NCLEX Flashcards
Diseases with too much aldosterone
Cushings (too much of all steroids), hyperaldosteronism (Conn’s)
too little aldosterone
Addisons- Need to ADD steroids- will go into FVD
ANP action
in response to atrial stretch (from vol excess) released to cause excretion of sodium and water
goes up with concentration and down in dilution
urine specific gravity, sodium and hematocrit
Anti diuretic hormone action (ADH)
causes retention of only water- think ADH-H20. ADH from pituitary in head- head injury or sx? increased ICP?
too much ADH
SIADH- too many letters, too much water! Na does not follow the water. retain water- FVE. urine concentrated (being retained) and blood dilute
too little ADH
DI= Diurese. Lose water, FVD, urine dilute and blood concentrated.
normal CVP
2-6 mmHg, or 5-10 cmH20
Fluid retention think
heart problems first. Watch the weight on all heart patients.
assessment or evaluation think
signs and symptoms
Bed rest induces
diureses- blood comes back to core- atrial stretch- ANP and reduction of ADH. Everything thinker- pulmonary secretions (pneumonia), blood (DVT), kidney stones- push fluids unless contraindicated. watch for crackles, edema, weight, BP, CVP
IVF slowly to
old, young, hx of heart or kidney problems
polyuria think
shock. loss of fluids from anywhere: thoracentesis, paracentesis, vomiting, diarrhea, hemorrhage, third spacing.
sxs FVD
decreased weight, BP, UO, skin turgor, dry membranes, increased respiratory rate, concentrated urine (increased specific gravity), cool and clay. SAFETY- risk for ORTHOSTATIC HYPOTENSION, risk for falls and overload
isotonic fluids action
increases blood pressure, NS goes with blood products. DO NOT give to HTN, cardiac or renal d/s can cause FVE, HTN, or hypernatremia (ones with sodium)
types isotonic fluids (4)
NS, LR, D5W, D5 1/4 NS
hypotonic fluids action and types (3)
(hypO= Out of vessel) shifts into cells- rehydrates without causing HTN. For those with hx of HTN, cardiac or renal d/s, to dilute hypernatremia. D2.5W, 1/2 NS, 0.33%NS ALERT- watch for cellular edema/ too much fluid to cells can cause FVD in vascular space and decrease BP
hypertonic fluids action and types
(hypEr= Enter the vessel) Volume expanders
for hyponatremia or severe third spacing. ALERT- monitor for FVE- BP, pulse, CVP. D10Wm, 3 or 5%NS, D5LR, D5 1/2NS, D5 NS, TPN
2 types of cancer
solid tumors and hematologic malignancies
sarcoma
solid tumor in connective tissue- bones, cartilage, tendons
carcinoma
solid tumor in epithelial tissues- line organs- and skin! most common type of cancer
hematologic malignancy
originate from blood or lymphatic system- leukemia, lymphomas..
metastasis
ability to travel- can travel by direct invasion, through blood stream or through lymphatic system
cancer primary prevention
no smoking, exercise good nutrition, maintain normal weight, limit or eliminate alcohol, vaccine for viruses, avoid exposure to carcinogens
secondary prevention for cancer (female)
screenings to detect early. Breast SE day 7-12, clinical breast exam q3yrs 20-39 and q1yr >40. paps q3yr >21 y/o. mammogram starting at 40 y/o
colonoscopy and fecal occult blood > 50 y/o
secondary prevention for cancer (male)
breast self awareness, yearly testicular exam, monthly self exam, (majority ages 15-36!!) teach testical self exam early. Digital rectal example, PSA, and fecal occult blood annually after 50. colonoscopy at 50 and q10yr.
Cachexia
extreme wasting and malnutrition (used in cancer)
Cancer symptoms think
Caution Chang in bowel/bladder habits A sore that does not heal Unusual bleeding or discharge Thickening or lump Indigestion or difficulty swallowing Obvious change in wart or mole Nagging cough or hoarseness Also- weight loss, FATIGUE, pain Fever- first in leukemia and lymphoma (infection! )
Cancer can invade bone marrow causing (3)
Anemia -hypoxia risk
leukopenia- infection risk
thrombocytopenia- bleeding risk
rupture of innominate artery
bleeding massively from the trach- call Dr, OR ASAP
sputum specimen
get first thing in the morning, sterile technique! sterile specimens. have client rinse out mouth first to decrease mouth bacteria, don’t let mouth touch the sterile cup. if they have a trach- get the sputum specimens from the trach.
total laryngectomy
removed vocal cords and epiglottis- have a permanent trach. can use an electrolarynx or Blom- Singer to talk. they cannot whistle, drink through a straw or swim, can smoke through the trach.
suctioning a trach
hyper oxygenate before and after, sterile procedure, stop advancing at resistance/ cough, intermittent suction on the way out for no longer then 10 seconds, monitor HR/arrythmias, can stimulate the vegas nerve and cause HR to drop
adjuvant
using two complimentary treatments together- like chemo and radiation
neoadjuvant
time specific therapies- one is done before the next- like surgery to remove tumor followed by chemo.
Grade of cancer
1-4 based off of how different cells are from the original cells- more different- more aggressive.
