high fidelity Flashcards
1
Q
DKA/ HHS assessments and interventions
A
Assessments:
- Neuro: LOC, weakness, lethargy, look at pupils, hand squeezes
- Heart: rate (tachy), listen, vitals, peripheral pulses (probably weak), get CBC with electrolytes (check K+), glucose test, urinalysis with ketones
- Resp: Kussmal’s, rapid, labored, accessory muscles, listen, breath fruity
- Skin turgor
- Ask if they’ve been vomiting and listen to bowels
- Assess for hx of diabetes
- Assess precipitating factors like infection, stress, poor management
Interventions:
- Hydrate with NS for dehydration and improve circulation (reassess turgor and peripheral pulses)
- Insulin drip to bring glucose levels down (reassess BG q30 min)
- Potassium to increase levels of K+ and improve cardiac function (reassess CBC)
- O2 if sat is low (reassess vitals including sat)
- Stop IV at 250 and switch NS to D5NS or D51/2NS
- Education - self care, triggers (infection, stress, insulin neglect) and sick day rules
2
Q
Thyroid storm assessments and interventions
A
Assessments:
- Neuro: altered LOC, N/V, anxiety
- Cardiac: Tachycardic, ECG, peripheral pulses
- Goiter?
- Vitals
- Fever
- Resp: SOB
- Shock
- GI: Listen to bowels; might be N/V
Interventions:
- turn if vomiting
- zofran if n/v (reassess nausea after administration)
- Ice pack and cooling blanked to decrease temperature (reassess temp)
- Tylenol to decrease temperature (reassess temp)
- Order TSH, T3 and T4 levels
- Antithyroid medication (PTU or methimazole) to slow down the production of thyroid hormone
- O2
- NG tube with intermittent suction to prevent vomiting and aspiration
- Beta blocker (propranolol) to slow heart rate and decrease BP
- educate
3
Q
Preeclampsia assessment and interventions
A
Assessments:
- Assess vitals: Blood pressure
- Neuro: headaches, reflexes, clonus, blurred vision/ blind spots, eyes for twitching and nystagmus
- Cardiac: edema, pulses, –CBC, liver enzymes- ALT and AST
- Abdominal pain
- Glucose
- Urinalysis/ urine output- proteinuria
- FETAL HEART MONITORING
Interventions:
- Dim lights to give less stimulation (reassess headache and seizure activity)
- Mg sulfate (keep Ca+ gluconate at the bedside) to help reduce seizures (reassess reflexes and seizure activity)
- Antihypertensive (Hydralazine or Labetalol) to lower blood pressure (reassess BP)
- O2 to provide adequate oxygen to the brain and vital organs and baby (reassess vitals with O2 sat)
- Turn if they have seizures to prevent aspiration and keep pillows by siderails to prevent injury
- Position on left side
- Time seizures
- Suction close by
- prepare for delivery because the only cure for eclampsia is delivery
- educate (reassess understanding)
- Oxytocin to stimulate contractions if going to deliver
4
Q
PP Hemorrhage assessment, interventions and NANDAs
A
Assessments:
- vitals
- pulses
- cross and type match
- H&H/CBC
- assess perineum
Interventions:
- Massage fundus
- Increase Pit to 20 mu/min
- Antibiotics to prevent infection
- Fluid administration
NANDA:
- Fluid volume deficit related to vaginal bleeding
- Ineffective tissue perfusion related to vaginal bleeding
5
Q
shaken baby syndrome assessments and interventions
A
Assessments:
- neuro: lethargy, stimulation, eyes
- retinal hemorrhaging
- bruising/ fractures
- vitals (sat, temp… both could be low)
- assess caregiver interaction and story
- past medical hx: colic precipitates shaken baby
- ask about non-abuse past trauma
TICLS:
- Tone: active or listless? do they grab your finger?
- Interactiveness: want eyes open or closed? turn to investigate noise?
- Consolability: can they be appropriately aggitated and calmed?
- Look (or gaze): does the infant look toward the new stimuli?
- Speech (or cry): strong or weak or absent?
interventions:
- order radiologic imaging… CT to diagnose any subdural hematomas or cerebral edema; XRay of skull to identify fractures
- oxygen to supply O2 to the brain
- swaddle to keep warm
- call CPS because we need to further investigate this case and make sure the baby is safe
- make sure someone stays with caregiver so baby is not alone with them to make sure baby is safe
- turn and suction if they are vomiting to prevent aspiration
- stabilize neck if possible to prevent further injury if there is a spinal injury
- anticonvulsants to prevent seizures
6
Q
pertussis assessment and interventions
A
Assessments:
- severe coughing spells, barking cough on inspiration
- lasting 2 weeks
- post cough vomiting
- weight loss
- respirations: dyspnea, cyanosis, nasal flaring
- vitals (fever, O2 sat)
- history of flu symptoms 1 to 2 days ago
- tachycarida
- neuro: confusion, headache, sleep disturbance, nervousness
- GI: difficulty eating
- Assess turgor
- Assess vacines
Interventions:
- oxygen if necessary: rapid breathing and tachy are early indicators of hypoxia
- cool air humidifier to dilute the mucus
- high fowler’s if possible: increases lung capacity
- if dehydrated, give fluids PO or IV
- monitor intake and output to detect dehydration
- order for a culture to confirm diagnosis (explain to parent that it is for the CDC)
- antibiotics to get rid of infection and prevent further infection and transmission
- educate parents that infants
7
Q
hypoglycemia assessment and interventions
A
Assessments:
- LOC
- glucose
- vitals
- last insulin administration
Interventions:
- glycogen
- carbs and protein
- education
8
Q
chest pain assessments and interrventions
A
Assessments:
- LOC
- Peripheral pulses
- Pain/vitals
- Heart sounds
- ECG
- respirations: might be short of breath
- what makes it better or worse?
- when did it start?
Interventions:
-Rest to reduce cardiac demands
-O2- to reduce O2 demands on the heart and get O2 to the vital organs
-Nitro sub lingual to cause vasodilation so the heart doesn’t have to work so hard to pump blood
-Teach side effects of Nitro and to be sitting when taking
-CBC and troponin levels
-beta blockers to decrease BP and heart rate, reducing the heart’s demand for oxygen
and therefore preventing angina
9
Q
DKA/HHS NANDAs
A
-Fluid Volume Deficit related to: osmotic diuresis due to hyperglycemia, excessive discharge: diarrhea, vomiting; restriction intake due to nausea -Imbalanced Nutrition: Less Than Body Requirements related to: insufficiency of insulin, decreased oral input, hypermetabolic state.
10
Q
sick day rules
A
- for DKA
- take medication/insulin as usual
- check glucose and ursine ketones q3-4 hrs… call providor if FSBG>300 or positive ketones
- avoid dehydration
11
Q
preeclampsia NANDAs
A
NANDA:
- anxiety r/t fear of the unknown, threat to self and infant
- deficient knowledge r/t lack of experience with the situation
12
Q
Shaken baby NANDAs
A
NANDA:
-increased intracranial adaptive capacity r/t brain injury
13
Q
Pertussis NANDAs
A
NANDA:
- activity intolerance r/t generalized weakness, dyspnea, fatigue, poor oxygenation
- ineffective breathing pattern r/t inflamed bronchial passages, coughing
- anxiety r/t respiratory distress and hospitalization stay
