Uworld Questions Flashcards
Parallel play is characteristic of what age
Toddlers typically exhibit parallel play, during which they participate in various activities alongside one another but remain primarily independent. Parallel play is without group organization or common goals.
Cooperative play
is organized, requires the ability to follow rules, and involves a leader-follower approach to activities. One or two children direct the activity and assign roles. Cooperative play, which develops during the PRESCHOOL years, is goal-oriented and may involve a formal game or task
Onlooker behavior
is when an interested child sits and observes others at play but does not engage in an activity.
Toxoplasmosis
- is a disease due to Toxoplasma gondii, a parasite that infects humans via cat feces or ingestion of undercooked meat.
- In a normal healthy adult, the infection goes unnoticed (no symptoms or only flulike symptoms are present) and causes no long-term damage.
- However, in a pregnant client, the parasite can be passed from mother to baby in utero and can cause significant damage to the growing fetus. If toxoplasmosis is acquired during pregnancy, it can cause stillbirth or serious fetal malformations.
- Pregnant clients should be advised to stay away from a litter box or cat feces to reduce toxoplasmosis risk.
Leukorrhea
- is a thin, milky white vaginal discharge that is normal during pregnancy.
- It is caused by increased levels of estrogen and is harmless.
- However, leukorrhea may become a problem if it changes color or develops a discernible odor, or if itching or burning occurs
Cervical lacerations
- should be suspected if the uterine fundus is firm and midline on palpation despite continued vaginal bleeding. - The bleeding can be minimal to frank hemorrhage.
- Severe pain or a feeling of fullness is not associated with cervical lacerations.
Complete inversion of the uterus presents
with a large, red mass protruding from the introitus.
A vaginal hematoma
- formed when trauma to the tissues of the perineum occurs during delivery.
- more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy.
- pt reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain may not be felt until the effects have worn off.
- Vaginal bleeding is unchanged.
- The uterus is firm and at the midline on palpation.
- If the hematoma is large, the hemoglobin level and vital signs can change significantly. In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma.
Uterine atony presents
with a boggy uterus on palpation and an increase in vaginal bleeding
Syndrome of inappropriate antidiuretic hormone (SIADH) secretion results in
- water retention and dilutional hyponatremia
- Clients with SIADH often require hypertonic saline for sodium repletion to increase serum sodium levels with a minimal infused volume of water.
Treatment of Sickle Cell Crisis
Sickle cell disease (SCD) is a hereditary hemoglobinopathy in which normal hemoglobin is replaced with abnormal hemoglobin S in red blood cells. The cells change to a sickle shape with triggers (eg, dehydration, infection, high altitude, extremes in temperature). This causes occlusion of small blood vessels with ischemia and damage to organs.
Sickle cell crisis occurs when inadequate oxygenation or hydration exacerbates sickling and causes red blood cells (RBCs) to clump together in the capillaries (vasoocclusion). Vasoocclusion causes severe ischemic pain, hypoxia, and possible organ dysfunction if left untreated.
Adequate oxygenation and hydration may reverse the acute sickling response. In the sickled state, RBCs cannot carry enough oxygen from the lungs to the tissues, even with supplemental oxygen. The priority intervention is the administration of IV fluids to reduce blood viscosity and restore perfusion to the areas previously affected by vasoocclusion (Option 1). Only after IV rehydration reverses vasoocclusion can nonsickled RBCs effectively carry supplemental oxygen to the tissues
Management of sickle cell crisis focuses on the following:
- Pain control with narcotics - analgesics are provided around the clock or with patient-controlled analgesia, rather than as needed, to prevent breakthrough pain.
- Hydration - aggressive intravenous and oral hydration is recommended (to reduce the viscosity of the blood)
- Oxygenation - to prevent pulmonary complications and provide comfort
- Infection prevention – age-appropriate vaccination plus pneumococcal, influenza, and meningococcal vaccination
- Diet - the client is encouraged to have a high-protein, high-calorie diet with folic acid and a multivitamin without iron
- Folic acid - given to help in the creation of the new red blood cells needed due to the hemolysis
- Don’t increase Iron in theses pts - The anemia in SCD is related to the destruction of red blood cells from sickling, not a deficiency in iron. Increased iron intake is not needed. Clients often require blood transfusions and run the risk of iron overload from multiple transfusions.
- Cold promotes sickling and should be avoided. Ice packs are used on joints with bleeding in hemophilia to promote vasoconstriction.
Priority interventions for active or suspected air embolism from a central line:
- Clamp the catheter to prevent more air from embolizing into the venous circulation.
- Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium.
- Administer oxygen if necessary to relieve dyspnea.
- Notify the HCP or call an RRT to provide further resuscitation measures.
- Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours.
latex allergy
The greatest risk factor for latex allergy is long-term multiple exposures to latex products. Powdered latex gloves were banned in the 1990s, and the incidence of latex allergy is decreasing. It is estimated that 73% of clients with spina bifida have a sensitivity to latex. This can be a result of frequent exposure to latex during their lifelong care.
A classic screening question is whether the lips swell when blowing up balloons (which have latex in them). Another is if your hands itch and/or burn after wearing rubber gloves
Some proteins in rubber are similar to plant-derived food proteins. Therefore, certain foods may cause a latex-food syndrome in clients with an allergy to latex. Common foods include bananas, avocados, tomatoes, chestnuts, kiwis, potatoes, peaches, grapes, and apricots
bananas, kiwis, avocados, tomatoes, peaches, and grapes because some proteins in rubber are similar to food proteins
Steps for chest tube removal include:
A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded.
The general steps for chest tube removal include:
- Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal
- Provide the health care provider (HCP) with sterile suture removal equipment
- Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space (Option 2).
- Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space
- Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame.
- The client should be placed in semi-Fowler’s position or on the unaffected side to promote comfort and facilitate access for tube removal.
Testing for CSF
Cerebrospinal fluid (CSF) rhinorrhea (or CSF otorrhea) can confirm that a skull fracture has occurred and transversed the dura.
- If the drainage is clear, dextrose testing can determine if it is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose.
- In this case, the halo/ring test should be performed by adding a few drops of the blood-tinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by CSF.
- Identification of this pattern is very important as CSF leakage places the client at risk for infection. The client’s nose should not be packed. No nasogastric or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected as there is a risk of penetrating the skull through the fracture site and having the tube ascend into the brain. These tubes are placed under fluoroscopic guidance in clients with such fractures.
Polycythemia is expected with COPD because
- The client with severe COPD will have a chronically low oxygen level, hypoxemia.
- To compensate, the body produces more red blood cells (RBCs) to carry needed oxygen to the cells.
- A high RBC count is called polycythemia.
Characteristics of schizophrenia with catatonia
A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following additional features:
- Immobility—the client remains in a fixed stupor or position for long periods
Refuses to move about or engage in activities of daily living - May have brief spurts of excitement or hyperactivity
- Remaining mute
- Bizarre postures—the client holds the body rigidly in one position
- Extreme negativism—the client resists instructions or attempts to be moved
- Waxy flexibility—the client’s limbs stay in the same position in which they are placed by another person
- Staring
- Stereotyped movements, prominent mannerisms, or grimacing
Infants with cyanotic cardiac defects can develop polycythemia
Infants with cyanotic cardiac defects can develop polycythemia (elevated hemoglobin levels) as a compensatory mechanism due to prolonged tissue hypoxia.
- Polycythemia will increase blood viscosity, placing an infant at risk for stroke or thromboembolism
- An infant with polycythemia must stay hydrated.
Decerebrate posturing is a sign
of severe brain damage.
- During assessment, the nurse would observe arms and legs straight out, toes pointed down, and the head/neck arched back
carotid endarterectomy
- surgical procedure that removes atherosclerotic plaque from the carotid artery.
- Clients with carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding.
- Blood pressure is closely monitored during the first 24 hours post surgery. Hypertension may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain.
Rationalization - defense mechanism
using excuses to explain away threatening circumstances
Displacement - defense mechanism
transferring thoughts and feelings toward one person or object onto another person or object
Regression - defense mechanism
returning to a previous level of development
Introjection - defense mechanism
taking on the qualities or attitudes of others without thought or examination
Reaction formation - defense mechanism
behaving in a manner or expressing a feeling opposite of one’s true feelings
Repression - defense mechanism
keeping unacceptable thoughts or traumatic events buried in the unconscious
sublimation - defense mechanism
transforming unacceptable thought or needs into acceptable actions
When should kids go to the dentist?
children have their first dental visit within 6 months of first tooth eruption or by their first birthday
After delivery of the placenta, how should the fundus be?
- After delivery of the placenta, the uterus begins the process of involution.
- The fundus should be firm, midline, and halfway between the umbilicus and symphysis pubis
A “boggy uterus”
indicates that the uterus is not in a contracted state and there is a risk of excessive blood loss. The contracted uterus muscle compresses the open vessels at the placental site and decreases the amount of blood loss.
- The immediate nursing action when a “midline, boggy uterus” is assessed is to massage the fundus with the palm of the hand in a circular motion.
- Fundal massage stimulates contraction of the uterus.
- If the uterus responds, the nurse should then recheck the uterine tone and position in 30 minutes.
- The first action is to use massage. If the uterus does not respond to massage, the next actions are to administer oxytocin (Pitocin)
- Oxytocin promotes contraction by stimulating the smooth muscle of the uterus.
- The HCP should be notified if there is no response to the massage as this lack of response can indicate complications such as retained placental tissue
If the uterus shifted to the side…
- it may indicate a distended bladder that is interfering with uterine contractibility.
- After massage, a woman with a uterus that is deviated, soft, or elevated above the umbilicus should then void. The nurse should reassess after the woman voids.
- If the woman cannot void, catheterization may be required.
Nonmaleficence means
doing no harm.
- It also relates to protecting clients who are unable to protect themselves due to their physical or mental condition. Examples include infants/children, clients under the effects of anesthesia, and clients with dementia
Autonomy is
freedom for a competent client to make decisions for oneself, even if the nurse or family does not agree (eg, informed consent, advanced directive). The nurse can provide information and should respect the client’s decisions.
neuroleptic malignant syndrome (NMS)
uncommon but life-threatening adverse reaction to anti-psychotic medications. most often seen with the “typical” antipsychotics (eg, haloperidol, fluphenazine). However, even the newer “atypical” antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome.