TNM system
cancer staging- TNM
Tumor size, lymph Node involvement, Metastasis?
mastectomy with lymph node removal
protect that side for the rest of life- no constriction, no: watch, purse on that side, IV, BP, sunburn, nail biting, elastic blouses, watch small cuts
brachytherapy
internal radiation close to cancer. both pts will emit radiation
unsealed- IV or PO, radioactive for 24-48 hrs and radioactive body fluids
sealed or solid- body fluids not radioactive, can be temp or permanent implants
*safe to assume all emit radiation!!!
nursing internal radiation precautions
time, distance, iron shield. rotate assignment daily, nurse should only get one radiation implant pt a shift, private room, film badge, wear gloves with risk of exposure to body fluids, mark room with instructions for specific isotope, prevent dislodgment- bed rest, fiber restriction, cath to prevent bladder distention
internal radiation pt visitors
limit, visitors must stay 6 ft away, cannot visit for more than 30 minutes. no visitors who are < 16 years old or pregnant.
after internal radiation precautions
client is immunosuppressed. stay 6 ft away from people for up to 10 days, close lid and flush toilet 2-3 times
radiation implant dislodgement
gloves, forceps, tongs- put in lead lined container and call radiation dept- leave it in the room
external radiation
AKA tele therapy or external beam radio therapy with a cobalt or gamma machine- pt is not radioactive- do not wash off markings or put lotion on them, protect the site from UV for 1 year
sxs from external radiation
1 c/o fatigue, location and dose related. erythema, shedding, altered taste, and pancytopenia (all blood components decreased)
calcitonin
hormone made by the thyroid gland. it takes ca from blood and puts it back into bones- so it decreases serum calcium. the drug calcitonin is given to pts with osteoporosis. need iodine to make hormones
don’t give beta blockers to
asthmatics or diabetics. hides the symptoms of hypoglycemia and can cause an asthma attack
parathyroid think
calcium. parathyroid secretes PTH (parathyroid hormone) which pulls calcium from bone and deposited it in the blood- increases serum calcium
hyperparathyroidism=
hypercalcemia= hypophosphatemia
too much PTH, serum ca is high and phosphate is low- client is sedated (Ca acts as a sedative) fix with partial parathyroidectomy
pheochromocytoma
benign tumors in adrenal medulla (on top of kidneys) that secrete boluses of epi and norepinephrine causing increase BP, pulse, flushing, HA, palpitations- check the catecholamine levels (vanilla test or metanephrine test, 24 urine collection) DO NOT palpate ABN, can cause bolus and severe HTN
4 major actions glucocorticoids
adrenal cortex steroid. Think MI-FI Mood, Immunosuppressed, Fat, Insulin
1- change mood
2- alter defense mech- suppress immune system
3- Breakdown fats and proteins -to glucose
4- inhibit insulin- hyperglycemia- monitor glucose
and don’t let them share room with infected b/c of suppressed immune system
Graves
hyperthyroid
addisons
insufficient steroids/ adrenocorticoids- glucocorticoids, mineralocorticoids (aldosterone), and sex hormones
aldosterone drug name
fludrocortisone
glucocorticoid administration
prednisone- give twice a day, 2/3 of dose in morning and 1/3 of dose in evening (for addisons disease)
addisons symptoms
Think no aldosterone or glucocorticoids. no aldosterone to help retain water and Na, so lose water and Na, retain K, hypotension; no glucocorticoids to make glucose or inhibit insulin, so hypoglycemic, confused, GI probs, fatigue, and skin discolorations- hyper pigment or depigment (vitiligo)
cushings
too many steroids- glucocorticoids, mineralocorticoids, sex hormones
magnesium and calcium think
sedatives/ muscles, loose, flaccid muscles, arrhythmia, decreased LOC, DTRs, pulse and respirations
normal magnesium
1.3-2.1 mEq/L
normal calcium
9.0- 10.5 mg/dL
low magnesium or calcium
tight rigid muscle tone, risk for seizure, stridor/ laryngospasm, chvosteks and or trousseaus sign, arrhythmia, DTRs increased, swallowing probs
calcium gluconate
given IVP very slowly (max 1.5-2mL/min) For hypermagnesium (antidote), or hypocalcemia
hypermagnesium causes, tx
renal failure or antacids (tums have magnesium) tx: vent if resp depression, dialysis if kidney prob, calcium gluconate antidote
hypercalcemia cause and tx
hyperparathyroid (too much PTH), Thiazides (retain Ca), immobilization- bear weight to keep Ca in bones, fluids to prevent kidney stones, DVT, sodium phosphate- inverse relationship, steroids, phosphorous foods, calcitonin, vitamin D
hypomagnesium cause and tx
diarrhea, alcoholism- give Mg but monitor kidney fin!, seizure precautions, eat magnesium
foods high in magnesium
spinach, mustard greens, summer squash, broccoli, halibut, turnip greens, pumpkin seeds, peppermint, cucumber, green beans, celery, kale, sunflower seeds, sesame seeds, flax seeds
hypocalcemia cause and tx
hypoparathyroidism, radical neck dissection, thyroidectomy (all not enough PTH)
Vit D, phosphate binders (sevelamer, calcium acitate), IV Ca- give slowly with pt on heart monitor
Na think
Neuro! neuro changes when sodium is high or low
hypernatremia= dehydration cause
feeding tube, hyperventilation, heat stroke, DI. give fluids, restrict Na, Daily weights, I&O, lab work
hyponatremia= Dilution cause and tx
Replacing fluid with only water, psychogenic polydipsia, D5W, SIADH
client needs salt, not water, give hypertonic saline if having neuro probs- 3 or 5% NS- very dangerous, messes with brain and can throw into FVE
hypernatremia symptoms
neuro and dry mouth, thirsty, swollen tongue
hyponatremia symptoms
neuro and HA, Seizure, Coma
hyperkalemia cause and tx
kidney probs, aldactone (spironolactone-retain K),
dialysis if kidney prob, calcium gluconate for arrhythmia, glucose and insulin, Kayexalate (sodium polystyrene sulfonate)
hyperkalemia ECG changes
bradycardia, tall peaked T waves, prolonged PR intervals, flat or absent P wave, widened QRS, conduction blocks, v fib
hypokalemia ECG changes
U waves, PVCs, v tach
hyperkalemia symptoms other than ECG
first muscle twitching, then weakness, then flaccid paralysis- then life threatening arrythmia
hypokalemia symptoms (not ECG)
muscle cramps and weakness then life threatening arrythmias
hypokalemia cause and tx
vomiting, NG suction, diuretics, not eating
potassium supps
GI upset with PO- give with food. IV always on a pump, mix well- settles, never IVP, burns during infusion, Assess kidneys/ urinary output before giving
potassium and metabolic A/B imbalance
metabolic acidosis= hyperkalema
metabolic alkalosis= hypokalemia
rule of 9s
head and neck-9
each arm-9
each leg-18
front-18, back-18
consensus formula
aka parkland formula
4mL LR X Kg X % burned= total for 24 hours
1st 8 hours- 1/2
next 16 hours- 1/2
titrate to 0.5mL/kg/hr urinary output (1mL for kids)
prealbumin
most sensitive indicator for nutritional status/ nitrogen balance
diet for burns
protein and vitamin C- always for max nutrition
meds to prevent GI stress ulcer
curlings ulcer
antacids= HYDROXIDE (a base!)-aluminum hydroxide, mag hydroxide (milk of magnesia). liquid on empty stomach at bedtime, when stomach empty more risk of acid on the ulcer, protects overnight.
