
- adminster orally or vaginally. rectal administration during postpartum hemorrhage
CONTRAINDICATIONS
- PREGNANCY CATEGORY X
- avoid taking with antacid
- the client receiving another uterotonic like oxytocin simustaneously
- abnormal fetal heart rate
- tachystole = more than 5 contractions in 10 mins
- c sections
narcotics during labor should be given slowly DURING THE PEAK of the next contraction = reduces the amount of narcotic that crosses the placental barrier and affects the fetus
subdural hematoma
- bleeding into the subdural space- elderly clients taking anticoagulants are at high risk
- result of blunt force head trauma
- surgical evacuation of the hematoma may be necessary to relieve pressure on the brain
- can lead to herniation (midline shift)
- assess for ICP, cushing triad = increased ICP = decreased cerebral perfusion
MANIFESTATION OF SUBDURAL HEMATOMA
- headache
- gait disturbance
- memory loss
- decreased LOC
EPIDURAL HEMATOMA = TEMPORAL BONE
- accumulation of blood between the skull and dura mater
- they lose conciousness at the time of impact then REGAINS consciousness quickly and feel well for some time (lucid interval) AND THEN FOLLOWED BY A QUICK DECLINE IN MENTAL HEALTH that can progress to coma and death.
- emergent diagnosis and treatments are needed to prevent brain stem herniation
subarachnoid hemorrhage
- often described as worst headache of my life
tardive dyskinesia
- movement disorder often irreversible
- may be caused by high doses metoclopramide which is a common antiemetic medication
- question the medication if they experience any symptom of tardive dyskinesia
cleft palate
FEEDING RULES TO ASPIRATION RISK
- position the child supine with an elevated HOB after feedings
- burp the infant often cus they swallow large amounts of air during feeding
- feed in upright position
- feed slowly over 20-30 minutes every 3-4 months
- use a specialty bottle: squeezable/assisted bottle
- bottle should be pointed down away from the cleft
- cross cut and preemie nipple due to inability to create suction and pull milk from nipple.
- elbow restraint is used to prevent the child from disrupting the surgical site
AVOID HARD OBJECTS
- utensils
- tongue depressors
- pacifiers
- starws
Premature ROM
- rupture prior to onset of labor at term gestation >37
- does not hurt the baby however, if labor dont begin after ROM, induction of labor might be necessary to decrease risk of infection
- green amniotic fluid = child has passed meconium in utero = can cause aspiration
falsely reading for oxygen saturation on pulse oximeter
- hypotension and low cardiac output example: heart failure
- artificial or dark fingernail polish
- peripheral arterial disease
- vasoconstriction eg hypothermia, vasopressor medications
- if they had a DYE procedure
ANEMIA
- if the patient is anemic, you should look at other indicators of good oxygenation besides the pO2 cus youd think they are better thna they actually are which is pretty dangerous
thiazide diurectics
- hydroCHLOROTHIAZIDE and CHLOROTHALIDONE
CONTRAINDICATIONS
- gout cus it increases uric acid
- causes hyperglycemia
- causes hypo sodium too
- sunlight = photosensitivity
- encourage client to use sunscreen and wear protective clothing
INDICATIONS
- edema
- hypertension
- USUALLY PRESCRIBED WITH SPIRONOLACTONE TO TREAT HYPERTENSION
- spironolactone is a potassium sparing drug so it counterracts the potassium loss from thizide diuretics
LABS
- HYPO potassium = muscle cramps (report)
- HYPO sodium = altered mental status and seizure
- HYPER uriCEMIA = worsen gout attacks
- HYPER glyCEMIA
- HYPER calCEMIA
considered potassium wasting diuretics
- AVOID LICORICE ROOT = can lead to hypokalmia since thiazide already puts patient at risk of hypokalemia
- diuretics should be taken in the morning cus nighttime will cause nocturia and interrupted sleep
- thiazide depletes every other electrolytes
THIAZIDE CALCIUM
