Random Things to Remember Flashcards
Do you expect drooling with parkinson’s?
yes
Clonidine patches, can you just rip it off?
No- can cause withdrawal, rebound HTN. takes a long time for the medication patch to work
used to treat hypertension (mainly), also anxiety and ADHD by allowing blood vessels to relax
myasthenia gravis starts at the
head and goes down body– dysfunction
self catheterization is a ____ procedure
clean procedure. do not re-use single use catheters
nursing care immediate postpartum
First hour: Q15min checks
Second hour: Q30min checks
Third-fourth hours: Q1hr checks
lochia: definition & types & timing
lochia= endometrial sloughing
day 1-3: rubra- bloody with fleshy odor, may have clots
day 4-9: serosa- pink/brown with fleshy odor
day 10+: alba- yellow/white
*foul odor= abnormal and indicates infection!
4 Nursing assessments immediate postpartum
- lochia: color, volume, clots
- vital signs: BP, HR, RR
- fundus: position, firmness
- bladder: UO, may have urethral edema, urine retention
fundal positions
first 12 hours after birth: at or 1cm/finger breadth above the umbilicus
descend by one finger breadth each succeeding day
becomes pelvic organ again by day 10
Postpartum breast care for non-breast feeding mother
non-breast feeding mother: revolves around engorgement (swelling d/t milk, occurs 72-96 hours postpartum)
considerations:
- non-opioid analgesics
- tight fitting bra
- home remedies can be used
postpartum breast care for breast feeding mother
- avoid using soap on nipples to avoid drying out
- use breast shields for inverted or sore nipples
- wear well-fitting, non-binding bra for support/comfort
- use breast pads for leakage
- to prevent let down: press on nipples
5 Fetal Complications
- meconium stained amniotic fluid
- intrauterine growth restriction (IUGR)
- Neural Tube Defects
- Myelomeningocele
- TORCH infections
Meconium stained amniotic fluid
- greenish colored amniotic fluid
- when fetus becomes hypoxic, intestinal peristalsis increases and anal sphincter relaxes allowing meconium to be released into amniotic fluid
- normal in breech deliveries
- indicates problems with fetus
- depending on when it is noted during pregnancy, severity of problems and types vary
intrauterine growth restriction
- condition of inadequate fetal growth
- causes: various complications of pregnancy such as gestational HTN or poor nutrition
neural tube defects
- defect in spinal cord ranging from anencephaly (underdeveloped brain and incomplete skull) to spina bifida (spinal cord fails to develop or close properly)
- includes: spina bifida occulta, meningocele (protrusion of meninges through gap in spine d/t congenital defect, fluid sac, more minor complications), myelomeningocele (type of spina bifida, most severe)
myelomeningiocele
- may be open or closed
- indications: bulging, sac-like lesion at lumbosacral spine filled with spinal fluid, meninges, portion of spinal cord + nerves; hydrocephalus, paralysis of lower extremities, musculoskeletal deformities (club feet, kyphosis, scoliosis), neurogenic bladder and bowel
-interventions: prevent infection, assess neurological involvement, surgical repair 12-72 hours after birth, shunt for hydrocephalus or ABX may need attention prior to surgery.
nursing care: prevent local infection and trauma (careful handling), sterile moist dressings to sac, observe for CSF leaks, irritation, signs of infection, perineal care and other good skin care, maintain: warmth, nutrition, hydration, electrolyte balance; gentle ROM to ankles, knees and feet, involve parents, teach how to stimulate child at age-appropriate level and observe for complications
TORCH infections
- group of maternal systemic infections that can cross the placenta or by ascending infection after rupture of membranes
- infection early in pregancy may produce significant and devastating fetal deformities
- later infection: overwhelming active systemic disease, CNS involvement causing severe neurological impairment or death of newborn
Infection types:
- toxoplamosis
- other: HIV, AIDS, HBV, HAV, human parovirus (spread via respiratory secretions), varicella zoster (chickenpox or shingles), gonorrhea, coxsackievirus
- rubella
- cytomegalovirus (CMV)
- herpes simplex
vasectomy education
sterility not complete until proximal vas deferens is free of sperm (approximately 3 months). another method of birth control must be used until two sperm-free specimens are performed
Tracheosotmy- cuffed vs. fenestrated
surgical incision and tube inserted into trachea
Cuffed: balloon encircles trachea to form seal between outer cannula and trachea, used to permit mechanical ventilation and protect lower airways, should not exceed 20cm of water
-should be inflated: during and after eating, 1 hour after tube feedings, when client is unable to handle oral secretions, during mechanical ventilation and respiratory treatments
Fenestrated: tube with hole/window in bend of tube, permits air to flow around and through tube to upper aiway, permits talking, tube is plugged to wean client from tracheostomy tube
-tube can be removed if: spontaneous ventilation is adequate, pharyngeal and laryngeal gag reflexes are active, client can: swallow, move jaw, clench teeth; voluntary cough is effective in removing secretions without suctioning, care should be performed Q8hrs and PRN
tracheostomy suctioning nursing considerations
- hyperoxygenate or deep breathe client
- suction sube: insert suction catheter length of tracheostomy tube without suction, apply suction for 10 seconds, remove suction catheter, oxygenate client between suction passes, observe for signs of distress such as decrease in HR, document
- indications for suctioning: noisy respirations, restlessness, increase HR and RR, presence of mucus in airway
tracheostomy cleaning nursing considerations