H2 antagonist= DINEs, ranitidine, famotidine..-take at night to inhibit acid secretion
proton pump inhibitors= ZOLE- pantoprazole, esomeprazole..take before first meal
Sucralfate- barrier over ulcer. 1 hr b4 meals and at bedtime, empty stomach, with glass of water- no other meds at same time.
tetanus toxoid
booster- takes 2-4 weeks for body to make antibodies- active immunity. give with burns unless overdue for booster or don’t know- then give immune globulin (antibodies)-passive immunity
circumferential burn
circulatory checks- pulse, color, temp, cap refill
if bad- escharotomy or fascitomy to relieve pressure
brown or red urine post burn
myoglobin from damaged tissues- can clog kidney- call dr. may give Mannitol to flush (diuretic) also given for increased ICP. EXCEPTION- normally want to give fluids not diuretics to burn pt- trying to save kidneys
burns and potassium
tissue damaged- k leaks out of cells, hyperkalemia
enzymatic debridement
sutilains or collagenase- eat dead tissue
not for face, if PG, over large nerves or if area is opened to a body cavity.
mycin drugs
cause nephrotoxicity and ototoxicity- monitor BUN, creatinine and hearing
autograft
(burns) graft from own skin, dressing at donor site until stops bleeding, then open to air, can re harvest from same donor site every 12-14 days in healthy pt
electrical burn
heart monitor for 24 hours, at risk for v fib, c collar until cervical fracture is r/o
Cardiac output assessment
focused assessment- do anytime a hear rhythm change!
LOC, Chest pain?, wet lungs, skin cold and clammy or warm and dry?, Urinary output, peripheral pulses
what is coronary artery disease
broad term that includes chronic stable angina and acute coronary syndrome (MI and unstable angina)
drugs for chronic stable angina
nitro- dilates all vessels, decreased BP, ASA
and BLOCK from happening again (prevention) with BB and CCB!
beta blockers (prevention)- decrease BP, pulse and contractility
ca channel blockers (prevention)- dilates arteries, including coronary arteries and decreases BP
don’t leave a hypotensive client- unstable!
given to protect kidneys from iodine dye
acetylcysteine preprocedure; iodine based dye makes them feel warm and flushed and palpitations are normal- cardiac cath uses dye!
Triad MI symptoms
in women with MI- indigestions/ abdominal fullness, chronic fatigue and SOB. women also c/o pain btwn shoulders, aching jaw or choking sensation
1 sign MI in elderly
SOB. they may faint or have a behavior change
anytime ELDERLY + BEHAVIOR CHANGE = PROBLEM could be UTI, but r/o life threatening causes first
MI labs
troponin most sensitive and specific- elevates 3-4 hours and remains elevated for 3 weeks
myoglobin increases within one hour and peaks in 12 hours- not specific for diagnosis, but can be used to R/O
troponin levels
troponin T < 0.10 ng/ml
troponin I < 0.03 ng/ml
digoxin
normal level- 0.5-2 ng.ml
increases contractility and decreases heart rate (check apical pulse) =increase CO
toxicity GI probs then arrhythmia and vision change
apical pulse location
5th intercostal , left midclavicular
fluid retention, think
heart problems (heart failure) report weight gain of 2-3 lbs (1-2 kg)
loss of capture
when pacemaker fires but does not result in a heart contraction
failure to sense
when pacemaker fires at inappropriate times when it is not needed
cardiac tamponade
blood fluid or exudates have leaked into pericardial sac resulting in compression of heart. hallmark signs: INCREASING CVP with DECREASING BP. NARROWED Pulse Pressure=CARDIAC TAMPONADE
WIDENED PP= INCREASED ICP
decreased CO= worry shock
TX- pericardiocentesis
Pulse pressure
difference btwn SBP and DBP.
Narrowed= Cardiac Tamponade
Widened= Increased ICP
these are changes from baseline
depression nursing interventions
help with self care during acute stage. help them experience accomplishments
no compliments, thoughts slowed- slow communication or give silence
prevent isolation- Seek them out! Interaction helps
manic interventions
decrease stimulation, no group- one on one, brief frequent contact with staff, writing activity good. walk with them during meals- use finger foods. weigh daily, don’t get manipulated, set limits and remove hazards
schizophrenia interventionsq
decrease stimuli, observe frequently w/o looking suspicious, orient frequently, keep conversations real world, they have concrete thinking and lots of communication probs (echolalia, neologism, word salad) “i don’t understand” may be LOA X4 and still have delusions or hallucinations
paranoid
trust issues- be reliable, be honest, build trust. ID meds, don’t mix, don’t be overly friendly/ touching. consistent nurses, no competitive activities- they have an abnormal anger response- tantrums- hypersensitive. all consuming jealousy- everyone has it better
alcohol withdrawal intervention
DTs (stage 2 and 3 delirium) keep the lights on
stage 1 and 2- walk and talk to them- keep reorienting
give anxiolytics- may have a tolerance q2h. thiamine injections, multivitamins and magnesium
alcoholic signs and symptoms
peripheral neuritis/impotence (kills nerves- low B vit effects)
kills GI- liver and pancreas probs, gastritis
diurese- lose mg and K
complications- korsakoffs (time disorientation- confabulate), wernickes (moody, tire easily)
panic attack
stay 6 feet away and use simple words. symptoms will peak within 10 minutes. have clients journal to reduce anxiety and identify triggers, peaks and valleys.