- diaphoresis, tachycardia, hypertension, tachypnea, dysrhymthia, altered mental status, fever, muscle rigidity
- characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia).
- Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment.
- Treatment includes supportive care (eg, rehydration, cooling body temperature) and immediate discontinuation of the medication.
Signs of subsequent hypovolemic (hemorrhagic) shock from tubal rupture include
- dizziness, hypotension, tachycardia, and decreased urinary output to <30 mL/hr.
- Free intraperitoneal blood pooling under the diaphragm can cause referred shoulder pain.
- Peritoneal signs (eg, tenderness, rigidity, low-grade fever) develop subsequently.
- hypovolemic (internal hemorrhage) shock. - Jugular veins would be flat in hypovolemic shock.
If a chest tube is dislodged from the client and the nurse hears air leaking from the site, the nurse’s immediate action should be
- to apply a sterile occlusive dressing (eg, petroleum jelly dressing) taped on 3 sides.
- This action permits air to escape on exhalation and inhibits air intake on inspiration.
- The nurse would then notify the HCP and arrange for the reinsertion of another chest tube
Why not tape 4 sides??? A tension pneumothorax develops when air enters the pleural space but cannot escape. Increased intrapleural pressure and excessive accumulation of air can apply pressure to the heart and great vessels and drastically decrease cardiac output. An occlusive dressing taped on 4 sides would prevent the air in the pleural space from escaping on exhalation and would increase the risk for a tension pneumothorax.
The procedure for bowel irrigation for someone with a colostomy is as follows:
- Fill the irrigation container with 500-1000 mL of lukewarm water, flush irrigation tubing, and reclamp; hang the container on a hook or intravenous pole
- Instruct the client to sit on the toilet, place the irrigation sleeve over the stoma, extend the sleeve into the toilet, and place the irrigation container approximately 18-24 inches above the stoma
- Lubricate cone-tipped irrigator, insert cone and attached catheter gently into the stoma, and hold in place
- Slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes
- Clamp the tubing if cramping occurs, until it subsides
- Once the desired amount of solution is instilled, the cone is removed and feces is allowed to drain through the sleeve into the toilet
If a client reports cramping or pain during instillation of an enema…
Too rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of fullness, cramping, and pain.
- If the client reports any of these symptoms, instillation should be stopped for 30 seconds and then resumed at a slower rate.
- Slow infusion will also decrease the likelihood of premature ejection of the solution, which would not allow for adequate bowel evacuation.
Clients with paroxysmal supraventricular tachycardia (SVT) are initially treated with
(regular, narrow QRS complex tachycardia) are initially treated with vagal maneuvers.
Cardioversion or defibrillation with supraventricular tachycardia
Cardioversion (not defibrillation) is used with this type of arrhythmia when it is refractory to medication. Cardioversion delivers a synchronized electrical current to the heart. This works by stopping the electrical activity to the heart and briefly allowing a normal heartbeat to return.
Lipomas are
benign, fatty masses and rarely become malignant.
They are subcutaneous, have a soft doughy feel, and are mobile and asymptomatic.
Masses that are hard and fixed, not soft and mobile, usually indicate malignancy.
The warning signs of cancer
can be remembered with the acronym CAUTION:
C - change in bowel or bladder habits
A - a sore that does not heal
U - unusual bleeding or discharge from a body orifice
T - thickening or a lump in the breast or elsewhere
I - indigestion or difficulty in swallowing
O - obvious change in a wart or mole
N - nagging cough or hoarseness
- Unintentional weight loss of >10% of usual weight (in non-obese clients) requires evaluation and could indicate underlying cancer. Nausea, anorexia, and dysgeusia (altered taste sensation) are also clinical features of cancer and contribute to weight loss
nutrients in cow’s milk
calcium and vitamin D
food sources of calcium
cow’s milk, beans, dark green vegetables, and calcium-fortified cereals and juices
sources of vitamin D
- exposure to direct sunlight.
- Alternate dietary sources include fish oils, egg yolks, and vitamin D-fortified foods (eg, orange juice), cow’s milk
Dietary sources of iron include
Meats (eg, beef, lamb, liver, chicken, pork)
Shellfish (eg, oysters, clams, shrimp)
Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal
sources of vitamin K
dark green vegetables, fish, and eggs
Hirschsprung’s disease
- a portion of the colon has no innervation and must be removed.
- Some children require a temporary colostomy.
operating a fire extinguisher
P - Pull the pin
A - Aim the spray at the base of the fire
S - Squeeze the handle
S - Sweep the spray.
When planning to become pregnant what prevents neural tube defects
- Women who are planning on becoming pregnant should consume 400-800 mcg of folic acid daily.
- Food options that are rich in folic acid include fortified grain products (eg, cereals, bread, pasta) and green, leafy vegetables
- Inadequate maternal intake of folic acid during the critical first 8 weeks after conception increases the risk of fetal neural tube defects (NTDs), which inhibit proper development of the brain and spinal cord.
Food options that are rich in folic acid
fortified grain products (eg, cereals, bread, pasta) and green, leafy vegetables (best choice), cooked beans, rice, fortified cereals, and peanut butter
anencephaly
lack of cerebral hemispheres and overlying skull
- a neural tube defect that results in very little to no brain tissue forming in utero.
- The majority of fetuses with anencephaly will be stillborn. Those born alive will not survive for long.
- Comfort care should be provided for the neonate. Drying, bundling, or placing the neonate skin-to-skin with the mother for warmth and possibly administering oxygen to the neonate will decrease the discomforts of impending death.
- Allowing the mother to hold the neonate will assist with the grieving process.
true labor signs
- A key indicator of true labor is the progressive effacement and dilation of the cervix
- Contractions in true labor are regular, and increase in frequency, duration, and intensity
- The pain may initially start in the lower back and radiate to the abdomen
when developed to eat with spoon
18 mo
trichomoniasis
- sexually transmitted infection (STI).
- Many women with trichomoniasis are asymptomatic but can have profuse frothy gray or yellow-green vaginal discharge with a fishy odor.
- Small red lesions (strawberry) may be present in the vagina or cervix. Pruritus is common.
signs of diabetic ketoacidosis (DKA)
lethargy, abdominal pain, hyperglycemia, urine ketones
characterized by hyperglycemia, ketosis, and acidosis
- Glucose cannot be used properly for energy when this deficit occurs and the body begins to break down fat stores, producing ketones, a byproduct of fat metabolism, resulting in metabolic acidosis. The lack of insulin also results in increased production of glucose in the liver, further exacerbating hyperglycemia.
- Hyperglycemia can cause osmotic diuresis, leading to dehydration. In addition, ketones are excreted in the urine as the body tries to restore its pH balance. Vital electrolytes such as sodium, potassium, chloride, phosphate, and magnesium become depleted during the process. Cardinal signs of dehydration such as poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, weakness, and lethargy can occur
- Other signs associated with DKA include Kussmaul respirations, deep, rapid respirations that have a fruity/acetone smell as the carbon dioxide is exhaled. This compensatory mechanism results in a lowered PaC02 in an attempt to restore the body’s normal pH level and should not be reversed
toxic megacolon
- severe inflammatory colon distension
- Clients with ulcerative colitis are at risk for developing
- Symptoms include fever, nausea, vomiting, pain, and abdominal distension.
- Clients require close monitoring, nasogastric tube for decompression, IV fluids, and antibiotics.
- Emergency surgery may be required.
Acute angle-closure glaucoma
is a form of glaucoma that requires immediate medical intervention to prevent permanent blindness
- Glaucoma disorders are characterized by increased intraocular pressure (IOP) due to decreased outflow of the aqueous humor, resulting in compression of the optic nerve that can lead to permanent blindness.
- In acute angle-closure glaucoma, IOP increases rapidly and drastically, which can lead to the following manifestations:
- -Sudden onset of severe eye pain
- -Reduced central vision
- -Blurred vision
- -Ocular redness
- -Report of seeing halos around lights
open-angle glaucoma
- Gradual loss of peripheral vision and difficulty adjusting to different lighting are manifestations of chronic open-angle glaucoma
- Although further evaluation and treatment are necessary, this condition develops slowly and is not considered an emergency situation.
Opaque lenses are characteristic of
cataracts, not an emergency
Discharge teaching for the client with a permanent pacemaker should include the following:
- Report fever or any signs of redness, swelling, or drainage at the incision site
- Keep a pacemaker ID card with you, and wear a medic alert bracelet
- Microwave ovens are safe to use and do not interfere with the pacemaker
- Learn to take your pulse and report it to the health care provider (HCP) if it is below the predetermined rate
- Do not place a cell phone in a pocket located directly over the pacemaker. Also, when talking on the cell phone, hold it to the ear on the opposite side of the pacemaker’s implantation site
- MRI scans can affect or damage a pacemaker
- Avoid lifting your arm above the shoulder on the side that the pacemaker is implanted until approved by the HCP. It can cause dislodgement of the pacemaker lead wires
- Air travel is not restricted. Notify security personnel that you have a pacemaker, which may set off the metal detector. A handheld screening wand should not be held directly over the pacemaker
- Avoid standing near antitheft detectors in store entryways. Walk through at a normal pace and do not linger near the device.
Do not __________ chest tubes when transferring a pt
- Clamping the chest tube during transport is contraindicated.
- Doing so can cause air to accumulate in the pleural cavity as it has no means of escape. This can lead to the development of a tension pneumothorax, a potentially life-threatening condition.
- A tension pneumothorax results in compression of the unaffected lung and pressure on the heart and great vessels. As the pressure increases, venous return is decreased and cardiac output falls.
Uterine contraction duration should not exceed
exceed 90 seconds.
- A duration exceeding 90 seconds can result in reduction of blood flow to the placenta due to uterine hypertonicity.
- contractions should not be less than 2 mins apart
Mastitis
- a common infection in postpartum women due to multiple risk factors leading to inadequate milk duct drainage (eg, poor latch). Bacteria are transmitted from the infant’s nasopharynx or the mother’s skin through the nipple and multiply in stagnant milk. Staphylococcus aureus is the most common offending organism. Symptoms of mastitis include fever, breast pain, and focal inflammation (redness, edema).
