NCLEX + 35 Page study guide, NCLEX UWorld
Risk associated with *stent placement* using the *femoral approach*
*retroperitoneal hemorrhage*
Pre-blood transfusion nursing interventions
- instruct client to *void prior to starting transfusion*
Acute pericarditis assessment
-*sharp pleuritic chest pain* -*aggravated on inspiration* and *coughing* -assessment shows *pericardial friction rub*
a post term baby findings
-deep creases and peeling on soles of feet
peripheral arterial pulses
0 absent 1+ weak 2+ normal 3+ increased, full, bounding
Conditions of being *ineligible to leave AMA*
1 *danger to self or others* 2. *lack of consciousness* 3. *Altered consciousness* 4. *Mental illness* 5. Being under *chemical influence* 6. *Court decision*
bmi pregnant client should gain how mucn per week in the 2nd and 3rd trimestes
1 ib per week
Signs of depression in adolescents
1. *Hypersomnolence* or insomnia; napping during daily activities 2. Low self-esteem; *withdrawal* from previously enjoyable activities 3. *Outbursts* or angry, aggressive, or delinquent behavior (eg vandalism, absenteeism); inappropriate sexual behavior 4. *Weight gain or loss*; increased food intake or lack of interest in eating
what modifications to take when giving cpr to a pregnant patient?
1. Perform *chest compressions slightly higher on sternum* 2. *displace uterus* to *left side*
Urine Specific Gravity
1.01-1.025. High gravity means urine is concentrated. Low gravity means urine is dilute.
therapeutic PTT
1.5-2 times normal reference of 25-35 scds so normal is about 37-70 scds right?? if you times them
when does the posterior fontanel close?
2 months
Expected number of *stools per day* in patient on *lactulose*
2-3 soft stools per day
pulmonic
2nd ICS
how to calculate MAP?
2xdiastolic + systolic all divided by 3
Max time for the grieving process is
3 years
Initiative vs. Guilt
3-6 yrs Assist parents to identify age/disease appropriate activities
Potassium (K)
3.5-5
normal albumin level
3.5-5.0;function of albumin keeps fluid from leaking out of vessels; low albumin causes pitting edema
normal urine output in mg/hr and mg/kg/hr
30 ml/hr 0.5-1 ml/kg/hr
PaCO2
35-45
RBC
4,000,000-6,000,000
PaO2
80-100
What volume of chest tube drainage should be reported to HCP
>100 mL/hr
what is the blood loss amount to be considered postpartum hemorrhage (PPH)?
>500 ml after vaginal birth >1000 ml after c-section
Glipizide is given to what type of client
A client with Type 1 diabetes where they produce none of their own insulin
What is trigeminal neuralgia
A cranial nerve disorder where there is stabbing/burning facial pain that is excruciating and unpredictable Often will be twitching and grimacing of the facial muscles
if pt is in resp distress what do you assess first
AIRWAY
Med of choice for SVT
Adenosine or Adenocard
skin cancer neumonic ABCDE what does it stand for?
Assymetry Border irregularity COlor changes Diameter more than a pencil eraser Evolving or changing in any way
signs of preeclampsia
BP > 140/90 proteinuria >300 mg of protein in urine in 24 hours headache visual changes 2+ pitting edema
where is gluten found?
BROW- barley, rye, oats, wheat
what to check labs wise when giving ace inhibitors?
BUN/creatinine, potassium, blood pressure
When we are admitting a psych patient, what type of admission history do we need to get
Biopsychosocial so we are encompassing all of them, not just a psych approach
When a client with parkinsons is experiencing extrapyramidal side effects, which med should we administer
Biperiden
Drugs for stones
Broad spectrum antibiotics Thiazide diuretics Allopurinol Vitamin B6 (pyridoxine)
Aminophylline
Bronchodilator
Terbutaline
Bronchodilator and anti-contraction Used to stop contractions in preterm labor and delay the process Side effects are maternal and fetal tachycardia, tremors, nervousness, headache, and pulmonary edema
proton pump inhibitors can increase the risk of
C-diff
Tartarazine and aspirin
Cross sensitivity, do not give together
Hypermagnesemia
Depress the CNS Hypotension Facial Flushing Muscle weakness Absent DTRs Shallow respirations Emergency
What is conductive hearing loss
Disorder in the auditor canal, ear drum, or ossicles from infection, inflammation, foreign body, trauma or ear wax
When do we hold potassium
Do not give potassium without adequate urine output "No Pee, No K"
What do we do if we note bleeding after an ear procedure
Do not put pressure!! Call the HCP immediately
Corticosteroids and surgery
During the few weeks leading up to surgery, we need to increase the dose of corticosteroids because surgery requires more. Nurse must monitor for side effects of too much corticosteroids
Position for an ABOVE the knee amputation
Elevate for the first 24 hours on a pillow. Position prone daily to help with hip extension
Position for a patient with a head injury
Elevate the HOB 30 degrees to decrease ICP
What do we do as the nurse for autonomic dysreflexia
Elevate the HOB to 90 Loosen constrictive clothing Assess for bladder distention and bowel impaction (trigger!) Administer antihypertensive meds
Position of a patient with bucks traction
Elevate the food of the bed for counter traction
Difference between Enteral nutrition and Parenteral nutrition
Enteral goes to the stomach via G-tube or something Parenteral goes through the heart straight into the cells
In delegation, nurses must take patients where there is...
Evaluation Assessment Teaching Dont delegate what you can EAT
Hypervolemia
Fluid overload Bounding pulse SOB Dyspnea Rales/crackles Peripheral edema HTN Urine specific gravity <1.010
What do we do as the nurse during the diuretic phase
Fluids need to be replaced Diet adjustment (high carb, restrict protein, potassium and sodium) Replace K Dialysis (hemodialysis or peritoneal)
what is the antidote used for benzodiazepams?
Flumazenil (Romazicon)
remember for lung positioning:
GOOD LUNG DOWN
Hip dysplasia in 16-18 months
Gradual reduction by traction (using bilateral Bryants traction Cast for immobilization
symptoms of addisons disease?
HYPERPIGMENTATION weight loss muscle weakness low bp hypoglycemia
How do we prevent retinopathy of prematurity
Have experts look at the eyes in all premature babies (less than 36 weeks or 2000g) Use minimal O2 Keep sats 95-100
Pneumonic to remember high vs low blood sugar
Hot and dry? Sugar is high Cold and clammy? Need some candy
what drug used to treat skin and athritic manisfestaions of Lupus
Hydroxychloroquine. when taking, make sure to have an eye appt every 6-12 mo take with food
ICP vs Shock vital signs
ICP: High BP, low pulse, low respirations Shock: Low BP, high pulse, high respirations
Treatment for V-tach
If monomorphic: give Procainamide, Sotalol, Amiodarone) If polymorphic: give Mag, Isoproterenol If Pulseless: give CPR, defib, epic, amiodarone
Causes of meningitis
Infection (virus, bacterial, fungal) Neurosurgical procedures Basilar skull fractures Otitis media, mastoiditis
What is a chalazion and what do we do for it?
Inflammatory cyst leading to a duct obstruction Must I&D
Do we hear S3 in left sided or right sided heart failure
Left
What do we do as the nurse to prevent thrombus formation
Leg exercises: flexion, extension of toes for 5 mins every hour
Med of choice for V tach
Lidocaine
Why do we do active range of motion
Maintains mobility of joint and increases muscle strength Performed by client without assistance
What is a complication from conductive hearing loss
Meningitis
Which MAOIs are used to treat depression
Pirates who say "arrrrr" take MAOIs when they are depressed Parnate (Tranylcypromine) Nardil (Phenylzine) Marplan (Isocarboxazid) and then Selegeline (Emsam) Or the Depressed pirates too a ship to PANAMA Parnate Nardil Marplan
When implementing droplet precautions, what do we have to do
Private room or cohort them with a client with the same infection Wear a mask Door may remain open
Position of an infant with spina bifida
Prone! So their sac does not rupture
What do we do as the nurse for bells palsy
Protect the head from cold or drafts Administer analgesics Teach isometric exercises for the facial muscles Emotional support for body image disturbance Full recovery takes 3-5 weeks
If you have carpal tunnel, what exercise do we recommend for you
Put the back of your hands together and bend both wrists at the same time
Renal arteriogram
Radiologic test performed to *visualize renal blood vessels* to detect abnormalities (renal artery stenosis or aneurysm). *Contrast medium* is injected into femoral artery; client should *increase fluid intake after procedure to flush dye*; *increased output* is *expected finding*
S&S of phelbitis
Redness in the area and red streaks
Hip dysplasia in newborn to 6 months
Reduction by manipulation Pavlik harness: worn from 3-6 months FULL TIME. Do not remove! Sponge bath is recommended Check skin 2-3 times a day Avoid lotions and powders Gently massage under skin to stimulate circulation Place diapers under straps Place shirt under chest straps and knee sox under foot and leg pieces Move child from room o room for environmental change
What do we do for penetrating eye injuries (pointed or sharp objects)
Refer to a surgeon Cover the eye with a patch
What is the only insulin that can be given IV
Regular. All others must be given sub Q
With injury to T1-T6 what do we most need to worry about
Respiratory function
When giving a client Lithium, what do we need to remember about their diet
Restrict their sodium
Why do we do passive range of motion
Retention of joint range of motion and maintenance of circulation Performed by the nurse without assistance from the client
parietal lobe
SENSATION. somatic and sensory input- injury causes deficits with sensation
Rhonchi
Snorous wheeze, *continuous, low-pitched adventitious breath sounds* similar to *moaning or snoring* that occur when *thick secretions* or *foreign bodies (eg tumors)* obstruct airflow in *upper airways*
Introducing a child to table foods: 5-6 months
Strained veggies Strained meat
What S&S will show if it proceeds to a Myasthenia crisis
Sudden inability to swallow, speak, or maintain a patent airway
Correct way to cough and deep breathe
Take three deep breaths, hold your incision, and cough
Where is insulin produced
The beta cells of the pancreas
Tobramycin
Therapeutic Level: 5-10 mcg/mL Toxic Level: >12 mcg/mL
For what diseases do we use droplet precautions
Think SPIDERMAN S:sepsis S:scarlet fever S: streptococcal pharyngitis P:Parvovirus B19 P:Pneumonia P:Pertussis I:Influenza Type B D: Diptheria (pharyngeal) E: Epiglottitis R: Rubella M:mumps M:Mengitis M:Mycoplasm or meningeal pneumonia An: Adenovirus
S&S of Neuroleptic Malignant Syndrome
Think of S&M You get hot (hyperpyrexia) You get stiff (increased muscle tone) You get sweaty (diaphoresis) BP, Pulse and Resp inrease Start to drool!