hallucinations interventions
warn before you touch, don’t say they, involve in an activity- out of hallucination and into real world. elevate HOB, turn off TV, and offer reassurance
ECT pre and post procedure
for severe depression and manic
NPO, void, atropine to dry secretions, succinylcholine chloride to relax muscles, baseline injuries
post- on side, don’t aspirate, stay with client, assure family temporary memory loss is expected, reorient over and over, involve in day’s activities ASAP
amount of fluid replacement in glomerullonephritis
24 hour loss + 500 mLs for insensible loss
kidney damaged so not excreting, careful of FVE
anasarca- when happens and patho
total body edema- seen in nephrotic syndrome-
inflammatory response produces large holes in kidneys lose large amount of proteins. no protein in the blood so blood goes into tissues, bp decreases. the only kidney patient will increase protein intake in
fixed specific gravity
seen in renal failure- kidney lose ability to concentrate and dilute urine. do a Fluid Challenge- give bolus of 250 or more NS and the specific gravity will not change.
acute renal failure oliguric phase- worry about
FVE and hyperkalemia- retaining fluid and potassium. UO is decreasing to 100-400mL/24 hrs
acute renal failure diuretic phase- worry about
FVD and hypokalemia. sudden increase in UO, excreting fluid and potassium
assessing patency of dialysis access
palpate a thrill and auscultate a bruit
feel thrill- can purr, hear bruit- turbulent blood flow
symptoms of peritonitis from peritoneal dialysis
abdominal pain and cloudy effluent— cloudy effluent with any peritoneal dialysis= infection! should be clear, stat color
diet for client on peritoneal dialysis
fiber- abdominal fluid is decreasing peristalsis
protein- lose protein in exchange bc holes in peritoneum are large
CCRT
continuous renal replacement therapy- done in ICU, never > 80 ml fluid out of body at one time- less stress on cardiovascular system. for pt with fragile cardiovascular status and acute renal failure
urolithiasis
means stone in ureter- renal calculi
symptoms: pain with N/V, WBC in urine, hematuria- urine test for RBC
tx with ketorolac, ondansetron and hydromorphone, increase fluids
extracorporeal lithotripsy
extracorporeal shock wave lithotripsy (ESWL) high energy shock wave to break kidney stones into sand- will come back with foley, want to see sediment in bottom of bag.
Glasgow coma scale- 3 responses
measures LOC
Eye opening, motor response, verbal response. 0 means no response. total can be 3-15, anything less than 13 bad, requires full neuro assessment hourly
Babinski reflex
normal for children under 1 year/ not walking, is fanning toes
plantar (curled toes) normal for adult
documenting reflex
(0) absent, (2+) normal, (4+) hyperactive. must have denominator to show scale used. so normal= 2+/4+
CT
computerized tomography - may use die (consent), picture slices/ layers, keep head still and no talking
MRI
magnetic resonance imaging- better than CT, not usually a dye, uses a magnet. no jewelry, pacemaker, credit cards, old tattoos may have lead, can’t talk or hear others in tube. teeth fillings okay
Cerebral Angiography
angiography- DYE (consent), x ray of cerebral perfusion
iodine based dye- hydrate, void, peripheral pulses, groin prepped, watch BUN, retaining, output hold metformin, warmth in face and metallic taste
after- bed rest 4-6 hours, monitor femoral bleed, possible embolus,
ECG
electroencephalography- records electrical activity of brain to dx seizure d/o, screen for coma/brain death, and to dx sleep d/o. no caffeine, no sedatives- but normal breakfast so no blood sugar drop. baseline EEG lying quietly- then hyperventilate or stimulate coma patient
lumbar puncture
to obtain spinal fluid to analyze for blood, infection, and tumor cells or measure pressure with manometer, admin drugs. position over bedside table with head down. CSF should be clear and colorless
after- lie flat or prone for 2-3 hrs, increase fluids, HA is common- increases with increase HOB, for HA: bed rest, fluids, pain med and blood patch- do not do puncture if known increased ICP
normal ICP
0-15 mm Hg
early symptoms of increased ICP
earliest- change in LOC, slurred slowed speech, delay in response to verbal suggestion, slow to respond to command, increased drowsiness, confusion and may have HA, vomiting, pupil changes
late signs of increased ICP
worse change in LOC progressing to stupor and coma
Cushing’s Triad, posturing and may have HA, vomiting,and or pupil changes
Cushing’s triad
changes in vital signs seen with increasing ICP
Systolic HTN with widening pulse pressure, slow, full, bounding pulse, irregular respirations- change in pattern like cheyenne stokes or ataxic (containing apnea)
posturing types
response to painful/ noxious stimuli when motor response centers are compromised
deCORticate- towards the CORE, arms flexed inward and bent in toward body, legs extended
Decerebrate- all 4 extremities in rigid extension- really bad and burning calories
complications of increased ICP
brain herniation- obstructs blood flow to brain
DI and SIADH (with head injury)
Tx of increased ICP
maintain O2, isotonic saline, inotropic agents (dobutamine and norepinephrine), monitor BP and HR closely, want to decrease ICP without decreasing cerebral perfusion. keep temp < 100, elevate HOB, keep head in midline to promote drainage from head, monitor ICP when turning, avoid straining (restraints, no blowing, hep flexion, bowl or bladder distention) limit suctioning, space out nursing interventions, monitor Glasgow coma, cushing triad, phenobarbital to decrease cerebral metabolism, osmotic diuretic (mannitol) steroids to decrease cerebral edema
ICP monitoring
ventricular catheter monitor or subarachnoid screw
risk for infection, no loose connections, keep dressings dry to decrease bacterial ability to travel through
neuro- when thinking intubate?
