Medical surgical NCLEX UWORLD 2

renal system physical assessment (in correct order)

1. empty bladder 2. observe the abdomen 3. Auscultate renal arteries in left and right upper quadrant 4. Percuss and palpate 5. Document

urine specific gravity value

1.003-1.03

target serum glucose range for clients receiving nutritional support

140-180 mg/dL (7.8-10.0 mmol/L) Monitor a client receiving TPN for hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) and hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L])

Degree of burns

1st degree (superficial): dry with blanchable redness) 2nd degree (partial-thickness): moist or weeping wounds with blisters and shiny, fluid-filled vesicles. a lot of pain 3rd degree (full-thickness): dry and inelastic with waxy white, leathery, or charred black color. 4th degree (full-thickness with muscle ,bone,tissue): pain is not the major feature

Glasgow Coma Scale

8 or lower is classified as a coma.

Chest drainage

>100 mL/hr should be reported to the HCP

endocarditis

A fever of 102 F (38.8 C) and petechiae in a post valve replacement client could indicate endocarditis

Supraventricular tachycardia (SVT)--Sx

A prolonged episode of SVT with a heart rate >180/min will cause decreased cardiac output and hypotension. The client may also experience palpitations, dyspnea, and angina

Continuous bladder irrigation (CBI)

3-way Foley catheter; The catheter balloon applies direct pressure to the bleeding tissue while the tubing allows the urine to drain. --During the first 24 hours, the urine color changes from reddish-pink to pink. --Small clots are also expected for up to 36 hours after surgery. --***The total Foley output should be more than the CBI input Notes: the nurse should adjust the irrigation rate with these normal findings so that the urine remains light pink without clots

normal value for albumin

3.5-5.0 g/dL (35-50 g/L).

retinal detachment

-- painless -- curtain blocking part of the visual field --floaters or lines --***sudden flashes of light.

The examination for skin cancer follows the ABCDE rule:

--Asymmetry (eg, one half unlike the other) (Option 2) --Border irregularity (eg, edges are notched or irregular) --Color changes and variation (eg, different brown or black pigmentation) (Option 5) --***Diameter of 6 mm or larger (about the size of a pencil eraser) (Option 4) --Evolving (eg, appearance is changing in shape, size, color)

retinal detachment repair surgery

--Avoiding activities that increase intraocular pressure (eg, rubbing the eye, straining) (Options 1 and 2) --Reporting sudden pain, flashes of light, vision loss, or bleeding, which may indicate detachment or infection, to the health care provider (Option 4) --Avoiding focused activities (eg, reading, writing, sewing), which can cause rapid eye movements and increase the risk for detachment (Option 5). --Wearing an eye patch or shield as directed to prevent rubbing/scratching of the eye and minimize eye movement --Ensuring appropriate positioning as instructed by the surgeon because clients may receive intravitreal oil or gas, which holds the retina in a specific position to allow healing

Hyperkalemia

--Calcium gluconate is administered to hyperkalemic clients with ECG changes:does not decrease the serum potassium level but temporarily stabilizes the myocardium by raising the threshold for dysrhythmia occurrence. ***Provide the most immediate protection from dysrhythmias --Intravenous regular insulin: temporarily corrects hyperkalemia by shifting potassium into the cells. Dextrose is administered concurrently to prevent hypoglycemia. --Sodium polystyrene sulfonate: causes excretion of potassium from the body via the gastrointestinal tract. -- hemodialysis: will effectively decrease serum potassium levels

CPR

--Chest compressions are performed at a rate of 100-120/min and a depth of 2.0-2.4 inches (5-6 cm), allowing complete chest recoil between compressions --Defibrillator pads are placed on the right upper chest, just below the clavicle, and on the left lateral chest, near the anterior axillary line below the nipple line https://www.ambulance.qld.gov.au/docs/clinical/cpp/CPP_Defibrillation.pdf --During CPR, compressions are paused every 2 minutes to assess the client's pulse. This pause should be no longer than 10 seconds to minimize delays between compression cycles --Manual breaths are administered at a rate of 2 breaths per 30 chest compressions in clients without advanced airways --Correct hand placement is in the center of the chest, on the lower half of the sternum (breastbone).