-remove old dressings, open sterile kit, put on sterile gloves, remove inner cannula, clean with hydrogen peroxide, rinse with sterile water and dry, reinsert into outer cannula, clean stoma with hydrogen peroxide then sterile water and dry, change ties as needed, apply new sterile dressing without cutting gauze pads
Types of fetal monitoring
electric external: monitors fetal HR to identify fetal distress and monitor uterine contractions
- uses: external electronic techniques, ultrasound, tocodynamometer
- tocodynamometer: used for estimating foce of uterine contractions, place over fundus (active contracting portion of uterus)
electronic internal:
- internal spinal electrode: electrode placed in presenting part, allows for continuous fetal data, requirements: amniotic membranes must be ruptured, cervix must be dilated at least 2cm, presenting part must be against cervix
- intrauterine pressure catheter: average pressure during contraction 50-85mmHg, monitors contractions- frequency, durations, intensity of contractions
Fetal heart rate: 6 types of changes observed
VEAL CHOP
VEAL CHOP
variable decelerations- cord compression
early decelerations- head compression
accelerations- okay
late decelerations- placental insufficiency
decreased variability
bradycardia
Fetal Heart Rate: Accelerations
increase in HR above baseline by 15 or more beats for 15 or more seconds for 2 minutes or less with return to baseline
indicates fetal well-being
Fetal Heart Rate: Early Decelerations
- normal, benign, gradual decrease of fetal HR before uterine contraction peak with return to baseline by contraction end
- caused by fetal head compression
- nursing care: CTM
Fetal Heart Rate: Late Decelerations
- begin after a contraction has been established (usually at or after peak of contraction)
- continues after contraction is over, with a gradual return to baseline
cause: uteroplacental insufficiency, supine hypotensive syndrome - fetal hypoxia and acidosis usually result
treatment: position client on LEFT side, give client oxygen, notify provider
Fetal Heart Rate: Variable Decelerations
- transient UV-shaped reductions occurring at any time during the uterine contracting phase, decrease usually more than 15 bpm lasting 15 seconds, returns to baseline in less than 2 minutes from onset, indicates cord compression, may be relieved by client position change, ominous if: repetitive, prolonged, severe, slow return to baseline
- treatment: administer oxygen, discontinue oxytocin
Fetal Heart Rate: Decreased Variability
variability in amplitude
- classified: absent, minimal, moderate, marked variability
- decreases caused by: fetal distress, fetal sleep, oxygen deprivation
Fetal Heart Rate: Bradycardia
heart rate less than 110-120 bpm
cause: fetal asphyxia, maternal hypotension, prolonged umbilical cord compression, fetal dysrhythmia
if accompanied by loss of variability, is considered ominous (=very bad)
Ileostomy nursing care & what foods to avoid & what not to take
surgical passage into end of ileum, remainder of large intestines removed. drainage is liquid stool containing proteolytic enzymes and bile salts, bad with pectin-based skin barrier must be worn at all times.
nursing care: empty pouch when 1/3 full, change pouch every 3-7 days during inactive period (before meals, bedtime), check skin for irritation, high-fiber and high-cellulose foods may cause diarrhea: popcorn, peanuts, coconut, Chinese vegetables, shrimp, rice, bran, corn, peas
do not take: enteric-coated medications, laxatives, enemas
report increase/decrease drainage to provider
thyroidectomy- complications & nursing care
excision of thyroid gland
complications: hemorrhage, respiratory distress, tetany d/t parathyroid injury, damage to laryngeal nerves
nursing care: check VS Q15min until stable then Q30min, check pain level, humidified air, cough/deep breathe Q30min-1hr, suction PRN, check dressing Q1hr then every 4 hours, monitor respirs, semi-fowlers, ice, speak Q2hours to check for change in tone or hoarseness, check for Chvostek and Trousseau signs (indicate tetany or decreased calcium), N/T extremities, keep at bedside: suction equipment, tracheostomy set, oxygen, suture removal kit, IV calcium
Increased ICP
causes: bleeding, tumors, edema
indications in adults: change in LOC, restlessness and confusion, pupil changes, motor changes, cardiac rate changes, HA, N/V, diploida (double vision)
indications in infants: tense, bulging fontanelle, separated cranial sutures, irritability, high-pitched cry, poor feeding
indications in children: HA, nausea, forceful vomiting, irritability and restlessness, drowsiness and lethargy
late signs of increased ICP
bradycardia, decreased response to commands, alterations in pupil size and reactivity, decorticate posturing, decerebrate posturing
increased ICP medications
osmotic diuretics, steroids, antiHTN, anticonvulsants, hyperventilation, surgery for decompression or shunt
Jewish (Kosher) Dietary Restrictions
-no meat or poultry at same meal as dairy, no using same utensils for meat and dairy, no pork products, no scavenger fish or fish with fins or scales, forequarters of other meats and poultry allowed
Varicella Zoster (Chickenpox) incubation period + nursing considerations
incubation period: 13-17 days
nursing considerations: isolation until vesicles crusted, communicable from 2 days before appearance of rash, avoid use of aspirin because of association with Reye syndrome, use acetaminophen, topical application of calamine lotion or baking soda baths
adequate fluid intake
1500-2000mL/day
dietary restrictions with gout
avoid meats rich in purines: organ meats, sardines, fish
opiate overdose- ____ pupils
constricted (pinpoint) pupils
cocaine overdose- ___pupils
dilated pupils
heroin overdose causes
respiratory depression, hyperpyrexia (very high fever), motor seizures, pinpoint pupils, etc.