- reduce urine calcium levels BUT increase blood calcium levels
warnings of cancer
CAUTION
- Chnage in bower and bladder habits
- A sore that do not heal
- Unusual bleeding or discharge
- Thickening or lump in breast or elsewhere
- Indigestion or difficulty swallowing that does not go away
- Obvious change in wart or mole
- Nagging cough or hoarseness
CANCER MED = methotrexate
SIDE EFFECT
- causes bone marrow suppression = risk of infection
- hepatoxicity (avoid alcohol)
- gastrointestinal irritation
EXAMINATION OF SKIN CANCER = ABCDE
A = asymmetry
B = boarder irregularities
C = color changes and variations
D = diameter of 6mm or larger
E = evolving (appearance is changing in shape, size and color)
pus or purulent drainage is usually indicative of an infectious disease NOT appearance
- AVOID TANNING BEDS = they emit UV radiation
acute manic episode bipolar disorder
DOs
- assign private room
- choose clothing for client
- have them participate in physical exercise
one on one interactions rather than group
- high protein, high calories
- low lightening
- quite calm environemnt
- limit number of ppl who come in contact with client
DONTS
- avoid group stuff and activities
- avoid loud areas
- dont let them eat in dining room with other ppl = too much stimulating
- avoid anything that causes too much stimulation
MED: lithium
scarlet fever/pharyngitis
- sore throat caused by group A strep (pharygitis)
- distinguised by bright red rash
PHARYNGITIS
- toothbrush should be replaced 24 hours starting antibiotics (bristles can harbor bacteria and reinfection may occur)
- soft diet and cool liquids (ice chips**)
- can lead to renal or cardiac complications if not treated
ORDER
- rapid streptococcal antigen test to confirm it
- throat culture is needed to verify result
STREP THROAT- contagious period starts from onset of symptoms and last through first 24 hours of beginning of beginning antibiotic treatment = they can return to school or daycare after they have completed 24 hours of antibiotics and are afebrile
hemorrhagic stroke
- blood vessel ruptures in the brain causing bleeding
NURSING INTERVENTION
- implement seizure options due to increased ICP
- during acute phase, dysphagia might occur so client must remain NPO until swallow screen functions reveals no deficit
- perform neurological assessments (LOC, pupillary response)
- administer stool softners
oropharyngeal airways
- temp airway devices used to prevent tongue displacement and trach obstruction in SEDATED or UNCONSCIOUS CLIENTS
- as conciousness is gained, client will cough or gag indicating the need to remove it!!
- nurses must enure it is easily removable, so do not tape it!!
INSTALLATION OF OROPHARYNGEAL AIRWAY
- measure the OPA airway against the cheek and jaw
- insert with distal end pointing upward towards roof of mouth
- rotate the device tip once it reaches the soft palate towards the esophagus = pushes tongue forward and maintains airway patency
- suction secretions prior to prevent asipiration
- never tape in place because when the client awakes, the device stimulates gag reflex and can cause aspiration
weight reduction strategies
- eliminate sugar containing bevs including fruit juices
- set relistic goals (losing 1-2 lbs) every week
- eat small, frequent meals to decrease hunger and tendency to eat
- adequate sleep 7-9 hours cus sleep deprivation is associated with weight gain and obesity
- dont skip meals
- incoporate daily exercise
HEALTHIER BEVERAGES OPTIONS
- flavored or unflavored club soda
- fresh veggie juice
- unsweetedned tea or coffee
- non fat or low fat milk in limited amounts
ORLISTAT
- inteferes with fat soluble vitamin intake so client should take vitamins ADE and K but MUST BE TAKEN 2 HOURS AFTER ORLISTAT
- lipase inhibitor that prevents the breakdown and absorption of fats
- take with or within 1 hour of meals that contain fat
- dose may be skipped if food does not contain fat
-
cold injury/frostbite
TREATMENT: rewarming is key!!