In addition to antistaphylococcal antibiotics (dicloxacillin or cephalexin) and analgesics (eg, ibuprofen), treatment of lactational mastitis requires effective and frequent milk drainage. Milk ducts are most efficiently drained by direct breastfeeding. The correct position for optimal milk intake involves the infant forming a tight seal around most of the areola. However, a common cause of severe pain during latching occurs when the infant only suckles on the nipple. This improper position can cause nipple blistering. Adequate rest and increase of oral fluid intake is also recommended.
- Breastfeeding should be continued every 2-3 hours to relieve milk duct obstruction. Mothers should be reassured that the infant can safely feed from the infected breast as the newborn is already colonized with the mother’s skin flora.
- Underwire bras (tight bras) are not recommended with breastfeeding or mastitis as milk flow is impeded, worsening engorgement. Soft cup bras are recommended for support and to encourage milk flow.
Testicular torsion
- an emergency condition in which blood flow to the testis (scrotum) has stopped. The testicle rotates and twists the spermatic cord, initially causing venous drainage obstruction that leads to swelling and severe pain. Arterial blood supply is subsequently interrupted, resulting in testicular ischemia and necrosis, which require surgical removal of the testis.
- The condition can be diagnosed with ultrasound.
- There is a short time frame in which testicular torsion can be treated (to untwist the rotation), generally 4-6 hours, making this condition a priority.
Right lower quadrant pain referred from the periumbilical area is a classic sign of
- appendicitis.
- If left untreated, the appendix could perforate and release bacteria into the abdomen, causing peritonitis, a more serious condition.
- Surgery is usually required within 24 hours.
Sudden-onset, right-sided flank pain radiating to the groin is classic for
- renal stones.
- Kidney stones are very painful but in most cases cause no permanent damage unless a stone completely blocks kidney flow.
postoperative cognitive dysfunction (POCD)
- Clients who have undergone surgery may experience
- This may include memory impairment and problems with concentration, language comprehension, and social integration.
- Some clients may cry easily or become teary.
- The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections.
- POCD can occur days to weeks following surgery.
- Most symptoms typically resolve after complete healing has occurred.
- In some cases, this condition can become a permanent disorder
when should you introduce pureed foods to baby
6 mo
- iron-fortified cereals (usually rice) offered first due to their low allergy potential and ease of digestion
Ventricular Fibrillation
- characterized on the ECG by irregular waveforms of varying shapes and amplitudes.
- This represents the firing of multiple ectopic foci originating in the ventricle. Mechanically, the ventricle is quivering with no effective contraction or cardiac output. VF is considered a lethal dysrhythmia. It results in an unresponsive, pulseless, apneic state. If not treated rapidly, the client will not recover.
- VF commonly occurs in acute myocardial infarction and myocardial ischemia and in chronic heart diseases such as heart failure and cardiac myopathy. It may occur in cardiac pacing or catheterization procedures due to catheter stimulation of the ventricle.
- Treatment consists of rapid initiation of CPR, defibrillation, and the use of drug therapy (eg, epinephrine, vasopressin, amiodarone).
Clients of the Orthodox Jewish faith follow Kosher rules which means
- no pork, shellfish, or fish without scales.
- When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product can be consumed.
Third-spacing
- can occur following extensive abdominal surgery and can lead to hypovolemia, decreased cardiac output, hypotension and tachycardia, and decreased urine output.
- Monitoring vital signs and urine output, and maintaining IV fluids are appropriate interventions to prevent prerenal failure and hypovolemic shock.
If Group B Streptococcus (GBS) status is unknown in pregnant woman then
- antibiotics are typically indicated when membranes have been ruptured for ≥18 hours, maternal temperature is ≥100.4 F (38 C), or gestation is <37 weeks
Group B Streptococcus (GBS) may be present as part of normal vaginal flora in up to 30% of pregnant clients. Although colonization with GBS rarely poses harm to the client, it can be transmitted to the newborn during labor and birth, resulting in serious complications (eg, neonatal GBS sepsis, pneumonia). Pregnant clients are tested for GBS colonization at 35-37 weeks gestation and receive prophylactic antibiotics during labor if results are positive.
Assault vs Battery
Assault is an act that threatens the client and causes the client to fear harm, but without the client being touched
Assault is the threat of battery.
Battery involves making physical contact with the client without permission. This includes harmful acts or acts that the client refuses (eg, performing a procedure). When interacting with the client, it is important to practice veracity, the ethical principle of being truthful.
Splenic sequestration crisis is
a potentially life-threatening emergency of sickle cell disease.
- A rapidly enlarging spleen and hypotension are the characteristic assessment findings.
- occurs when a large number of “sickled” cells get trapped in the spleen, causing splenomegaly
- This is a life-threatening emergency as it can lead to severe hypovolemic (hypotensive) shock
The caregiver of a child with a VP shunt must understand symptoms of
- Increased ICP may occur with VP shunt malfunctions.
- The caregiver must recognize symptoms of vomiting, headaches, vision changes, and changes in mental status.
- Early intervention by the HCP will decrease the risk of damage to the brain tissue
hemoglobin normal values
- 11.7-15.5 g/dL for females
- 13.2-17.3 g/dL for males
positive TB test
> 5 - positive if Immunocompromised clients cannot elicit a good inflammatory response
– these clients include all HIV and organ transplant recipients (who are usually on immunosuppressant medications). An individual exposed to active TB is at very high risk of developing TB infection
> 15 is all normal healthy individuals with no known risk factors
> 10 is Clients who do not belong to either the ≥5 mm group or the ≥15 mm group
Receptive aphasia refers
to impairment or loss of comprehension.
- ask questions that require simple “yes” or “no” responses.
- It is helpful to see gestures or pictures of the goal of the activity
When caring for a client with severe burns, the nurse can expect to administer pain medication via which route?
IV
Bell palsy
- presents as acute onset of unilateral facial paralysis related to inflammation of the facial nerve (ie, cranial nerve VII) that may be triggered by a viral illness (eg, herpes simplex virus).
- Standard treatment includes corticosteroids (eg, prednisone) within 72 hours of symptom onset.
Symptoms include the following:
- Inability to completely close the eye on the affected side
- Flattening of the nasolabial fold on the side of the paralysis
- Inability to smile or frown symmetrically
- Alteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to lower eyelid muscle weakness
Client teaching should include the following:
- Eye care: Use glasses during the day; wear a patch (or tape the eyelids) at night to protect the exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea
- Oral care: Chew on the unaffected side to prevent food trapping; a soft diet is recommended. Maintain good oral hygiene after every meal to prevent problems from accumulated residual food (eg, parotitis, dental caries)
for kids with scabies what to do with to disinfect home
Scabies mites do not survive away from human skin for more than 2-3 days. Therefore, disinfecting the client’s clothes, linens and stuffed animals involves placing these in a plastic bag (for a minimum of 3 days) or machine washing them in hot water and drying them on the hottest dryer cycle.
- Fumigation of living areas is also not needed for the same reason
Serotonin syndrome
- potentially life-threatening condition
- develops when drugs affecting the body’s serotonin levels are administered simultaneously or in overdose. - Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), dextromethorphan, ondansetron, St. John’s wort, and tramadol.
- Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia).
trisomy 21 =
Down syndrome
- Characteristic features include a single palmar crease and a short neck with excess skin (nuchal fold).
signs of fetal alcohol syndrome
growth deficiency, neurological symptoms (eg, microcephaly), or specific facial characteristics (indistinct philtrum, thin upper lip, epicanthal folds, flat midface, and short palpebral fissures).
nonmaleficence =
do no harm
Beneficence =
is a nurse’s duty to promote good and do what is best for the client
Beneficence is the ethical principle of doing good. It involves helping to meet the client’s (including the family) emotional needs through understanding. This can involve withholding information at times.
Paternalism =
is a type of beneficence whereby clients are treated as children. The nurse claims to know what is best for the client and coerces the client to act as the nurse wishes without considering the client’s autonomy.
Veracity =
the duty to tell the truth. This principle should always be applied to client care and documentation.
cardiac tamponade
Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade.
- This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart.
- Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus.
- Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration.
what is in airborne isolation
Tuberculosis
Varicella (chickenpox)*
Rubeola (measles)
negative pressure room with N95 particle respirator
The nurse should take immediate action when a client recovering from a vaginal hysterectomy saturates how many peripads
more than one perineal pad in an hour.
The nurse should assess the client for pulsus paradoxus when
cardiac tamponade is suspected. The amount of paradox is the difference between the pressure heard at the first Korotkoff sound during expiration and the Korotkoff sounds heard throughout inspiration and expiration. A difference of <10 mm Hg is normal, but if it is >10 mm Hg, this may indicate cardiac tamponade.
laparoscopic cholecystectomy is the safest and most commonly used procedure for
gallbladder removal
Babinski reflex
<1 year - toes fan out and big toe goes up
>1 year - plantar flex - so toes go down = no Babinski
the toes going upward in an adult (Babinski) indicates an upper motor neuron (brain or spinal cord) lesion.
The presence of sunset eyes (sclera above iris) is a late sign of
increased intracranial pressure
when you see umbilical cord protruding out of vagina
- Position the client on hands and knees (eg, knee-chest position) or Trendelenburg position is used to relieve pressure on the compressed cord
- the nurse may also use a sterile, gloved hand to help lift the presenting part off the cord; the hand should remain in the vagina until the HCP arrives. Other actions include administration of oxygen and IV fluids.
Umbilical cord prolapse
may occur after rupture of membranes if the presenting fetal part is not firmly applied to the cervix. Cord compression caused by a prolapsed cord will produce abrupt fetal heart rate deceleration, fetal bradycardia, and disruption of fetal oxygen supply.
The priority action is to inspect the vaginal area and perform a sterile vaginal examination to assess for a prolapsed cord. If a prolapsed cord is visualized or palpated, the nurse should then manually elevate the presenting fetal part off the umbilical cord, leave the hand in place, and call for help
An emergency cesarean section is usually required unless vaginal birth is imminent and considered safe by the health care provider .
Suprapubic pressure helps to
dislodge an impacted anterior shoulder from under the client’s pubic bone in the event of shoulder dystocia
Leopold maneuvers are used as
a systematic approach to palpating the pregnant abdomen to identify fetal presentation
The McRoberts maneuver consists of
- sharply flexing the thigh onto the maternal abdomen to straighten the sacrum.