S&S of a preschooler who overdosed on aspirin
Tinnitus and gastric distress
Hypomagnesemia
Tremors Tetany Seizures Dysrhythmias Depression Confusion Dysphagia
If an infant if allergic to cow milk, what do we do
Try soy milk formula first Then try a predigested formula
Med of choice for status epilepticus
Valium
what can thiamine deficiency lead to?
Wernicke encephalopathy
What is important to tell the patient before a PET scan
You must empty your bladder before this test
what is Midalozam (Versed)?
a benzo used for conscious sedation. commonly siven with an opioid
what lab is monitored when receiving unfractioned heparin?
aPTT
delirium
acute, consciousness impaired, fluctuating, reversible
after a med error happens, what should you always do first?
assess the patient
warfarin
blocks the availibility of vitamin k and reduces risk of stroke venous thrombosis or PE; check PT/INR levels
what is troponin
cardiac marker used to detect an MI
diabetic ketoacidosis (DKA)
common for type 1 diabetes cardinal signs are fruity breath and rapid deep respirations (Kussmaul respirations) hyperglycemia, ketosis, acidosis caused by an intense deficit of insulin treat: *IV normal saline first*, then IV regular insulin, fingerstick glucose
autonomic dysreflexia
common in ppl wwith spinal injuries T6 or higher, -severe hypertension -throbbing headache -sweating above level of injury -bradycardia -goose bumps -flushing
what is asystole?
complete absence of ventricular electrical activity in the heart. no ventricular contraction occurs client is pulseless, apneic, and unresponsive
what is exopthalmos?
complication of hyperthyroidism from graves disease. keep eyes moist and protected
when can fetal sex be determined?
end of 12 weeks
ethambutol
eye exams
hypokalemia can cause
heart arrythmias and muscle cramps and weakness
respiratory alkalosis
high pH, low PaCO2
when is the best time to give a pregnant client that is nonimmune to MMR the vaccine?
immediately postpartum
Normal age for *head lag*
infants display head lag from *birth through age 4-6 months*
what is trismus
lockjaw
what is myopia?
nearsightedness, have trouble seeing objects at a distance
elevated bun and creatinine may indicate what?
nephrotoxicity
regression
returning to a previous level of development
SSRIs
sexual dysfunction
metoprolol
slows the HR and lowers the BP
test visual acuity in cuuildren
snellen chart 10 ft away (adults is 20)
erythropoeitin Epogen
stimulates bone marrow to make RBCs and combats the effects of chemo and used for kidney disease
before ABGs are taken, what test must be performed?
the Allen's test
*Nursing precautions* when administering *peritoneal dialysis*
use *sterile technique* when spiking and attaching bags of dialysate to the PD catheter
if a patient has phantom limb pain after an amputation, what can the nurse do for comfort?
wrap and apply ice/heat
what are some non pharmacologic interventions that help with phantom limb pain?
wrapping the extremity or applying ice
what must be done after ng tube placement?
xray to confirm location
at 12 months can in infant go fom standing to siting
yes
can UAPs transfer a dead client to the morgue?
yes
is aspirin contraindicated in children and why?
yes bc they can get reye syndrome
is the babinski sign present at birth?
yes but it disappears at 1 year
should bulemic patients be allowed to keep a doof diary in the hospotal?
yes, to keep track of the amount and type of food the client has eaten
HIV precautions- blood borne so STANDARD PRECAUTIONS are good unless
you anticipate splashing body fluids in that case wear a gown,gloves
when giving an IM injection use which method?
z-track
compartment syndrome
"7 P's" 1. parasthesia 2. pain 3. pressure 4. pallor 5. pulselessness 6. poikilothermia (cool skin temp) 7. paralysis never eevated if this develops
examples of proton pump inhibitors (PPIs)
"prazoles" omeprazole, lansoprazole, pantoprazole
fifth disease
"slapped face" distinct red rash on cheeks its on communicable before the onset of symptoms spreads via respiratory
How to go up and down stairs with a cane
"up with the good, down with the bad" Going up: Step up on the good extremity, then place the cane and affected extremity on the step Going down: Step down on the bad extremity with the cane, and follow with the good leg
parkland formula for burns
% BSA x weight (kg) x 4 give 1/2 fluids in first 8 hours. remaining 1/2 in last 16 hours.
Peripheral Arterial Disease *(PAD)* - *Assessment Findings*
(due to *decreased blood flow* to *lower extremities*) - *Hair loss* - *decreased peripheral pulses* - *Intermittent claudication* (ischemic muscle pain) - *cool, dry, shiny skin* - *thick, brittle nails* - *toe ulcers*, *gangrene*
*normal range* for *wet diapers* *first 48 hours of life*
*2-6 wet diapers every 24 hours*
Normal *weight gain* from *age 6-12 months*
*3-5 oz (84-140 g) a week*
Normal *weight gain* in *first 6 months* in infants
*5-7 oz (140-196 g) a week*
*normal range* for *wet diapers* by *3-4 days of life*
*6-8* wet diapers every 24 hours*
*LEFT-to-RIGHT congenital heart defects*
*ACYANOTIC defects* 1. *Patent ductus arteriosus* (PDA) 2. *Atrial septal defect* (ASD) 3. *Ventricular septal defect* (VSD)
*RIGHT-to-LEFT congenital heart defects*
*CYANOTIC defects* - *decreased pulmonary circulation* 1. *Tetralogy of Fallot 2. *Transposition of the Great Vessels*
How do *10-12 month olds* *play*
*Interactive games* (eg peek-a-boo, pat-a-cake)
what med is given for encephalopathy?
*Lactulose* - *decreases intestinal ammonia absorption* (gets rid of the ammonia)
Acute pericarditis treatment
*NSAIDs* and *colchicine* (antiinflammatory)
*1st line treatment* for *Myasthenia Gravis*
*Pyridostigmine*
How to *reduce portal pressure* in *liver failure* and *esophageal varices*
*TIPS (transjugular intrahepatic portosystemic shunt) procedure* and *beta blockers (propanolol)*
Herpes Zoster (Shingles) Characteristics
*Unilateral, linear* (dermatomal distribution) *vesicular rash* (fluid filled blisters)
Atrial fibrillation priority
*Ventricular rate control* by giving *diltiazem,metorpolol, or digoxin* to decrease ventricular response rate to <100/min
Dystonia
*abnormal muscle movements* of the *face, neck, and trunk* caused by *sustained muscular contractions* (eg *torticollis, oculogyric crisis, opisthotonos*)
Cystic fibrosis (CF) nursing priorities
*airway & oxygen saturation* (*pneumothorax* can be a complication)
Ways to reduce dumping syndrome symptoms
*avoid fluids with meals* and *lie down after eating*
what is Sjogren's syndrome?
*chronic autoimmune disorder* that *damages moisture-producing glands* dry eyes, mouth, skin, and vagina
Pertussis (whooping cough) symptoms
*cough lasting ≥ 2 weeks* with *≥1* of the following: - *violent, spasmodic cough/paroxysms of cough* - *inspiratory whooping sound* - coughing up *thick mucus plug* sometimes followed by *vomiting (posttussive emesis)*
Causes of *hypernatremia* in *infants*
*dehydration* (eg decreased oral intake, vomiting, diarrhea)
Third-degree (full-thickness) burns
*dry & inelastic* with *waxy white, leathery, or charred black color* Destroy the *dermis* and may involve *subcutaneous tissue*
First degree (superficial) burns
*dry with blanchable redness* usually only epidermis is damaged
what is a primary component in TPN?
*glucose,* so the nurse should be monitoring blood glucose and be assessing for signs of hyperglycemia
Infertility
*inability to conceive* after unprotected intercourse for *more than 12 months*
Juvenile idiopathic arthritis (JIA) - physical activity recommendations
*low impact weight bearing and non weight bearing* exercises that involve *range of motion & stretching* (eg *swimming,* stationary bike, throwing/kicking ball, low-impact dancing, walking, yoga)
Second-degree (partial thickness) burns
*moist or weeping wounds* with *blisters* and *shiny, fluid-filled vesicles* and *moderate to severe pain*
what is spironolactone and what is it used in?
*potassium sparing diuretic* used in *liver failure, ascites,* and *edema* to *promote diuresis*
*Left-to-right cardiac shunts* results
*pulmonary congestion* (increased pulmonary blood flow* Compensatory mechanisms (eg tachycardia, diaphoresis) result from *sympathetic stimulation*
superventricular tacycardia SVT
*regular, narrow QRS complex tachycardia* with *HR 150-220/min* *stimulants* like cocaine, caffeine, nicotine can cause SVT. client may experience palpitations, dyspnea, and angina *IV adenosine is treatment of choice, vagal stimulation* the lines up are very narrow
during instillation and dwell time of peritoneal dialysis, what are clients closely monitored for?
*respiratory distress* from infusing too quickly, overfilling the abdomen, or fluid entering the thoracic cavity
Meniere disease key to remember
*safety * falls -salt restricted diet to prevent further fluid build up
How to relieve pain in acute pericarditis?