- depending on the extremity, putting it in warm water immediately is the key!! 104 degrees water
- keep wounds open immediately after water bath before applying loose, nonadherent, sterile dressings
DO NOT MASSAGE BODY PART THAT HAS SUSTAINED COLD INJURY
- face and keys can be rewarmed with warm facecloths
- give them something warm to drink but only after putting the place of affect in warm water
new-onset restlessness
- oxygenation should be considered first before med = CHECK PULSE OP
- if the client is speaking, airway is open
- if they’re snoring = opening airway is priority
AMNIOTIC FLUID
produced by fetal kidneys and serves 2 major purposes
- prevent cord compression
- promote lung development
COMPLICATIONS OF OLIGOHYGRAMNIOS = low
- pulmonary hypoplasia = small lungs = have additional neontal personel available for possible resuscitation and evaluation of the newborn
- umbilical cord compression = continuos (not intermitten) fetal monitoring should be applied to monitor for variable deceleration
normal amniotic fluid causes extra room for the umbilical cord to float freely, when theres not enough amniotic fluid, the baby body part is likely to press on the cord against the uterus
priapism
- prolonged, painful erection not necessarily related to sexual arousal
requires urgent treatment in the emergency department as it can lead to erectile tissue ischemia (blue discoloation of the penis) and necrosis
MANIFESTATIONS
- extreme pain is expected
- difficulty voiding
- anxiety and embarassment
REPORT
- blue discoloration of the penis
- can manifest in male clients with sickle cell
external fixation
- stabilizes bone by inserting metal pins through the skin into the bone and attaching them to. ametal rod outside the skin
- promote early mobilization for clients, may begin walking with physcial therapy the day after surgery
ASSESS FOR AND REPORT(indicates infection)
- low grade fever
- drainage
- pain
- redness
- swelling
Ethical principles
- nonmalefience: doing no harm
- beneficience: to do good(implenting measures to promote client well being) = it can involve withholding information at times
- fedelity: loyal and fulfilling commitments
- justice: treating all clients fairly without bias
- veracity: telling the truth
- autonomy: right to make decisions for self/ allowingthe clients to choose the direction of care
- paternalism: teating clients as children
antiplatelet drugs
- aspirin
- clopidogrel = should be discontinued 5-7 days before surgey
- prasugrel
dont adminster before procedure
MANIFESTATIONS
- prevent thomboembolic events in clients with increased risk of stroke and myocardial infarction
SIDE EFFECTS
- brusing
- monitor for and reports signs of uncontrolled bleeding such as bloody stools
- signs of stokes
antiplatelet agents does not affect blood pressure
potassium wasting diurectics
- furosemide, bumetanide
GIVE THEM SLOWLY TO PREVENT OTOTOXICTY
- report muscle cramps
HOW TO TAKE THEM
- take with full glass of water
- sit up for like 30 mins after taking = prevent tablet from dislodging in esophagus or reflux from the stomach
- DO NOT TAKE ON AN EMPTY STOMACH take during meals or immediately after meals to prevent stomach upset
MONITOR NAD REPORT SIGN OF
- hypokalemia = unmanaged hypokalemia can lead to lethal cardiac dysrhtymias
- muscle cramps and flushing
INTERVENTION
- potassium supplement
high potassium diet may be required
AVOID
- licorice
SIDE EFFECTS
- muscle cramps, weakness
- paresthesia
POTASSIUM SPARING
- “SAME” acronym with “one”
beta blockers
CONTRAINDICATION
- apical pulse less than 60
SIDE EFFECTS
- fatigue
presence of wheezing after taking propranolol may indicate bronchoconstriction or bronchospams is occuring = assess them for asthma
cervical cerclage
- heavy sutures, placed transvaginally or transabdomininally to prevent preterm delivery by keeping the cervical os closed
INDICATED FOR
- clients with histories of second trimester loss or premature birth
- clients with history of cervical insufficieny
CERVICAL INSUFFICINCEICY
- painless
- premature cervical dialtion
- miscarriage or preterm baby
placement occurs at 12-14 weeks gestation and should remain in place unitl 36-37 weeks
DISCHARGE INSTRUCTIONS
- activity restriction/ bed rest for a few days
- recognize pre term labor such as low back aches, contractions and pelvic pressure
- recognize ROM
- report feeling pressure in pelvic
phlebitis
- inflammation of vein
CAUSES
- irritating drugs (vancomycin)
- catheter movement within vein (inadequate stabilization
- bacteria due to poor aseptic technique
PRIORITY AND REPORT
- when redness and inflamation occurs especially with irritating drugs like vancomycin. IMMEDIATE REMOVAL because it can lead to thromboplebitis, eboli or other bloodstream infections
Carpal tunnel syndrome
- compression of MEDIAN nerve within the carpal tunnel at the wrist.
- phalen test is used to diagnose carpal tunnel syndrome
INTERVENTION = WRIST IMMOBILIZATION SPLINTS
- avoid hand exercises cus it leads to more compression of the median nerve
MANIFESTATIONS
- weakness
- pain
- impaired sensation in the median nerve distribution
- numbness
alpha blockers
end of drug ends in -sin
RULES
- take at bedtime
MONITOR
- orthostatic hypotension
- avoid erectile dysfunction drugs and any other drugs that increases smooth muscle relaxation
aortic dissection
- medical emergency
- tear in the characterized by ripping/ tearing back pain
TREATMENT = CONTROLLING HYPERTENSION!!
