Other important stuff Flashcards
Addison’s Disease (what it is, 10 data)
Autoimmune disorder causing a deficiency in glucocorticoids
- Lethargy, fatigue, muscle weakness
- GI disturbances
- Weight loss
- Menstrual changes in women; impotence in men
- Hypoglycemia
- Hyponatremia
- Hypercalcemia
- Hyperkalemia
- Postural hypotension
- Hyperpigmentation of the skin
AVOID: stress, infections, trauma, surgery because it can lead to Addison’s crisis
Addisonian Crisis (what it is and 5 data)
Can cause hyperkalemia, hypoglycemia, hyponatremia, and shock
Symptoms:
- Severe headache
- Severe abdominal, leg and lower back pain
- Irritability and confusion
- Severe hypotension – need to monitor BP!
- Shock
Symptoms of cholecystitis (2)
- Severe pain in RUQ
2. Bloating
How does a fractured hip present as?
Legs appear shortened and adducted and externally rotated
Bell’s Palsy
Affects cranial nerve 7; usually temporary and causes inability to close affected eye, decreased corneal reflex, increased lacrimation, drooping mouth, speech difficulty, and eating difficulty
Bell’s phenomenon: eye rolling upward when eye closes
Interventions: prevent corneal abrasians (artificial tears), isometric facial exercises, sunglasses during day, eye patches at night
*May need analgesics or prednisone
Colostomy Irrigations (3)
- Performed once a day, ideally at the same time to establish normal bowel routine
- Should never be inserted more than 4 inches
- Should be body temperature
Clomiphene citrate
induces ovulation by changing hormonal effects of ovary; used for fertility
Naproxen Sodium
NSAID
*Watch for fluid retention, dizziness, and liver function
Where do you auscultate right middle lobe?
Right anterior chest between the fourth and sixth intercostal spaces
Where do you auscultate point of maximal impulse?
Apical pulse; left of the sternum, midclavicular, at fifth intercostal space
Duodenal Ulcer symptoms (3)
- Pain 2-3 hours after a meal
- Pain during the night
- Pain prior to ingesting food
Methenamine madelate
Prescribed for UTI (antibacterial agent)
Avoid drinking milk, limit intake of alkaline foods/fluids, increase cranberry juice intake
Suggested iron intake per day in pregnant women
30mg/day
Calories per day in male adolescents
12-13 –> 2,200
14 –> 2,400
15 –> 2,600
16-18 –> 2,800
Calories per day in female adolescents
12-18 –> 2,000
Cystic Fibrosis diet
High calorie, high protein
*Same with sickle-cell anemia and COPD
Cystic Fibrosis Signs and Symptoms (7)
- Salty skin
- Neonates don’t pass stool when first born
- Frequent coughing and respiratory infections
4 Sputum - Ongoing diarrhea, foul-smelling greasy stools
*B/c intestines can’t fully absorb fat and proteins - Pancreatitis
- Males will be infertile, women will have difficulty getting pregnant
Vaccines given at birth
Hep B
Vaccines given at 2,4,6 month visits (4)
- Hep B
- Hib
- IPV
- DTaP
* By 6 months they have had 3 doses of each (except HepB they will have had 4)
Negative vs. Positive Indirect Coombs results
Negative: Give mother RhoGam; she is unsensitized
Positive: Sensitized; fetus will be monitored for hemolytic disease of the newborn
Hiatal vs. Inguinal Hernia
Hiatal: part of the stomach pushes through the diaphragm muscle; patient will report waking up at night with heart burn
Inguinal: bulge in lower right quadrant and pain at umbilicus radiating down to the groin
Memory trick with walking with cane/crutches
The good goes up, the bad goes down
Going up stairs: Cane –> good leg –> bad leg
Going down stairs: Cane –> bad leg –> good leg
On flat surface: cane –> weaker leg –> strong leg
Guillain-barre syndrome
Begins with varying degrees of weakness or tingling sensations in the legs; symmetrical weakness and abnormal sensation spreads to the arms and upper body
Other signs and symptoms include:
- Tachycardia
- Difficulty breathing
- Hypotension
- Difficulty with eye or facial movements and chewing
- Unsteady walking or inability to climb stairs
Leading to….