*sit up & lean forward*
How do *8 month olds* *play*
*solitary play* by *maneuvering & teething soft toys*
Peripheral Arterial Disease (PAD) - *Home Management Instructions*
- *Lower extremities* below heart when sitting and lying down - Engage in *moderate exercise* (eg 30- to 45-min walk, twice daily) - Perform daily *skin care*, including application of lotion - prevents skin breakdown from dry skin - Maintain mild *warmth* (eg lightweight blankets, socks) but *never use heating pads* - *stop smoking* - *avoid tight clothes and stress* - Take *prescribed medications (vasodilators, antiplatelets)*
Examples of *cost-effective care*
- *considering inside of sterile glove wrapper* as a *small sterile field* - *donning clean*, rather than sterile, *gloves* to *remove client's dressing*
Sleep apnea interventions
- *continuous positive airway pressure device* at night - *limiting alcohol intake* at bedtime - *weight loss and exercise* - *avoiding sedating medications* (eg benzos, sedating antidepressants, antihistamines, opiates)
Schizophrenia: Assessment
- *delusions* - *tangentiality* (deviating from original topic of conversation) - *waxy flexibility* (tendency to remain in immobile posture)
Sjogren's Syndrome symptoms
- *dry eyes* (xerophthalmia) - can lead to *corneal ulcerations* - *dry mouth* (xerostomia) - can lead to *dental caries, oral thrush* - *dry skin & rashes* - *chronic dry cough* - *vaginal dryness & painful intercourse*
Sjogren's syndrome Treatment & Patient Education
- *eye drops* - wearing *goggles* - *sugar free gum* and/or *artificial saliva* -regular *dental appointments* for dental caries - *lubricants* (eg KY Jelly) - *sip water frequently* - use *lukewarm water* and *mild soap* when showering - *humidifiers* to maintain adequate humidity (mainly at *night*)
Middle stage Alzheimer's disease - eating problems
- *forgetting to eat at all* - *not recognizing sensations* of hunger or thirst - *forgetting how to use utensils* - *consuming nonfood items* - *refusing to eat* - *restlessness:* inability to sit long enough to consume a meal
Earlier stage Alzheimer's disease - eating problems
- *forgetting* that *meal was consumed* due to short-term memory loss - *anorexia & weight loss* secondary to depression &/or recognition of disease
Acceptable *methods of blood collection* in *neonate*
- *heel stick* - *venipuncture* (drawing blood from vein) - considered *less painful* and often requires *fewer punctures* to obtain sample, especially if *larger volume* is needed
Postpartum psychosis - risk factors
- *history bipolar disorder* - *previous discontinuation* of *mood-stabilizing medications* (eg lithium)
Late stage Alzheimer's disease - eating problems
- *inability to feed onself* - *dysphagia*
*Symptoms* of *hyponatremia* in *infants*
- *irritability, lethargy* - in severe cases, *hypothermia* and *seizure activity*
Acute hemolytic transfusion reaction
- *life threatening reaction* develops within the *first 15 mins* s/s are: *chills, feverm lower back pain, tachycardia, tachypnea, and hypotension*
Airborne precautions diseases & equipment
- *negative pressure isolation room* Disease acronym (*airing MTV*): - *Measels* - *TB* - *Varicella zoster (chicken pox)* infections
*Signs & Symptoms* of *hypernatremia* in *infants*
- *neurological symptoms* (restlessness, seizures) - on *history* indicates *adequate oral intake & signs of fluid overload* (eg facial edema), not dehydration
Pertussis management & treatment
- *oral antibiotics* - *droplet precautions* - supportive measures (*humidified oxygenation* and *oral fluids*)
examples of extrapyramidal symptoms
- *pseudoparkinsonism* - *dystonia*
Suspected *child abuse - injury patterns in nonaccidental trauma*
- *subdural & epidural hematomas* - *retinal hemorrhage on fundoscopic examination* - *Frenulum tears & gingival lesions* - *Linear-type immersion burns* - *long bone fractures in humerus or femur*
Abnormal findings post circumcision
- *unusual swelling, increasing redness* - *odor, abnormal discharge* - *excessive bleeding* - *absent/decreased urine output* (notify HCP if *no voiding within 6-8 hours*)
Circumcision care
- *washing hands* before providing care - *applying petroleum jelly* to glans penis at *diaper changes* (unless plastic ring was used) for *3-7 days* to prevent adhering to diaper - site typically *heals within 7-10 days* - expect *yellow exudate* on penis after the first day, a *normal part of healing* - use *warm water (without soap)* to remove urine/feces during diaper changes or at least twice daily
COPD exacerbation nursing monitoring
- Most important for nurse to monitor *mental status* frequently and *report changes (restlessness, decreased LOC, somnolence, difficult arousal, confusion)* to *HCP* - may indicate *increased CO2 retention & worsening hypercapnia* - Altered mental status poses greatest threat to survival b/c can lead to *decreased protective reflexes (eg gag, swallow, cough), periods of apnea, and airway compromise
*Pulse assessment* *post abdominal aortic aneurysm (AAA) repair*
- Pulses can be *absent* for *4-12 hours after surgery* due to *vasospasm* - *pedal pulse decreased* from *baseline* or *absent pulse* with a *painful, cool, or mottled extremity* can indicate presence of *arterial or graft occlusion* (life-threatening)
Pursed lip breathing instruction
- Regular practice (eg 5-10 min 4 times a day) 1. *relax neck & shoulders* 2. *inhale 2 seconds* through *nose* while *mouth closed* 3. *exhale 4 seconds (or twice as long as inhalation)* through *pursed lips*.
Causes of *hyponatremia* in *infants*
- can result from *water intoxication* when *formula is diluted* to "stretch feeding" - can also result from *ingestion of plain water*
Cystoscope
- inserted through urethra to *directly visualize* bladder wall and urethra. May cause *slight burning sensation with voiding for a day or two*
Strategies to prevent accidental drug overdoses in children
- keep medications *out of sight* in a *locked drawer or cabinet* - put them *away after each use*
Pleurisy
- manifests with *pleural friction rub* - loud, rough rubbing or grating sound heard throughout *inspiration & expiration* that's caused by the pleural surfaces rubbing together
Myasthenia gravis clinical manifestations
- ocular (*ptosis*) & facial muscle weakness - *difficulty speaking, swallowing, chewing* - can progress to *respiratory muscles* and affect *breathing*
Noninvasive positive airway pressure ventilation (NIPPV)
- often prescribed *short-term* to support gas exchange in pt with moderate to severe *COPD exacerbations* and *acidosis (pH <7.3) or *hypercapnia* (PaCO2 >45 mmHg) - can prevent need for tracheal intubation - administered until underlying cause of ventilatory failure is reversed with parmacologic therapy
Neonatal CPR positioning
- placed on back with *neck slightly extended*as if "sniffing" a flower - a *blanket or towel roll* can be placed *under shoulders* elevating them 0.75-1.0 inches off mattress
Primary use of radioactive iodine?
- primary treatment for *nonpregnant adults* with *hyperthyroid disorders* (eg *Graves disease*) - RAI damages or *destroys thyroid tissue* and can result in *hypothyroidism* - clients need to take thyroid *supplementation (levothyroxine) for life*
teaching for pediculosis capitis
- treatment with *pediculicide* (usually permethrin 1% cream) -soak childs comb and hair accessories in *boiling water for 10 minutes* -may need to treat child's sibling if they share things -use a *nit comb daily for 2 weeks after treatment* -*vaccum* furniture, carpet, etc -wash linens/beding in hot and dry on hot -*pets dont need to be treated* as human lice doesnt get on animlas
Bilevel positive airway pressure (BIPAP) device
- used in *conscious client* who is breathing spontaneously - delivers oxygen to lungs and removes CO2
Neonatal heel stick
- used to collect a blood sample to *assess capillary glucose* and perform *newborn screening for inherited disorders* (eg *congenital hypothyroidism, phenylketonuria*)
Hypercalcemia signs and symptoms
-*muscular weakness* -*constipation* -*depressed reflexes* -anorexia -nausea/vomiting -polyuria; polydipsia (extreme thirst) -dehydration -flank pain -calcium stones -deep bone pain -hypertension
females prescribed isotretinoin (accutane) acne medication must have what
-2 negative pregnancy tests before starting-causes serious birth defects-category X -must use 2 forms of contraception -enroll in a risk management program to make sure these are both being followed through
ECT pt teaching
-NPO 6-8 hrs before -anesthesia and muscle relaxant given before; pt will be unconscious during -no driving -temporary memory loss and confusion in immediate recovery period --discontinue anticonvulsants bc the treatment induces a seizure
teaching for a phenylketonuria baby
-a low phenylaline diet -lifetime dietary restrictions -monitor serum levels ac its an mino acid and is necessary but just in moderation -infants on special formulas -eliinate high phenylaline foods like meat eggs and milk
macrolide antibiotics like azithromycin, erythromycin, and clarithromycin can cause what? 2 things
-a prolonged QT interval which can lead to torsades de pointes and sudden death -also hepatotoxicity
electroconvulsive therapy ECT
-a treatment for MDD with psychotic features or when patients are highly suicidal and are not responsing to meds and need imeedaite treatent to keep them safe where they cant wait for meds -electrodes applied to scalp causeing a brief convulsion -general anesthesia and muscle relaxant given -common side effects after? confusion and memory loss
why is a post op c section pt pt at high risk for pulmonary embolism?
-abdom c section -engorged BVS from hypercoagubility of blood and venous stasis -immobolity due to surgey -postpartum hypercoagubility state bc the body makes a lot more blood to prepare for blood loss during birth
normal findings after the birth of a preterm baby
-abundant lanuga (should disappear around 36 weeks) -smooth pink skin with visible veins (bc lack of fat) -flat areolae without palpable breast buds (palpable and raised in newborns closer to term)
care for after an open radical prostatectomy
-avoid anything that causes strain on the rectal area. so no suppositiores or enemas to not mess with healing of surgicl area -ways to prevent constipation (fiber, lots of water, exercise) -dont strain with a BM
whata re some indicators that a child is ready for toilet training?
