Rationales Flashcards
ASSESSMENT autonomic dysreflexia? What is a spinal cord Injury? Autonomic Dysreflexia Syndrome? Causes? TX? Interventions (PRIORITY NURSING ACTIONS) ? (aka Autonomic hyper-refelxia).
A severe, uncompensated CV reaction that occurs in response to visceral stimulation after spinal shock has resolved. Pts w/spinal cord injuries @ T6/above are at risk of developing autonomic dysreflexia. A sudden, throbbing headache is 1 of most impt warning symptoms that a pt is experiencing this life-threatening condition.
ASSESSMENT: Flushing above level of injury; Pale extremities below level of injury; Nausea; Dilated pupils/blurred vision; Sweating; Piloerection (goose bumps); Restlessness & a feeling of apprehension.
- Damage to spinal cord causes permanent changes in strength, sensation & other body functions below site of injury.
- Symptoms depend on location of injury.
- Higher injury -more function that is lost.
- Injuries above T6: Monitor for autonomic dysreflexia.
- S/S: Syndrome characterized by:
- SUDDEN SEVERE HYPERTENSION (systolic 20-40 mmHg higher than baseline; EX: 106/78 to 146/92)
- Bradycardia
- THROBBING HEADACHE (If pt report HA? Check BP STAT!
- Nasal Stuffiness
- Flushing (Pale, cool, clammy)
- Sweating
- Blurred vision
- Anxiety
IF BP still elevated…
- Meds to help treat AD
- Nitropaste: topical administration
- Don’t administer if pt has taken a phosphodiesterase inhibitor in past 24hrs…Slidenafi/Tadalafil. Other meds: Nifedipine (CCBs)
CAUSES Triggered by sustained stimuli @ T6/below from:
- Blister (Breakdown of skin): remove Binding Devices; Reposition q 2hrs; Assess Skin Regularly; Protect from injury.
- Restrictive clothing
- Anxiety
- Dehydration
- Fecal Impaction (BOWEL) Check for impaction; Assess Bowel Sounds; Palpate for Distention; Assess last Bowel Movement; Use anesthetic jelly, prior to stool removal.
- Full bladder/UTI (MOST COMMON)
- Keep bladder EMPTY; Foley draining?; Assess UOP; Routine Bladder Scans-Kinked/Blocked?; Prevent UITs; Use anesthetic jelly, if needs catheterized
- Commonly caused by visceral distention from a distended bladder/impaction rectum.
TX:
- SIT CLT UP TO LOWER THEIR BP
- Antihypertensives
a. HYDRALAZINE - Find cause & treat
a. Full bladder? CATH
b. Constipated? REMOVE IMPACTION
c. Pressure injury? REPOSITION
d. Painful stimuli? REMOVE STIMULI
e. Cold room? CHANGE TEMPERATURE - A neurological emergency & must be treated STAT to prevent a hypertensive stroke.
Medical Emergency
-Prevent (THINK 3 BIG B’s: Bladder most common cause, Bowel, Breakdown of skin)
-Detect
-ACT!!
Anaphylactic Reaction
- Quickly assess respiratory status & maintain a patent airway.
- Call PHCP & Rapid Response Team (ACTION: Position pt @ 90 degrees w/legs lowered; Assess BPq2-5mins; Remove binding devices/clothing; Investigate 3 BIG B’s & CORRECT it!; Start w/BLADDER, then proceed to bowel, & then skin!)
- Administer oxygen
- Start an IV line & infuse NS
- Document event, action taken, & cat’s response.
Definition of Reye’s Syndrome?
PATHOPHYSIOLOGY ASSESSMENT? Diagnosis & Manifestations? INTERVENTIONS? RISK FACTORS? LABS? NURSING CARE?
- Acute encephalopathy associated w/other characteristics organ involvement. Key characteristics of disorder are fever, impaired consciousness, & disordered hepatic function. Defining characteristics of Reyes syndrome are cerebral edema & fatty changes in liver. Reyes syndrome commonly caused by a viral illness (varicella/influenza).
- Exact cause is unclear; it commonly follows a viral illness (influenza/varicella)
- Acetaminophen/ibuprofen are considered meds of choice.
- Early diagnosis & aggressive tx are impt; goal of tx is to maintain effective cerebral perfusion & control increasing ICP.
PATHO
Abnormal mitochondrial function induced by various viruses, drugs, exogenous toxins & genetic factors -> Elevated serum ammonia levels -> Cerebral edema & fatty changes in liver.