- Respiratory failure
- Flaccid paralysis
- Urinary retention
Continuous tube feeding nursing care
Rinse the bag and change formula every 4 hours
Acid phosphatase test
Screening for prostate cancer; test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value
Gravity Drip
Piggyback fluid should be higher than primary infusion
Chorea
A neurological disorder characterized by jerky involuntary movements affecting the shoulders, hips, and face
What should the pH be after properly placing an NG tube?
pH of 3
Acute Gout Patching Teaching (7)
- Limit intake of red meat and shellfish
- Do not immobilize extremity between activities
- Do partial weight-baring while ambulating
- do not do passive ROM before ambulating
- Increase fluid intake
- No need to decrease calcium/dairy intake
- Decrease intake of purine foods; organ meats, meat soups, gravy, anchovies, sardines, fish, seafood, asparagus, spinach, peas, dried legumes, wild game
Biperedin
Anti-parkinsonian medication used to counteract extrapyramidal side effects of other medications
Scleral Buckling Procedure
Repairs retinal detachment; nursing priority post-op is to assess for nausea, because vomiting can increase intraocular pressure and damage the repaired area
*After first operative day, assess for infection of the eye by looking at color of the drainage
Heroin Withdrawal symptoms (5)
- Runny nose
- Yawning
- Fever
- Muscle and joint pain
- Diarrhea
Barbiturate Withdrawal Symptoms (4)
- N/V
- Tachycardia
- Coarse tremors
- Seizures
Procainamide (3)
- Used to treat PVCs or atrial tachycardia
- Severe hypotension and bradycardia are ADEs
- Sedimentation rate of 10 is WNL
Analgesics not contraindicated with bleeding disorders (4)
Codeine, Ketoralac, Hydromorphone, Acetaminophen
Dumping Syndrome (what it is, 6 data, and 6 prevention)
Can develop 10-30 minutes or hours after eating post-abdominal/GI surgery
Data:
- Diaphoresis
- Diarrhea
- Hypotension
- N/V
- Flushing
- Increased heart rate
Prevention:
- Increase protein and fat intake; reduce/avoid carbohydrate and simple sugars
- Eat in semi-recumbant position (head and torso up 45 degrees)
- Restrict fluids with meals, have fluids between meals
- Lie down 20-30 minutes after meals
- Don’t walk around right after meals
- Anti-spasmotics if necessary
What is rapid acting insulin called? What are two long acting insulins?
Rapid –> Humalog (Lispro)
Long acting –> Ultralente, Glargine (never mix!)
Incentive Spirometer Instructions (6 steps)
- Hold spirometer at eye level
- Put mouthpiece to mouth
- Exhale normally
- Seal lips on mouthpiece, inhale slowly and deeply
- Keep ballsor cylinder elevated for 2-3 seconds while inhaling
- Exhale and repeat
Wilm’s Tumor
Intraabdominal and kidney tumor common in children
- DO NOT PALPATE ABDOMEN
- Check pre-op abdominal girth
- Check post-op Ins and Outs
- HTN may occur due to increased renin
Correct way to use crutches (4)
- Weight of body goes to hands and arms
- Crutches are placed 8-10 inches in front with each step
- Don’t wear leather soles
- Elbows should be slightly flexed 20-30 degrees when walking
Post-pericardiotomy Syndrome (5)
Can occur 1-6 weeks after heart surgery
- Elevated temperature
- Excessive fatigue
- Pleural pain
- Elevated WBCs
- Dysrhythmias
Compartment Syndrome (5 data, 3 interventions)
If untreated, neuromuscular damage can occur within 4-6 hours and limb can become permanently useless within 24-48 hours
Data:
- Unrelenting pain after meds
- Decreased pulse strength
- Numbness and tingling of extremity
- Possible cyanosis
- Pale, cool extremity
Interventions:
- Release restrictive dressing/cast
- Elevate limb above level of heart
- Many need fasciotomy (fascia is cut to relieve tension/pressure)
Caution with epopoetin
The likelihood of HTN and seizures increases if hematocrit increases more than 4 points in 2 weeks