-child can express the need to pee or poor -can understand commands, communicate, and follo directions -pull clothing up and down (nt necessarily get dressed and undressed by themselves) -walk to and sit on toilet for about 5-8 mins without crying or gettting up -remain dry deveral hrs thru nap
care of anorexic patient
-determine pt daily calorie requirement -monitor weight at same time every day with same scale, same amount of clothes on -limit exercise initialy bc they are obsessed -reflecting with the patient on triggers -dont encourage a log of food bc this contributes to patient's obsession with food
before/after a kidney biopsy
-discontinue all antiplatelet and blood thinners one week before -type and cross match in case blood is needed -place in prone position -monitor vitals q15 after for first hour -place patient on procedure side to put pressure -bed rest for 24 hrs
ace inhibitors side effects
-dry cough, orthostatic hypotension, hyperkalemia, angioedema
nursing care for NG tube feeding
-elevate HOB during and after -check gastric residual every 4 hours with continuous feeding or before each intermittent feeding/medication giving -flush tube before and after bolus feedings -aspirate but return contents to stomach -check for excessive residual volume -start feeding after getting residual volume <100 ml -gastric ph should be acidic <5
barium enema post op teaching
-expect chalky white stool (this is the contrast) -take a laxative MIlk of Magnesia to expel stol -drink plenty of fluids and eat high fiber
how does the nurse prevent refeeding syndrom?
-get baseline electrolytes -initiating nutrition support cautiously with hypocaloric feedings -closely monitor electrolytes increase caloric intake gradually
chronic bronchitis interventions
-increase fluids to 2-3 L which helps thin secretions -humidifier -Guaifenesin an expectorant -abdominal breahting using huff method (sit in chair lean forward and expel it out) chest physiotherapy
umbilical cord care after birth
-keep it clean and dry an open to air (so dont put dipare over it) -do not put alcohol on it, just soap and water to clean -report signs of infection redness swelling and pus (but remember the normal yellow crust that should form) -the cord is cut after birth and a little remains there. the cord will shrivel and turn black in a few days and will fall off by itself in a 1-2 weeks- teach them not to mess with it or pull it off
care of alzeimers in the home
-keyed deadbolts -med bracelet -remove clutter and throw rugs -grab bars in showers/bathrooms -household hazards removed
teaching for ace inhibitors
-kidney levels in the first week -contraindicated in pregnancy -watch foods high in potassium since can cause a mild hyperkalemia -get out of bed slowly -possible allergic reaction like rash or angioedema
what is homonymous hemianopsia?
-loss of one half of the field of vision on the same side in both eyes -so like a patient can only see one side of their plate -teach them to scan with their good eye by turning their head -they are at risk for neglecting that side with the deficit or not eatign food placed on the side they cant see -they are also at risk for safety related injuried bc they simplye cant see as well
if a patient has a chest tube and all of the sudden the dainage stops, what are some interventions?
-lung sounds (bc maybe the lungs have re expanded and there is no more drainage) -reposition patient -get them to cough and deep breathe
steps for putting in an NG tube
-measure, mark, and lube -tell client to extend neck back -unsert tube just passed nasopharynx -tell client to flex neck forward and swallow -advance tube to the marked point -verify placemt of tube and ancor to nose
long term corticosteroid treatment
-never abruptly discontinue- could lead to addisonian crisis -report any signs of infection immediately bc use can cause immunosuppression and can even mask signs of infection -watch for signs of hyperglycemia -cataracts are a side effects- eye apt every year -never take on an empty stomach
pt teaching for IBS
-no gas producing foods (bananas cabbage onions), caffeine, alcohol, honey, high fructose corn syrup, and other GI disturbances like spices, hot food/drink, dairy, fatty foods -gradually increase fiber intake -generally tolerated well re protein, bread, and bland food
chest physiotherapy
-parents are taught -BEFORE meals -give supplemental pancreatic enzymes -hungry but underweight -high protein high calorie
correct CPR
-place heel of hand in center of chest betweeen nipples -compress 2-2.4 in -rate of 100-120 -30 compressions to 2 breaths
containdications to thrombolytics
-previous brain bleed -ischemic stroke or head trauma within 3 mo -active bleeding -cerebral aneurysm all thrombolytics lyse the pathologic clot (one whats causing the MI) and may lyse other clots so bleeding is a complication
criteria for diagnosis of IBS
-recurrent adbominal pain/discomfort 3 or more days a month for 3 months and at least 2 of these -improvement with bowel movement, change in frequency of stool, or change in form of stool
patient care for acute manic episode
-reduce environment stimuli -calm quiet low lit -limiting person contact -ONE on ONE- not group activities -structured scheudle of activities to keep focus -physical activities one on one to relieve energy -high protein high calorie finger foods -SET LIMITS
diverticular disease-->dviverticulitis
-sac like protrusions off the large intestine. asymptomatic usually and pt not aware until they become infected or inflammed called diverticulitis. -what pt can do? prevent constipation which may cause diverticula to become inflamed -high fiber diet, daily intake 8 glasses water, and exercise -decrease red meats and high dat foods
how to deliver a dose via a metered dose inhaler?
-shake MDI and attach to spacer -exhale completely -place lips tightly around the mouthpiece -deliver a single puff of med into spacer -take a slow deep breath and hold for 10 scds -rinse mouth with water after dose
what can lead to recurrent otis media?
-smoke, regular pacifier use, drinking from a bottle while lying down, lack of immunizations
a little facts about cystic fibrosis
-sticky thick respiratory secretions -chronic cough -at risk for recurrent lung infections -reduced pulse ox but 90% requires immediate intervetion -can cough up blood sputum -lose weight -fecal retenion/impaction
what to do if patient is on oxytocin and late decels, fetal bradycardia, tachycardia, and decreased variability happen, what does the nurse do in order?
-stop the oxcytocin right away -put pt in side lying position -give oxygen (10L via face mask) -IV fluid bolus -maybe give terbutaline -notify HCP -document
preprocedure instructions for barium enema
-take a cathartic (magnesium citrate, polythylene glycol) to empty stool from the colon -CLD day before procedure for bowel prep and to avoid dehydration. avoid red/purple liquids -NPO 8 hours before test -abdominal cramping may be felt during procedure
barium enema teaching pre op
-take a cathartic to empty stool from colon -CLD the day before for bowel prep and prevent dehydration- avoid red or purple -dont eat or drink 8 hours before test -may feel abdom cramping during test
when is using an indwelling catheter appropriate?
-urinary obstructin or retention -the need of strict I/Os in crtically ill pts -peri op like urologic procedurs, prolonged surgeries, or when lg fluids or diuertics re given durign surgery -prolonge dimmobilzation when bed rest is necessary -to improve end of life comfort -to promote healing of an open perineal or sacral wound in incontinent pts
teaching for an electroencephalogram
-wash hair before to remove oils -avoid caffeine, stimlants, and cns depressants before the test -test is not painful, as electrodes are just placed on the head
Trust vs. Mistrust
0-1 yr Teach parents to meet infant's physical and social needs
lithium therpeutic range
0.6-1.2
Creatinine
0.6-1.2.
what is the fluid of choice for the rapid correction of hypotension?
0.9 sodium chloride
partial weight bearing
1 person assist stand & pivot transfer with gait belt or motorized assist device if cooperative 2 person assist with full body sling if uncooperative
When does the Babinski reflex disappear
1 year
at what age does an infant have equal head and chest circumference?
1 year
children under what age should not be given honey?
1 year
when giving a needle IM, the needle length should be what?
1-1 1/2 inch
first trimester in weeks
1-12 weeks
Onset of Isophane (NPH)
1-2 hr
When should a baby umbilical cord fall off
1-2 weeks after birth No tub baths until them Should be drying up and getting more hard to the touch
Autonomy vs. Shame and Doubt
1-3 yrs Provide child with acceptable options. Let them CHOOSE
Drugs *contraindicated* in patients with *hyperkalemia*
1. *ACE inhibitors* 2. *Angiotension 2* *(ARBs)* 3. *Potassium-sparing diuretics*
Appropriate order of actions when client found on floor
1. *Assessment* of *physiological stability* ABCs 2. *Assessment* of *injuries* 3. *Moving client* 4. *Notifications* 5. *Documentation*
Hemophilia Patient Education
1. *Avoid medications* that *inhibit platelet aggregation* (eg ibuprofen & aspirin) 2. *Avoid IM injections* (SubQ is preferred) 3. *Avoid contact sports & safety hazards* (*noncontact activities* - swimming, jogging, tennis - and use of *protective equipment* are *preferred*) 4. Dental hygiene is necesssary - *soft toothbrushes* should be used 5. *MedicAlert bracelets* should be worn at all times
Clinical Manifestations of *Right-to-Left* congenital heart defects
1. *Clubbing of fingertips* - associated with chronic hypoxia 2. *Cyanosis* - evident *shortly after birth* and during *periods of physical exertion*
Pneumonia assessment findings
1. *Crackles* 2. *Fever, chills, productive cough, dysnpea,* and *pleuritic chest pain* 3. *Increased vocal/tactile fremitus* 4. *Bronchial breath sounds in peripheral lung fields* - can be an *early sign* 5. *unequal chest expansion* 6. *dullness* on percussion
Positive (diagnostic) signs of pregnancy
1. *Fetal Heartbeat* heard with doppler 2. *Fetal Movement* (felt by an examiner or visible) 3. *Visualization of Fetus* (ultrasound)
Safety promotion for client with *moderate* Alzheimer's disease
1. *Keyed deadbolts* and *close supervision* 2. *Medical identification/location devices* 3. Decreased *water heater temperature* and "hot" and "cold" labels on faucets to prevent burns 4. Household hazards (eg *gas applicanes, rugs, toxic chemicals) removed* to prevent injury 5. *Grab bars* installed in showers and tubs
Drugs that cause *hyperkalemia*
1. *Potassium sparing diuretics* (spironolactone) 2. *ACE inhibitors* (*-pril*) 3. *NSAIDs*
what is *monitored* carefully *after*an *abdominal aortic aneurysm (AAA) repair*?