renal arteriogram
injection of radiopaque contrast medium dye, uses femoral artery, allows visualization of renal arteries
infiltration
needles moves out of vein and fluid leaks into adjoining tissues
extravasation
when certain medications leak into adjoining tissue, reported to provider immediately
phlebitis
d/t presence of IV in susceptible clients, reported to provider immediately
air embolism
indications: CP, dyspnea, anxiety, tachycardia
prevention: place client supine when changing tubing, client perform Vasalva maneuver
if RN suspects air embolism: clamp catheter, place in left lateral trendelenberg position, notify provider, start oxygen therapy
Post-op care: VS checks
VS Q15 mins x4, Q30min x 2, Q1hr x2, then every hour or as needed
play therapy
children express themselves more easily in play than in verbal communication
choice in colors, toys, and interaction with toys is revealing as reflection of child’s situation in the family
nursing considerations: provide materials and toys, observe play, help child resolve problems through play
cast care
immediate cast care:
-avoid covering cast until dry, handle with palms, not fingertips (plantar cast), avoid resting cast on hard surfaces or sharp edges, keep affected limb elevated above heart on soft surface until dry, observe for blueness or paleness, pain, numbness on affected area
intermediate cast care:
-encourage client to perform prescribed exercises, report any break in cast or foul odor, inform client not to scratch skin underneath cast, avoid putting anything underneath cast
Schizophrenia, Schizoaffective d/o, catatonic schizophrenia
schizophrenia indications: inappropriate or no display of feelings, hypochondriasis and depersonalization, hallucinations, delusions, short attention span, regression, inability to meet survival needs
schizoaffective d/o:
observable bodily expression of emotions of a person. commonly used terms: flat, blunted, inappropriate, labile
catatonic schizophrenia:
pronounced decrease in amount of movement (hours)
Normal newborn BP
60-80/40-50
normal BP child 1-4 years
90-99/60-65
normal BP child 5-12 years
100-110/56-60
normal adult BP
less than 120/less than 80
adult hypertension guidelines
elevated: 120-129/less than 80
HTN stage 1: 130-139/80-89
HTN stage 2: 140+/90+
CNS Stimulants (ADHD/Narcolepsy)
AE: insomnia, restlessness, palpitations, weight loss
amphetamine: used for narcolepsy, AE- hyperactivoty, dry mouth
dextroamphetamine: used for narcolepsy, short-term adjunt to exogenous obesity. AE: dry mouth, impotence. high abuse potential, dependence
methyphenidate: AE: tachycardia, growth suppression. Monitor: CBC, platelet count, BP
mood stabilizers
lithium and divalproex
lithium
mood stabilizer
AE: dizziness, hand tremors, impaired vision
normal ranges:
initial 1-1.5mEq/L or mmol/L
maintenance 0.8-1.2
toxicity: above 1.5
nursing considerations: monitor blood levels 2-3x/week when started, monthly when on maintenance
fluid intake of 2500-3000mL/day, adequate salt intake
divalproex
mood stabilizer for bipoloar, and antiseizure medication
rapid onset, safe
dosage: 750 (starting)-2500mg/day
AE: thrombocytopenia, pancreatitis, liver failure, GI upsets, weight gain
**teratogen- don’t take during pregnancy
dumping syndrome
rapid passage of food through stomach
indications: diaphoresis, diarrhea, hypotension
treatment: restrict fluids with meals, avoid stress after eating, lie down, eat smaller frequent meals, low carbohydrate and fiber diet
digoxin
cardiac glycoside
decreases HR, increases force of contraction
AE: bradycardia, anorexia, N/V, fatigue, dysrhythmias, diaphoresis
Nursing considerations:
know baseline VS, check for signs of toxicity especially fi taking furosemide concurrently: anorexia, N/V/D, confusion, visual disturbances, furosemide may cause hypokalemia, take apical pulse for 1 full minute noting rate and rhythm and quality, withhold medication and notify provider if rate below 60 bpm, observe K+ levels
therapeutic levels: 0.5-2.6 ng/mL (nmol/L)
Infants/children: therapeutic serum level 0.8-2 ng/mL, hold if apical pulse below 90 to 110 bpm in infants/young kids, 70 bpm in older kids.
ACE inhibitors
block conversion of ang I to ang II
dilates arteries and veins
decreases preload, afterload, cardiac workload
Addison’s disease is the deficiency of what hormones
adrenocortical
Addison’s disease info
causes: surgical removal of adrenal cortex, idiopathic destruction or by infections, inadequate pituitary ACTH
- sudden stopping of exogenous adrenocortical hormone therapy may cause secondary adrenal insufficiency
indications: weakness, hypoglycemia, hyponatremia, hyperkalemia, dehydration, hypotension, anorexia, GI symptoms, emaciation, DARK PIGMENTATION OF SKIN
treatment: hormone replacement
nursing responsibilities: monitor I&O balance of fluid and electrolytes, VS, WEIGHT
education: diet, medications, activity level
addisonian crisis (Adrenal Crisis)
- acute adrenocortical insufficiency precipitated by stress, surgery, trauma, and infection
- indications: hypotension, cyanosis, fever, classic shock symptoms, HA, ABD pain, N/V/D, confusion
nursing responsibilities: same as addison’s disease- monitor fluid and lytes, VS, weight, BP, educate about diet, medications, activity level
inflammatory bowel disease indications and recommended diet
indications: ABD pain, diarrhea, fluid imbalance, weight loss
diet: high protein, high calorie, low fat, low fiber
diarrhea is less severe in ____ than in ulcerative colitis
Chron’s disease
encouraging a laboring mom to pant-blow minimizes…
the urge to push
infant stools: meconium to transitional to formed
meconium- black and tarry, passed in 12-24 hours
transitional stools- thin, green-brown, part meconium and part fecal, day 2-3
formed- 1-2 pale yellow to light brown stools per day with formula feeding. loose golden yellow stools with sour milk odor with every breast feeding
fontanel closing times
anterior fontanel: closes by 18 months
posterior fontanel: closes by 8-12 weeks
babinski reflex
stroke sole of foot from heel upward across ball of foot causing toes to fan
reverts to usual adult response by 12 months
moro reflex
elicited by sudden disturbance in infant’s immediate environment
body stiffens, arms in tense extension followed by embrace gesture with thumb and index finger in a C formation
disappears after 3-4 months
rooting and sucking reflex
turns toward object touching/stroking cheek/mouth
opens mouth and sucks rhythmically when finger/nipple is inserted into mouth
usually disappears by 4-7 months
stepping reflex
makes stepping movements when held with toes touching a surface
tonic neck
when lying on back with head turned to one side, arm and leg outstretched to that side
disappears at 3-4 months
palmar and plantar grasp relfex
hand and toes grasp object placed in hand or at toes
palmar disappears at 3 months
plantar disappears at 8 months
truncal incurvation relex
body curves toward side of trunk stroked
extrusion
disappears at 4 months allowing for spoon feeding
*abnormal responses may indicate neurological damage
amputation complications and nursing responsibilities
complications: phantom limb pain, infection, hip contracture
nursing responsibilities:
- prevent hip contracture by doing ROM, place client prone for 20-30min every 3-4 hours
- don’t elevate residual limb on a pillow after the immediate postoperative period
- inspect wound for inflammation after pressure dressing and drains are removed
- change dressing DAILY until sutures are removed
- wrap residual limb with an elastic bandage to shape the residual limb and keep the dressing in place