brain natriuretic peptide (BNP) levels

--Clients with heart failure are expected to have elevated brain natriuretic peptide (BNP) levels. --The nurse should compare BNP levels with those from the previous day. **Elevation of BNP >100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea.

peripheral artery disease Sx

--Coolness of the skin and shiny, hairless legs, feet, and toes --**Dry, scaly skin --"burning pain" that is worsened by elevating the legs and improved when the legs are dependent --Ulcers and gangrene occur usually at the most distal part of the body, where circulation is poorest. --Clients should be advised that a progressive walking program will aid the development of collateral circulation. --**apply moisturizing lotions on legs daily --**Keep legs below heart level

Common causes of metabolic acidosis

--GI bicarbonate losses (eg, diarrhea) (Option 2) --Ketoacidosis (eg, diabetes, alcoholism, starvation) --Lactic acidosis (eg, sepsis, hypoperfusion) (Option 4) --Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt) (Option 5) --Salicylate toxicity

Chronic open-angle glaucoma.

--Gradual loss of **peripheral vision --difficulty adjusting to different lighting

Genital herpes (STI)

--Herpetic lesions should be kept clean and dry. --There is no cure for herpes infection. Genital herpes often leads to local recurrence. Some clients may need long-term suppressive therapy. --During periods of active lesions, abstinence from sexual intercourse is indicated --Condoms should be used during periods of dormancy due to viral shedding. --**use gloves when applying topical medication to herpes lesions to avoid the spread of infection (e.g. to other parts of the body).

Lyme's disease prevention

--Insect repellent spray that contains tick-repelling ingredients (eg, DEET, picaridin) (Option 1) --Avoid tall grass and thick underbrush, and hike only in the center of the trails (Option 2) --Wear long-sleeved shirts tucked into pants, long pants tucked into socks or boots, and closed-toed shoes --Ticks should be promptly removed using tweezers, being careful to grasp the tick close to the attachment site and not crush it during removal Notes: Report Bull's-eye rash or flulike symptoms to providers

deep venous thrombosis (DVT)--Interventions to prevent DVT reoccurrence i

--Obtain adequate fluid intake and limit caffeine and alcohol intake (Option 2). --Elevate the legs when sitting and dorsiflex the feet often to reduce edema and promote venous return (Option 3). --Resume an exercise program (eg, walking, swimming) and change positions frequently to promote venous return (Option 4). --Stop smoking to prevent endothelial damage and vasoconstriction. --Avoid restrictive clothing (eg, tight jeans), which interferes with circulation and promotes clotting. --Consult with a dietitian if overweight; excess weight increases venous insufficiency by compressing large pelvic vessels. Notes: Clients do not need to avoid traveling in a car or airplane. However, during extended travel (>4 hours), clients must use preventive measures (eg, wear compression stockings, exercise calf and foot muscles frequently, walk every hour)

Skin cancer risk factor

--Outdoor occupation --family history --many moles --immunosuppressant use --aging --lighter skin

6 Ps of compartment syndrome--uworld

--Pain: Increasing despite elevation, analgesics, and ice. Pain will also increase with passive stretching/movement. Increasing pain is an early sign and indicates muscle ischemia (Option 3). --Pressure: Affected extremity or digits are firm and tense; skin is tight and appears shiny. --Paresthesia: Tingling, numbness, or burning sensation, which is also an early sign and indicates nerve ischemia (Option 1). --Pallor: Skin appears pale; capillary refill is >3 seconds. These indicate poor perfusion. --Pulselessness: Pulse distal to injury or compartment is impalpable. Absent pulses are a late sign. --Paralysis: Loss of function or inability to move extremity or digits. Notes: Muscle weakness occurs before paralysis which is also a late sign and indicates dead muscle tissue.