Taking acetylsalicylic acid (Aspirin), or salicylate containing products to treat fever associated w/viral illnesses greatly increases a child’s risk of developing Reyes Syndrome.
ASSESSMENT
- History of systemic viral illness 4 to 7 days b4 onset of symptoms.
- Fever.
- N&V
- Signs of altered hepatic function (lethargy).
- Progressive neurologica deterioration
- Increased blood ammonia levels
Definitive diagnosis is by liver biopsy, staging is based on degree of liver dysfunction & neurologic signs. MANIFESTAIONS: - Notable onset - Profuse, effortless vomiting - Varying degrees of neurological impairment * Lethargy * Personality changes * Seizures * Coma * Increased ICP * Herniation * Death
AGGRESSIVE SUPPORTIVE THERAPY
- Observe for alterations in consciousness & increasing ICP
- Accurately & frequently monitor I&O; prevent dehydration & cerebral edema
- Lab tests to determine impaired coagulation
PARENT EDUCATION
- Thorough explanation of diagnostic procedures & therapeutic management
- Salicylate containing products (aspirin, Pepto-Bismol) should NOT be given to a child w/influenza-like symptoms. All labels should be carefully read for hidden salicylates.
1. Provide rest & decrease stimulation in environment.
2. Assess neurological status.
3. Monitor I&O
4. Monitor for signs of bleeding & signs of impaired coagulation (prolonged bleeding time).
Risk Factors
- Aspirin use
- Typically occurs after a viral illness
LABS:
- Increase AST/ALT
- Increase Ammonia
- Increase coagulation time
Nursing Care: - Hydration-IVF - Strict I&O (catheter) - HOB elevated 30 - Pain Meds, VIT K (Liver) - Seizure precautions - Assist intubation/vent if needed - Educate family - Administer mannitol (HELP decrease cerebral swelling) - Observe for increase ICP AFTER Recovering: - Avoid Aspirin - Pt may hv long-term neuron damage
DEEP TENSION REFLEXES
Hyperactive deep tendon reflexes (DTRs) would NOT be expected in a pt w/muscular dystrophy. Muscular dystrophy DTRs are typically decreased/absent.
A) Testing following reflexes: biceps, triceps, brachioradialis, patella, Achilles.
B) Limd should be reflexed
C) tendon is tapped quickly w/a reflex hammer, which should cause contraction of muscle.
D) Scoring deep tension reflex activity
SCORING DTR Activity:
0 =No response
1+ = Sluggish/diminished
2+ = Active/expected response
3+ = Slightly hyperactive, more brisk than normal; NOT necessarily pathological
4+ = Brisk, hyperactive w/intermittent clonic associated w/disease
Kosher diet, gelatin potassium capsule treat hypokalemia.
A kosher diet refers to a basic conceptual structure for consumption, preparation, & processing of food that is common for clients who practice Jewish-Orthodox faith. Gelatin that is used to make capsules is composed of pork; prohibited for clients who follows this diet.
Clients who follow a Kosher diet will often NOT accept med in capsule form most are made of a gelatinous substance that is derived from pork. Pork is prohibited when following a Kosher diet. Best response by nurse is to request a different form of prescribed med so that it can be safety administered while respect client’s dietary needs.
Client does NOT take potassium @ home in a gelatinous pill due to following a Kosher diet; best response from nurse is to ask pharmacy for a different form of med that is NOT based in gelatin, a material that is prohibited by clients who follow a Kosher diet.
Administering an injection of enoxaparin to an overweight client warrants intervention by the supervising nurse?
Enoxaparin is a low molecular weight heparin (LMWH) that is prescribed to prevent/treat DVT. This med is administered by subcutaneous injection.
Novice nurses are often assigned nurse preceptors during 1st 6 to 12 wks of employment. Nurse preceptor is responsible for ensuring that novice nurse provides safe client care. Actions by novice nurse when administering prescribed enoxaparin that indicate a need for intervention by supervising nurse include: administering med @ a 15 degree angle of insertion & steadily delivering med; prompting client to massage injection site for 5 mins after administration; & removing all bubbles from syringe b4 injecting med.
Rationales:
This med is administered @ a 45 degree angle of insertion for clients who are underweight & a 90 degree angle of insertion for clients of normal body weight & for those who are obese. This action by new nurse indicates a need for intervention by supervising nurse.