- maintain normal blood pressure in the aorta
- administer IV beta blocker
INTERVENTION
- bed rest and low stimulation environment
MANNIFESTATIONS
- abrupt
- tearing
- moving (upper to lower)
- back pain
- epigrastic pain
CAUSE
- hypertention
water intoxication (water overload)
- often in infants when formula is diluted. which parents do to save money
MANIFESTATION
- irritability
- lethargy
- hypothermia
- seizure
Obsessive compulsive disorder (OCD)
MANIFESTATIONS
- intrusive thoughts
- urges
- complusions
- extreme rigidity and inflexibility
- impulses
- unwanted thoughts
- punctual to rules and regulations
- teach client how to use the technique of thought stopping
MANAGEMENT
- recognzing triggers and using relaxation or redirection techniques
- use behavioral technique to decfease or eliminate time spent performing the ritualistic behavior
Schizophrenia
MANIFESTATIONS
- paranoia
POSITIVE SYMPTOMS OF SCHIZO
INTERVENTIONS
- struggling with social interactions = first start with one on one interactions before group activities
- during hallucination = reinforce reality and acknowlege how the client may be feeling i know you are frigthened but i do not see a man in your room
cauda equina syndrome
- injury to the lumbosacral nerve roots (l4-l5) causing motor and sensory deficits
MAIN SYMPTOMS
- lower back pain
- saddle anesthesia: motor weakness/loss of sensation to inner thighs and buttocks
- bowel and bladder incontinence (late sign)
postpartum sexuality
- ovulation may occur as early as 4 weeks after birth before resumption of menses.
- MANY CLIENT RESUME SEXUAL ACTIVITY BEFORE their postpartum check up(4-6 weeks after birth)
-encourage clients to use contraceptive such as condoms to prevent pregnancy
drugs contraindicated in nasogastric (NG) route
- slow release
- enteric coated
- extended release
- sustained release
these drugs are designed to release at a slowly within a specififc frame
ALSO
you would have to crush these drugs to pass through NG tube and crushing these drugs are contraindicated and introduces risk of adverse effects BUT REG DRUGS NEEDS TO BE CRUSHED FOR NG TUBE
during abdominal surgeries, it is customary to insert a nasogastric tube that is left in place during the immediate post op period. green bile colored drainage is expected but bloody drainage would cause concern
bishop score
- assessment and rating of cervical favorability and readiness for induction of labor
higher bishop score indicates likelihood of successful induction that results in vaginal birth
for nulliparous(never gave birth) women, a score of 6-8 indicates induction will be successfull
NONSTRESS TEST
- reactive: fetus is well oxygenated and establishes fetal well being = it does not provide information about the likely success or failure of labor induction
- nonreactive: bad!
pica
- abnormal craving for food and substances of no nutritional value during pregnancy
often accompanied by iron deficiency anemia so MONITOR HEMO AND HEMA LEVELS
FOODS TO INCREASE HEMOGLOBIN LEVELS
- meat
- fish
- poultry
iron deficiency anemia is the most common nutritional disorder in children = mostly due to excessive intake of milk
if a client of 50 or above has new onset of anemia, the nurse should find the etiology first before treatment = SCREENING COLONOSCOPY
worm infections
PINWORM
- intestinal worm infection from eating from contaminated food, drinks toys
charcterized by anal itching and troubled sleeping
HOOKWORM
- blood sucking roundworms from larvae in contaminated soil
- migrate to intestines and causes BLEEDING AND ANEMIA
eczema and psoriasis is not contagious
TINEA CORPORIS/RINGWORM
- caused by fungus
- red,scaly, blistered RINGS on the skin or scalp = easily spread by sharing hair care instruments, towels, hats, clothings etc
- contagious fungal infection
- direct contact precaution = shared hairbrushes, bedding, towels, hats
- NOT CAUSED BY WORM INFESTATION
MED: griseofulvin and 1% selenium sulfide shampoo applied several times each week
- treatment should not be discontinued early even if symotoms subsides. tretament can go from weeks to months
MED (griseofulvin) INSTRUCTION
- absorption occurs best after eating high fat food like ice cream
- avoid prolonged exposure to sunlight = photosensitivity
jackson-pratt closed wound system
- purpose is to prevent fluid build up in a closed space (abdominal and breast reconstruction surgeries)
HOW TO EMPTY
- perform hand hygiene = assepsis must be maintained to prevent transmission of microorganisms
- pull the plug on the bulb to open the device and pour the drainage into a small calibrated container
- empty device every 4-12 hours unless its 1/2 or 2/3 full because as the capacity bulb of 100mL fills, the amount of negative pressure in the bulb decreases