- watch for signs of inadequate tissue perfusion
Adult Immunizations: Influenza
given yearly, preferably october to may
recommended for all people age 6months and older
contraindicated:
- previous anaphylactic reaction to vaccine or eggs
- had previous guillain-barre syndrome
- currently have a moderate or severe illness
Adult Immunizations: tetanus-diphtheria (TD) or tetanus-diphtheria-acellular pertussis (TDaP)
-tetanus and diphtheria toxoid (Td) administered to persons 7 years and older
-provides protection for 10 years
-tetanus toxoid- booster dose given in case of dirty wound
one TDaP and then TD every 10 years
Adult Immunizations: Chickenpox (Varicella)
2 doses if not had as a child
Adult Immunizations: Human papillomavirus (HPV)
3 doses before age 26
Adult Immunizations: shingles (herpes zoster)
shingrix
age 50 and older
2 doses 2-6 months apart
Adult Immunizations: measles, mumps and rubella (MMR)
2-3 doses before age 55
AE: fever, allergic rxn, arthritis, arthralgia, encephalitis, burning, stinging pain at injection site
nursing considerations: administer SQ, do NOT receive if pregnant or immunosuppressed, may receive as separate injections if unusual reaction occurs
Adult Immunizations: Pneumococcal
administered to immunize against streptococcus pneumoniae
first vaccination recommended:
- clients under 65 years if: chronic lung disease, cardiovascular disease, DM, spleen disorders, immunocompromised status
- residents of nursing homes
- clients 65+
- cigarette smokers
re-vaccination recommended:
- clients over 65 if vaccinated more than 5 years previously
- less than 65 with initial vaccination
- clients 19-64 if: chronic kidney problems, immunocompromised
Adult Immunizations: meningococcal
1 dose depending on lifestyle
Adult Immunizations: HAV
2 doses depending on lifestyle
Adult Immunizations: HBV
indicated for: adults at risk for exposure to blood or blood-containing body fluids, hemodialysis clients, household contacts, sex partners of HBV clients, international travelers, injecting drug users, gay men, sluts, STDs, all unvaccinated adolescents
given in 3 doses, with second dose 1-2 months after the first dose, and third dose 4-6 months after the first dose
Adult Immunizations: polio
- adults traveling to certain parts of the world
- laboratory workers who might handle polio virus
- healthcare workers who treat polio clients
post prostatectomy care and education
bladder irrigation, high oral fluid intake 2-3 liters, frequent ambulation, stool softners, catheter care, avoid caffeine, kegal exercises to prevent dribbling or incontinency, avoid long periods of sitting or strenuous activities for several weeks.
preparation for procedures with children- different fears with various age groups
toddlers: fear of separation, strangers, changes in environment. teach parents to expect regression
preschooler: fears mutilation, allow child to play with equipment, encourage expression of feelings (anger)
school-age: fears loss of control, explain procedure in simple terms, allow choices when possible
adolescent: fears loss of independence, being different from peers, alterations in body image. explain procedure, involve in therapies, expect resistance, express understanding of concerns, point out strengths.
alzheimers disease results in
cerebral atrophy, decline in intellectual/cognitive functioning, motor and sensory functioning, affect
alcoholism nursing considerations
monitor VS frequently, allow to “sleep it off”, protect airway from aspiration, assess: need for IV glucose, injuries, signs of withdrawal, chronic alcohol dependence
alcoholism withdrawal indications
occurs 4-6 hours after last drink
tremors, agitation, anxiety, insomnia, mild tachycardia, HTN
alcoholism delirium tremens
indications: tremors, anxiety, panic, disorientation, hallucination, vomiting, tonic-clonic seizures (first 48 hours after withdrawal)
alcoholic hallucinations: occur 48 hours after last drink
indications: auditory, visual, tactile (in absence of other psychotic behavior)
nursing responsibilities: sedation PRN, monitor VS, seizure precautions, quiet and well-lighted environment, alcohol provides calories but no nutriton
Blood administration + transfusion reactions
19 gauge needle and standard blood filter
start infusion slowly during first 15 minutes and stay with client, check for reactions
infuse over 2-4 hours
transfusion reaction: usually in first 15 minutes. stop the blood, restart saline, notify provider, provide supportive care
types of reactions:
- allergic (hypersensitivity to donor antibodies): uticaria, pruritis, fever, anaphylactic shock
- hemolytic (imcompatibility): N/V, lower back pain, hypotension, hematuria
- febrile (antibodies to donor platelets or leukocytes): fever, chills, nausea, HA, flushing, tachycardia
- bacterial (contaminated blood products): tachycardia, hypotension, fever, chills, shock
*also watch for circulatory overload: cough, dyspnea, pulmonary congestion, tachycardia, HA, sudden anxiety, HTN, JVD
adverse effect of multiple FFP transfusions
hypocalcemia
newborn cord care
clean and dry, open to air until falls off (7-14 days after delivery), no tub baths until healed, stump requires care 3-5 days after cord falls off
newborn hearing assessment
newborn should respond to loud noise by the moro reflex
2-3 mo: should turn head side to side when sound is made at that level of ear
3-4mo: able to locate sound by turning head and looking in that direction
6-8mo: responds to own name
1 year: knows several words and their meanings
black cohosh
commonly used to treat menstrual and menopausal symptoms
considerations: women at risk for breast cancer should avoid
garlic
actions: anti-microbial, lipidemic, thrombotic, tumor, inflammatory
uses: reduction cholesterol and HTN, prevention atherosclerosis, cancer, stroke, MI, prevention and tx of colds and flu
AE: flatulence, heartburn, halitosis, irritation of mouth, esophagus and stomach, allergic rxn.
considerations: don’t administer with GERD/PUD, cautious with antiplatelet/coag patients (increase bleeding), caution with anti-DM medictions (cause hypoglycemia), caution with HTN/HLD meds, cyclosporines or hormonal contraceptives, don’t administer to clients with lily family allergy
ginger
uses: N/V, indigestion, gas, anorexia
AE: minor heartburn, dermatitis
considerations: contraindicated with gallstones, potentiate action of antiplatelet and anticoag meds and increase bleeding, hypoglycemia with antiDM meds
ginkgo biloba
enhances cerebral and peripheral blood circulation, antidepressant
uses: dementia, STML, vertigo, PVD, depression, sexual dysfuntion
AE: GA, GI upset, contact dermatitis, dizziness
considerations: potentiate meds that prevent clotting and MAO inhibitors, decrease anticonvulsant effectiveness, interfere with DM management (close glucose monitoring and change pharm dependence)
licorice
made from glycyrrhiza glabra root, dried
large amounts cause: salt retention, potassium excretion, HTN
St. Johns wort
antidepressant
action: SSRI, antifundal, viral, inflammatory, bacterial
uses: depression, OCD, skin inflammation, burns, wound/injury
a lot of interactions
AE: HTN, diarrhea, flatulence, serotonin syndrome, hypoglycemia, dizziness, ABD pain, phototoxicity, neuropathy, restlessness, sleep disturbances, dry mouth, allergic skin reaction
nursing responsibilities: monitor depression S&S and suicidal tendencies
client education: take as directed, discuss with provider, use sunscreen and protective clothing, take for 4-6 weeks, if no change, talk to provider
is clumsiness expected during adolescent growth and development?