*Would need to decrease dose of epoetin
Toxic Shock Syndrome (5 data, 3 treatments)
- Sudden fever
- Hypotension
- Rash
- V/D
* Worry about FVD with severe vomiting - Myalgia
Treatments:
- Fluid replacement
- Antibiotics
- Monitor V/S, blood gases, kidney function, hydration
*Usually only occurs in women 30 or less
Hypothyroidism (16)
ALSO KNOWN AS MYXEDEMA
- Decreased BMR, T3, T4
- Increased TSH
- Decreased activity level
- Sensitivity to cold
- Weight gain
- Constipation
- Decreased perception of stimuli
- Potential for respiratory difficulties
- Alopecia
- Bradycardia
- Dry skin and hair
- Decreased ability to perspire
- Reproductive problems
- May cause cardiac enlargement and risk for stroke
- May cause forgetfulness and memory loss
- May cause general puffiness around face and eyes
Hypothyroidism Treatments
- Levothyroxine
- Synthroid
*These can increase urinary output and decrease edema
Side effects:
- Nervousness
- Tremors
- Insomnia
- Tachycardia, palpitations
- Dysrhythmias, angina
Hyperthyroidism (17)
ALSO KNOWN AS GRAVE’S DISEASE
- Increased BMR, T3, T4
- High titer anti-thyroid antibodies
- HTN
- Diaphoresis
- Goiter
- Hyperactivity/irritability
- Weight loss
- Insomnia
- Sensitivity to heat
- Increased perception to stimuli
- Diarrhea
- Tachycardia
- Exopthalmus - protrusion of eyeballs
- Potential for respiratory difficulties
- Frequent mood swings
- Nervous, jittery
- Fine, soft hair
Hyperthyroidism Treatments (5)
- Methimazole (give with meals)
- Propylthiouracil (give with meals)
- Lugol’s iodine solution (give after meals)
- Potassium iodide (give after meals)
- Radiactive iodine (only done overnight before surgery)
Cushing’s Disease (14)
Hypersecretion of glucocorticoids
- Generalized muscle wasting and weakness
- Moon face
- Buffalo hump
- Osteoperosis
- Weight gain
- Hyperglycemia
- Hypernatremia
- Hypocalcemia
- Hypokalemia
- Truchal obesity with thin extremities
- Hirsuitism
- Fragile skin that bruises easily
- May have redish, purple striae on abdomen and upper thighs
- Increased blood pressure
Thyroid Storm (8)
Can occur with uncontrollable hyperthyroidism. manipulation of thyroid gland in surgery, and severe infection or stress
- Increased temperature
- Tachycardia
- Systolic HTN
- n/vd
- Agitation, tremors, anxiety
- Irritability, restless
- Confusion
- Seizures as it progresses –> delirium –> coma
Hypocalcemia (12)
SERUM CALCIUM LEVEL BELOW 8.6
- Positive Trousseau’s - inflate BP cuff causing carpal sapsm
- Positive Chvostek’s - contraction of facial muscles in response to light tap over facial nerve in front of ear
- TETANY*
- Hyperreflexia*
- Tachycardia
- Hypotension*
- Parasthesis
- Twitching
- Cramps
- Diarrhea*
- Hyperactive bowel sounds
- Prolonged QT interval
Hypercalcemia (10)
SERUM CALCIUM LEVEL ABOVE 10
- Tachycardia
- Increased BP*
- Bounding pulse*
- Decreased reflexes*
- Bradycardia = late sign
- N/V
- Constipation*
- Abdominal distention
- Confusion, lethargy –> coma
- Shortened QT interval and widened T wave
Nursing Care with Buck’s Traction (6)
- Elevate foot of bed
- Let weights hang freely and don’t have more than 8-10lbs
- DO NOT ELEVATE KNEE GATCH
- Use trapeze for movement
- If no fracture, may turn to either side
- With fracture, turn only to unaffected side
Balanced Suspension Traction Nursing Care (2)
- Requires low fowler’s on either side or flat
- Maintain 20 degree angle from thigh to bed
*Used to approximate fractures of the femur, tibia, and fibula
Meds that cause hyperglycemia (5)
- Corticosteroids
- Thiazide diuretics
- Phenytoin
- Oral contraceptives
- Estrogen
Meds that cause or mask signs of hypoglycemia (6)
- Beta adrenergics
- Anticoagulants
- Chloramphenicol (antibiotic)
- MAOIs
- Pentamidine (antifungal)
- Sulfonamides
Post-op Mastectomy Positioning
position client in Semi-Fowler’s position with affected arm elevated