Receive prophylactic antibiotics prior to dental procedures to prevent infective endocarditis (IE).

--Prosthetic heart valve or prosthetic material used to repair heart valve --Previous history of IE Some forms of congenital heart disease: --Unrepaired cyanotic congenital defect --Repaired congenital defect with prosthetic (mechanical) material or device for 6 months after procedure --Repaired congenital defect with residual defects at the site or adjacent to the site of a prosthetic patch or device --Cardiac transplantation recipients who develop heart valve disease

Sunburn care

--Protecting the burned area from further sun exposure (eg, avoid going outside during midday when the sun's rays are hottest) (Option 1) --Promoting increased fluid intake to avoid dehydration (Option 2) --Providing pain relief with over-the-counter analgesics such as ibuprofen or acetaminophen (Option 3) --Reducing inflammation and pain by taking tepid baths; using cool compresses; and applying soothing, protective lotions or gels (eg, aloe vera, calamine) to the sunburned area (Option 4) Notes: Corticosteroid creams is not recommended

abdominal wound evisceration

--Remain calm and stay with the client. Have someone notify the HCP immediately and bring sterile supplies. Instruct the client not to cough or strain. --Place the client in low Fowler's position (no more than 20 degrees) with knees slightly flexed to relieve pressure on the abdominal incision and have the client maintain absolute bed rest to prevent tissue injury. --***Assess vital signs (and repeat every 15 minutes) to detect possible signs and symptoms of shock (eg, hypotension, tachycardia, tachypnea). ---Cover the viscera with sterile dressings saturated in NS solution to prevent bacterial invasion and keep the exposed viscera from drying out. --Document interventions taken and the appearance of the wound and eviscerated organ (eg, color, drainage). If the blood supply is interrupted, the protruding organs can become ischemic (dusky) and necrotic (black). Notes: This client should immediately be made NPO in preparation for possible emergency surgery. Only IV analgesics should be administered if the client is in pain.

Acute angle-closure glaucoma

--Sudden onset of severe eye pain --Reduced **central vision --Blurred vision --Ocular redness --Report of seeing halos around lights

streptococcal infective endocarditis (IE).

--Teach the client to monitor temperature regularly at home. --Persistent temperature elevations may mean that the antibiotic therapy is ineffective or complications have developed --causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can occur --require IV antibiotics for up to 4-6 weeksA fever of 102 F (38.8 C) and petechiae in a post valve replacement client could indicate endocarditis

Steps to perform defibrillation

--Turn on the defibrillator --Place defibrillator pads on the client's chest (Option 1) --Charge defibrillator. Chest compressions should continue until defibrillator has charged and is ready to deliver the shock. --Before delivering the shock, ensure that the area is "all clear." Confirm that no personnel are touching the client, bed, or any equipment attached to the client (Option 2). --Deliver the shock --Immediately resume chest compressions

DVT --Sx

--Unilateral leg edema --Redness ---warmth --Calf pain --**occasionally low-grade fever Notes: blue, cyanotic toes indicate artery problem (arterial occlusion (eg, arterial embolism))f , not a sign of DVT

HIV education

--Use latex or synthetic barriers during all sexual encounters --

benign prostatic hyperplasia

--acute urinary retention --voiding urgency --incomplete emptying --straining to void --weak urinary stream --urinary frequency --nocturia. Notes: Frequency of sexual intercourse is unrelated

Atrial fibrillation (Treatment goal)

--decrease in ventricular rate to <100/min --adequate anticoagulation to prevent thromboembolic complications Notes: risk for stroke

Septic shock manifestation

--fever or hypothermia --hypotension --Prolonged capillary refill --Tachycardia --WBC count >12,000/mm3 (12 x 109/L) or immature neutrophils (bands) of >10%

Ventricular fibrillation (V-fib)--treatments

--rapid initiation of CPR --defibrillation --the use of drug therapy (eg, epinephrine, vasopressin, amiodarone)