While it is appropriate to apply gentle pressure to insertion site following administration of subcutaneous enxoaparin, it is inappropriate to massage site as this can lead to tissue damage; this action by novice nurse indicates a need for intervention by supervising nurse.
Enoxaparin comes in a prefilled syringe w/an air bubble that is meant to ensure delivery of entire dose of med; it is contraindicated to remove air bubble prior to administration. Based on this data, this action indicates a need for intervention by supervising nurse.
Cardiovascular Medications
Enoxaparin/Rivaroxaban– low molecular-weight heparins
1. Enoxaparin & Rivaroxaban have same MOA & use as heparin but are NOT interchangeable w/heparin; they have longer half-lives than heparin does.
2. Interventions:
a) Administer enoxaparin only to recumbent client by subcutaneous injection into anterolateral/posterolateral abdominal wall; do NOT expel air bubble from prefilled syringe/aspirate during injection.
b) Rivaroxaban is taken orally, once daily.
c) Monitor results of Anti-Xa assay. Therapeutic range of anticoagulation: 0.5 to 1.2 IU/mL.
d) Antidote to low-molecular-weight heparin (LMWH): Protamine sulfate.
Diagnosis of severe migraines & history of headaches.
Clinical manifestations to report to HCP?
A migraine is defined as a headache that can cause severe throbbing pain/a pulsing sensation, usually on 1 side of head. Migraine attacks can last for hrs to days, & pain can be so severe that it interferes w/normal daily activities.
A client who experiences a sudden change in LOC should be assessed STAT by HCP. LOC is earliest, most sensitive & reliable indicator of a client’s neurological status. Any change in LOC could represent a serious underlying problem including a stroke & increased ICP. New onset lethargy & weakness in a previously alert & oriented client requires immediate assessment & intervention to decrease likelihood of life-threatening consequences.
Any acute change in LOC could indicate a serious underlying problem that is causing increased ICP. This client’s status change should be STAT reported to HCP.
Imipramine
An antidepressant med that can cause severe adverse reactions when ingested by those who are NOT prescribed med.
Nystatin
Antifungal med that is prescribed for tx of oral candidiasis. When prescribed for this infection, it is prescribed as a suspension.
Clinical manifestations associated w/this fungal infection include white lesions on inner cheeks, gums, roof of mouth, tongue, & tonsils. An oral nystatin suspension is often prescribed to treat oral candidiasis (Thrush). Nurse is responsible for providing client w/information for safe & effective med administration. Actions by novice nurse that warrant intervention by nurse preceptor include following: reminding client to stop med when symptoms resolve; teaching client to avoid shaking nystatin b4 administering it; & warning client that abrupting stopping med can cause herpes zoster.
Rationales:
Med should be taken for prescribed course & NOT stopped when symptoms disappear; this action by novice nurse warrants intervention by nurse preceptor.
Nystatin that is prescribed for oral thrush is a suspension. All suspension meds are shaken prior to administration; This action by novice nurse warrants intervention by nurse preceptor.
Nurse provides discharge instructions to a client who is diagnosed w/peripheral arterial disease (PAD). Which need additional discharge teaching?
PAD is a circulatory problem caused by narrowed arteries which reduce blood flow to extremities. Education related to symptomatology & tx is essential for client safety.
PAD occurs when atherosclerosis, or hardening of arteries, lead to buildup of plaque w/in peripheral arteries causing decreased peripheral circulation. Decreased circulation leads to peripheral neuropathy, or decreased sensation in affected extremities. When performing teaching w/clients who are diagnosed w/PAD, it is essential to emphasize that heating pads should NOT be used, extremities should NOT be elevated, & that edema is NOT an expected finding. Light activity & moisturizing lotion may be applied to affected extremities per evidence-based practice guidelines for tx of PAD.
Rationales:
Application of a heating pad can cause significant tissue damage in a client w/PAD due to peripheral neuropathy; this client statement indicates a need for additional education.
Clients w/PAD should NOT elevate their legs for long periods as this further decreases circulation to extremities; this statement indicates a need for additional education.
Edema (swelling) is expected in clients w/peripheral venous insufficiency but it is NOT an expected finding in clients w/PAD; this client statement indicates a need for additional education from nurse.
V: Legs going elevated up
A: legs going danged down
Diagnosed w/Irritable bowel syndrome (IBS) experiences explosive diarrhea.
Nurses educates client on ways that a proper diet can reduce symptoms.