1. *Pulses* (femoral, posterior tibial, dorsalis pedis), *skin color*, and *temperature* of *lower extremities* 2. *renal status* so things like *BUN, creatinine,* and *urinary output*
SBAR Communication Framekwork Components
1. *S* = Situation - what *prompted* the communication (eg *what* changes occurred) 2. *B* = Background - *pertinent information, relevant history, vital signs* 3. *A* = Assessment - nurse's assessment of the situation (*when* & *what changes* occurred) 4. *R* = Recommendation - *request* for *prescription* or *action* from HCP
Acute hemolytic transfusion reaction - Nursing Interventions
1. *Stop* transfusion *immediately* and *disconnect tubing* at catheter hub 2. *Maintain IV access* with *normal saline* using *new tubing* to prevent hypotension & vascular collapse 3. *Notify HCP & blood bank* 4. Monitor *vital signs* 5. *Recheck labels, numbers,* and *client's blood type* 6. *Treat symptoms* according to *HCP's prescription* 7. Collect *blood* and *urine samples* to evaluate for *hemolysis* 8. *Return blood & tubing set* to *blood bank* for additional testing 9. Complete necessary facility *paperwork* to document reaction
Situations that nurses must legally report
1. *Suspected abuse* 2. *Suspicious deaths* - medical examiners has *legal authority & obligation* to perform an *autopsy* independent of family wishes when *deaths* are suspected to be result of *crime, trauma, or suicide* 3. *Impaired* or *intoxicated health care professionals* regardless of their position
Objective (probable) signs of pregnancy
1. *Uterine/cervical changes* -Goodell sign, -Chadwick sign, -Hegar sign, -Uterine enlargement 2. *Braxton hicks contractions* 3. *Ballottement* 4. *Fetal outline palpation* 5. *Uterine & funic souffle* 6. *Skin pigmentation changes* -Chloasma, -linea nigra, -areola darkening) 7. *Striae gravidarum* 8. *Positive pregnancy tests*
Written consents - Nurse's Role
1. *Witness* that consent was signed *voluntarily* 2. That patient was *competent* at time of signing 3. *Documenting in medical records* after signature obtained with *date/time* of signature
Pulmonary embolism (PE) signs & symptoms
1. *anxiety/restlessness* 2. *pleuritic chest pain/tightness* 3. *shortness of breath* 4. *tachycardia* 5. *hypoxemia* 6. *hemoptysis*
Disorders associated with *manipulative behaviors*
1. *borderline & antisocial personality disorders* 2. *substance abuse problems* 3. *somatic symptom disorder* 4. *bipolar disorder* (during manic phase)
Conditions when rhonchi are heard
1. *bronchitis* 2. *cystic fibrosis* 3. *some types* of *pneumonia* may clear with *coughing* or *suctioning*
what medications interact with grapefruit?
1. *calcium channel blockers* (diltiazem, nifedipine, verapamil, etc) 2. *statins* 3. *SSRIs*
Posttransplant infections symptoms
1. *fever >100.4 F (38 C) 2. *productive or dry cough* 3. *changes in secretions*
Factors contributing to *female infertility*
1. *hormonal dysfunction* (eg *PCOS*) with *anovulatory cycles* 2. *High or low BMI* (normal: 18.5-24.9 kg/m2) 3. Maternal age >35 4. *Endometriosis* 5. *Recurrent infections* (eg chlamydia, PID)
Pulmonary embolism - Nursing Priorities
1. *rapid symptom identification* 2. *assessment of oxygenation* 3. *notification of HCP*
Nursing interventions for manipulative behaviors
1. *setting limits* that are realistic, nonpunitive, and enforceable 2. Using a nonthreatening, matter-of-fact tone when discussing limits and consequences of unacceptable behaviors 3. *enforcing all unit, hospital, or center rules* 4. Ensuring *consistency* from all staff members in enforcing set limits
Hypocalcemia can result in
1. *tetany* 2. *laryngeal stridor* 3. *seizures* 4. *cardiac dsyrthmias*
UAP scope of practice
1. ADLs 2. hygiene 3. linen change 4. routine, stable vital signs 5. documenting input/output 6. positioning
Hyperkalemia priority interventions
1. Administer *IV 50% dextrose + regular insulin* rapidly 2. If *ECG changes* are present, give *calcium gluconate* FIRST
Subjective (presumptive) signs of pregnancy
1. Amenorrhea; 2. Nausea and vomiting 3. Excessive fatigue; 4. urinary frequency; 5. Breast tenderness; 6. Quickening.
*Risk factors* for *cervical cancer*
1. Infection with high-risk HPV strains 2. History of sexually transmitted diseases 3. Early onset of sexual activity 4. Multiple or high-risk sexual partners 5. Immunosuppression 6. Oral contraceptive use 7. Low SES 8. Tobacco use
Steps for preparing *sterile field* for a *wet-to-damp dressing change*
1. Perform *hand hygiene* 2. *Open a sterile gauze package* that has a partially sealed edge *with ungloved hands* by grasping both sides of the edge, one with each hand, and pull them apart while being careful not to contaminate the gauze 3. *Hold the inverted opened gauze package 6" (15cm) above waterproof sterile field* so it does not touch the field, and then drop the cause dressing onto sterile field 4.Place the sterile dressings on *the sterile field 2" (5cm) from the edge*; the 1" (1.25cm) margin at each edge is considered unsterile because it is in contact with unsterile surfaces 5. *Use sterile NSS* from a recapped bottle that was *opened <24 hours ago*
testicular self-examination (TSE) instructions
1. Perform *monthly on same day* 2. Perform while taking a *warm shower* 3. Use *both hands* to feel each testis *separately* 4. Palpate each testicle gently, using the *thumb and first 2 fingers* 5. Check that the testicle is normally egg-shaped and moveable with a smooth surface
Steps for suctioning an *endotracheal tube (ETT)*
1. Perform hand hygiene and don *clean gloves* 2. Suction oropharynx and *perform oral care* 3. Ensure that the system is connected to appropriate wall suction (*<120 mm Hg) 4. *Hyperoxygenate* the lungs (*100% FiO2) 5. Advance catheter into trachea until resistance is met. *Do not suction* while advancing the catheter 6. Gently remove catheter while suctioning and rotating it. Do not suction for more than *10 seconds* 7. Evaluate client tolerance; if further secretions remain, suctioning can be repeated 1 or 2 times. Document procedure when complete. 8. Resume oxygenation and ventilation settings as prescribed.
Five Rights of Medication Administration
1. Right Client 2. Right Drug 3. Right Dose 4. Right Route 5. Right Time
Five Rights of Delegation
1. Right Person 2. Right Task 3. Right Circumstance 4. Right Direction and Communication 5. Right Supervision and Evaluation
*Neonatal heel stick* proper *technique*
1. Select location on the *medial or lateral side* of the *outer aspect of the heel* 2. *Warm the heel* for several minutes with warm towel compress or approved single-use instant heat pack 3. *cleanse* intended puncture site with *alcohol* 4. *Sucrose and nonnutritive sucking* on a pacifier may reduce pain 5. Use an *automatic lancet*,
Clinical Manifestations of *left-to-right cardiac shunts*
1. Tachypnea 2. Tachycardia, even at rest 3. Diaphoresis during feeding or exertion 4. Heart murmur or extra heart sounds 5. Signs of congestive heart failure 6. Increased metabolic rate with poor weight gain
2 major clinical features of major depressive disorder
1. depressed mood 2. loss of interest or pleasure. one of these two symptoms must be resent dailyr for 2 weeks for the diagnosis to be made
what are the 3 signs of positive (diagnostic) pregnancy?
1. fetal heartbeat w/ doppler 2. visualization of fetus with ultrasound 3. fetal movement felt by the hcp
infant formula teaching
1. keep parts of bottles as clean as possible (boil or wash in dishwasher) 2. *wash the top* of can before opening 3. keep *unused prepared formula or cans in refrigerator* after opening but *discard after 48 hours* -but throw away formula that infant left in bottle 4. *never microwave* but instead can be placed in pan of hot water to warm it, then test temp on inner wrist. should be lukewarm 5. *Never dilute or concentrate* formula
LPN scope of practice
1. monitoring RN findings 2. reinforcing education 3. routine procedures (catheterization) 4. most med administraions 5. ostomy care 6. tube patency and enterl feeding 7. specific assessments (like lung, bowel, neurovascular checks)
things that UAP are allowed to do
1. passive/active ROM exercises, 2. transport body to the morgue, 3. pick up something from pharmacy 4. Measurement of vital signs 5. Fingerstick glucose testing 6. Personal hygiene & skin care 7. Oral care 8. Measurement of urine output
3 main categories a person with PTSD has
1. reexperiencing the traumatic event 2. avoiding reminders of the trauama 3. hyperarousal
Magnesium (Mg)
1.5-2.5
how many cm is the complete dilation to birth?
10 cm
Onset of Glulisine
10-15 mins
BUN
10-20
normal vancomycin level
10-20
Dumping syndrome
10-30 mins after eating you get diarrhea and rapid gastric emptying Pt should lay down after eating to delay gastric emptying time, should not drink 1 hour before, during, or 2 hours after meals and should eat smaller meals more frequently
with CO poisoning, what should be the nurses primary action?