- compress the empty bulb by squeezing it from side to side with 1 or 2 hands until it is totally collapsed = more effective in establishing the negative pressure needed
- clean the spout on the bulb with alcohol and replace the plug when it is totally collapsed to restore negative pressure
placenta accreta
- abnormal placental adherence to the MYOmetrium INSTEAD OF THE ENDOMETRIUM
RISK FACTORS
- previous c sections
COMPLICATIONS
- life threatening hemorrhage when an attempt is made to separate it
INTERVENTION = blood transfusion
-two large bore IV(18 guage) and a blood type and crossmatch
cognitive impairment (intellectual disability)
- diagnosed prior to adulthood
- have limited levels of intellectual functioning and adaptive skills for their chronological age
NURSING INTERVENTION
- consistenly assigning the same staff
- providing toys that are developmentally appropriate NOT BASED ON AGE
- involve parents but dont exclude patient
- prevent self-injury by reinforcing the parents limit-setting measures
- use visual demonstrations to facilitate communication
DISORDERS THAT CAUSES INTELLECTUAL DISABILITY
- hypothyroidism
- down syndrome
- phenylketonuria
-
dry dressing change
- done clean gloves and perform hand hygiene before and after
- clean the wound bed (form center outward)
- monitor site for infection
- apply dry sterilze gauze over wound bed
- cover the gauze with occlusive sterile dressing to keep gauze in place. COVERING SHOULD BE APPLIED WITHOUT TOUCHING THE WOUND BED
factor Xa inhibitors
- dabigaTRAN
- apixaban
- rivaroxaban
INDICATIONS
- used to reduced risk for clots and strokes in clients with A fib
- they are being prescribed more often often over oral anticoag like warfarin DUE TO LOWER RISK OF BLEEDING AND REQUIRES LESS MONITORING
- also used to prevent venous thromboembolism
CONTRAINDICATIONS
- NSAIDS
KEEP CAPSULES IN THEIR ORIGINAL CONTAINER UNTIL USE
INTEERVENTION
- implement bleeding. precautions
AVOID ASPIRIN, GARLIC, GINGER
- routine monitoring of clotting times are unnessary for clients with Xa inhibtors
Triage nursing
RED = HIGHEST PRIORITY
- the patient has life-threatening injuries, but a high chance of survival once stabilized
YELLOW
- the victim has injuries that are not immediately life-threatening
- can wait up to an hour before receiving treatment
GREEN
- the patient has minor injuries such as cuts or abrasions and can wait several hours before receiving treatment
BLACK = EXPECTED TO DIE
- the patient’s injuries are so severe that there is little to no chance of survival
- apnea
SPINAL IMMOBILIZATION
- acronym NSAIDS
- Neuro exam
- Significant traumatic mechanism
- Alertness
- Intoxication
- Distracting
- Sinal exams
pain topical patches
absorbed systmeically so does not need to be applied excatly on site of pain
should be applied on area of flat, intact skin (upper back, chest) to prevent accidental removal
- not recommended for acute post op pain, temporary or intermitten pain. ONLY CHRONIC
AVOID
- heating pad over them = increases absorption
- cutting = cutting damages delivery system
DONT SHAVE AND APPLY THERE cus there might be microcuts
DISPOSAL
- fold the used patch in half so the edges adhere and immediately discard
- remove old patch when applying a new patch every 72 hours (days)
caring for psych patients
AVOID WHY AND HOW QUESTIONS!!!!
first thing to do when a person is experiencing severe anxiety / panic attack
- move them away from the cause of the attack by accompanying to a vacant room
- don’t try to talk to client as they are already anxious and cannot recollect themselves
what do you not say to an agitated psych patient
- do not tell them to calm down
- Once the client is at risk of harming himself, other clients, or staff, the nurse should call for help and prepare to administer a sedative/tranquilizer to calm him down
a client experiencing psychosis and says anything like “ya trying to kill me
- ask what make you think we are trying to kill you?
- pick the answer that keeps them talking
RN scope of practice
- initial assessment (ADMISSION, POST OP)
- assessment and care for unstable patients
- administer IV push, blood products, TPN and medications requiring titration and continuous monitoring
- monitoring, qualitative data and assessments
- access implanted device
- interpret and analyze data requiring COMPLEX critical thinking
- Care plan development
- initiation of client referrals
- initial and discharge teaching
NURSE SHOULD MONITOR FOR SIDE EFFECTS OF MEDS OR INTERVATIONS
RNs are required to follow up to ensure that the task was completed accurately
5 rights of delegation
Right Task.
Right Circumstances.
Right Person.
Right Direction/Communication.