- It is used for shoulder dystocia
The Bishop score is
- a system for the assessment and rating of cervical favorability and readiness for induction of labor.
- The cervix is scored (0-3) on consistency, position, dilation, effacement, and station of the fetal presenting part.
- A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth. For nulliparous women, a score ≥8 usually indicates that induction will be successful
Strabismus =
crossed eye
- one eye may appear deviated inward (esotropia) or outward (exotropia)
Epiglottitis refers to
- inflammation of the epiglottis that may result in life-threatening airway obstruction.
- Edema can develop rapidly (as quickly as a few minutes) and obstruct the airway by occluding the trachea. There has been a 10-fold decrease in its incidence due to the widespread use of the Hib (Haemophilus influenzae type B) vaccine.
- The affected child will typically progress from having no symptoms to having a completely occluded airway within hours.
- Symptoms begin with abrupt onset of high-grade fever and a severe sore throat, followed by the
4 Ds: drooling, dysphonia, dysphagia, and distressed airway (inspiratory stridor). - Children are typically toxic-appearing and may be “tripoding” (sitting up and leaning forward) with inspiratory stridor.
- The child should be allowed to assume a position of comfort (usually sitting rather than lying down). The priority nursing response is to protect the airway
- throat inspection should not be done until emergency intubation is readily available (if necessary).
- This is a pediatric emergency and should be managed with endotracheal intubation; however, intubation of such clients is difficult, and preparation for possible tracheostomy is also standard. The complications of epiglottitis are serious and include sudden airway obstruction.
Rotavirus is
a contagious virus and the leading cause of diarrhea in children less than 5 years old
- spread via the fecal-oral route.
- Because the virus lives easily outside a human host, transmission can occur through contact with food, toys, diapers, and hands. Meticulous handwashing and proper diaper disposal prevent the spread of the virus
- Symptoms include foul-smelling, watery diarrhea that lasts 5-7 days and is often accompanied by fever and vomiting.
- Vaccination is available and must be given before the child is 8 months old. However, vaccinated children can still acquire Rotavirus as many strains are not covered by the vaccine. Antibiotics are not effective against this viral agent.
- Because the virus can easily lead to dehydration, parents should be taught the symptoms (eg, lack of tears when crying, extremely fussy or sleepy, decreased urination, dry mucous membranes). Oral rehydration solutions should be used to combat dehydration
Sepsis neonatorum is
- a medical emergency.
- Newborns may not exhibit obvious signs of infection but instead may have elevated temperature or be hypothermic. Subtle changes such as irritability, increased sleepiness, and poor feeding should be considered red flags.
- Blood, urine, and cerebrospinal fluid cultures should be obtained immediately and broad-spectrum antibiotics started.
hydrocele
a fluid-filled testicular mass
- painless, bilateral testicular swelling
Signs and symptoms of cardiac tamponade include:
- Hypotension with narrowed pulse pressure
- Muffled or distant heart tones
- Jugular venous distension
- Pulsus paradoxus
- Dyspnea, tachypnea
- Tachycardia
cardiac tamponade
Pericardial effusion is a buildup of fluid in the pericardium. Tamponade, a serious complication of pericardial effusion, develops as the effusion increases in volume and results in compression of the heart. The heart struggles to contract effectively against the fluid, and cardiac output can decrease drastically. This life-threatening complication requires an emergency pericardiocentesis (a needle inserted into the pericardial sac to remove fluid).
open-angle glaucoma
- eye condition characterized by an increase in intraocular pressure and gradual loss of peripheral vision (ie, tunnel vision).
- The signs/symptoms of POAG develop slowly and include painless impairment of peripheral vision with normal central vision, difficulty with vision in dim lighting, increased sensitivity to glare, and halos observed around bright lights.
- POAG can lead to blindness if left untreated.
Retinal detachment
- separation of the retina from the underlying epithelium that allows fluid to collect in the space.
- The signs/symptoms include sudden onset of light flashes!!, floaters, cloudy vision, or a curtain appearing in the vision.
- emergency management. - An unrepaired complete retinal detachment can cause blindness
macular degeneration
- progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins to deteriorate with age.
- This causes distortion (blurred or wavy disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact.
- “Dry” macular degeneration occurs when the microvasculature supplying the macula is blocked, causing ischemia.
- “wet” macular degeneration, abnormal blood vessels form and eventually destroy the macula. If it is diagnosed early, further progression of wet macular degeneration can be slowed or stopped using surgery or antineoplastic agents.
- Age and heredity are the biggest risk factors for macular degeneration.
cataract
- cloudiness (ie, opacity) of the lens that may occur at birth or more commonly in older adults.
- The signs/symptoms of a cataract include painless, gradual loss of visual acuity with blurry vision; scattered light on the lens producing glare and halos, which are worse at night; and decreased color perception.
Anaphylaxis is
a medical emergency requiring rapid assessment and intervention.
Symptoms of an anaphylactic reaction include signs of respiratory compromise (eg, oral and airway swelling, stridor, wheezing, chest tightness) and shock (eg, dizziness, loss of consciousness).
SIRS → Sepsis → Septic shock → MODS
SIRS → Generalized inflammatory response to an infectious or noninfectious insult to the body
Sepsis → Presence (probable or documented) of infection along with systemic manifestations of infection
Septic shock → Sepsis-induced hypotension despite adequate fluid resuscitation (30 mL/kg)
SIRS
- systemic inflammatory response syndrome
- Generalized inflammatory response to an infectious or noninfectious insult to the body
- fever, tachycardia, tachypnea
Diagnostic criteria for SIRS include 2 or more of the following manifestations:
- Hyperthermia (temperature >100.4 F) or hypothermia (temperature <96.8 F)
- Heart rate >90/min
- Respiratory rate >20/min or alkalosis (PaCO2 <32 mm Hg)
- Leukocytosis (WBC count >12,000/mm3)
Sepsis
- SIRS + infected source Identified
- ex pneumonia, UTI
- systemic inflammatory response (ie, increased heart rate, respirations, temperature, and decreased systolic blood pressure) to a documented or suspected infection
is a systemic inflammatory response to an infection and can occur as a complication of pneumonia in clients who do not respond to antibiotic therapy. It is caused by the entry of bacteria from the alveoli into the bloodstream. Manifestations characteristic of sepsis include heart rate >90 beats/min, temperature >100.9 F (38.3 C), systolic blood pressure <90 mm Hg, altered mental status, and hyperglycemia (>140 mg/dL [7.8 mmol/L]) in the absence of diabetes.
The assessment findings most important for the nurse to report to the health care provider include the following:
- Absent bowel sounds. Paralytic ileus occurs in the presence of sepsis and hypoxia as blood is shunted away from the gastrointestinal tract to the vital organs.
- Capillary refill 5 seconds. Prolonged capillary refill (>3-4 seconds in an adult) indicates inadequate blood flow to peripheral tissues.
- Serum glucose >140 mg/dL (7.8 mmol/L). Gluconeogenesis occurs in response to the physiologic stress of infection. Insulin resistance is associated with anaerobic metabolism
Septic Shock
- Sepsis + hypotension despite adequate IV fluid intake ex 2L of NS
MODS
- multi-organ dysfunction syndrome
- the failure of 2 or more body organs (eg, acute kidney injury, acute respiratory distress syndrome).
- Septic shock can progress to multiorgan dysfunction (ie, severe end of sepsis and septic shock).
Kawasaki disease (KD)
- a childhood condition that causes inflammation of arterial walls (vasculitis). The coronary arteries are affected in KD, and some children develop coronary aneurysms.
- The etiology of KD is unknown; there are no diagnostic tests to confirm the disease, and it is not contagious.
- KD has 3 phases:
- –Acute - sudden onset of high fever that does not respond to antibiotics or antipyretics. The child becomes very irritable and develops swollen red feet and hands. The lips become swollen and cracked, and the tongue can also become red (strawberry tongue).
- –Subacute - skin begins to peel from the hands and feet. The child remains very irritable.
- –Convalescent - symptoms disappear slowly. The child’s temperament returns to normal.
- Initial treatment consists of IV gamma globulin (IVIG) and aspirin. IVIG creates high plasma oncotic pressure, and signs of fluid overload and pulmonary edema develop if it is given in large quantities. Therefore, the child should be monitored for symptoms of heart failure (eg, decreased urinary output, additional heart sounds, tachycardia, difficulty breathing).
Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent coronary aneurysms and subsequent occlusion. KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet and anti-inflammatory properties. However, parents should be cautioned about the risk of Reye syndrome. Cardiopulmonary resuscitation should also be taught to parents of children with coronary artery aneurysms.
When children with KD are discharged home, parents are instructed to monitor them for fever by checking the temperature (orally or rectally) every 6 hours for the first 48 hours following the last fever. Temperature should also be checked daily until the follow-up appointment. If the child develops a fever, the health care provider should be notified as this may indicate the acute phase of KD recurrence. The child may require additional treatment with IV immunoglobulin to prevent development of coronary artery aneurysms and occlusions.
Appropriate actions for a client in Buck’s skin traction include:
- The client should be supine or in semi-Fowler’s position (maximum of 20-30 degrees). Elevating the head of the bed more than 30 degrees would promote sliding
- These clients are at increased risk for impaired skin integrity and neurovascular status as traction exerts pressure on nerves, blood vessels, and soft tissue. Skin breakdown can occur very quickly, especially at pressure points. Therefore, the nurse should perform neurovascular (eg, pulse, capillary refill, color, temperature, sensation, movement) and skin assessments (eg, heel, dorsum of foot) every 2 hours
- Loosen Velcro straps if the boot is too tight as they can impair neurovascular status and skin integrity; tighten the straps if the boot is too loose as this can decrease effectiveness of the traction. When a change is made in the application of the boot or traction pulley system, the nurse should reassess neurovascular status in 30 minutes
- Provide a fracture pan, which is smaller than a bedpan, for elimination needs to minimize client movement and provide comfort
- Weights should be free-hanging at all times and should never be placed onto the bed or touch the floor. A staff member should support the weight while the client is repositioned up in bed to prevent excessive pull on the extremity
- Do not turn a client in Buck’s traction from side to side. An abduction pillow is used to maintain proper thigh and hip alignment in postoperative hip arthroplasty. The nurse encourages the client to use the overhead trapeze to lift, move the upper body, and change position frequently.