Peritoneal dialysis--Insufficient outflow r

--results most often from constipation: assess the client's bowel patterns and administer appropriate prescribed medications --check the tubing for kinks and reposition the client to a side-lying position or assist with ambulation Notes: The nurse should identify the problem before instilling additional fluids and perform routine assistive measures before contacting the health care provider.

prostatectomy (complication)

--up to 36 hours after surgery, small blood clots may occur, although they should not impair the urine stream. --Consistent passage of clots after this time could indicate a postoperative complication. --Signs of such complications (eg, reduced urine stream, persistent bleeding/blood clots, urinary retention, fever, dysuria) after discharge should be evaluated by the health care provider for further treatment (Option 1).

Burns (rehabilitation phase ）

--water-based lotion to alleviate itching and minimize scarring Planning for reconstructive surgery --Pressure garments to prevent hypertrophic scars and promote circulation (Option 4) --Range-of-motion exercises to prevent contractures (Option 2) --Sunscreen and protective clothing

respiratory acidosis (causes)

Hypoventilation: such as using alcohol, benzo,...sleep apnea, anesthesia, drug overdose, progressive neuromuscular disease, and chronic obstructive pulmonary disease depress the respiratory center; t

Ocular chemical burns

Irrigation is continued until the pH of the eye returns to normal (pH 6.5-7.5), which typically requires 30-60 minutes depending on the type of chemical.

Active TB Sx

Low-grade fever Night sweats Anorexia and weight loss Fatigue Additional symptoms depend on the location of the infection. Pulmonary tuberculosis typically includes: --Cough --Purulent or blood-tinged sputum --Shortness of breath Notes: the classic manifestations of TB can be absent in immunocompromised clients and the elderly.

Acute urinary retention with rapid, complete bladder decompression

Monitor for hypotension, hematuria and postobstructive diuresis

Urge incontinence (UI)

Occur without cause or may result from spinal cord injury and impairment of the bladder (eg, interstitial cystitis) or neurological system (eg, Parkinson disease, stroke). Interventions for clients with UI include: --Loss of excess weight to reduce pressure on the pelvic floor (Option 1). --Anticholinergic medications (eg, oxybutynin, tolterodine) to decrease bladder spasms. Dry mouth (xerostomia) is a frequent adverse effect (Option 2). --Avoidance of bladder irritants (eg, artificial sweeteners, caffeine, citrus juices, alcohol, carbonated drinks, nicotine) (Option 3). --Pelvic floor exercises (eg, Kegel) to strengthen the muscles and help prevent urinary leakage (Option 4). --Bladder training (eg, voiding every 2 hours while awake) and gradually lengthening intervals between voiding (Option 5).

cystoscopy

Pink-tinged urine, frequency, and dysuria are expected for up to 48 hours following a cystoscopy. Complications: --urinary retention --hemorrhage -- infection. clients are instructed to report immediately if they have bright red blood when urinating, blood clots, inability to urinate, fever >100.4 F (38 C) and chills, or abdominal pain unrelieved by analgesia. Notes: slight burning sensation with voiding for a day or two.

Cholecystectomy (complications)

Pneumonia : Postoperative incentive spirometry, ambulation, and cough/deep breathing exercises help keep alveoli open and prevent pneumonia (Option 3). --Surgical site infections present with localized redness, warmth, swelling, and purulent drainage. Proper wound care and sterile dressing changes help prevent infection (Options 2 and 5). --Urinary tract infections (UTIs), caused by the use of indwelling urinary catheters during surgery, can present with frequency, urgency, and dysuria. Prompt removal of catheters after surgery helps prevent UTIs. --Peritonitis (peritoneal infection) presents with rebound tenderness, boardlike abdominal rigidity, and shallow breathing related to abdominal distension. Peritonitis may lead to sepsis and death if untreated (Option 4).