when glasgow coma is less than 8, think intubate
meningitis
inflammation of spinal cord or brain
bacterial- transmitted through respiratory system-DROPLET PRECAUTIONS, very contagious, very deadly- immunize before college
Viral transmitted by feces and requires CONTACT PRECAUTIONS seen more in infants and children
symptoms of meningitis
chills/ fever, severe HA, N/V, nuchal rigidity (stiff neck), photophobia
meningitis tx
steroids, antibiotics (bacterial), analgesics
DROPLET PRECAUTION- Bacterial
CONTACT PRECAUTION- Viral
generalized seizure
AKA non focal- involves entire brain and initial manifestation is Loss of Consciousness
Partial seizure
AKA focal- involves a local area of brain- symptoms vary widely. simple means no loss of consciousness, complex means impaired consciousness, confused, unable to respond
tonic- clonic
AKA grand mal
tonic- lose consciousness and completely rigid
clonic- jerking, muscles tense and relax
myoclonic seizure
sudden, brief contractions of a muscle or group of muscles
absence seizure
AKA petit mal characterized by brief loss of consciousness
anticonvulsants for seizure
rapid acting- lorazepam
long acting- phenytoin or phenobarbital, have toxic SE so used smallest effective dose, monitor drug levels for tox through lab values, abrupt withdrawal can cause seizure
autonomic dysreflexia
upper spinal cord injury (above T6), aka hyperreflexia. characterized by severe HTN and HA, bradycardia, nasal stuffiness, flushing, sweating, blurred vision, anxiety- can cause stroke
sit client up to decrease BP, put in catheter for distended bladder, removed impaction (constipation), look for skin pressure/ pain, cold draft…
where would you see bleeding with basal skull fracture
EENT, ears, eyes, nose, throat
difference in open/ closed skull fracture
whether the dura was torn
surgery for depressed skull fractures (skull depressed into brain), don’t normally need surgery for non depressed
NO Smoking when?
Anytime NPO. smoking increases stomach secretions- increase risk for aspiration. Also increases stomach motility- will effect an Upper GI series test- which you are NPO for as well (after midnight) also no gum or mints
go lytely
polyethylene glycol, put in freezer to make extra cold- can tolerate better, no straw (air), causes nausea- antiemetic- used for colon prep, colonoscopy
McBurney’s Point
Lower right quadrant -location of appendix and pain with appendicitis (initially generalized pain, eventually localizes here with rebound tenderness, N/V (after abdominal pain), anorexia)
clotting times
therapeutic INR 2-3
aPTT 30-40, >110 need antidote- protamine sulfate
normal PT 11-13 seconds, therapeutic is 1.5-2.5X normal
D dimer
blood test that increases in presence of blood clots. look at to dx pulmonary embolism, but if had surgery will be increased from clotting at incision site- VQ scan best to dx PE
crutches with stairs
up with good leg, down with bad leg
cane
use on strong side of body
LVN/ LPN delegation
Cannot plan or assess independently or care for unstable pt, but do not assign them anything a UA can do. they can reinforce teach
full chemo precautions
chemo/ isolation gown, 2 pairs of chemo gloves, goggles and or mask if splashing or inhalation can occur (with drugs or body fluids) YELLOW waste container or waste bag. excretion 3-7 days
PPE order
mask, gown, gloves, goggles
vesicant
type of chemo drug that causes extravasation if infiltrates. stay with any client receiving vesicant drug, if extravasation happens, stop infusion, cold pack, follow extravasation protocols
infection prevention cancer pt
private room, limit visitors, change dressings and IV tubing daily, cough and deep breathe, no fresh plants, bathe moist areas twice/day, wash hands after touching person or pet, avoid or wash really well fresh fruits and vegetables, drink only fresh water (can be out only 15 minutes), teach come to hospital with temp >100.4
ANC
absolute neutrophils count. watch on cancer patients, indicates how well they can handle an infection. normal is 2200-7700
Neutrophenic precautions
infection prevention + V/S q4h, private room with closed door and posted sign, antimicrobial soap for HH, no invasive tx (IM injection, rectal exam/meds, indwelling caths, NG (when possible)), limit acetaminophen
CMV
cytomegalovirus- very common herpes virus, dormant/ asymptomatic in healthy people. blood products for immunosuppressed is tested for it, they need CMV negative blood or CMV “safe”= blood with CMV goes through leukoreduction
patient has symptoms of being pregnant is called
presumptive signs- ex: amenorrhea, N/V, urinary frequency or breast tenderness. signs that can be observed by the Dr are probable sings- unless they are positive signs like a heartbeat
can hear baby heartbeat on doppler at ? weeks
10-12 weeks
fetoscope at 17-20 weeks
Gravida Parida
Gravida- number of pregnancies
parida- pregnancies when fetus reaches 20 weeks- not viable
viability
24 weeks
TPAL
term, preterm, abortion (spontaneous or elective), living children
naegele’s rule
due date estimator, first day of LMP, add 7 days, subtract 3 days, add 1 year. accurate within 2 weeks
increase calories and protein by how much during pregnancy
increase calories by 300/day AFTER first tri (500 if adolescent). 500 calories during breastfeeding
increase protein from 40-45 (normal) to 60
expect to gain 4 lbs in first tri
to prevent neural tube defects in baby
take 400 msg/day of folic acid. spina bifida is an example of neural tube defects
exercise rule during pregnancy
do not let your HR > 140. your CO and uterine perfusion will decrease. no high impact exercise- rec walking and swimming
fetal HR
120-160, 110-120 worry, <110 panic
need RBC when H and H
hgb of 8 and Hct of 24%
lightening
sign of labor- about 2 weeks before term, presenting part of fetus descends into pelvis, pt can breathe easier and is less congested but urinary frequency (last had in 1st tri) returns
engagement
largest presenting part in pelvic INLET. will block the cord from prolapse when membranes rupture. ROM- check fetal heart tones!!!