- The extremity in traction should be kept above the client’s heart level for effective countertraction (between body and weights)
Atopic dermatitis
(eczema) - a chronic skin disorder characterized by pruritus, erythema, and dry skin.
- In infants, red, crusted, scaly lesions may also be present.
- It is commonly first diagnosed before age 1 year.
- The exact cause is unknown, although it is associated with an impaired skin barrier that allows penetration of allergens, leading to an immune response.
- The primary goals of management are to alleviate pruritus and keep the skin hydrated to prevent scratching. Scratching leads to the formation of new lesions and predisposes to secondary infections.
- Important measures to prevent scratching include cutting and filing nails short, placing gloves or cotton stockings over the hands, not wearing rough fabrics or woolen clothing, and applying moisturizer.
Preeclampsia
a systemic disease characterized by hypertension and proteinuria after the 20th gestational week with unknown etiology.
Eclampsia
is the onset of convulsions or seizures that cannot be attributed to other causes in a woman with preeclampsia.
sleep apnea
At night, clients experience repeated periods of apnea, loud snoring, and interrupted sleep.
During the day, morning headaches, irritability, and excessive sleepiness are common.
Interventions:
- Continuous positive airway pressure device at night to keep the structures of the pharynx and tongue from collapsing backward
- Limiting alcohol intake at bedtime as it can cause muscles of the oral airway to relax and lead to airway obstruction
- Weight loss and exercise can reduce snoring and sleep apnea-associated airway obstruction. Obesity contributes to the development of OSA
- Avoiding sedating medications (eg, benzodiazepines, sedating antidepressants, antihistamines, opiates) as they may exacerbate OSA and worsen daytime sleepiness
Cataplexy
is a brief loss of skeletal muscle tone or weakness that can result in a client falling down.
- It is associated with narcolepsy, a chronic neurologic sleep disorder.
Bacterial conjunctivitis
(pink eye) presents with conjunctival erythema; thick, purulent drainage; and “crusted” eyelids.
- The client will receive antibiotic drops or ointment, warm soaks/cool compresses, and infection control.
- Pink eye is highly contagious but not emergent.
- washing hands is very important
C-reactive Protein test
- CRP is a non-specific test used to detect acute or chronic inflammation in the body.
- can be used to evaluate the effectiveness of medications that decrease inflammation.
- An elevation would be expected in clients with RA, especially during a flare
Genu varum
(bowlegs) , the lateral bowing of the legs, is common in toddlers as they learn to walk.
- resolves by 18-24 months after they develop strength in their legs and lower back.
- After 2 years, normal alignment will again progress to valgus deformity until age 4 and then will return to normal adult alignment by age 7.
- All of this is a normal physiologic alignment.
Teaching topics for clients on anticoagulants:
- Take medication at the same time daily
- Depending on medication, report for periodic blood tests to assess therapeutic effect
- Avoid any action that may cause trauma/injury and lead to bleeding (eg, contact sports, vigorous teeth brushing, use of a razor blade)
- Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs)
- Limit alcohol consumption
- Avoid changing eating habits frequently (eg, dramatically increasing intake of foods high in vitamin K such as kale, spinach, broccoli, greens) and do not take vitamin K supplements
- Consult with health care provider before beginning or discontinuing any medication or dietary/herbal supplement (eg, Ginkgo biloba and ginseng affect blood clotting and may increase bleeding risk)
- Wear a medical alert bracelet indicating what anticoagulant is being taken
Mechanical prosthetic valves are more durable than biological valves but require
long-term anticoagulation therapy due to the increased risk of thromboembolism
Trisomy 18
(Edwards syndrome) is a chromosome anomaly characterized by severe cardiac defects and multiple musculoskeletal deformities.
- Life expectancy for trisomy 18 is a few weeks after birth, neonates rarely survive to their first birthday.
- End-of-life issues should be discussed early after the diagnosis is confirmed.
- Trisomy 13 (Patau syndrome) also results in early death.
A client diagnosed with cirrhosis may experience
- pruritus (itching) due to buildup of bile salts beneath the skin. The nurse encourages the client to cut the nails short, wear cotton gloves, and wear long-sleeved shirts to avoid injury to the skin from scratching. Other comfort measures include baking soda baths; calamine lotion; and cool, wet cloths, which cool and soothe irritated skin.
Cholestyramine (Questran) may be prescribed to increase the excretion of bile salts in the feces, thereby decreasing pruritus. It is packaged in a powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be given one hour after all other medications are administered.
To measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at
the phlebostatic axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at the midway point of the AP diameter (½ AP)of the chest wall.
- If the transducer is placed too low, the reading will be falsely high; if placed too high, the reading will be falsely low.
- This concept is similar to the positioning of the arm in relation to the level of the heart when measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure-monitoring device. The upper arm should be at the level of the phlebostatic axis
Celiac disease
- an autoimmune disorder in which the body is unable to process gluten, a protein found in most grains.
- Gluten consumption will damage the villi of the small intestine; this results in malabsorption of fats (steatorrhea, foul-smelling stools) and other nutrients, which can lead to malnutrition and failure to thrive.
- The child will need to adhere to a gluten-free diet for life.
A child with celiac disease cannot eat barley, rye, oats, or wheat (mnemonic - BROW) !!!!
The following are important dietary principles to teach clients with celiac disease:
- All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats.
- Rice, corn, and potatoes are gluten free and are allowed on the diet
- Processed foods (eg, chocolate candy, hot dogs) may contain “hidden” sources of gluten, such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free.
- Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from their diet reduces the risk for nutritional deficiencies and intestinal cancer (lymphoma).
- Eating even small amounts of gluten will damage the intestinal villi, although the client may have no clinical symptoms. All sources of gluten must be eliminated from the diet.
To prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions:
- Instruct the client to lie in a supine position. This will increase the central venous pressure and decrease the possibility of air getting into the vessel
- Instruct the client to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure
- Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line
- Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client’s vessel
oral candidiasis
from Candida albicans (thrush) include white patches on the oral mucosa, palate, and tongue.
- The patches are nonremovable and tend to bleed when touched.
- The affected infant may have difficulty sucking or feeding due to the associated pain.
- Thrush is generally linked to antibiotic therapy or poor caregiver hand hygiene.
- The infection is usually self-limiting, but treatment with a fungicide (eg, nystatin) may hasten recovery.
often occurs after a course of antibiotics or corticosteroids or can occur in infants with immature immune systems. An infant who is breastfed can transfer candidiasis to the mother’s breast. There is also a small risk of transmission when infants place pacifiers or toys in their mouths and subsequently transfer these items to another child’s mouth.
Immunosuppressed individuals such as those taking corticosteroid medications, clients undergoing chemotherapy or radiation, or clients with immune deficiency states (eg, AIDS) have an increased incidence. Clients receiving prolonged or high-dose antibiotic treatment are at increased risk as the normal microbial flora of the mouth is reduced, allowing other opportunistic infections to arise. Individuals with dentures and infants also commonly experience monilial infections. Treatment is antifungal medications (eg, nystatin) and proper oral hygiene.
Erythema toxicum neonatarum
- characterized by firm, white or yellow papules or pustules surrounded by erythema.
- This idiopathic rash, which closely resembles flea bites, appears in the first few days after birth and resolves within 5-7 days.
- There are no additional systemic effects, and the rash requires no treatment.
Epstein pearls
are small, white cysts found on the hard palate of newborns.
These cysts are considered common findings, and they disappear a few weeks after birth.
The sequence of basic life support (BLS) for an unconscious, pulseless client includes:
- Verify unresponsiveness by tapping or gently shaking the client while calling by name or shouting, “Are you all right?”
- Activate the emergency response system by calling for help if in the hospital, or by calling 911 and obtaining an automated external defibrillator (AED) if outside the hospital. The emergency response system should be activated for all unresponsive clients. This allows the nurse to quickly proceed with assessment of pulse and respirations without delaying to retrieve a defibrillator.
- Simultaneously check the carotid pulse and check the client for breathing for no more than 10 seconds
- Attempt cardiopulmonary resuscitation if no pulse is felt, starting with chest compressions (circulation, airway, breathing [CAB] sequence)
- - Chest compression rate should be 100-120/min.
- - Chest compression depth should be 2-2.4 in (5-6 cm). - Notify the health care provider if not already on scene
if pt with peritoneal dialysis has Insufficient outflow
- results most often from constipation when distended intestines block the catheter’s holes.
- If outflow becomes sluggish, the nurse should assess the client’s bowel patterns and administer appropriate prescribed medications (eg, stool softeners)
- The nurse should also check the tubing for kinks and reposition the client to a side-lying position or assist with ambulation
- The drainage bag should be maintained below the abdomen to promote gravity flow.
- The nurse should assess for fibrin clots and milk the tubing to dislodge or administer fibrinolytics (eg, alteplase) as prescribed.
- If these measures are ineffective, an x-ray may be needed to check the catheter location.
Hyperparathyroidism
- usually due to a benign adenoma on the parathyroid gland.
- The parathyroid gland produces parathyroid hormone (PTH), which regulates serum calcium levels.
- The majority of the body’s calcium is stored in the bones, and elevated levels in PTH will accelerate osteoporosis as calcium is released from storage.
- Elevated serum calcium is excreted into the urine, forming kidney stones (nephrolithiasis). In addition, calcium has a diuretic effect, producing symptoms of polyuria and polydipsia.
- High calcium levels can cause constipation.
Fifth disease
Parvovirus B-19 - (“slapped face,” or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms.
- The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces.
- The child may have general malaise and joint pain that are typically well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen.
- Affected children typically recover quickly, within 7-10 days.
- Once these children develop symptoms (eg, rash, joint pains), they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition.
- Pregnant women should avoid contact with infected individuals as the virus can be transmitted to the fetus and cause anemia or cause fetal anomalies (eg, hydrops fetalis, stillbirth)
Percutaneous kidney biopsy
- an invasive diagnostic procedure that involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases.