Hemodialysis

Prior to dialysis treatment: --assess the client's fluid status (weight, blood pressure, peripheral edema, lung and heart sounds) --vascular access (arteriovenous fistula, arteriovenous grafts) --vital signs (Option 4). --The amount of fluid removed (ultrafiltration) is determined by calculating the difference between the **last post-dialysis weight and the client's current pre-dialysis weight (Option 3). After the client is connected to the dialysis machine: --IV heparin is added to the blood from the client to prevent clotting that can occur when blood contacts a foreign substance --

tonsillectomy

Risk for bleeding for 14 days The nurse should instruct this parent that the child should not resume strenuous activity or contact sports for at least 7-14 days post surgery.

2 hours after surgery,

Serosanguineous (pink) drainage would be expected

a sickle cell crisis (SCC).

Severe, acute pain is a common symptom of SCC due to impaired capillary blood flow (ie, vasoocclusion) and tissue ischemia. Without prompt recognition and intervention, vasoocclusion may lead to irreversible tissue damage (eg, myocardial infarction, limb necrosis, stroke) and death

Torsades de pointes

The first-line treatment is IV magnesium

Allen's test

The modified Allen's test includes the following steps: --Instruct the client to make a tight fist (if possible) --Occlude the radial and ulnar arteries using firm pressure --Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded --Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery (positive Allen's test) If the Allen's test is positive, the arterial blood gas can be drawn;

Creatinine clearance

The test requires a 24-hour urine specimen and a blood specimen. When the test begins, the first urine specimen is discarded and the time is noted.

septic arthritis.

This client is exhibiting localized (eg, pain, limited range of motion) and systemic infection symptoms (eg, fever) considered a surgical emergency

percutaneous nephrostomy tube

Used after Percutaneous nephrolithotripsy If little drainage, irrigate the tube with a small amount of sterile normal saline

vagal maneuvers

Valsalva, coughing, and carotid massage.

Rules of nines for calculating Total Body Surface Area (TBSA) for burns

Whole head: 9% Whole trunk: 36% (anterior 18% +posterior 18%) Whole arm: 9% (anterior 4.5% +posterior 4.5%) Whole leg: 18% (anterior 9% +posterior 9%) pubic area: 1%

Arterial steal syndrome

a Arteriovenous fistula (AVF) complication that occurs when the anastomosed vein "steals" too much arterial blood, causing distal extremity ischemia. Symptoms occur distal to the AVF, including skin pallor, pain, numbness, tingling, diminished pulses, and poor capillary refill. Without prompt intervention, ischemia may lead to limb necrosis

Antiretroviral therapy (ART)--for HIV

a medication regimen consisting of multiple drugs for managing and preventing progression of HIV infections --Leads to decreased viral loads and increased CD4+ --***treatment is lifelong and requires strict adherence Notes: Even clients with undetectable viral loads remain infected with HIV.

Decerebrate posturing vs Decorticate posturing

a sign of severe brain damage. arms and legs straight out, toes pointed down, and the head/neck arched back Decorticate: "arms towards the core of the body"

ileal conduit

a surgical technique that uses an excised piece of the client's ileum to create an incontinent urinary diversion. The client's ureters are connected to the ileal conduit, which is used to create an abdominal stoma that allows the passage of urine.

considered a surgical emergency

an expected manifestation of poststreptococcal glomerulonephritis. It is usually mild and does not require urgent attention.

West Nile virus (prevention）

avoiding mosquitoes --using an insect repellent --wear long-sleeved and light-colored clothes

blood dyscrasia

can be caused by medication use can be a priority.

near-drowning

can cause brain damage decerebrate posturing

Hypomagnesemia

causes a prolonged QT interval Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval--lethal Magnesium normal range 1.5-2.5 mg/dL/4-7 is therapeutic range

signs of hypovolemia.

decreased BP increased capillary refill decreased urine output increased urine specific gravity poor skin turgor (tent) Notes: Narrowing pulse pressure (the difference between systolic and diastolic) is a sign of hypovolemic shock