Right Supervision/Evaluation. = following up to see they did the task just like it should be
when language is a barrier, USE INTERPRETER
MANAGEMENT FUNCTIONS
- planning
- organizing
- staffing
- directing
- controlling
EFFECTIVE TIME MANAGEMENT
- include the patient in it = asking what is their priory to be accomplished each day
- using teamwork can enhance performance also
LPN scope of practice
- monitor RN findings ( obtain BP, HR )
- gather data (focused and subsequent) on stable patients
- auscultating lung or bowel sounds after intitial assessment by RN
- can give most meds except for IV medications
- can give subque meds
- monitoring behavior chnages
- basic client care (CHANGING BANDAGES, INSERTING CATHERS ( but not central lines/ picc) NG tube,
- WOUND CULTURES DURING DRESSING CHANGES
- BLOOD SAMPLES
- report client status and concerns to RN/PHCP
- care for stable clinicals with PREDICTABLE outcomes (chronic, ready for discharge, consistent lab, expected findings)
- reinforce RN education
- ostomy
- tracheostomy care
- stool samples
- NO INTRAVENOUS MEDICATIONS!!!
CAN ADMINISTER DRUGS (EXCEPT IV PUSH) TO PPL WITH CHRONIC CONDITIONS
UAP scope of practice
- ambulation, ROM, hygiene, ADL
- feeding, oral care for STABLE PATIENTS (NOT IF AT RISK FOR ASPIRATION)
- they cannot feed a stroke patient until 48 hours have passed
- routine vital signs, intake and output
- positioning and linen chnage
- pacing bed alarms to reduce falls
- transfer/transport T/FROM BED, CHAIR, COMMODE, STRETCHER
when transferring, use distal not pivotal - report concerns to RN/LPN
patient controlled analgesia (PCA)
- continuos IV solution (normal saline) is required to keep the vein open and flush the PCA medication so it reaches the client
- if doctor says to turn off saline = question it to clarify it
DONT CONVERT IT TO A SALINE LOCK
OTHER IV OPIODS WITH SALINE
- convert to a saline lock
- SALINE LOCKS KEEPS THE LINE PATENT AND ALLOWS FOR GREATER MOBILITY THAN A CONTINUOS INFUSION
PAIN
when it’s 8-9 on a scale of 1-10 after a procedure
- REMEMBER PAIN IS WHAT THE PATIENT SAYS IT IS!! ASK!!
STAT PAIN MEDS NEEDS TO BE ADMINISTERED ONCE! = need to obtain a new prescription from doc to administer again
nausea, vomiting
diaphoresis
increased pulse
tachypnea
increased glucose
dilated pupils (mydriasis)
delivery oxygen methods and how much oxygen they deliver
ALWAYS MAINTAIN A PATENT AIRWAY FIRST (example is turning them to their side) BEFORE DELIVERY OXYGEN!!
cannula: 24-44
simple face mask: 40-60
partial rebreather: 60-75
non rebreather: 80-95 = short term use (pulmonary edema)
venturi mask = consitently delivers O2 regardless RR, depth or tidal volume. BEST FOR COPD
CANT USE CANNULA FOR SEIZURE. AMBU BAG IS NEEDED. cannula doesn’t deliver enough oxygen
NASAL CANNULA
- avoid vaseline cus its flammable
- use a water soluble lubricant instead
-
NONREBREATHER MASK
- monitor the resevoir bag to assure continual inlfation during inhalation
- if resevoir bag is deflated during inspiration, increased oxygen flow
- valves close on inhalation to prevent entry of room air
- valves close on exhalation to prevent reinhalation of exhaled air
open angle glaucoma
- INTENSE PAIN
- fixed and mild dilated pupil
INTERVENTION
- PLACE THEM SUPINE
this decreases pupillary block and help keep lens from falling away from the iris
MEDS
- timolol = used to decrease intraocular pressure
- acetazolamide - diuretic
intraocular pressure
10-20 = timolol used to decrease it
- tested with tonometer
- lying down increases intraocular pressure
AVOID UNNESSARY MOVEMENT.