- The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled (goal <140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy
The client being admitted for heart failure-related fluid overload is likely to have
dyspnea (difficulty breathing), orthopnea (labored breathing in a supine position), and paroxysmal nocturnal dyspnea (waking suddenly with difficulty breathing).
- Rales or “crackles” may be auscultated in the lungs as a result of pulmonary congestion.
Hemophilia
is a bleeding disorder caused by a deficiency in coagulation proteins.
- Clients with classic hemophilia, or hemophilia A, lack factor VIII.
- Clients with hemophilia B (Christmas disease) lack factor IX.
- When injured, clients with hemophilia should be monitored closely for external as well as internal bleeding.
- The most frequent sites of bleeding are the joints (80%), especially the knee.
- Hemarthrosis can occur with minimal or no trauma, with episodes beginning during toddlerhood when the child is active and ambulatory.
- Over time, chronic swelling and deformity can occur
- The nurse should avoid procedures that can cause bleeding (eg, intramuscular injections, rectal temperature measurement). Vaccinations are administered subcutaneously whenever possible to prevent intramuscular hematoma. The smallest gauge needle is used, and firm, continuous pressure is applied at the site for 5 minutes
- Children with hemophilia should avoid aspirin and nonsteroidal anti-inflammatory drugs due to the risk of bleeding. Acetaminophen is recommended for pain relief.
- Firm pressure should be held on the site without rubbing or massaging due to the risk of bleeding and hematoma formation. Superficial bleeding can be controlled using ice packs, which promote vasoconstriction. Applying a warm compress would cause vasodilation and prolong bleeding
Treatment of frostbite should include the following:
- Remove clothing and jewelry to prevent constriction.
- Do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged
- Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temperatures do not significantly decrease rewarming time but can intensify pain
- Avoid heavy blankets or clothing to prevent tissue sloughing.
- Provide analgesia as the rewarming procedure is extremely painful
- As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to reduce edema
- Keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings
- Monitor for signs of compartment syndrome.
pincer grasp
- a thumb to forefinger movement, develops at age 8-10 months.
- This is the time to start offering small finger foods, such as Cheerios or cut-up pieces of nutritious foods.
- Caregivers should inform their health care provider if the infant does not achieve this significant milestone in fine motor development.
nitrazine pH test strip
- is inserted into the vagina can differentiate between amniotic fluid, which is alkaline, and vaginal fluid, which is acidic.
- A blue-green, blue-gray, or deep blue color indicates a positive result and probable rupture of membranes.
- A yellow, olive-yellow, or olive green color indicates a negative result and suggests that membranes are intact.
Magnesium toxicity
- causes central nervous system depression because the toxic levels block neuromuscular transmission.
- Absent or decreased deep-tendon reflexes (DTRs) are the earliest sign of magnesium toxicity. DTRs are scored on a scale of 0-4+ and should be assessed during magnesium infusion; normal findings are 2+
- Urine output <30 mL/hr is a sign of magnesium toxicity
- If toxicity is not recognized early (eg, decreasing DTRs), clients can progress to respiratory depression, followed by cardiac arrest
- Assessments (including vital signs) should be performed every 5-15 minutes during the loading dose, followed by 30- to 60-minute intervals until the client stabilizes, then every 2 hours.
- Treatment for magnesium toxicity is immediate discontinuation of the infusion.
- Administration of calcium gluconate (antidote) is recommended only in the event of cardiorespiratory compromise.
signs of hyperglycemia
excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision
Paracentesis is performed to
- remove excess fluid from the abdominal cavity or to provide a specimen of ascitic fluid for diagnostic testing. - it is not a permanent solution for resolving ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites.
Nursing actions include:
- Explain the procedure, sensations, and expected results
- Instruct the client to void to prevent puncturing the bladder
- Assess the client’s abdominal girth, weight, and vital signs
- Place the client in high Fowler’s position and remain with the client during the procedure
- After the procedure, assess and bandage the puncture site and reassess client weight, girth, and vital signs
Diverticulitis
- Diverticula are saclike protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal pressure (chronic constipation). The left (descending, sigmoid) colon is the most common area for diverticula to develop.
- When these diverticula become inflamed (diverticulitis), the client may experience acute pain (usually in the left lower quadrant) and systemic signs of infection (eg, fever, tachycardia, nausea, leukocytosis).
- Complications that can occur in some clients are abscess formation (continuous fever despite antibiotics and palpable mass) and intestinal perforation resulting in diffuse peritonitis (progressive pain in other quadrants of the abdomen, rigidity, guarding, rebound tenderness).
- The client with peritonitis prefers to lie still and take shallow breaths to avoid stretching the inflamed peritoneum. Peritonitis is a potentially lethal complication and should be reported immediately.
ventriculoperitoneal shunt
- used to treat hydrocephalus and is usually placed at age 3-4 months.
- Blockage and infection are complications of shunt placement.
- Blockage results in signs of increased intracranial pressure (ICP).
- The normal pulse range for a 1-year-old is 100-160/min. A pulse of 78/min is considered bradycardia, a part of Cushing’s triad (bradycardia, slowed respiration, widened pulse pressure).
Meningocele is
- a saclike protrusion through a bony defect that contains meninges and cerebrospinal fluid
- it is corrected with surgery.
- In some children, residual bowel and bladder incontinence can result despite surgery. If bowel and bladder control is obtained but incontinence reoccurs, the child should be evaluated for infection (a common complication).
Muscular dystrophy is
- an inherited condition of muscle fiber degeneration and muscle wasting. (muscle fibers are replaced by connective tissue)
- Respiratory and cardiac problems are the leading causes of mortality.
- These clients should take precautions to prevent respiratory infections (eg, pneumococcal and influenza vaccination, avoiding contact with infected individuals).
Discharge teaching after tonsillectomy
- Avoid coughing, clearing the throat, or blowing of the nose
- Limit physical activity
- Milk products are discouraged due to their coating effect, which can prompt clearing of the throat
- Oral mouth rinses, gargling, and vigorous tooth brushing should be avoided to prevent irritation
Lithium therapeutic levels
- usual ranges are 1.0-1.5 mEq/L (1.0-1.5 mmol/L) for treatment of acute mania
- and 0.6-1.2 mEq/L (0.6-1.2 mmol/L) for maintenance therapy
- Acute lithium toxicity >1.5 mEq/L
when do you give the MMR vaccine ?
given to children between age 12-15 months to ensure optimal vaccine response.
As advised by the CDC, a child age <12 months can and should receive the MMR vaccine when there is an outbreak of measles and the child risks contracting the illness due to an exposure. The child will need to be revaccinated between age 12-15 months and between age 4-6 years.
Hepatic encephalopathy is a
reversible neurological complication of cirrhosis caused primarily by increased ammonia levels in the blood.
- Normally, ammonia created in the intestines is converted to urea in the liver and excreted in the kidneys.
- However, in the presence of liver damage, blood is shunted around the liver portal system and ammonia is able to cross the blood-brain barrier, leading to neurological dysfunction
- Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person. A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists. Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts.
- Oral lactulose is given to reduce the ammonia by trapping it in the gut and then expelling it with a laxative effect. Improved mental status implies reduction of ammonia levels
Pre-procedure client instructions for a pharmacologic nuclear stress test include the following:
- Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). Small sips of water may be taken with medications
- Avoid caffeine products 24 hours before the test
- Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine
- Do not take theophylline 24-48 hours prior to the test (if tolerated).
- If insulin/pills are prescribed for diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can result if the medicine is taken without food
- Some medications can interfere with the test results by masking angina. Do not take the following cardiac medications unless the HCP directs otherwise, or unless needed to treat chest discomfort on the day of the test:
- -Nitrates (nitroglycerine or isosorbide)
- -Dipyridamole
- -Beta blockers
The most common clinical manifestations of hip fractures include:
- Ecchymosis and tenderness over the thigh and hip – occur from bleeding into the surrounding tissue as the femur is very vascular and a fracture can result in significant blood loss (>1000 mL)
- Groin and hip pain with weight bearing
- Muscle spasm in the injured area – occurs as the muscles surrounding the fracture contract to try to protect and stabilize the injured area
- Shortening of the affected extremity – occurs because the fracture can reduce the length of the bone and the muscles above the fracture line pull the extremity upward
- Abduction or adduction of the affected extremity depending on location and mechanism of injury.
- The affected extremity is usually externally rotated.
Retinoblastoma
a unilateral or bilateral retinal tumor, is the most common childhood intraocular malignancy.
- it is typically diagnosed in children under age 2 and is usually first recognized when parents report a white “glow” of the pupil (leukocoria).
- Light reflecting off the tumor will cause the pupil to appear white instead of displaying the usual red reflex
- Parents may even accidentally visualize leukocoria when taking a photograph of the child using a flash.
- Strabismus (misalignment of the eyes) is the second most common sign; visual impairment is a late sign indicative of advanced disease.
Distension of jugular neck veins should be performed with the client sitting with the head of the bed at a
30- to 45-degree angle.
- The nurse will observe for distension and prominent pulsation of the neck veins.
- The presence of JVD in the client with heart failure may indicate an exacerbation and possible fluid overload.
Intussusception
- a common obstructive disorder in infancy that occurs when one segment of the bowel telescopes into another. - The classic clinical triad is intermittent, severe, crampy abdominal pain; a palpable “sausage-shaped” mass on the right side of the abdomen; and “currant jelly” stools - the stools are mixed with blood and mucus
- Other manifestations include inconsolable crying, drawing the knees up to the chest during episodes of pain, and vomiting. The child may appear normal and comfortable between episodes.
- Most cases of intussusception are successfully treated without surgery using hydrostatic (saline) or pneumatic (air) enema.
- The nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs, the HCP should be notified immediately to modify the plan of care and stop all plans for surgery.
occurs when part of the intestine telescopes into another adjacent part and causes a blockage. This leads to swelling and decreased blood supply to the intestine. Tissue death as well as perforation to the bowel may result. If perforation occurs, the client could develop peritonitis in which the peritoneum in the abdomen becomes inflamed due to infection. This can quickly lead to sepsis and multiple organ failure. Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness. This condition can be fatal if it is not treated quickly.
A contrast enema is used for diagnostic purposes and often reduces the intussusceptions. An air enema is considered safer than a barium enema.