yes
MS patients fatigue early so…
they want to get to the point of their statements before they get tired, use images if they can’t use words, eye contact and facing who talking to etc.
gastrostomy tube
rotate G tube 360 degrees 1x/day to prevent skin breakdown and don’t want it to get stuck against the skin
check for slight in and out movement- detects if it is not embedded in stomach wall
diabetic ketoacidosis- you want to start ____ first
FLUIDS
they are fluid depleted and need to fix their volume status and then insulin (then after insulin causes potassium to shift into the cells from the bloodstream, then replace potassium)
RA can cause
anemia
any heat source _____ rate of absorption of medication through skin
increases
signs of hemolytic reaction
hypotension
low back pain
fever
signs of fluid overload
severe SOB
wet breath sounds
urticaria is a sign of a ____ reaction
anaphylactic
____ increase risk for dumping syndrome
carbohydrates
*avoid them
patients with dumping syndrome should:
eat smaller meals for frequently
lie down after eating (decrease GI motility)
avoid drinking fluids meals with meals (1 hour before and after)
Meniere’s disease requires a low ____ diet to prevent vertigo
sodium
Meniere’s disease: patients will be prescribed
antihistamines
antiemetics
antivertigo
diuretics
is it expected to see bubbling in water seal chamber after insertion of chest tube on patient with a pneumothorax?
yes however the bubbling should NOT be continuous
with a pneumothorax, we expect ___ to exit the lungs, not fluid
AIR
when a client with a chest tube coughs, fluctuations is expected in the ____ chamber
water-sealed chamber
not the suction controlled chamber
how many cm of water should be in the water sealed chamber?
2cm
what position should a client be in for a tracheostomy suctioning
semi-fowlers
calcium channel blockers and beta blockers are first line treatment for
afib
digoxin is not a first line treatment
if you observe continuous bubbling in water seal chamber of a chest tube, you should be concerned of an
air leak
in the beginning of dialysis treatment, clients may experience
headaches, nausea, fatigue may occur after hemodialysis d/t disequilibrium syndrome
lanolin is contraindicated when breast feeding
yes
used for cracked nipples
babies can suck on one nipple for _____ minutes at a time
15-45 min
ventilated patients prevention of VAP, overall care
brush teeth Q8
Q2 turns
pantoprazole- prevent GI ulcers
normal magnesium levels
1.3-2.3 mg/dL
normal digoxin levels
0.5-2ng/mL
croup is an
upper airway infection blocking breathing and has a distinctive barking cough
unemancipated minors may receive/consent to what types of medical treatment without parental consent?
pregnancy, STD, substance abuse, mental health
*need to know why the minor is seeking treatment
herpes zoster is
shingles
can a person who was not vaccinated for chicken pox get infected with chicken pox after exposure to someone with shingles?
yes
how often to older adult patients need to get their eyes checked?
every 1-2 years
you need consent by proxy (spouse) if the client is confused
yes
AIDS client has drenched sheets with perspiration can indicate they have
tuberculosis
dawn phenomena
hyperglycemia in the morning
treat by adjusting: evening diet, bedtime snack, insulin dose* (order 3 additional units of intermediate acting insulin at 2200), and exercise to prevent early morning hyperglycemia
- do not eliminate evening snack, just adjust it. don’t reduce diet
- do not order an additional 10 units of short acting insulin at 2000 because it would peak in 1-5 hours which would not prevent the hyperglycemia
when a client returns from an abdominal surgery, you first want to assess if they can…
lift their head off the pillow
if they can’t, they likely have remaining effects of neuromuscular agents in their system and their ability to deep breath will likely be affected.
assess this before asking the client to cough and deep breathe
use ____ to prepare a toddler for surgery
puppets/dolls
no books/pictures of surgery. use simple terms of what the child will see, hear, taste, smell and feel. do not use timing
how to prepare a school age child for surgery
draw a picture of the eye to explain what will happen
read an age-appropriate illustrated book about eye surgery
placenta previa is _____ vaginal bleeding
painless
no N/V, not related to activity
who is most at risk for developing herpes zoster?
- 19 yr old with tibia fracture
- 50 yr old with diabetic foot ulcer
- 62 yr old with transplant rejection
- 84 yr old with COPD
-62 yr old with transplant rejection
the only one who is immunocompromised
do not massage Haldol into the injection site because…
it is very irritating to the SQ tissue
needs to be administered deep IM in a large muscle mass in a single dose using a 2 inch 21 gauge needle
____ exercises are key for RA patients to reduce swelling, increase circulation and diminish stiffness and preserve joint motility
ROM exercises (also heat application)
massaging joints will prob cause pain.
post cholecystectomy stab site (type of incision) care-
observe saturated dressing with dark green-yellow drainage
remove dressing and replace with more absorbent dressing
expected drainage and not indicating infection. it will continue to drain until the wound seals. keep the wound clean and change dressing as needed. dehiscence usually doesn’t occur with this type of wound
procainamide is used to treat
PVCs or atrial tachycardia
AE: severe hypotension and bradycardia
the client is prescribed regular insulin before breakfast. the client is nauseated with a blood glucose of 74. what does the nurse do?
administer insulin on time
encourage eating food on breakfast tray. recheck glucose in 30-60min, and it should be monitored anyways every 3-4 hours because hyperglycemia can occur in illness. sip 8-12oz/hour if tolerated to decrease risk of dehydration, or substitute solid foods if liquids aren’t tolerated.