INTRAOCULAR FOREIGN BODIES/PENETRATING SHOULD BE TREATED BY OPTHALMOLOGIST ONLY!! = cover the eyes with a cup and tape it in place and call doctor. this prevent further damage that may be caused by rubbing eye
- do not flush eyes with cool water as it may cause further damage by moving the pathogen
surface foreign bodies can be removed with irrigation and a mositened cotton tipped applicatorSA
hepatic encephalopathy (hepatic coma, liver coma)
MANIFESTATIONS
- mental status is altered ask if they know what day it is
- asterixis (flapping tremors of the hand) ask them to extend arm
MEDS
- lactulose = laxative effect to trap and expel ammomnia
- lactulose is commonly used to treat asterixis (flapping hand tremors)
- neomycin
LACTULOSE INSTRUCTIONS
- desired effect is 2-3 soft stools a day so don’t hold if that occurs
- give on empty stomach for rapid effect
- mix with fruit or juice for better flavor
- assess mental status and orientation
CONTRAINDCATION
- benzodiazepines
HYPERTENSIVE ENCEPHALOPATHY
- sudden elevation of blood pressure
- medical emergency
- visual impairment
- epistaxis
- seizures
- coma
Irritable bowel syndrome (IBS)
spasms of the large bowel = diarreha
alternating constipation and diarrhea
- anticholinergic drugs are CONTRAINDICATED cus they relaxes smooth muscles leading to uirnary retention, bowel ileus, closed angle glacuoma
INTERVENTION
- add probiotic supplement to reduce IBS symptoms
- increase amount of fiber for constipation predominant
- promote healthy coping skills with the child, talk about problems
- ensure adequate exercise
barium enema
uses contrast media to visualize the colon
- no informed consent is needed
- USE OF LAXATIVE IS GOOD AND ASSIST IN EXPELLING THE CONTRAST
WORRY MORE ABOUT TELLING THEM NOT TO EAT OR DRINK ANYTHING PRIOR
- take cathartic to empty stool
COLONOSCOPY
- no prophyl antibiotics fro healthy clients
- no food or drinking prior
- clear liquid diets the day prior
- drink polyethyelene glycol as directed the day before
POST COLONOSCOPY EXPECTED FINDINGS
- polyethylene glycol is prescribed as bowel preparation for colonscopy
- abdominal cramping
- frequent, watery stools
- recurring flatus
REPORT = signs of perforation
- positive rebound tenderness
- abdominal distension
- boardlike (rigid) abdomen
CLEANSING ENEMAS
- should be administered at room temperature or warmed
- place in sims position (left lateral with one knee flexed
- hang the enema bag no more than 12 inches or 30 cm above the rectum to avoid rapid adminstration
- lubricate the ebema tip and gently insert 3-4 inches into the rectum
- direct tubing tip towards the umbilicus to prevent intestinal perforation
- encoyrage to hold enema for as long as possible (5-10 mins)
if cramping occurs, slow administration rate
PTSD
- ppl who have experienced terrifying, traumatic event (war, tonardo, rape, plane crash)
3 months or more after trauma - less than 3 months = acute stress disorder
FIRST STEP TOWARD RESOLUTION = readiness to discuss the details of the traumatic event without experiencing high levels of anxiety
MANIFESTATIONS
- re-expericing the traumatic event
- they are usually restless and hypervigilant
- avoiding reminders of the trauma
- difficulaty concentrating
- persistent angry, fearful mood
- increased anxiety = clients with high anxiety levels 8/10 and pacing behavior are demonstrating distress and require IMMEDIATE ATTENTION as they might harm themselves or others
- emotional arousal
toddlers (1-3) style of play
PARALLEL PLAY autonomy vs shame & doubt
- PLAY ON THEIR OWN but still around eachother
- they thrive on rituals and routines
- they play next to each other and are happy to be in the presence of peers but they do not play directly with one another
- tactile play
- not interacting
- independent don’t wanna play with anybody = egocentric
PROCEDURES EDUCATION
- teach them about the procedure immediately before it is performed
INFANTS (birth to 1 year)
- focus on their own activity
- play in the presence of others
- separation anxiety produces more stress to infants than any other factor
- separation or stranger anxiety starts at 6 months and peak at 10-18 months and can last until age 3
SEPARATION ANXIETY INTERVWNTION
- provide visual reminders of the parent in pictures
- encourage the parent to leave stuffed animals
- given plenty oppotyunity to play
TOILET TRAINING
- easier than uirna
- child should be able to pull down clothes
- child may be ready when they are able to communicate and follow directions
fun facts about toddlers
- head cirucmference increases by 1 inch during the second year until 5. its less than 0.5 a year from there