Ear irrigation may be prescribed to remove impacted or excess cerumen; the following steps describe this procedure:
- Assess client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify that the tympanic membrane is intact and ensure there are no foreign bodies
- Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth).
- Place the client in a side-lying or sitting position with the head tilted toward the affected ear. Place a towel and an emesis basin under the ear
- Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort.
- Straighten the ear canal, pulling the pinna up and back for adults or down and back for children age ≤3 years
- Irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal. Avoid occluding the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if the client experiences severe pain, nausea, or dizziness.
- Repeat as tolerated until the ear canal is clear or the prescribed amount is instilled.
8, Document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client teaching.
Pica
- is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible.
- Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption.
- The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia.
what to do with recently extubated pts
Recently extubated clients are at high risk for aspiration, airway obstruction (laryngeal edema and/or spasm), and respiratory distress.
- To prevent complications, clients are placed in high Fowler position to maximize lung expansion and prevent aspiration of secretions.
- Warmed, humidified oxygen is administered immediately after extubation to provide high concentrations of supplemental oxygen without drying out the mucosa
- Oral care is provided to decrease bacteria and contaminants as well as promote comfort
- Clients are instructed to frequently cough, deep breathe, and use an incentive spirometer to expand alveoli and prevent atelectasis
- Clients are kept NPO after extubation to prevent aspiration. They may have either a bedside swallow screen or a more formal swallow evaluation by a speech therapist prior to swallowing any food, drink, or medication.
Accidental dislodgement of the tube in a fresh (immature, < 1 week) tracheostomy
is a medical emergency.
- Immediate nursing actions include pulling the retention sutures apart if present, or inserting a curved hemostat to hold the stoma open if sutures are absent.
- If desaturation progresses, the nurse should apply a sterile occlusive dressing over the stoma and ventilate the client with a bag-valve mask over the nose and mouth.
Some risk factors for preterm birth include:
- History of spontaneous preterm birth in a previous pregnancy (single largest independent risk factor)
- Previous cervical surgery, such as a cone biopsy (weakens cervical support)
- Tobacco and/or illicit drug use
- Maternal ages <17 and >35 are associated with increased risk for preterm birth.
- Maternal undernutrition can increase the risk for preterm birth and low infant birth weight.
- Non-Hispanic black women have the highest rates of preterm labor and birth.
- Infection is strongly associated with preterm labor, particularly when untreated - Infection causes release of inflammatory mediators such as prostaglandins, which are uterotonic (ie, promote contractions) and contribute to cervical softening.
Abdominal aneurysms
- may present with a pulsatile mass in the periumbilical area slightly to the left of the midline.
- A bruit may be auscultated over the site.
- Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA).
- Rupture of an abdominal aneurysm can quickly cause exsanguination and death.
Hypovolemic shock
- most common type of shock
- occurs when blood volume decreases through hemorrhage or movement of fluid from the intravascular compartment into the interstitial space (third-spacing).
- most commonly occurs from blood loss but can occur in any condition that reduces intravascular volume. Hypovolemia is classified as either an absolute (eg, hemorrhage, surgery, gastrointestinal bleeding, vomiting, diarrhea) or a relative (eg, pancreatitis, sepsis) fluid loss. Reduced intravascular volume results in decreased venous return, decreased stroke volume and cardiac output, inadequate tissue perfusion, and impaired cellular metabolism.
Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include:
- Change in mental status
- Tachycardia with thready pulse
- Cool, clammy skin
- Oliguria
- Tachypnea
- Treatment involves preventing additional fluid loss, restoring volume through IV fluids, and improving hemodynamic stability through vasoactive medications (eg, norepinephrine, dopamine).
Femoral central venous catheters
- may be placed in emergency situations
- but should be removed/replaced as soon as possible due to the high risk of contamination and infection.
Signs and symptoms of hepatitis include
jaundice of the eyes and skin, fatigue, weakness, nausea, and anorexia
pyloric stenosis
Pyloric stenosis is a hypertrophy of the pyloric sphincter that eventually causes complete obstruction.
Classic signs
- often present with excessive hunger (frequent feeder)
- a palpable olive-shaped mass in the epigastrium to the right of the umbilicus
- projectile vomiting (can be up to 3 feet)
- weight loss
- dehydration (eg, sunken fontanelle, decreased skin turgor, delayed capillary refill)
- and/or electrolyte imbalance (metabolic alkalosis).
The amount of milk consumed (particularly with bottle feedings) along with the mother’s technique (mainly adequate burping) should be assessed to ensure there is no excessive air swallowing or overfeeding as an etiology.
The proper method of delivering a dose via Metered Dose Inhaler (MDI) includes the following steps:
- First shake MDI and attach it to the spacer.
- Exhale completely to optimize inhalation of the medication.
- Place lips tightly around the mouth piece.
- Deliver a single puff of medication into spacer.
- Take a slow, deep breath and hold it for 10 seconds to allow for effective medication distribution.
- After the dose, rinse mouth with water to remove any left-over medication from oral mucous membranes. Spit out the water to ensure no medication is swallowed.
Ankylosing spondylitis (AS)
- an inflammatory disease affecting the spine that has no known cause or cure.
- characterized by stiffness and fusion of the axial joints (eg, spine, sacroiliac), leading to restricted spinal mobility.
- Low back pain and morning stiffness that improve with activity are the classic findings.
- Involvement of the thoracic spine (costovertebral) and costosternal junctions can limit chest wall expansion, leading to hypoventilation.
The client with AS should do the following:
- Promote extension of the spine with proper posture, daily stretching, and swimming or racquet sports
- Stop smoking and practice breathing exercises to increase chest expansion and reduce lung complications
- Manage pain with moist heat and nonsteroidal anti-inflammatory drugs (NSAIDs)
- Take immunosuppressant and anti-inflammatory medications as prescribed to reduce inflammation and increase mobility
- It is best to rest during flare-ups. The client should wait to exercise until the pain and inflammation are under control.
- Clients with AS are encouraged to sleep on their backs on a firm mattress to prevent spinal flexion and the resulting deformity.
Metabolic syndrome
(insulin resistance syndrome) is characterized by a group of health complications that increase a client’s risk for the development of diabetes mellitus and cardiovascular disease.
- The presence of abdominal obesity causes increased insulin production (hyperinsulinemia); this excess insulin leads to insulin resistance, the primary feature of metabolic syndrome
- presence of 3 or more of the following conditions: abdominal obesity, hyperglycemia, low HDL, high triglycerides, and hypertension.
Criteria for metabolic syndrome include the presence of 3 or more of the following 5 conditions:
- Abdominal obesity with increased waist circumference (≥40 inches in men, ≥35 inches in women)
- High serum triglycerides >150 mg/dL or on drug treatment for elevated triglycerides
- Low HDL cholesterol (<40 mg/dL in men, <50 mg/dL in women)
- Hypertension ≥130/85 mm Hg or on drug treatment for elevated blood pressure
- Fasting blood glucose level ≥100 mg/dL or on drug treatment for hyperglycemia
Delusions
Delusions are one of the positive symptoms of schizophrenia. Delusions are false beliefs that have no basis in reality and are unrelated to a client’s culture or intelligence. When presented with proof that the delusion is irrational or untrue, the client continues to believe it is real.
- delusions of reference - will believe that songs, newspaper articles, and other events are personal and significant to them.
- Grandeur – “I need to get to Washington for my meeting with the president.”
- Control – “Don’t drink the tap water. That’s how the government controls us.”
- Nihilistic – “It doesn’t matter if I take my medicine. I’m already dead.”
- Somatic – “The doctor said I’m fine, but I really have lung cancer.”
lumbar puncture procedure
(spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic purposes (eg, meningitis).
- A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5, and a sample of CSF is drawn.
- The nurse’s role when assisting with a lumbar puncture includes the following:
1. Verify informed consent
2. Gather the lumbar puncture tray and needed supplies
3. Explain the procedure to older child and adult
4. Have client empty the bladder
5. Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table)
6. Assist the client in maintaining the proper position (hold the client if necessary)
7. Provide a distraction and reassure the client throughout the procedure
8. Label specimen containers as they are collected
9. Apply a bandage to the insertion site
10. Deliver specimens to the laboratory
Herpes zoster
or shingles, has a characteristic unilateral, linear pattern of fluid-filled blisters.
- Affected clients commonly report pain and itching.
- due to the varicella-zoster virus (VZV), which also causes chickenpox.
- After initial VZV infection (chickenpox) in early childhood, the virus remains dormant in the sensory nerves.
- Reactivation of VZV when the immune system is compromised (eg, aging, immunosuppression) results in the formation of lesions along the distribution of one or more such nerves (dermatomal distribution).
- Vaccination can prevent shingles.
- Shingles lesions that are open may transmit the infection by both air and contact. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital.
- Localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions.
presbyopia
- Inability to see things close up
- occurs when the lens of the eye becomes less elastic with age and thus unable to adjust to near and far vision.
Otitis media (OM)
- inflammation or infection of the middle ear.
- OM typically occurs in infants and children under age 2, sometimes following a respiratory tract infection. - The eustachian tubes in infants and young children are short, wide, and fairly horizontal, which results in ineffective draining of respiratory secretions and a potential for recurrent infections.
- Episodes of OM often follow a respiratory tract infection, such as influenza or respiratory syncytial virus (RSV).
- OM risk also increases when fluid pools in the mouth and then reaches the eustachian tubes (eg, drinking from a bottle while lying down).
Potential complications of AOM include hearing loss and spread of the infection. To prevent permanent damage, severe cases of AOM are treated with antibiotics. Amoxicillin is the standard treatment in most cases. However, if AOM symptoms do not improve within 48-72 hours of initiating antibiotic therapy, the client should return for further assessment. The HCP will then assess for other causes of persistent symptoms and determine if a different antibiotic is required to treat drug-resistant organisms.Following treatment with antibiotics, clients with AOM should be evaluated for complete infection resolution and screened for hearing impairment.
Established family patterns that can play a role in recurrent OM should be assessed and include:
- Recurring exposure to tobacco smoke
- Regular pacifier use, particularly after age 6 months
- Drinking from a bottle while lying down
- Lack of immunizations, particularly the pneumococcal vaccine series
Key preventive measures include eliminating exposure to smoke, obtaining routine immunizations to prevent infection, and reducing or eliminating use of a pacifier after age 6 months
low pressure alarm with arterial line could mean
can indicate the presence of hypotension or disconnected tubing
Necrotizing enterocolitis
- occurs predominantly in preterm infants secondary to gastrointestinal and immunologic immaturity. On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine. As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the bowel wall.