because blood glucose increases during illness, insulin or oral hypo-glycemic agents must be given on time even though the client cannot eat
if the client is given orange juice, it may cause vomiting at this time.
infant cannot sit up unsupported and say a few words until
8 months
12 months: can say 3-5 words
battery is
harmful or offensive touching of another person
unless court ordered, clients have a right to ____ medication, even if psychotic
refuse
adverse effects of haldol
galactorrhea- excessive or spontaneous flow of milk
lactation
gynecomastia- excessive growth of male mammary glands
what intervention prevents infection in partial thickness burns
removing clothing and covering client with clean sheet
don’t use any soaps or ointments in an emergency situation
intermittent peritoneal dialysis (IPD) expected & unexpected side effects:
expected AE: pain during inflow of diasylate, blood-tinged fluid around the intra-abdominal catheter (d/t SQ bleeding) common during the first few exchanges. Also constipation (inactivity, decreased nutrition, medications –> high fiber diet & stool softners to prevent)
unexpected/abnormal AE: cloudy diasylate outflow –> indicated peritonitis. will also see: N/V, anorexia, ABD pain, tenderness and rigidity
*warm diasylate solution with heat pads to reduce pain caused by cold solution
when going through with a behavior modification plan, make sure that all team members
understand and comply with the plan
plebitis
reddened area or red steaks at the site and up length of vein
strabismus
visual axes are not parallel, so the brain receives two images
*child closes one eye to see a poster on the wall
refractive error (myopia= near sightedness)
able to see objects at close range
child places head close to the table when drawing
child rubs eyes frequently
cataracts or peripheral vision problems
child is unable to see objects in peripheral vision
nystagmus
when eye makes uncontrolled, repetitive movements
can result in reduced vision and depth perception, and affect balance and coordination
zidovudine is used for
HIV
*write out schedule of when to take medicine
when obtaining a history on a psych client, you want data addressing a
psychosocial approach, including a family system assessment
not just a mental status exam
damage to the parathyroid gland after a thyroidectomy could result in
tetany
keep calcium gluconate IV set up for administration if needed
post thyroidectomy, you need:
calcium gluconate IV- treat possible tetany from possible parathyriod damage
for airway: tracheostomy set up, suction equipment
_____ levels are the best indicators of long term nutritional status
albumin
normal albumin levels
3.4-5.4 g/dL
restraints
we must obtain permission from the ___ for restraints.
if the client is deemed incompetent, permission is obtained from the _______ ________
client
legal guardian
confusion, cold & clammy skin, elevated pulse, mental confusion, fine hand tremors are signs of
hypoglycemia
normal blood glucose
70-110 mg/dL
lethargy, hot & dry skin, rapid & deep respirations are signs of
hyperglycemia
*treatment for severe hyerglycemia: IV fluids, IV insulin, then later IV potassium after insulin causes it to decrease (shift into cells from bloodstream)
perphenazine is an antipsychotic med used to treat
& AE
schizophrenia
extra pyramidal AE: neck stiffness and arched at angle, muscle spasms
*give benztropine= antiparkinsonian agent to counteract the EPS
benztropine
antiparkinsonian agent to counteract muscle spasms/rigidity
promazine & thiothixene
older antipsychotic meds to treat schizophrenia
after a scleral bucking procedure, what assessment data is important
N/V presence
could increase intraocular pressure
ewald tube
large, orogastric tube designed for rapid lavage
insertion often causes gagging and vomiting, suction equipment must be immediately available to reduce risk of aspiration
SDH + cerebral edema S&S initially
decreasing LOC (as pressure increases, LOC decreases), ipsilateral pupil dilation (dilation same side as hematoma) , HA (1st Sx)
late sign of high ICP: tonic/clonic seizures
late sign of brainstem damage: decerebrate posturing
cesarian vs general surgery medications
cesarian- similar sedation + hypnotics, decreased narcotics because it crosses the placental barrier causing neonatal respiratory depression
client with history of oliguria, HTN, peripheral edema, BUN=25, K+=4
what foods should the client restrict?
what foods should the client eat?
protein
decreasing protein intake can decrease production of urea nitrogen. metabolic wastes cannot be excreted by kidneys
client should eat fats & carbs because they decrease nonprotein nitrogen production. magnesium should also not be restricted.
transfusions: order of priority
itching, HA, vomiting, JVD
- vomiting- acute hemolytic rxn
- JVD- fluid overload
- itching- allergic rxn
- HA- febrile rxn
hemolytic transfusion rxn
most dangerous
N/V, lower back pain, hematuria
tx: stop blood, obtain urine specimen, maintain blood volume and kidney perfusion
JVD- circulatory overload tx with transfusion
adjust rate of infusion of blood, place in upright position, oxygen and possibly diuretics
itching with transfusion
allergic rxn
sx: urticaria, pruritis, fever
tx: stop infusion, give antihistamine, restart transfusion slowly
urticaria =
hives
pruritis=
itching
transfusion- HA
febrile rxn
sx: fever, chills, nausea, HA
tx: stop infusion, administer antipyretics
nitroglycerin can cause
hypotension
vasodilator
avoid quick changes in position
infant hip dysplasia
see limited abduction,
folds and creases will be longer and deeper on affected side,
decrease in limb length,
may or may not see internal rotation
normal BUN
10-20 mg/dL under 60 years old
acetaminophen can cause ____ damage
liver
normal liver enzyme levels
AST: 1-36 units/L
ALT: 1-45 units/L
normal WBC
5,000-10,000/mm^3
____ can cause fetal hemorrhage, don’t use during pregnancy
aspirin
most effective way of deep breathing and coughing to dilate airway and expand lung surface area after abdominal surgery
take three deep breaths, hold incision, and then cough
famotidine should be given when?