fetal stations measures
measured in cm and measures relationship of presenting part of the fetus to the ischial spines of the mom
labor- when go to hospital
5 minutes apart or ROM
Non stress test
(NST) want to see 2+ accelerations of 15+ WITH FETAL MOVEMENT (pt push button when feel mvmt). acceleration is abrupt increase from baseline that lasts 15+ seconds and come back to base within 2 minutes. recorded for 20 minutes
biophysical profile test (BPP)
done by U/S, each parameter counts as 2 pts- want 8-10/10. done in last tri or earlier in high risk, also high risk may do every 1-2 wks in 3rd tri. measures over 30 minutes: reactive NST, muscle tone (1 flex/extend), movement (3 times), breathing (1 mvmt), amniotic fluid adequate
contraction stress test
CST. oxytocin challenge test. oxytocin is very dangerous- one on one observation. determines if baby can handle stress of contraction, want non reactive. do not want to see late deceleration= uterine/placenta insufficiency. want a negative test, rarely done before 28 wks and RESULTS GOOD FOR ONE WEEK, positive= hospitalization
three types of decelerations
Early- okay- hypoxia from fetal head compression
late- bad- uteroplacental insufficiency
variable- bad- umbilical cord compression- move patient
epidural complication
Can have acute severe hypotension. give bolus 1000mL NS or LR before epidural and monitor BP- put in semi fowlers on side to prevent compression to vena cava.
when to turn off oxytocin
contractions too frequent or too long (want 1 every 2-3 minutes lasting 60seconds), or any signs of fetal distress- like late decels. TURN OFF not down
post partum lochia
Dark red (RUBRA) 3-4 DAYS
Pink/brown (SEROSA) 4-10 days
white/ (ALBA)- 10-28 days or up to 6 weeks anything abnormal (amount, color, smell) decrease activity and call doctor. goes backward to rubra, call 911
close no larger than a nickel
peripad rule
do not saturate more than 1 peripad per hour. more think hemorrhage
kangaroo care
should be done for 1 hour at least 4 times a week. bonding for baby: stabilizes HR, improves O2 sats, regulates temp, conserves calories
dx of early post part hemmorrhage
more than 500 mL blood loss in first 24 hours AND 10% drop in hematocrit from admission. late is anytime after 24 hours to 6 weeks.
meds: oxytocin, methylergonovine maleate, carboprost
mastitis tx
usually 2-4 wks pp from staphylococcus
bed rest, support bra, feed frequently from affected side first, heat and pain meds, penicillin drug of choice- allergy? erythromycin. take antibiotic after feeding
apgar
done at 1 and 5 minutes look at HR respirations, reflex irritability, color. want at least an 8
drugs at birth
erythromycin drops or ointment for eye prophylaxis from gonococcus and chlamydia, phytonadione (vit k) for clotting factors to vastus laterals
pathologic jaundice
jaundice within the first 24 hours of life. usually means Rh/ ABO incompatibility. after 24 hours is physiological jaundice (hyperbilirubinemia) normal hemolysis of excess RBCs, liver immaturity
Rh sensitization or Rh factor occurs when?
only with Rh (-) mom and Rh (+) baby, get exposed with first baby and develop antibodies (become sensitized) with subsequent pregnancies babies will have increased immature RBCs (making more because getting attacked- this is called Erythroblastosis fetalis)
Coombs
indirect coombs- test to mom measures antibodies for Rh
Direct Coombs- done on cord blood to count antibodies on RBCs.
with Rh + baby and sensitized mom will do frequent ultrasounds and deliver when baby stops growing.
Rho (D) immune globulin (RhoGAM) RULE
must give before antibodies form. given at 28 wks (just in case any mixing of blood, protects current baby) and anytime bleeding episode/ ANY chance mixing of blood. also given within 72 hours after birth (protects future baby) give after car wreck, before abortion or amniocentesis, ectopic pg, percutaneous cord blood
cystic fibrosis
usually discovered by salty kiss to baby or meconium illeus. losing salt, have steatorrhea. causes thick sticky mucus everywhere, need pulmonary txs, pancreatic enzymes get stuck, need enzymes with food (don’t digest fat well), need water soluble vitamins, autosomal recessive d/o (BOTH parents).
celiac d/s diet
lifelong genetic malabsorption d/o to gluten. canNOT eat BROW Barley, Rye, Oats and When
Can have rice, corn and soy.
normal infant heart rate and blood sugar
infant HR 30-60
bs 40-60
intussusception
bowl folds inside itself and obstructs- 3-36 months old, inconsolable, knees to chest, currant jelly stools with blood and mucus. is an emergency
number 1 sign MI in elderly
SOB, may faint, change in behavior
food high in both potassium and magnesium
CHoice Should Both Mag And K
cucumbers, spinach, broccoli/ banana, halibut, mustard greens, avocado, kale
hypoglycemia sxs and tx
cool, clammy, confusion, shaky, HA, nervous, nausea, increased pulse- give simple sugar (soda, milk, juice) then give complex carb with protein like crackers with cheese. AVOID fat- it delays absorption of sugars-
drugs to treat nephrotic syndrome
Diuretics to remove excess fluids
ACE Inhibitors - to block aldosterone (being excreted bc low fluid vol in vascular spaces- third spacing)
Prednisone to decrease inflammation and shrink holes in kidneys to stop losing protein
Lipid lowering drugs (cholesterol and lipids increased due to liver making albumin to replace whats lost
Anticoagulation therapy for 6 months- loss of plotting factors
increase protein- losing it.