100% oxygen at 15ml via nonrebreather mask
what is the normal pulse rate for a 1 year old
100-160
Diet of a premature infant
100-200 kcal/kg/day Need more sodium, calcium, and protein than full term infants Supplements: Vitamin A, C, D, and iron. Sometimes Vitamin E. Vitamin K to prevent clotting problems
PT
11-15. Warfarin Therapeutic Range: 1.5-2 times normal value (16.5-30)
what are normal fetal heart tones?
110-160
what is a normal newborn HR
110-160
fundal height- just need to memorzie this
12 weeks: just above pubic symphysis 16 weeks: halfway btwen public symbiosis and umbilicus 20-22 weeks: reaches umbilicus 36 weeks: xiphoid process
MMR and Varicella are first given at what age?
12-15 mo
Hgb
12-18
Identity vs. Role Confusion
12-20 yrs Provide same age support group
Diet of a full term infant
120 cal/kg/day Human milk is ideal for first 0-12 months IF using formula, should me for 12 months, before going to regular cows milk
second trimester in weeks
13-26 weeks
Sodium (Na)
135-145
how soon after a blood transfusion does an acute hemolytic reaction occur?
15 mins
Onset of Aspart
15-30 mins
Onset of Lispro
15-30 mins
ammonia level
15-45
Platelets
150,000-400,000. <20,000 be very concerned.
Duration of Isophane (NPH)
16 hours
when does the anterior fontanel close?
18 mon
when should quickening happen?
18-20 weeks in first time baby havers and sooner for previous moms
what is the normal force of the pulse on the scale
2+
what number is the normal, expected deep tendon reflex?
2+
therapeutic INR is what
2-3
short acting (regular) insulin peak
2-5 hrs
Phosphorus (PO4)
2.5-4.5
Intimacy vs. Isolation
20-35 yrs Provide private time with partner/family
HCO3 (bicarbonate)
22-26
Duration of Glargine (Lantus)
24 hours
When will thumb sucking go away
24 months
PTT
25-35. Heparin Therapeutic Range: 1.5-2 times normal value. (37.5-70)
third trimester in weeks
27 weeks to end of pregnancy
aortic
2nd ICS
When does the Grasp reflex disappear
3 months for palmar 8 months for plantar
what are the criteria?
3 or more of the following: increased waist circumference high bp 130/85 triglyceride level over 150 HDL below 40 or 50 fasting glucose levels above 100 mnemonic: We Better Think High Glucose
glasgow coma scale ranges from
3-15; 3 being worst 15 being best condition (8 or below in a coma)
Onset of Glargine (Lantus)
3-4 hr
When does the Moro reflex disappear
3-4 months
When does the Tonic Neck reflex disappear
3-4 months
Duration of Aspart
3-5 hours
Duration of Glulisine
3-5 hours
Duration of Lispro
3-6 hours
normal respiratory rate for a neonate?
30-60
Onset of Regular
30-60 min
normal newborn RR
30-60;glucose levels are normally decreased 1 hour after birth
rapid acting insulin peak (aspart, lispro, glulisine)
30mins-3 hours
Average head circumference of a newborn
32-36 cm
noral newborn head circumference
32-37 cm
when are pregnant clients tested for Group b streptococcus (GBS)?
35-37 weeks
Generativity vs. Stagnation
35-65 yrs assist client with illness adaptation and home/work demands
Hct
36-50
what number of weeks is considered term?
37
erbs point
3rd ICS
Intermittent peritoneal dialysis
4 days a week for 10 hours a day Can be automated or manual
how to calculate the parkland formula
4 x % x wt in kg then divide by 3 bc they should receive half the fluid in the first 8 hours
parkland formula... what is the formula and actually how much is given?
4 x weight in kg x % of body burned half of the calculated fluid must be given in the first 8 hours
Age for imaginary play
4-6
introduction of solid food usually happens how many mo?
4-6
long acting (detemir, glargine)
4-9 hrs
how much after TB injection should arm be checked?
48-72 hours
WBC
5,000-10,000
what should ph be when you aspirate for ng tube?
5.5 or below
avoid IM/venipncture when the platelet count is below what?
50,000
platelets (at least afte chemo) are not considered urgent untl below what?
50,000
tricuspid
5th ICS
mitral AKA apex
5th ICS at midclavicular line
How long does a diaphragm need to be left in the vagina after intercourse
6 hours
separation anxiety in babies
6 mo- about 3 years. this is a normal reaction
Duration of Regular
6-10 hr
when does teeth eruption happen in infants?
6-10 months
when does tooth eruption occur in infants?
6-10 months
what is the *normal range* for *wet infant diapers per day*?
6-10- great way to measure hydration status in infants
Idustry vs. Inferiority
6-12 yrs Encourage child's participation in their care
How many diapers for a full term infant
6-8 wet diapers and one stool daily
what is normal MAP
60 or more
pneumonia vaccine
65 and above need 2 vaccines
Integrity vs. Despair
65+ yrs Encourage use of personal items when not at home
pH
7.35-7.45
Calcium (Ca)
8.5-10.5
asthma green
80 ot above of personal best
elbow sling placement
90 deg hand abve elbow bottom of sling ends in middle of palm with fingers visible
How long does an MRI ususally last for
90 minutes
in pregnancy, pts are considered anemic when hemoglobin drops below what?
<11
INR
<2. Warfarin Therapeutic Range: 2-3
Cholesterol
<200
Refractory hypoxemia
= *inability to improve oxygenation with increases in oxygen concentration* *hallmark* of *acute respiratory distress syndrome (ARDS)* - progressive form of acute respiratory failure that has *high mortality rate*
Mastitis
= postpartum breast infection from *clogged milk ducts* (poor latch). not draining properly - Symptoms: *fever, bresat pain, breast inflammation and redness* - Treatment: 1. antistaphylococcal *antibiotics (dicloxacillin* or *cephalexin*) and *analgesics (ibuprofen)* 2. *Frequent continued breastfeeding (every 2-3 hours)* 3. *increase oral fluid intake* 4. wear *soft cup bras* to encourage milk flow
when are lithium levels considred toxic?
>1.5
Pseudoparkinsonism
A *medication-induced temporary constellation of symptoms* associated with Parkinson's disease, (eg *masklike face, shuffling gait, rigidity, resting tremor, psychomotor retardation [bradykinesia])
What is bells palsy
A 7th cranial nerve disorder where there is an inability to close the eye, decreased corneal reflex, increased lacrimation, speech difficulty, loss of taste, distortion of one side of the face
What is acoustic neuroma
A benign tumor of the 8th cranial nerve that causes deafness (partially initially) and dizziness
What suggests that a client has an inguinal hernia
A buldge in the lower right quadrant
What is retinopathy of prematurity
A cause of blindness in premature infants because when they are premature, we slam them with O2, but this its much causing the retinal vessels to constrict and leads to blindness
Gout
A high level of uric acid that leads to joint deterioration Put on a low purine diet (no fish or organ meats) You do not need rest and activity and exercise like you do in RA and osteoarthritis, you just need to manage the pain
What is an ewald tube
A large orogastric tube that is designed for rapid lavage and often causes gagging and vomiting. Always have suction equpiment at the bedside
What is aluminum hydroxide gel
A medication to prevent epigastric pain. Take it one hour after a meal to neutralize stomach acids. Contains sodium so check if the patient is on a sodium restricted diet
Butorphanol Tartate
A narcotic pain reliever similar to morphine Monitor rate and depth of respirations
Describe an electromyography
A noninvasive procedure that takes about 30 minutes. Electrodes are attached to the legs and impulse transmission is measured
S&S of syphillis
A papule - like lesion in the vaginal area
What is a flourescin angiography
A series of photographs taken that detail the circulation of the eye. The clients eyes are dilated with mydriatic eyedrops before the exam and have to protect their eyes from the sun after the exam.
If an african american needs a blood pressure med, which are we likely to prescribe
A thiazide diuretic Not a beta blocker or an ACE inhibitor (pril)
ovarian cancer symptoms
ABDOMINAL BLOATING PELVIC PAIN OR PRESSURE early satiety abdominal, back, or leg pain urinary urgency/frequency gi disturbances
Anti diuretic hormone
ADH is a hormone made by the hypothalamus in the brain and stored in the posterior pituitary gland. It tells your kidneys how much water to conserve. ADH constantly regulates and balances the amount of water in your blood.
which patients should LR not be given to?
AKI or chronic kidney disease
APETOMAN
APETM aortic, pulmonary, erbs point, tricuspid valve, mitral valve
which heart meds cannot be given during pregnancy?
ARBs and ACE inhibitors
temporal lobe
AUDITORY input cannot understand visual or written language
What to *avoid* with *Sjogren's syndrome*
AVOID - *decongestants* can cause further dryness - *oral irritants* (eg coffee, alcohol, nicotine) - *acidic drinks* - *low-humidity environments* (eg centrally heated houses, airplanes)
What scale do we use to detect the presence of tradeoff dyskinesia
Abnormal Involuntary Movement Scale (AIMS)
What is Cor Pulmonale
Abnormal enlargement of the right side (right HF) of the heart as a result of disease of the lungs or the pulmonary blood vessels (left heart failure). Choose Edema or JVD if its a choice
What is glaucoma
Abnormal increase in Intraocular pressure leading to visual disabilities and blindness Cloudy, blurry vision or loss of vision Artificial lights have rainbows or halos around them Decrease in peripheral vision
If someone has a gastric ulcer, when are they going to experience the most pain
About 30 mins to one hours after eating
If you have a cervical cancer radium implant in, how long do you need to abstain from sex and tampons for?