Active TB diagnosis

early morning sputum sterile specimen on 3 consecutive days Then, sputum culture

hemicolectomy

excision of half of the colon

Renal colic pain (in response to renal calculi)

excruciating, sharp, and stabbing radiating to groins

Sinus bradycardia (with Sx)

first treated with atropine. If atropine is ineffective, transcutaneous pacing or an infusion of dopamine or epinephrine is considered

Hepatitis A

hand hygiene (especially after toileting and before meals) is the most important intervention to reduce the occurrence of hepatitis A infection Vaccination is an important way to prevent infection (not transmission)

Unstageable pressure injuries

have full-thickness skin loss with slough and/or eschar, which prevents visualization of the wound base. The wound cannot be staged until slough and eschar are debrided by a wound care nurse or health care provider and the base can be visualized

Burn injury (fluid resuscitation stage)

hyperkalemia (tall, peaked T wave) elevated H & H Hyponatremia

respiratory alkalosis (causes)

hyperventilation: usually caused by anxiety, hypoxia and pain

Chronic venous insufficiency

inadequate venous blood return to the heart. Too much venous blood remains in the lower legs, and venous pressure increases. --development of stasis ulcers typically found around the medial side of the ankle (脚踝内侧） --The skin of the lower leg becomes thick with a brown pigmentation. Notes:compression bandaging is needed to reduce the pressure.

positive tuberculin skin test

indicate TB infection (may be latent or active） induration greater than 15mm (ordinary people greater than 10-14 mm (immigrants from countries,.....) greater than 5mm (HIV, immune compromised)

Asthma exacerbations

may require repeat nebulization every 20 minutes, or continuous nebulization for 1 hour, to relieve severe bronchoconstriction until the administered corticosteroids take effect and start to reduce the inflammation

Psoriasis

no cure for psoriasis --avoidance of triggers (eg, stress, trauma, infection) --topical therapy (eg, corticosteroids, moisturizers) --phototherapy (eg, ultraviolet light) --systemic medications, including cytotoxic (eg, methotrexate) and biologic (eg, infliximab) agents (Options 3 and 4) Notes: **Exposure to ultraviolet light (eg, phototherapy, sunlight) can help slow epidermal turnover

rheumatic fever (RF) 风湿热

occurs 2-3 weeks after a streptococcal pharyngitis RF affects the heart, skin, joints, and central nervous system. The presence of 2 major criteria or 1 major and 2 minor criteria and evidence of a preceding streptococcal infection indicate a high probability of RF. Major: --joint: arthritis --Heart: carditis --Nodules: subcutaneous --erythema marginatum: a type of erythema （skin rash) involving pink rings on the torso and inner surfaces of the limbs which come and go for as long as several months --Sydenham chorea: rapid, irregular, and aimless involuntary movements of the arms and legs, trunk, and facial muscles. Prevention: Penicillin for Group A strep

Overflow urinary incontinence

occurs due to compression of the urethra (eg, uterine prolapse, prostate enlargement) or impairment of the bladder muscle (eg, spinal cord injury, diabetic neuropathy, anticholinergic medications). --Implement a fixed voiding schedule (eg, every 2 hours) to prevent bladder overfilling. --Instruct the client to use the ***Valsalva maneuver (ie, "bearing down") and Credé maneuver (ie, gently applying pressure to the lower abdomen) to help facilitate bladder emptying (Option 2). --Assess the perineal area for skin breakdown related to incontinence (Option 3). --Measure postvoid residual volumes as prescribed to ensure that the client is not retaining large amounts of urine (Option 4). --Instruct the client to wait 20-30 seconds after voiding and then attempt to void a second time (ie, double voiding) to help empty residual urine (Option 5).