Hemorrhoidectomy post-op position
Lateral side lying position to prevent pain and bleeding
Liver biopsy position (during and after)
During: supine with right side of upper abdomen exposed; right arm raised and extended over left shoulder and behind the head
After: Right lateral side-lying position; place small pillow under puncture site for at least 3 hours to prevent bleeding
NG tube position (insertion and feedings)
Insertion: high fowler’s with head tilted forward
Irrigations/Feedings: Semi-Fowler’s and maintain elevated for 1 hour to px aspiration
Abdominal aneurysm resection position
Limit elevation of head to 45 degrees (Fowler’s) to avoid flexion of graft
HF and Pulmonary Edema Position
High Fowler’s
DVT and Vericose Vein Position
Legs elevated
Conversely, with peripheral arterial disease, you do’t want to raise legs above level of heart
Cataract Surgery Post-op position
Fowler’s or semi-fowlers
Autonomic Dysreflexia Position
ELEVATE HOB TO HIGH FOWLER’S
ICP Position
Elevate HOB 30-45 degrees; maintain head in neutral, midline position, avoid hip and neck flexion
Total Hip Replacement Positioning (6)
- Avoid extreme internal and external rotation
- Avoid adduction
- Side lying is permissible on unaffected side
- Maintain abduction in supine position
- Place pillow between legs to maintain abduction
- Don’t cross legs!
Serotonin Syndrome (9)
- Agitation/restlessness
- Confusion
- Increased HR and BP
- Loss of muscle coordination/muscles twitching
- Muscle rigidity
- Dilated pupils
- Diaphoresis
- Diarrhea
Severe –> fever, seizures, arythmies, unconscious
Antidote for MAOI HTN Crisis
Phentolamine by IV injection
Lithium Toxicity: Mild Symptoms (7)
- Lithium level of 1.5
- Apathy
- Lethargy
- Decreased concentration
- Mild ataxia
- Coarse remors
- Slight muscle weakness
Lithium toxicity: Moderate symptoms (7)
- Lithium level 1.5-2.5
- N/V/D
- Mild to moderate ataxia and incoordination
- Slurred speech
- Tinnitus
- Blurred vision
- Muscle twitching and irregular tremor
Lithium Toxicity: Severe symptoms (8)
- Lithium level above 2.5
- Nystagmus
- Muscle fasciculations
- Deep tendon hyperreflexia
- Visual or tactile hallucinations
- Oliguria or anuria
- Impaired LOC
- Tonic clonic seizures –> coma –> death
Neuroleptic Malignant Syndrome (12)
- Fever - very high, very sudden – cooling blanket!
- Dyspnea or tachypnea
- Tachycardia or irregular pulse
- Oculogyric crisis
- Loss of bladder control
- Seizures – initiate seizure precautions!
- Severe extrapyramidal side effects
- Difficulty swallowing
- Excess salivation
- Excessive weakness/fatigue
- Dyskinesia
- Increased WBC, LFT, Creatinine, phosphokinase
Autonomic Dysreflexia (9)
- Sudden onset of severe, throbbing headache
- Severe HTN and bradycardia
- Flushing above level of lesion
- Pallor below level of lesion
- NASAL STUFFINESS
- Dilated pupils or blurred vision
- Sweating
- Pilorection
- Restlessness and apprehension
Autonomic Dysreflexia Interventions (4)
- Raise HOB to High Fowler’s
- Loosen tight clothing
- Check for bladder distention or other noxious stimuli
- Administer anti-HTN meds
Spinal Shock (5)
- Flaccid paralysis
- Loss of reflex activity below the injury
- Bradycardia
- Hypotension
- Paralytic ileus
*Occurs immediately after spinal cord injury but usually lasts less than 48 hours
Cushing’s Triad
- HTN
- Bradycardia
- Irregular respirations
SIGN OF ICP
Hypovolemic Shock (early recognition and 5 interventions)
Early recognition: Increased RR and restlessness
Interventions
- Modified Trendelenburg; elevate foot of bed
- Administer o2
- Monitor LOC and V/S
- Isotonic fluids
- No heavy covers
Hemolytic Transfusion Reaction (9)
- Low back pain
- Headache
- Chest pain
- Apprehension
- Chills
- Fever
- Tachycardia
- Decreased BP
- Increased RR
Allergic Transfusion Reaction (5)
- Hives
- Rash
- Wheezing - compromised airway!