About 6 weeks, whenever your followup with your primary care physician is
Med of choice for CHF
Ace inhibitor "pril"
What will increase the absorption of iron
Acidic foods! Take with orange juice
Addison disease vs Cushings disease
Addisions: down down down up down (hyponatremia, hypotension, decreased blood volume, kyperkalemia, hypoglycemia) Cushings: up up up down up (hypernatremia, hypertension, increased blood volume, hypokalemia, hyperglycemia)
What is the priority for a patient with sickle cell crisis
Adequate hydration
What do we do as the nurse for BPH
Administer meds (5-alpha reductive inhibitor and alpha-blocking agents) Suprapubic cystostomy (mini urostomy to drain bladder) Prostatectomy (TURP, Suprapubic resection through bladder, retropubic resection through abdomen) Assess for Shock and hemorrhage Avoid long periods of sitting and strenous activity
As the nurse, what do we do for myasthenia gravis
Administer meds before eating (anti cholinesterase, corticosteroids, immunosuppressants) Optimal eye care (to prevent and help diplopia) Maintain optimal mobility Avoid things that precipitate myasthenia crisis (infections, stress, neomycin/streptomycin, surgery)
Where do we get pulses for CPR in an adult and infant
Adult: Neck (sternoceidomastoid) Infant: Arm (Brachial)
When does "stormy" behavior onset?
Age 11
When does a child have an actual concept of death
Age 9
What is the best lab value to look at for long term nutritional status
Albumin
Contraindication to administering the flu vaccine
Allergy to eggs
Memantine treats what?
Alzeimers
Treatment for PVC
Amiodarione Betablockers Procainamide
Bladder scanner residual urine volume to report
Amounts *>100 mL* - may have urinary retention
Chronic phase of AKI
Anemia Azotemia Acidosis Fluid retention Urinary output alterations
Two types of glaucoma
Angle closure: sudden onset, emergency from allergy, vasomotor problems, and emotional disturbances Open angle: blockage of aqueous humor flow from trauma, tumors, hemorrhage, aging
Aluminum hydrozide
Antacid Take it one hour after meals
What do we do as the nurse for otitis media
Antibiotics (organism specific) Antihistamines for allergies Nasal decongestants Ventilatory tubes (inserted in the eustachian tube for continuous ventilation) Tympanoplasty (reconstruction of the ossicles and tympanic membrane) Myringotomy (incision to tympanic membrane to relieve pressure and release purulent drainage.. no water allowed in ear)
What is imipramine
Antidepressant and nerve pain medication Side effects include: fever, dry mouth, vomiting/diarrhea, fatigue, sore throat
Acetaminophen (Tylenol)
Antidote/Reversal: acetylcysteine (Muscomyst) Toxic Level: >250mcg/mL
Iron
Antidote/Reversal: deferoxamine (Desferal)
Curare
Antidote/Reversal: edrophonium (Tensilon)
Ethylene Poisoning
Antidote/Reversal: fomepizole (Antizol)
Cyanide Poisoning
Antidote/Reversal: methylene blue
Lead
Antidote/Reversal: succimer (Chemet)
What meds are we giving to someone with Menieres disease
Antihistamines Anti emetics Antivertigo Diruetics
Anuria vs oliguria vs polyuria vs dysuria vs enuresis
Anuria = <100 ml in 24 hours (basically nothing) Oliguria = 100-400 ml in 24 hours Polyuria = >2000 ml in 24 hours (too much!) Dysuria = painful or difficult voiding Enuresis = bed wetting in a child over 5 (usually have small bladder and more common in males)
APGAR
Appearance (color all pink, pink and blue, blue/pale) Pulse (>100, <100, none) Grimace (cough, grimace, none) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, none)
What do we do for patients with rheumatoid arthritis
Apply heat and do ROM exercises This reduces swelling, increases circulation and decreases stiffness while preserving joint mobility
Position for a detatched retina
Area of detachment should be in the dependent position
Use of aspirin during pregnancy
Aspiring can cause fetal hemorrhage, do not use this during pregnancy
Once we start mag on a pregnant client with hypertension, what do we do
Assess for their deep tendon reflexes
Med of choice for asystole
Atropine
What do we give for bradycardia
Atropine
Treatment for sinus bradycardia
Atropine or possible pacemaker
Audiogram vs tuning fork
Audiogram: quantitates the degree of hearing loss Turning fork: qualitates : the type of loss
Continuous peritoneal dialysis
Automated machine used at night Final exchange is left in place for the next day and then drained at night
What do we do as the nurse for sleep apnea syndrome
Avoid alcohol and meds that depress the upper airway Talk about weight loss and diet CPAP or BiPAP Surgery Low-flow O2 Position (fixing devices are used to prevent subluxation of the neck and tongue obstruction)
How do we diagnose it
BUN and creatinine PSA (Prostate specific antigen) (should be less than 4mg/ml) Transabdominal/transrectal ultrasound Prostate biopsy
what labs to check before giving digoxin?
BUN and creatinine bc this drug is mostly excreted by the kidney
If there is a low potassium level, why do we need to hold the digoxin
Because hypokalemia can lead to dig toxicity. We have to call the HCP and ask for a potassium supplement before giving the dig
Glucose levels during and after pregnancy
Because of hormone levels and a baby in you, glucose rises during pregnancy. Glucose will drop after delivery
What do we do for a patient with a detached retina
Bedrest (don't bend forward, no excessive movements) Area of detachment needs to be in dependent position Surgery to reattach the retina to the choroid (gas or air bubble used to apple pressure the the retina) No hair washing for 1 week Avoid strenuous activity for 3 months
What do we as nurses do for Pyelonephritis
Bedrest during the acute phase Antibiotic therapy, antiseptics, analgesics Encourage 3000ml/day
PH of gastric contents should be:
Between 1 and 4
What are the 5 dangers we need to educate the public on for S&S of glaucoma
Brow arching Halos around lights Blurry vision Diminished peripheral vision Headache or eye pain
what are the 2 signs the nurse does to check for meningitis?
Brudzinski and Kernig
when you think hyperkalemia, think what?
CARDIAC PROBLEMS
Hypocalcemia
CATS Convulsions Arrythmias Tetany Spasms Stridor
Hypoparathyrodism
CATS: convulsions, arrythmias, tetany, spasms, stridor Too little calcium
warning signs of cancer
CAUTION
cystic fibrosis
CF is genetic bronchodilators before chest physiotherapy- to remove secretions that cause ineffective airway clearance diet high in fat calories and proteins;high fluids pancreatic enzyme supplements with all meals and snacks recurrent respiratory infections
parent teaching for Kawasaki disease
CHECK FOR FEVER
When is S3 a normal sound
CHF it is normal, but NOT in MI
First test to show evidence of an MI
CK MB (appears in 3-6 hours) Then Troponin (appears in 4-12 hours)
what happend when carbon monoxide enters the body relating to hemoglobin?
CO displaces oxygen from HGb causing hypoxia that is NOT REFLECTED BY A PULSE OX. the pulse ox cant differentiate btwn carbohemoglobin and oxyhemoglobin. so, their pulse ox may relfect normal findings, yet severe hypoxia may be present
Treatment for V fib
CPR
how to treat asystole?
CPR initiate advanced cardiac life support give epinephrine and/or vasopressin place an airway
what does a dnr exactly mean to withhold?
CPR and other lifesaving measures
Treatment for A Fib
Calcium channel blockers Digoxin Beta blockers Cardioverson Warfarin
Diet for adolescent
Caloric, protein and calcium is high! For adolescent girls that are menstruating, we need to increase their iron Must have high minerals and high vitamins
When walking with a cane, what is the sequence of steps
Cane first Then weak foot then good foot
Thyroid storm
Caused by untreated Hyperthyroidism. Increased temp, pulses and BP Give hypothermia blanket, O2, PTU, potassium iodine
meds common for an open fracture?
Cefazolin (Ancef), tetanus toxoid, Toradol, opioids
Introducing a child to table foods: 4-5 months they can have
Cereal (usually rice cereal first) Strained fruits next
Central sleep apnea
Cessation of airflow and respiratory movements
What must we do after an endoscopy
Check the gag reflex
When someone has a permanent pacemaker, what is something that we have to be sure they do
Check their pulse for a full one minute every day at the same time of day
Methotrexate
Chemotherapy/Immunosuppressant Toxic Level: >10 mcmol over 24 hours
Signs and symptoms of air/pulmonary embolism
Chest pain Difficulty breathing Tachycardia Pale/Cyanotic Sense of impending doom
What is a positive sweat test significant for
Child has CF (need replacement enzymes, high calorie, high protein diet)
What meds do we give for Alzheimers
Cholinesterase inhibitors NMDA receptor antagonists antidepressants
Introducing a child to table foods: 7-9 months:
Chopped meat, hard breads and "finger foods", baked potato and mashed potato
What is Raynauds phenomenon
Chronic connective tissue disease that causes inflammation, fibroids, and sclerosis of the skin and vital organs Pain and color changes of the extremities when exposed to the cold Arterial peripheral vascular disease
Risk factors for colorectal cancer
Chronic inflammatory bowel disease Over 50 years of age First relative with polyps or colorectal cancer Diet high in fat and low in fiber
Continuous ambulatory peritoneal dialysis
Client performs self-dialysis 7 days a week 24 hours a day Dialysis is warmed (using heat pad), then infused and then dwell time is 4-8 hours Tubing and bag is disconnected or rolled up and worn under the clothing After the dwell time, the fluid is drained back into the bag and then the process is repeated
What do we do for people with strabismus
Close good eye to strengthen bad eye Eye exercises Surgery on rectus muscle of eye
What do we do for non-penetrating contusions
Cold compresses, analgesics
what is the pavlik harness used to treat
DDH in kids. it keeps kids legs bent and spread apart
What best detects fluid gain/retention in an infant
Daily weights
Most important way to see if diuretic therapy is working
Daily weights and decreased edema K+ and Na are not the best way
Glomerulonephritis
Damage to the glomerulus caused by an immunological action that results in proliferative and inflammatory changes within the glomeruli Acute glomerulonephritis = Group A beta hemolytic strep infection that is somewhere else in the body(like a skin or throat strep infection) Usually happens 10 days after the skin or throat infection
What drugs do we give for SIADH
Declomycin or diuretics
Diabetes insipidus
Decreased ADH Excessive urine output and thirst Dehydration Weakness We always get a urine specific gravity to tell the doctor how aggressively to treat it
what is the brand name for valproic acid?