Influenza transmission

peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins

Oral candidiasis

small risk of transmission

Kidney biopsy

uncontrolled hypertension is a contraindication

UTI

urethra to bladder to kidneys Sx: burning with urination (dysuria), urinary frequency and urgency, hematuria, and suprapubic discomfort Systemic manifestation will develop only when the infection ascends to the kidneys: nausea, vomiting, fever with chills, and flank pain Assessment shows costovertebral angle tenderness. Prevention: **Avoid douching and using any feminine perineal products (eg, deodorants, powders, sprays),

Supraventricular tachycardia (SVT)--treatment

vagal stimulation and drug therapy. --IV adenosine Notes: If vagal stimulation and drug therapy are ineffective and the client becomes hemodynamically unstable, synchronized cardioversion is used.

pessary

子宫托 a vaginal device that provides support for the bladder (for bladder prolapse) --Clients who are able to remove and reinsert the pessary on their own will have the choice to remove it weekly, possibly even nightly, for cleaning. --Clients who are sexually active may prefer to remove the pessary prior to intercourse, although this is not necessary. --When the client cannot remove the pessary regularly, removal by an HCP at 2- to 3-month intervals is recommended. --Increased vaginal discharge is a common side effect. However, if an odor is present, the client should be instructed to notify the HCP to be treated for a possible infection.

Toxic epidermal necrolysis

毒性表皮溶解症 --Wound care: Sterile, moist dressings are applied to open areas of skin (Option 2). --Infection prevention: Strict sterile technique and reverse isolation decrease infection risk. The nurse should also monitor for any signs of infection (eg, fever) (Option 3). --Fluids and nutrition: Vital signs and urine output are monitored for signs of hypovolemia. a nasogastric tube may be necessary. --Hypothermia prevention: Maintain a room temperature of 85 F (29.4 C) or more, and use passive rewarming methods such as sterile, single-use warming blankets or digitally regulated warming pads (Option 4). --Pain management: Analgesics are administered around the clock and before painful procedures. --Eye care: Sterile, cool compresses are applied to relieve discomfort. Lubricants may relieve dryness and prevent corneal abrasion (Option 1).

fluid resuscitation therapy for burns

Adequate urine output (at least 30 mL/hr, or 0.5 mL/kg/hr) depends on adequate renal perfusion and is the greatest indicator (vital signs is not) that fluid resuscitation therapy has effectively restored tissue perfusion Lactated ringers is the choice

Acute respiratory failure

Altered mental status (eg, confusion, agitation, somnolence) is a common and often overlooked symptom. CANNOT use morphine for restlessness

Bladder scan

Amounts >100 mL should be reported as the client may be experiencing urinary retention

Angina pectoris

Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina, including the following: --Physical exertion (eg, exercise, sexual activity): --Intense emotion (eg, anxiety, fear): --Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling) --Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction and catecholamine release --Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction --Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium

car accident injury--unconcious

Assess airway Spine immoblization transfer the survivor to hard backboard Perform glasgow coma scale use the jaw-thrust technique to open airway

Asystole

CPR, CANNOT defibrillate drug therapy

Urinary retention

Can also be caused by body position; If the client is a man, can assist him to stand up first

Increased intraocular pressure

Can cause damage to the blood vessels and retina and cause potential permanent vision loss. Antiemetic medication is administered as needed following ophthalmic surgery to prevent vomiting.

Hypovolemic shock

Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include: --Change in mental status --Tachycardia with thready pulse 丝状脉 --Cool, clammy skin (Warm, flushed skin can be an early sign of septic or neurogenic shock) --**Oliguria (<0.5 mL/kg/hr) --Tachypnea

pyelonephritis

Dull flank pain radiating to umbilicus

peritoneal dialysis and complications

During the instillation and dwell portions of the cycle, clients are monitored closely for indications of respiratory distress (eg, difficulty breathing, rapid respirations, crackles) that can result from instilling the dialysate too rapidly, overfilling of the abdomen, or fluid entering the thoracic cavity (Option 3). --Crackles can also occur if over time there is more dialysate infused than is removed (fluid gain) --peritonitis: Cloudy outflow (effluent), tachycardia, and low-grade fever

Supraventricular tachycardia (SVT)

Dysrhythmia that originates from an ectopic focus above the bifurcation of the bundle of His. Stimulants (eg, nicotine, caffeine, cocaine) and organic heart disease can cause SVT.