before meals or at bedtime to treat gastric/duodenal ulcers
H2 blocker- decreases food-induces acid secretion
Right sided HF
peripheral edema (fluid accumulation, decreased heart pumping), distended neck veins (fluid overload, HF), anorexia (malaise), polycythemia (increased RBC as compensation for decreased oxygenation
acute gout diet restrictions
low-purine diet
avoid: red and organ meats, shellfish and oily fish with bones
the healthcare provider may begin treatment without written consent if contacting the ______ is not possible
next of kin
cranial nerve III
oculomotor
provides innervation for extraoccular movement
cranial nerve V
trigeminal
provides sensation to facial muscles
cranial nerve VII
facial
provides motor activity to the facial muscles
cranial nerve XI
spinal accessory
provides innervation to the trapezius and sternocleidomastoid muscles
normal response 1 month after mastectomy for breast cancer
“i have been having difficulty coping with the surgery and cry frequently”
integration into normal life is not normal for this stage
cytomegalovirus (CMV) precautions
standard precautions
eyewear worn whenever there is risk of slash or splatter
no need for private room
herpes strain
glipizide is indicated for
type two diabetic tx- produce minimal amounts of insulin, oral medication
stimulates pancreas to release insulin in response to hyperglycemia (wouldn’t work for type 1)
hepatitis A precautions
contact precautions
requires single patient room
nonstress test
noninvasive test to evaluate the response of fetal heart rate to the stress of fetal movement
the response will be reflected on the fetal monitor
instruct client to push a button when a fetal movement is felt
S&S of neuroleptic malignant syndrome
pallor, tachycardia, HTN or hypotension, diaphoresis, fever, convulsions, loss of bladder control, respiratory distress, severe muscle stiffness, tiredness
identify early, notify provider, administer emergency care as needed
any suspected child abuse, report it to
child protection agency
pertinent assessment for a client receiving magnesium sulfate for pre-eclampsia
assess respirations and urine output
have calcium gluconate available as an antidote
safe oxytocin administration
palpate uterus frequently
oxytocin stimulates uterus to contract
prolonged tetanic contraction can lead to a ruptured uterus
promethazine
H1 blocker
antiemetic
ranitidine
H2 histamine antagonist
reduces acid production in stomach, prevents stress ulcers
morphine sulfate
narcotic analgesic
causes CNS and respiratory depression
contraindicated in head injury because it masks signs of increased ICP
pediatric lumbar puncture: nurse must appropriately _____ the child
restrain
prevent trauma during procedure
kussmaul respirations are a sign of
hyperglycemia
diaphoresis and trembling are signs of ____
hypoglycemia
regular insulin peaks in
1-5 hours
give skim milk
fluoxetine HCl
energizing antidepressant
as client begins to demonstrate a positive response, the client has increased energy level, and is able to participate more in milieu (social environments)
why can you not suddenly withdraw from steroids
the client may die of acute adrenal insufficiency
priority action for a client with a vasoocclusive crisis
provide adequate hydration
oxygen is not priority
what pain medication is best for a client with hemophilia A
acetaminophen
aspirin, ibuprofen and naproxen (NSAIDs) increase bleeding times by decreasing platelet aggregation
*contraindicated for persons with bleeding disorders
Kaposi sarcoma are seen in patients with
AIDS
dark lesions on the skin, brown/purple/red patches or nodules
clean with mild soap daily and pat dry. want to eliminate risk for secondary skin infection
sucralfate and digoxin
sucralfate gets best results on an empty stomach. take one hour before breakfast then digoxin one hour after breakfast
medications should be separated by 2 hours for max absorption. sucralfate forms a barrier on the GI mucosa, preventing absorption of other medications
sucralfate treats
GI ulcers- forms a covering over them
digoxin treats
HF and chronic afib
cardiac glycoside
4 month infant response to increased ICP
high pitched cry (first signs)
posterior fontanelles should be closed by 3 months (wouldn’t see bulging at 4 mo)
when does stormy behavior start in kids?
age 11
school-aged child: parenting
should advise parents to
give child responsibilities around the house
allows them to develop feelings of competence and self-esteem through their industry
symptoms of hyponatremia
HA, apprehension, lethargy, muscle twitching, convulsions, diarrhea, fingerprinting of skin
symptoms of hypernatremia
sticky mucous membranes, decreased urinary output (oliguria), firm & rubbery tissues, restlessness, weakness, coma, tachycardia, flushed skin, fever
heroin withdrawal
narcotic withdrawal is very similar to flu sx
runny nose, yawning, fever, muscle and joint pain, diarrhea
cocaine withdrawal
severe cravings, depression, fatigue, hypersomnia
amphetamine withdrawal
depression, disturbed sleep, restlessness, disorientation
barbiturate withdrawal
N/V, tachycardia, coarse tremors, seizures
gemfibrozil
lipid lowering agent prescribed for high triglyceride levels
AE: ABD pain, cholelithiasis
take 30 minutes before breakfast and dinner
can affect liver function- monitor AST
ESR is used to monitor
inflammation
normal range 0-20
creatinine assesses ______
normal Cr levels
kidney function
0.7-1.4 mg/dL
myelogram + post interventions
diagnostic imaging test using contrast dye and XR/CT to look for problems in the spinal canal
interventions: encourage oral intake to flush out dye, HOB 30-40, monitor vital/neuro signs, bedrest 24 hours
MS + labor
anticipate giving lower pain medications d/t decreased pain perception
trochanter rolls can be used on outer aspect of thigh to
hold hip in neutral position and leg in normal alignment. the entire weight of leg cannot be held by props placed below knee
sudden decrease in NG output and patient is nauseated, first you
aspirate the gastric contents with a syringe to ensure the NG tube is in the right place- the pH of the contents should be 0-4. if the tube is not in the right place, gastric secretions could build up causing nausea.
after confirming its in the right place, then irrigate the tube with NS
terbutaline action and maternal/fetal AE
tocolytic: anti-contraction medication to delay preterm labor for up to 48 hours
can also be used as a reliever inhaler for asthma management
maternal AE: maternal tachycardia (hold med if tachy), nervousness, tremors, HA, pulmonary edema
fetal AE: tachycardia, hypoglycemia
terbutaline is preferred over ritodrine because it has minimal effects on blood pressure
continuous ambulatory peritoneal dialysis (CAPD) encourages a high ___ diet and daily ____ measurements
protein
weight (at the same time of day)
at what age can a child grasp for a toy out of reach?