- Itching
- Facial flushing
Febrile Transfusion Reaction (6)
- Fever
- Chills
- Anxiety
- Headache
- Tachycardia
- Tachypnea
Iron Supplement Patient Teaching (4)
- Give between meals
- Give with multivitamin or juice (vitamin C increases absorption)
- Do not give with milk or antacids
- S/E - black stools, constipation, foul aftertaste
Glomerulonephritis (13 data, 4 nursing care)
Data:
- Fever
- Chills
- Hematuria
- Red cell casts
- Proteinurea
- Weakness
- Pallor
- Dyspnea
- Weight gain
- Lung rales
- Fluid overload
- Generalized and/or facial and periorbital edema
- HTN
*Usually occurs post strep infection
Nursing care:
- Antibiotics and Anti-HTN
- Restrict sodium intake and water if oliguric
- Daily weight
- Monitor ins and outs
Progressive Systemic Sclerosis
Connective tissue disease that causes dysphagia esophageal reflux due to decreased motility
*Nurse should assess problems with swallowing
CREST:
Calcinosis
Raynaud’s phenomenon “tolerate pressure on hand?”
Esophageal Dysmotility
Sclerodactyly (thickened/tightened skin on fings/toes)
Telangiectasia (dilated capillaries showing)
Hypoparathyroidism (8 data, 2 safety)
Data:
- Increased phosphorus
- Decreased calcium
- Paresthesia
- Muscle aches
- Fatigue
- Painful menstruation
- Patchy hair loss
- Dry coarse skin
Safety:
- ALWAYS HAVE TRACH KIT BY BEDSIDE
- MONITOR DYSRHYTHMIAS
What exercise is recommended for casted leg?
Quadriceps setting of affected leg; isometric exercises= contraction of muscle without movement of joint; maintains strength while in cast
Legionnaire’s Disease
Type of pneumonia caused by legionella bacteria
Risk factors:
- Old age
- Immunosuppression
- Diabetes
- Smoking
- Pulmonary disease
Alcohol Withdrawal (13 data, 6 interventions)
- Anorexia (may have N/V)
- Anxiety
- Easily startled
- Hyperalertness
- HTN
- Insomnia
- Irritability
- Jerky movements
- May have hallucinations, illusions, nightmares
- Feelings of shakiness
- Seizures (usually appear 7-48 hours after cessation of last drink)
- Tachycardia
- Tremors
Interventions:
- May be prescribed Chlordiazepoxide or another benzodiazepine to reduce withdrawal symptoms
- IM injection of Vitamin B may be prescribed to prevent Wernicke-Korsakoff’s syndrome
- Monitor V/S and neuro status q15 and may need one-to-one supervision
- Quiet, non stimulating environment
- Seizure precautions
- Small, frequent, high carbohydrate foods
Disulfiram
Alcohol deterrent used for alcohol dependence; must abstain from alcohol for at least 12 hours before the initial dose is administered
ADEs begin within minutes after consuming alcohol and may last 30 minutes-2 hours
ADEs:
- Flushing
- Sweating
- Throbbing headache
- Neck pain
- N/V
- Hypotension
- Tachycardia
- Respiratory distress
Signs of Liver Damage (6)
- Nausea
- Pain in upper stomach, usually RUQ
- Loss of appetite
- Dark urine
- Clay-colored stools
- Jaundice
Signs and Symptoms of Hyperkalemia (6)
MURDER
Muscle weakness Urine (low) Respiratory distress Decreased cardiac contractility EKG changes Reflexes (hyper and areflexia)
Signs and Symptoms of Hypokalemia (6)
6 L’s
Lethargy Leg cramps Limp muscles Low, shallow respirations Lethal arrhythmias Lots of urine (polyuria)
Magnesium Toxicity Signs (5)
- Flushing
- Sweating
- Hypotension
- Decreased reflexes
- CNS depression, including respiratory
MagSulf toxicity also includes decreased urinary output and cardiac arrest