Which client statement indicates that nurse’s teaching is effective?
IBS is characterized by abdominal pain that is associated w/a change in bowel patterns. Cause of IBS is currently unknown.
LEARNING OUTCOMES
Management of IBS includes dietary & lifestyle modifications in addition to pharmacologic therapies. Common clinical manifestations associated w/IBS include a change in frequency/form of bowel movements; lower abdominal pain; & gas & bloating. Education regarding dietary changes to treat IBS is essential & should include information regarding low-FODMAP (Fermentable Oligo-, Di-, Mono-saccharides & Polyols) foods including meats & whole grains. Additionally, spicy foods are often considered GI irritants; should be AVOIDED.
RATIONALES
Meat & whole grains are low-FODMAP foods (Fermentable Oligo-, Di-, Mono-saccharides & Polyols) & appropriate foods for client who has IBS.
Spicy foods can be an irritant for those w/a sensitive GI tract that results from IBS; these foods should be AVOIDED.
Furosemide 160 mg by IV piggyback over 60 mins. Adverse effect is nurse avoiding w/this action?
Ototoxicity: adverse reaction to certain meds, including furosemide. Symptoms of toxicity include hearing loss, ringing of ear, or balance disorders.
Furosemide: a loop diuretic which can be given by mouth/IV. When med is prescribed IV, it must be given slowly to help reduce incidence of ototoxicity, a common adverse reaction associated w/furosemide. A common symptom of ototoxicity is tinnitus. When administering doses of furosemide that are >120 mg, furosemide should NOT be administer med faster than 4 mg/min.
Furosemide: A loop diuretic that can cause ototoxicity when administered too quickly by IV route. A symptom indicate of toxicity is tinnitus; this is adverse reaction nurse is trying to avoid by administering prescribed dose of furosemide by IV piggyback over 60 mins.
Cardinal movements
For a fetus to pass through birth canal, fetal head and body must adjust to passage and go through positional changes. These positional changes are referred to as cardinal movements.
Order:
- Engagement: Occurs when widest diameter of presenting part (usually head) enters mother’s pelvis.
- Descent and flexion: Descent is downward passage of fetus through pelvis. Flexion occurs as fetal head encounters resistance from pelvic bones and soft tissues of pelvic floor, causing embryo to flex head.
- Internal Rotation: Occurs as head, which is usually in a transverse position, rotates 45 degrees to A/P position under symphysis pubis.
- Extension: Follows descent and flexion of head when occiput comes into contract w/inferior margin of symphysis pubis. Force of uterine contractions causes occiput to extend and rotate around symphysis.
- Restitution and external rotation: Occurs as fetal head untwists to left and right, returning head to original anatomical position.
- Expulsion: Fetal head is delivered and anterior shoulder is rotated under symphysis, followed by posterior shoulder and rest of fetal body.
Medical diagnosis of diabetes mellitus.
Nursing Diagnosis: Ineffective peripheral tissue perfusion related to compromised blood flow secondary to diabetes mellitus as evidenced by bilateral lower extremity edema and non healing wound to left lower extremity.
Collaborative interventions, which are therapies that involve partnership and cooperation between multiple health care professionals. Of options provided, referring patient for a physical therapy consultation is only 1 considered as a collaborative intervention.
Changes in an older adult?
Physiological changes to ears and hearing include a widening and lengthening of auricle, coarse, wiry hair growth in external ears, narrowing of auditory canal, and dry cerumen in external auditory canal. Tympanic membrane in middle ear becomes dull, less flexible, retracted, and turns gray. Organ of Corti atrophies, causing sensory healing loss, and cochlear neurons are lost, causing neural healing loss. Changes to inner ear can reduce older adult’s ability to discriminate sounds, especially in noisy conditions.
Jackson-Pratt drainage build, how does the nurse reestablish negative pressure in the system?
A Jackson-Pratt drain creates negative pressure when the bulb is compressed and the valve is close. This cause fluid around the surgical site to flow into the drain.
Contraindications for administering an enema include all of the following EXCEPT
An enema may be used to administer sodium polystyrene sulfonate (Kayexalate) for the tx of hyperkalmeia. Kayexalate can be administered either orally/as an enema. Sodium polystyrene sultanate: NOT absorbed from GI tract. As resin passes through GI tract, resin removes potassium ions by exchanging them for sodium ions. Recent colon surgery, acute MI, & suspected appendicitis are contraindications for administering an enema. With elderly clients, enemas should be used with caution because of their higher risk of hyperphosphatemia, perforation, and sepsis.