6 months
esophageal speech after a total layrngectomy is when the client
swallows air and then eructates (belching from stomach) it while forming words with the mouth
how does a client with a tracheostomy speak
places a finger over the tracheostomy, forcing air up through the vocal cords
most asthma attacks are a result of inhaled ______
allergens
avoid allergens!!
metronidazole is used for
anti-infective
treatment of intestinal amebiasis (parasitic infection), trichomoniasis, inflammatory bowel disease
ketoconazole is used for
treatment of candidiasis
S&S: mouth pain, difficulty swallowing, white discharge in back of throat
trimethoprim-sulfamethoxazole is used to treat
Pneumocystis pneumonia (PCP)
S&S: dyspnea, tachypnea, persistent dry cough, fever, fatigue
rifampin is used to treat…?
commonly used in a cocktail with isoniazid and ethambutol
tuberculosis
S&S: fever, chills, night sweats, weight loss, anorexia
cocktail prevents resistant strains
client has a sprained ankle- where should he hold the cane?
left hand
advance cane 6-10 inches with body weight on both legs
acute phase of rape trauma syndrome- nurse’s initial priority is for the client to
begin expressing reactions and feelings about the assault before leaving the ED- gain some acceptance and perspective. Help the client begin dealing with this.
what is the duration of warfarin
2-5 days
lupus (SLE) & pregnancy
client should wait two years after diagnosis to conceive
client should be in remission for at least 5 months prior to conceiving
fixed and dilated pupil represents
neurological emergency
tetracycline
ABX
take on empty stomach
AE: photosensitivity
pregnant client urine test positive for glucose and acetone is a sign of
gestational diabetes
hazard of placental insufficiency
How to collect a pinworm specimen from child?
collect early in the morning with scotch tape touched to the child’s anus
pinworms crawl outside the anus in the early monring to lay their eggs
atropine sulfate is used for
bradycardia
antidysrhythmic
isoproterenol is used for
heart blocks, ventricular dysrhythmias
antidysrhythmic
verapamil is a
antihypertensive
calcium channel blocker
lidocaine is used with cardiac patients for
frequent PVCs occurring in excess of 6-10 per minute; for coupled PVCs or for a consecutive series of PVCs that may result in VT
myxedema
slowing of all body functions
severely advanced hypothyroidism
S&S: lethargy, confusion/non-responsiveness, feeling cold, low body temp, swelling of body (especially face, tongue, lower legs), difficulty breathing
abruptio placenta is when
the placenta prematurely separates from the uterus leading to hemorrhage
fluid volume deficit is the major nursing concern
when client is confused, first check their
oxygen levels
prochlorperazine is an
antiemetic
given deep IM in a large muscle mass
can lead to hypotension
butorphanol is an
opioid analgesic
given deep IM in a large muscle mass
can cause hypotension and respiratory depression
Addison’s disease- patients need to be educated on _____ replacement
steroid
adrenal insufficiency- low cortisol and aldosterone
angioplasty is
surgical repair or unblocking of blood vessel, especially coronary artery
you should empty a colostomy bag when it is ___ full to prevent leakage
1/3
about 6+ times per day
HF patients should limit their sodium intake to ___ grams/day
2
HF patients should avoid what medications at home?
NSAIDs
cause sodium and fluid retention
if you observe other healthcare workers talking about a patient and violating HIPAA, you
contact the manager
don’t need to confront the employees, go up chain of command
milieu therapy
psych therapy for behavior and personality disorder treatments- good to provide consistent set of activities and responsibilities for each client to allow them to develop healthy social behaviors. recreating a home environment may be detrimental to the client as it could trigger problematic behaviors
insulin glulisine peaks at
60-90 minutes after SQ injection
short-acting
when priming an insulin infusion with NS first, how much fluid should you discard?
50mL
insulin sticks to tubing and the initial concentration could have a decreased concentration of insulin. most institutions recommend priming tubing with NS first then switching to an insulin bag
when determining the patency of an AV fistula, you should assess:
auscultate to detect bruit
palpate pulses distal to site
observe capillary refill to fingers distal to site
check for altered sensation
tenderness- indicates infection
positive contraction stress test signifies
late decelerations following at least 50% of contractions indicating uteroplacental insufficiency
why do you instruct pregnant women to lay on their sides?
don’t want to lay on back (supine) because it can cause vena cava syndrome
laying on side promotes good cardiac output by taking weight of the uterus off the vena cava and increases blood return to the heart
client presents for r/o CVA (sudden HA and loss of consciousness) what is more important to tell provider: history of a fib or client takes warfarin daily?
history of a fib
CVA could be caused by an embolus, and afib accounts fo 17% of all CVAs
hemorrhagic stroke- resulting from warfarin toxicity, tends to have symptoms with more subtle progression
polio vaccine- oral vs IM
oral- live attenuated
weakened organisms that produce an immune response but not illness. although, people can shed the virus and spread disease to immunosuppressed individuals
IM- inactivated (or killed) poliovirus and causes an immune response but incapable of reproducing and causing infection
when a bipolar client is in a manic state, you expect to see
agitation, grandiose delusions, euphoria, concentration problems, more extreme levels of behavior
sputum collection
use suction if client cannot cough effectively
don’t have the client cough into the container because it could contain saliva not sputum. advise to deep breathe then COUGH to provide the sample
offer oral care before to prevent contamination of the sputum with oral microbes
send specimen to lab immediately
obtain specimen in the morning
tingling sensation in the face and arm could indicate a
stroke
headache, fever and neck stiffness could indicate
meningitis
stages 1, 2, 3 of alcohol withdrawal syndrome (AWS)
stage 1 (initial 24 hours): mild tremors begin in first 5-8 hours
stage 2 (1-3 days)- grand mal seizures, hallucinations
stage 3 (3-4 days)- fever, HTN, delirium, drenching sweats, severe tremors
firm, painless and moveable adenopathy in cervical area is characteristic of
Hodgkin’s lymphoma
when can solid foods be introduced to an infant?
6 months
how long can breastmilk be stored in the freezer?
6 months
renal failure and HF, what to avoid?
salt substitutes (renal, high in potassium and not excreted well)
high chicken and fish- high protein breaks down to urea and nitrogen which is not excreted by compromised kidneys. just have normal protein intake.
only 1-2 L of water intake for HF and RF patients
*encourage increased whole grain pasta and breads- maintain energy requirements and doesn’t compromise kidneys or heart
when taking lithium, which lab value do you not want to be low?
sodium
low sodium causes the body to compensate by retaining lithium, causing lithium toxicity