common is albumin to pull fluid out of tissues with lasix to flush it out.
how is protein metabolized, what happens if liver broken?
protein is broken down into ammonia, the liver converts the ammonia to urea and the kidneys excrete the urea. so in liver failure ammonia builds up in blood- - decrease protein and salt in diet, lactulose and cleansing enemas to get rid of GI bleed and ammonia- protein in the blood is getting turned into ammonia…
hypothyroid looks like? sxs?
hypothyroid looks like depression. no energy, fatigue, no expression, depressed mood, slow/slurred speech, weight gain, GI slow, always cold, amenorrhea. may be immobile. tend to have coronary artery d/s (CAD)
hydatidiform mole Dx, tx/follow up
uterus grows too fast, no FHT, bleeding- confirm with U/S, D&C to remove. follow up- will do chest X-rays to determine metastasis, will measure hCG weekly until normal and then every 2-4 weeks, then q1-2 months for 6 mos to a year- do not get pregnant during this time!
leading cause of neonatal death
group b strep. give penicillin or clyndamycin
what is HELLP syndrome
severe pre-eclampsia. Hemolysis, Elevated Liver enzymes, Low Platelet sxs- RUQ pain, N/V malaise
cystic fibrosis think, electrolyte? dx test?
thick sticky mucus everywhere- main probs respiratory and GI, sweat sodium chloride, hyponatremia. test is sweat chloride test. newborn doesn’t pass first stool (meconium illeus) is first sign- too thick and sticky. high fat, calorie, protein diet and water soluble vitamins (ADEK)
CDU intermittent/ continuous bubbling, what is okay and what is not?
continuous gentle bubbling expected in suction chamber. water seal chamber can have intermittent bubbling, but never continuous bubbling in water seal chamber- leak, call dr.
heart failure tx- meds, diet monitor
standard is ACE I’s and ARBS (watch K), will go home on ACEI and/or Beta B. Also, Dig, diuretics, lo(
pulmonary edema cause and tx
heart, kidney prob and/or rapid fluid admin. have pink frothy sputum (like TB). keep O2>90%, diuretics, nitro, morphine, nesiritide (bnp), upright position
nephrotic syndrome tx (diet, 5 meds)
diet- low sodium, high protein (even though kidney problem, losing too much protein)
Give albumin to pull fluid back into vessels and diuretic to get rid of the excess fluid, ACEI to block the aldosterone that is causing retention, prednisone reduce inflammation and hopefully shrink hole too small for protein leak, lipid lowering drugs for hyperlipidemia, anticoagulation therapy for up to 6 months. dialysis
signs and symptoms of nephrotic syndrome (urine, blood)
proteinuria, hypoalbumineia, anasarca, hyperlipidemia, prone to clots
catheter for peritoneal dialysis
tenckhoff catheter
types of peritoneal dialysis
continuous ambulatory - 4 times a day, everyday
continuous cycle- at night
miscellaneous signs of increasing ICP
head injury/ problem with HA. changes in pupil and pupil response (fixed, dilated), projectile vomiting- pressure in vomiting center of the brain
Increased ICP Tx
maintain O2, maintain adequate perfusion so don’t allow hypotension or bradycardia, isotonic saline and inotropic agents, keep temp below 100 F (increased temp increases metabolism- maybe cooling blanket, hypothermia to decrease cerebral edema), elevate HOB, head midline position avoid anything that could increase ICP or cerebral metabolic demand- maybe barbiturate induced coma, mannitol, steroids, ventricular cath or subarachnoid screw
sxs of pancreatitis
pain that increases with eating- mass (swollen pancreas) in upper middle to left side, abdominal distention /ascities- losing protein rich fluids and blood- rigid board like abdm with culling sign or gray turns sign, fever, N/V, Jaundice. hypotension (bleeding/3rd spacing!)
pancreatitis dx blood work
lipase and amylase increase
WBC increase, blood sugar increase (pancreas makes insulin!), liver enzymes increase so now bleeding times increase and bilirubin increase. h/h may go up or down- bleeding/ dehydrated
long term use of steroids can cause
DM or cushings
treatment for pancreatitis (5 meds)
NPO, NG to suction and bed rest
control pain- PCA narcotics/ fentanyl patches
steroids for inflammation, anticholinergics to dry up, GI protectants (dines, zoles, antacids (hydroxides), insulin, maintain F&E balance and nutritional status= start with TPN, daily weights, no alcohol and AA (unless the cause is gallbladder d/s)
4 functions of the liver
detox the body,
helps blood clot
metabolizes drugs and proteins
synthesizes albumin
cirrhosis patho and symptoms- blood work
liver scarring causes hepatic portal hypertension
firm nodular liver, abdominal pain, ascites, change in bowel habits, chronic dyspepsia (GI upset), splenomegaly, jaundice
Blood- elevated liver enzymes, low albumin (not synthesizing), anemia (not clotting)
worry about BLEEDING
how is cirrosis dx, how is the procedure done?
first U/S, CT, and/or MRI
liver biopsy to confirm- worry about bleeding!
pre procedure VS and clotting times, position supine, no pillow, right arm behind head
tell to exhale and hold breath to get diaphragm out of the way
lie on right side post procedure and VS
cirrosis tx
antacids, vitamins, diuretics, I&O, daily weight, rest (tired from toxins), bleeding precautions, measure abdominal girth and maybe paracentesis for the ascites, skin care for jaundice, avoid narcotics- can’t metabolize, low protein diet and low salt
hepatic coma caused by
too much ammonia- damaged liver cannot convert the ammonia to urea or make albumin.