Before administering a scheduled 300 mL enteral feeding bolus to a comatose adult client, the nurse aspirates 100 mL of gastric residual volume.
Administer the bolus as prescribed. Standard practice includes measuring gastric residual volume prior to administering an enteral feeding. Enteral feedings can be administered with a residual up to 500 mL; however, individual HCP orders should be followed, signs of feeding intolerance include abdominal distention and/or pain, constipation, nausea, vomiting, and sense of fullness.
Enteral Nutrition
A) Provides liquefied foods into the gastrointestinal tract via a tube.
B) Indications
1. When the GI tract is functional but oral intake is NOT meeting estimated nutrient needs.
2. Used for clients with swallowing problems, burns, major trauma, liver, or other organ failure, or severe malnutrition.
C) Nursing Considerations
1. Clients with lactose intolerance need to be placed on lactose-free formulas.
A patient receiving chemotherapy is experiencing stomatitis.
Warm saline rinses 4x each day. Warm saline rinses are non-irritating and help climate bacteria that can cause infection.
Stomatitis: Irritation of the lips, mouth, tongue, and oropharynx, which occurs when chemotherapy kills healthy cells that are rapidly dividing. It can impair nutrition, speech, sleep, and the quality of life. Other nursing interventions include gentle oral hygiene and administration of a topical analgesic as ordered by the physician.
Which of the following is the proper procedure for cleaning and storing dentures as part of a client’s HS oral care?
Remove dentures, clean with cool water, place in denture cup with cool water, leave within reach at client’s bedside.
Proper denture care: crucial to maintaining the life of the appliance and sustaining oral health. If dentures aren’t properly cared for, plaque can build up, causing additional tooth loss, bad breath, and even gum disease. Dentures are fragile and easily damaged; they’re also expensive, costing several thousand dollars. After removing them, the proper procedure for denture care is as follows:
- Take the dentures to the sink, line the basin with a washcloth, and fill the basin partway with cool or tepid water, but do NOT place the dentures in the sink.
- Using a toothbrush, clean the surface of the dentures as if you were brushing your own teeth. Work with 1 denture at a time. Using a small amount of toothpaste or denture cleaner is appropriate. Be sure to clean the areas where the denture comes in contact with the gums or roof of the mouth.
- Rinse the denture thoroughly and place it into a clean denture cup filled with cool water. Repeat this process with other denture.
- Place the cup within the client’s reach.
- Assist the patient with proper oral care using sponge swabs and mouthwash. Look in the client’s mouth for signs of infection such as lesions.
NEVER store dentures in a washcloth or paper towel; they could accidentally be thrown away.
Smallest garage intravenous catheter that can be used to administer blood
20 gauge
- 18 gauge needle/catheter is generally used to administer blood/push fluids, or for testing protocols that require large IV bores.
- 20 gauge is acceptable if facility’s policy allows it. This size is better for clients with small veins.
- 22 gauge is used for IVs of short duration or for clients who are NOT critically ill. Blood cannot be administered because of hemolysis of the RBCs.
- 24 gauge is used for pediatrics and adults who cannot tolerate a larger gauge.
- 16 gauge is mostly used in intensive care and surgery units because most fluids and blood products can be quickly administered.
- 26 gauge needles are used for injections.
Which one facilities maximum air exchange?
Orthopneic
(sitting in a leaning position)
allows for the most lung expansion.
High Fowler’s can help, but it isn’t as effective as orthopedic position.
Trendelenburg: Used for hypotension or low cardiac output.
Lithotomy: Used for vaginal examinations and childbirth.
Addison’s disease about nutrition
A patient with Addison’s disease (adrenal insufficiency) requires normal dietary sodium to maintain electrolyte balance and prevent excess fluid loss. The patient should be instructed to maintain adequate caloric intake with a diet high in protein and complex carbohydrates, including grains.
A patient receiving chemotherapy is experiencing stomatitis.
Warm saline rinses 4x each day.
Stomatitis: Irritation of the lips, mouth, tongue, and oropharynx, which occurs when chemotherapy kills healthy cells that are rapidly dividing. It can impair nutrition, speech, sleep, and the quality of life.
Warm saline rinses are non-irritating and help climate bacteria that can cause infection. Other nursing interventions include gentle oral hygiene and administration of a topical analgesic as ordered by the physician.