- chest circumferance is greater than abdominal circumference
preschoolers (3-6) style of play
PRETEND, ASSOCIATIVE, IMAGINATIVE PLAY
- iniative vs guilt = they intiate and feel guility for things that happens to them like sickness
- they think they caused their sickness and its a punishment
- imitating adults
- play with eachother together in groups
- engage in similar activity or play with the same or similar items
- play is unorganized without specific goals or rules
- borrow items from each
other without directing each others play
- respond best to positive reinforcement and rewards (stickers)
- magical thinkers
TOYS
- playing dress up
- using household toys, telephones, medical kits, dolls and puppets
initiative vs guilt
- work on their FINE MOTOR (finger dexterity
- work on BALANCE ( tricycles, dance class, iceskates
- Characterized by CO-OPERATIVE play (play with eachother together in groups)
- they like to PRETEND = HIGHLY IMAGINATIVE
- they can draw and copy a scare
school age (6-12) style of play
COOPERATIVE PLAY
- complex and competitive
- play with one another with specific goal (building castle from blocks)
- have set of rules
- COMMON GOAL
- patients should provide them with schoolwork during hospitalization
PROCEDURES EDUCATION
- use simple diagrams with correct anatomical terms
trigerminal neuralgia (tic douloureux)
- TREATMENT = carbamazepine
- unilateral excrutiating facial pain along the trigerminal nerve (CRANIAL NERVE 5)
- not life threatening
- electric shock like pain in the lips, gums and severe pain along the cheekbone
TRIGGERED BY
- touch
- talking
- hot/cold air or intake
Rupture of membranes (ROM)
- after ROM = prioritization is assessing the fetal status (fetus heart tones)
- pregnant clients are tested for GBS (group B strep) colonization at 35-37 and RECEIVE PROPHYLACTIC ANTIBIOTICS DURING LABOR IF RESULTS ARE POSITIVE
NITRAZINE PH TEST
- used to differentiate between amniotic fluid which is alkaline and normal vaginal fluid which is acidic
- bluish color suggest ROM
- recent sexual intercourse should be reported to the health care provider
presence of blood or semen may result in false positive nitrazine ph test
cranial nerves
- Ofactory
- Optic
- Oculomotor
- Trochlear
- Trigerminal
- Abducens
- facial
- acoustic/vestibulococlear
- glossopharyngeal - swallowing
- vagus
- spinal accessory
- hypoglossal
Oh Oh Oh To Touch And Feel A Girls Vagina Ah Heaven
FUNCTIONS
Some Say Marry Money But My Brother Says Big Brains Matter Most
- S = sensory
- M = motor
- B = both
CEREBELLUM
- balance and posture
- coordination
- heel to shin test is used to assess cerebellar fucntion
ROMBERG TEST
- loss of balance when eyes is closed and legs together indicates positive
GTPAL
- Gravida: number of times preggo regardless of outcome
- Term: 37 weeks or beyond
- Preterm: between 20 weeks and 36 weeks 6days
- Abortion: ending before 20 weeks
- Living: living
to determine if a client is currently pregnant, combine term, preterm and abortions. if the gravida is greater, then the client is currently pregnant
when to call rapid response
- heart rate less than 40 or over 130
- systolic less than 90
- respiratory rate less than 8 or above 28
- O2 levels less than 90
- urine output less than 90 in 4 hrs
- chnage in loss of conciousness that does not respond to treatment
DRUGS TO AVOID DURING PREGNANCY (teratogenic)
PLIMAWV
- phenytoin
- lithium
- isotretinoin
- methrotrxate
- ACE inhibitors
- warfarin
- valproate
- alcohol
- NSAIDS
huntington disease
- CHOREA (INVOLUTARY, tic-like movement)
- respiratory complications
- autosomal dominant that causes progressive nerve degeneration
- hereditary, not spontaneous
INTERVENTION
- genetic counseling is recommended
- one carrier parent is needed to cause disease
herbal supplements
- kava and valerian root: used for anxiety, insomnia and depression
abdominal aneurysm
- pulsatile mass in the preumbilical area slightly to the left of midline = MONITOR FOR HEMORRHAGEE*
- very high priority, even over peritonitis
MANIFESTATION
- back:abdominal pain
- bruits heard upon auscultation
ABDOMINAL AORTIC ANEURYSM
- monitor for peripheral pulses
- monitor renal
- monitor neurologic status
ENDOVASCULAR ABDOMINAL AORTIC ANEURYSM REPAIR
- done via femoral artery so check groin puncture sites for bleeding
- NO ABDOMINAL INCISION IS REQUIRED
- NO CHEST TUBE REQUIRED
- monitor fluid intake and urine output = kidney function
ANTIDOTES
• Acetaminophen - N-acetylcysteine
• Benzodiazepines - Flumazenil
• Beta-blockers - Glucagon
• Carbon Monoxide - 100% 02
• Heparin - Protamine Sulfate
• Iron - Deferoxamine
• Opiods O - NalOxOne
• Warfarin - Vitamin K
natrexone is for opiod DISORDER