- Measuring the client’s abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-associated swelling.
- Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines.
- Parenteral hydration and nutrition and IV antibiotics are given.
- Clients are placed supine and undiapered.
- Rectal temperatures should be avoided due to the risk of perforation.
Psychomotor retardation is
a clinical symptom of major depressive disorder.
- Manifestations include slowed speech, decreased movement, and impaired cognitive function.
- The individual may not have the energy or ability to perform activities of daily living or to interact with others.
- Psychomotor retardation may range from severe (total immobility and speechlessness -catatonia) or mild (slowing of speech and behavior).
Specific clinical findings of psychomotor retardation include the following:
- Movement impairment - body immobility, slumping posture, slowed movement, delay in motor activity, slow gait
- Lack of facial expression
- Downcast gaze
- Speech impairment – reduced voice volume, slurring of speech, delayed verbal responses, short responses
- Social interaction – reduced or non-interaction
- Clients with major depressive disorder may also show symptoms of psychomotor agitation, characterized by increased body movement, pacing, hand wringing, muscle tension, and erratic eye movement.
Psychogenic dystonia is a
psychogenic movement disorder characterized by involuntary muscle contractions that cause slow, repetitive movements such as twisting and abnormal postures.
Psychogenic gait is a
psychogenic movement disorder characterized by unusual standing postures and walking. The client may experience knee buckling and falling or may veer from side to side as if staggering.
Somatization is
a term to describe physical symptoms that cannot be explained by a medical condition or disease.
Ventricular bigeminy
- is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation).
- Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia.
- After assessing the client’s vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the health care provider (HCP).
Postoperative nursing care after laparoscopic cholecystectomy
focuses on prevention of respiratory complications.
- The client is placed in the Sims’ position to facilitate movement of carbon dioxide (CO2) utilized during surgery to fill the abdominal cavity. CO2 can irritate the phrenic nerve and diaphragm, potentially causing breathing difficulty.
esophageal atresia (EA) and tracheoesophageal fistula (TEF)
consist of a variety of congenital malformations that occur when the esophagus and trachea do not properly separate or develop. In the most common form of EA/TEF, the upper esophagus ends in a blind pouch and the lower esophagus connects to the primary bronchus or the trachea through a small fistula. EA/TEF can usually be corrected with surgery.
Clinical manifestations of EA/TEF include frothy saliva, coughing, choking, and drooling. Clients may also develop apnea and cyanosis during feeding. Aspiration is the greatest risk for clients with EA/TEF, and newborns who demonstrate signs of the condition are immediately placed on nothing by mouth (NPO) status.
A newborn with EA/TEF may have a distended abdomen due to the buildup of air in the stomach via the fistula from the trachea to the lower esophagus. A concave (ie, scaphoid) abdomen is associated with a congenital diaphragmatic hernia due to the migration of abdominal organs to the thoracic space.
- Excessive frothy mucus and cyanosis could be seen
- If EA/TEF is suspected, the infant should be kept supine with the head elevated at least 30 degrees to prevent aspiration.
- A nasogastric tube should be inserted and connected to continuous or intermittent suction until surgical repair
Aspiration is the greatest risk for clients with EA/TEF. Priority nursing interventions for infants with suspected EA/TEF include maintaining NPO status, positioning the client supine, elevating the head at least 30 degrees, and keeping suction equipment by the bed to clear secretions from the mouth. If surgery must be staged or delayed due to the infant’s condition, the priority is to maintain a clear airway and prevent aspiration..
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
- caused by the ectopic production of ADH by a malignant lung tumor (eg, lung cancer). Increased ADH leads to increased water reabsorption and intravascular volume, which results in dilutional hyponatremia.
- Severe neurologic dysfunction (eg, confusion, seizures) can occur when serum sodium drops below 120 mEq/L (normal: 135-145 mEq/L).
- Hyponatremia requires immediate evaluation and treatment (eg, seizure precautions, fluid restriction, intravenous hypertonic saline) by the health care provider.
s/s of PE
Dyspnea (85%) Pleuritic chest pain (60%) Tachycardia Tachypnea Hypoxemia (impaired gas exchange, decreased perfusion with normal alveolar ventilation, shunting) Apprehension and anxiety
client with osteoporosis and calcium
- take supplemental calcium with food to increase its absorption.
- Vitamin D will also enhance absorption.
- Multiple daily doses are recommended as calcium absorption is impaired when taken in excess of 500 mg per dose.
- Constipation is a frequent side effect of calcium supplementation.
normal urine specific gravity values
ranges from 1.003 to 1.030.
- Causes of increased specific gravity include fluid deficit.
Trismus
(inability to open the mouth due to a tonic contraction of the muscles used for chewing) may indicate a more serious complication of tonsillitis, a peritonsillar or retropharyngeal abscess (collection of pus).
- Other features include a “hot potato” or muffled voice, pooling of saliva, and deviation of the uvula to one side.
- This abscess can occlude the airway, making it a medical emergency. Surgical intervention (tonsillectomy or incision and drainage) is often required. In the meantime, maintaining an adequate airway is essential.
administering medications through feeding tube
- When a feeding tube is used, medications should be crushed, dissolved, and administered separately to prevent interactions.
- Sterile water should be used to dissolve medications and flush the feeding tube.
- Liquid medications should be used if possible.
Hemorrhagic cystitis
(eg, bladder inflammation) is a well-known complication of cyclophosphamide (immunosuppressant and chemotherapy agent).
- The client is instructed to drink plenty of fluids. This client may need IV hydration and other preventive measures (eg, mesna therapy).
- Bleeding is usually minimal and occasionally requires a blood transfusion, but is rarely life threatening.
Supine hypotensive syndrome
- occurs when the weight of the abdominal contents compresses the vena cava causing decreased venous return to the heart. This results in low cardiac output (maternal hypotension) and reflex tachycardia.
- Manifestations include dizziness, pallor, and cold and clammy skin.
- The client should be immediately repositioned onto the right or left side until the symptoms subside.
- Prevention of this condition includes using a wedge under the client’s hip while in a supine position.
A foul odor of lochia suggests
endometrial infection
- The odor of lochia is usually described as “fleshy” or “musty.” A foul smell warrants further evaluation.
- Other signs of endometrial infection are maternal fever, tachycardia, and uterine pain/tenderness.
- During the first 24 hours postpartum, temperature and WBC count are normally elevated
Nephrotic syndrome
a collection of symptoms resulting from various causes of glomerular injury. Below are the 4 classic manifestations of nephrotic syndrome:
- Massive proteinuria – caused by increased glomerular permeability
- Hypoalbuminemia – resulting from excess protein loss in the urine
- Edema – specifically periorbital and peripheral edema and ascites; caused by low serum protein and albumin as fluid is pulled into interstitial spaces and body cavities
- Hyperlipidemia – related to increased compensatory protein and lipid production by the liver
- Additional symptoms include decreased urine output, fatigue, pallor, and weight gain.
The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is generally considered idiopathic. Less common secondary causes may be related to systemic disease or infection, such as glomerulonephritis, drug toxicity, or acquired immunodeficiency syndrome.
Supportive care for symptom relief and prevention of complications are the major goals in clients with acute pancreatitis. These strategies include:
- NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the excretion of pancreatic enzymes. A nasogastric tube is used to suction out gastric secretions; this will reduce nausea and lessen stimulation of the pancreas as these juices will move to the duodenum.
- Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain management. Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi pressure has not been proven in studies.
- IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (fluid going into empty spaces).
borderline personality disorder (BPD)
- people live in fear of rejection and abandonment. To avoid abandonment, they use manipulation and control, often unconsciously, to prevent a person from leaving. The manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature, such as distancing from the other person. An individual with BPD may also engage in self harm or suicidal behaviors in an attempt to gain attention from the other person and keep that person from leaving.
For this client, the nursing care plan must include the assignment of different staff members. This will help diminish the client’s dependence on a particular individual and help the client learn to relate to more than one person.
Hyperthyroidism, teaching and learning objectives to satisfy hunger and prevent weight loss and tissue wasting include:
- Adherence to a high calorie diet (4000-5000 calories per day).
- Consumption of approximately 6 full meals and snacks per day. These should be packed with protein (1-2 g/kg of ideal body weight), carbohydrates, and be full of vitamins and minerals
- Avoidance of high-fiber foods due to the constant hyperstimulation of the gastrointestinal (GI) tract. High-fiber foods may increase GI symptoms (eg, diarrhea) However, high-fiber diets are recommended if the client with hyperthyroidism has constipation.
- Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft drinks).
- Avoidance of spicy foods as these can also increase GI stimulation.
Neologisms –
made-up words or phrases usually of a bizarre nature; the words have meaning to the client only.
Example: “I would like to have a phjinox.”
Concrete thinking –
literal interpretation of an idea; the client has difficulty with abstract thinking.
Example: The phrase, “The grass is always greener on the other side,” would be interpreted to mean that the grass somewhere else is literally greener
Loose associations –
rapid shifting from one idea to another, with little or no connection to logic or rationality
Echolalia –
repetition of words, usually uttered by someone else
Tangentiality –
going from one topic to the next without getting to the point of the original idea or topic
Word salad –
a mix of words and/or phrases having no meaning except to the client.
Example: “Here what comes table, sky, apple.”
Clang associations –
rhyming words in a meaningless, illogical manner.
Example: “The pike likes to hike and Mike fed the bike near the tyke.”
Perseveration –
repeating the same words or phrases in response to different questions
normal urine output
30ml/hr
or 0.5 mL/kg/hr
chest tube drainage
Chest drainage >100 mL/hr should be reported to the HCP.
- Large losses of blood may indicate a compromise of the surgical suture site and may require repair. The client can quickly become hemodynamically unstable and may require a return to surgery or transfusion of blood products.
Desquamation
(peeling skin) is a normal finding in newborns, especially those born at post-term gestation.
Moisturizers can be applied if desired, but desquamation resolves on its own over several days.