sxs of hepatic coma
minor mental and motor probs, difficult to arouse
asterisks (flapping hands), handwriting change, reflexes decrease (sedative), EEG is slow, fetter (ammonia breath) liver problem pts tend to be GI bleeders (hepatic portal HTN- increase pressure along whole GI tract) and protein in blood will increase ammonia
tx for hepatic coma
lactulose, cleansing enema (get the GI bleeding blood out), decreased protein diet, monitor serum ammonia
treatment for esophageal varices
replace blood, VS, CVP, oxygen (anemic/bleeding)
Octreotide (reduces hepatic HTN)
Ballon Tamponade to put pressure on site (Blakemore- scissors at bedside),
cleansing enema to get rid of blood, lactulose to decrease ammonia, aline lavage to get blood out of stomach
gastroscopy
EGD, endoscopy- used to dx peptic ulcer
NPO 8 hrs before, sedated, NPO until gag reflex returns (tickle back of throat), watch for perforation- pain, bleeding, having trouble swallowing- check temp q15-30 mins for 1-2 hrs- sudden spike=perforation.
warm saline gargle for soar throat
upper GI series
looks at esophagus and stomach with dye- also used to dx peptic ulcer, NPO after midnight
client teaching peptic ulcer
decrease stress, stop smoking, eat what you can tolerate- avoid temp extremes, spicy, caffeine. need to be followed by a dr for 1 year, takes a long time to heal.
gastric ulcer vs duodenal ulcer
gastric- malnourished, pain 0.5-1 hr after meals, food doesn’t help but vomiting does- vomit blood
duodenal- well nourished, night time pain common, pain 2-3 hours after meal, eating helps, blood in stools
hiatal hernia
hole in diaphragm too large stomach moves up-
sxs- heartburn, fullness after eating, regurgitation, dysphagia (diff swallow)
tx- small frequent meals, sit up for 1 hour after eating, elevate HOB (at home too), surgery- lose weight most important! lifestyle changes, healthy diet
foods that empty stomach fast
carbs and electrolytes- avoid foods high in them with dumping syndrome- eat in semi recumbent position and lay on left side after
painful breathing like from cracked ribs causes what imbalance
respiratory acidosis- taking shallow breaths
hyperventilation- respiratory alkalosis
rebound tenderness seen in
means peritoneal inflammation- peritonitis
ulcerative colitis, crohn’s d/s, appendicitis
one side pneumonia
lie good lung down
call rrt
acute one of HR <40 or >130 SBP<90 RR <8 or >28 O2 <90% with supportive O2 U/O<50 mL in 4 hours LOC change
venturi mask
for COPD pts guaranteed amount of O2
Hold epoetin (ESA) when
HTN or Hgb> 11- normal is 12-17
upper right quad pain could be
HELLP, gallbladder or pancreas
Guillain Barre synd
acute rapidly progressing ascending symmetrical paralysis- starts 1-3 wks after an upper respiratory or GI infection- can have full recovery with PT, prevent clots- ROMs and immunglobulin
phenylkentouria
PKU- rare inherited d/o can’t breakdown phenylanine- in all things protein- must follow diet for life with special supplements
cervical spine injury
cervical C1 highest through C8 lowest.
around 4/5 make difference in ability to breath, speak, some arm movements
thoracic spine injury
T1-T12, T5 above is paraplegia, arms and hands okay- trunk down paralysis. T6-12, can control trunk
Lumbar
Hip and leg probs, may be able to walk with braces or may need wheelchair- sacral below this
thrombotic thrombocytopenia purpura
hemolytic anemia with fragmentation of erythrocytes, hemolysis, thrombocytopenia, decreased kidney fxn, and fever- worry about bleeding- especially brain bleed! Bleeding and clotting, clots in capillaries. caused by autoimmune d/o, cyclosporine, clopidegrel, oral contraceptives
pyelonephritis
UTI in kidneys- causing dull flank pain, N/V, fever
rhabdomyolosis
myoglobin released from trauma or intense exercise, heat stroke, STATIN drugs! (A/E)- too much, overwhelm kidneys- get dark, maybe bloody urine, oliguria, fatigue. give fluid boluses to flush and protect kidneys
hemolytic uremic syndrome
can be caused by e.coli diarrhea- RBC being attached, damaged RBCs clog kidneys. uremic acid builds up (uremia) and low platelet count
DKA tx
IV insulin (reg?) ECG, hourly BS and I&O, RAPID fluids- NS until BS reaches 300 or less then switch to D5W and when labs show potassium low or normal may add potassium
if you have an stony, don’t eat:
CABBAGE! onions, alcohol, garlic, fish asparagus- trying to limit smell, gas, diarrhea- beans, carbonated beverages, strong cheese. obstructions: raw veg, seeds popcorn, nuts, raisons
stridor
high pitch rub or wine on inspiration, this is the one to worry about, sign of resp distress
when use cardioversion
supra ventricular tachycardia, a fib, a flutter, v. tach with a pulse. this synchronized on R wave- NPO 8 hours before, stop dig 48 hours before, pt awake, stable, with midazolam for sedation
iron foods
Liver and muscle meat, egg, dried fruit, legumes, dark leafy veg, potato, whole grain/ enriched bread and cereal
microblastic/cytic anemia
from Vit B12 or folic acid deficiency- usually strict Vegan vegetarians
priapism
sustained erection, can happen with sickle cell anemia- tx with fluids pain meds, nifedipine- if still prob urologist with dilute epi
pneumococcal vaccine
against S. pneumonia- for anyone high risk or over the age of 65, need to repeat 1 time in 5 years