Depakote- anticonvulsant
What is Menieres disease
Dilation of the membrane of the labyrinth There is recurrent attacks or vertigo and sensorineural hearing loss that can occur multiple times a week and go into remission for years at a time
Position of a patient after total hip replacement
Do not sleep on the operated side. No flexing the hip more than 45-60 degrees. Don't elevate the HOB more than 45 degrees. Keep the hip abducted by separating legs with a pillow or abductor
When a patient says something like "Someone is trying to kill me tonight" what do you do
Don't go along with their delusion like you support it. Just acknowledge how they are feeling and move on. Say something like "It must be frightening to think someone is trying to kill you"
When a mom chooses to bottle feed, what do we need to recommend for her
Don't use a breast pump because your body will think that you need to continue to produce milk. The milk will subside on its own in 5-7 days
What is sensorineural hearing loss (perceptive)
Due to a disorder of the organ of Corti or the auditory nerve caused by congenital things (mother being exposed to a communicable disease), infection, drug toxicity, trauma, Menieres disease
Barium enema
During the test, patient is instructed to take slow deep breaths so they can retain the enema without blowing it all out Table will tilt in various positions, and the stool might be a different color for 2-3 days following, but this is not the most important information
cuput succedaneum
EXPECTED FINDING remember C and S for "crosses suture" -edema/hematoma above periosteum tat crosses suture lines -resolves within the first week of life
What is acute otitis media
Ear infection in the middle of the ear from a pathogenic organism (bacteria or virus)
Early stage of dementia vs late stage
Early: impaired concentration and memory loss Late: Disorientation to person, place and time
What is benign prostatic hypertrophy
Enlargement of the prostate gland that causes urinary flow obstruction, incontinence, and possible infection
How often do we need to rinse and change a bag of continuous tube feeding
Every 4 hours to minimize the growth of organisms
Additional calories needed for a pregnant woman, and then for a lactating woman
Extra 300/day for a pregnant woman Extra 500/day for a lactating woman
What do we do for a patient with cataracts
Extracapsular extraction (cutting through anterior capsule to expose opaque lens) Intracapsular extraction (removal of entire lens/capsule,easier for us, more harmful to client) Then implant a new lens
What do we do for non-penetrating abrasions
Eye patch for 24 hours
when i see pericardial effusion and/or cardiac tamponade, think what?
FLUID BUILD-UP
any kind of shock, what do you do
FLUIDS
How to get a client from sitting to standing
Face client and firmly grasp rib cage Push nurses knees against one of clients knees Rock client forward until they come to a standing position Pivot client to position him/her into chair (chair should be on clients strong side)
Possible complications from ear surgery
Facial nerve damage Infection Vertigo, tinnitus
Hyperparathyroidism
Fatigue Muscle weakness Renal calculi Back/joint pain and pathological fractures Too much calcium
What is placenta previa
First and second trimester bleeding Third trimester bleeding that is sudden, bright red, profuse and PAINLESS This is where the placenta is implanted in the lower uterine segment usually near or over the cervical opening No vaginal or rectal exams
If you are doing an autologous blood donation, when can you donate to yourself
Five weeks away from your surgery up to three days before
Position for a BELOW the knee amputation
Foot of bed elevated for the first 24 hours. Position prone daily to help with hip extension
What is a tilt table and what is it used for
For weight bearing on long bones to prevent de-calcification and bone weakess Use elastic stockings to prevent postural hypotension Board can gradually be tilted in 5-10 degree increments BP needs to be checked during procedure
Correct positioning for a trochanter roll
From the lateral aspect of the hip to the mid-thigh. Trochanter roll is a positioning device that is placed under the greater trochanter to prevent prevent external rotation of the hip joint and prevents the femur fro rolling
Fruits and veggies that are high in potassium
Fruits: Bananas, cantelopes, oranges Veggies: Broccoli, spinach, potatoes
GTPAL
G number of times pregnant T carried to term 37 weeks or later P preterm delivered 20-36 weeks A abortions- ending before 20 wks L currently living children
botulism is what and caused from?
GI absorption of toxin produced by clostridium botulinum from improperly canned or stored food. found in soil and can grow in food. look out for swollen/bulging cans
Side effects of Haldol
Galactorrhea Lactation Gynecomastia
What medical / surgical procedure can often lead to dumping syndrome
Gastrojejunostomy Have the patient lay down after eating!
Which disease should you avoid when you are pregnant?
German measles! AKA Rubella
What do we do as nurses for cystitis
Get a clean catch for testing Encourage 3000ml of fluid a day Give cranberry juice / urinary acidifiers Void every 2-3 hours Teach females to void after intercourse and to wipe from front to back
What do we do as a nurse for glomerulonephritis
Give meds to treat the infection Treat volume overload and hypertension (Antibiotics, corticosteroids, antihypertensives, immunosuppresives, diuretics) Restrict sodium intake Daily weights Assess I&O and serum potassium Bed rest
nursing interventions that decrease ICP?
HOB at 30 degrees keep head and body midline give stool softeners suction only when necessary provide a calm environment with dimmed lights treat fever
Pneumonic to remember ventilator alarms
HOLD High alarm? Obstruction in the tube (increased secretions, kink, patient coughs/gags/bites) Low alarm? Disconnection or leak in the ventilator or patient airway cuff. Patient spontaneously stops breathing
How to remember the four defects in tetralogy of fallot
HOPS Hypertrophy of right ventricle Overriding aorta Pulmonary stenosis Septal defect
What do we do if the Parenteral nutrition needs to be stopped immediately or the new feeding bag is not ready on the unit
Hang D10% so we can keep the patients sugars in check and they don't suddenly go hypoglycemic
What is battery
Harmful or offensive touching of another person Clients can refuse medication, do not force them, even if they are psychotic
What position is the patient in AFTER a lumbar puncture (and also oil-based myelogram)
Have the pt lie Flat and Supine to prevent CSF from leaking out and prevent a headache
S&S of meningitis
Headache, fever, photophobia Nuchal rigidity Kernigs sign, Brudinskis sign, Change in LOC Seizures In infants: Refuses feedings, vomiting/diarrhea Bulging fontanelles Vacant stare, high pitched cry
What suggest a client has a hiatal hernia
Heartburn because of reflux
for adults and children over 1, how do you help someone that is choking
Heimlich maneuver (abdominal thrusts)
Gemfibrozil
Helps reduce cholesterol and triglyceride levels Must monitor liver function! AST and ALT Take 30 mins before breakfast/dinner
what is HELLP related to pregnancy?
Hemolysis Elevated Liver enzymes Low Platelet it is a severe sign of preeclampsia. symptoms may be RUQ pain n/v and malaise
What do we usually see with BPH S&S
Hesitancy (dribbling, weak urinary system) Frequency, dysuria, urgency, nocturua Hematuria before or after voiding Retention
majority cases of epiglottitis are caused by what?
HiB. most cases are prevented by standard vaccinations
Diet for someone with glomerulonephritis
High calorie, low Protein
When a baby has increased ICP, what S&S will they display?
High pitched cry
Diet for toddler through adolescent should be
High protein and high calcium Allow the toddler to pick foods to avoid an argument (we just want them to eat! Anything!)
How to use a cane
Hold cane in the opposite hand of the affected extremity Advance the cane with the affected/hurt extremity. Lean on the cane when advancing the good leg
TPN Total Parenteral Nutrition
Hypertonic Solution Given via PICC line, tunneled catheter Prepared daily by pharmacy Use Sterile Asepsis for dressing change Check blood glucose every 4-6 hours Change bag every 24
When administering anti-psychotics, what do we need to monitor for?
Hypotension. Ask them to sit and stand while you take their BP two times to make sure they aren't hypotensive before you give the med
what is the most important med to give for anaphylactic shock?
IM epinephrine
what lab is monitored when receiving warfarin?
INR
what route is the best way to give burn victim meds?
IV
What do we do as the nurse for meningitis
IV antibiotic therapy Monitor ABGs, arterial pressures, body weight, serum electrolytes, urine volume, specific gravity, osmolality Droplet precautions Prevent it! Give vaccines for those 65+ and revaccinate every 5 years. Hib vaccine for infants
what med is given right away for malignnant hyperthermia?
IV dantrolene bc it reversws the process by slowing metabolis
what is the first line treatet for kawasaki disease?
IV immunoglobulin and aspirin to prevent the aneurism
Never give potassium via which routes?
IV push, intramuscular, or subq
after calcium gluconate, what 3 things are given to actually decrease the potassium in a hyperkalemic patient?
IV regular insulin w/ dextrose, sodium polystyrene sulfonate, and hemodialiysis
parenteral?
IV route
what should all intoxicated patients be given?
IV thiamine before or with IV glucose
What do we do as the nurse for trigeminal neuralgia
Identify and avoid what causes this Avoid rubbing of the eye Chew on the unaffected side Treatment: Carbamazepine, alcohol injection to the nerve, resection of the nerve, microvascular decompression
When would we hold off on a polio vaccine (IPV)
If the client is allergic to neomycin, streptomycin, or polymyxin B
When a patient has a thyroidectomy, what is MOST important to assess
If the parathyroid accidentally gets nicked during thyroidectomy surgery, there can be a decrease in serum calcium. Must look for tingling around the mouth, toes, fingers, and also for muscular twitching
What do we do as the nurse for neuroleptic malignant syndrome
Immediately withdraw anti-psychotic meds (like Haldol) Control hyperthermia Hydration Give Dantroline and Bromocriptine
What is an EARLY symptom of hepatic encephalopathy
Impaired thought process and forgetfulness
When does a depressed client have the highest level of functioning and activity
In the morning hours right after they wake up
What to remember about feeding an infant with Tetralogy of Fallot
Increase the size of the hole in the bottle so the infant can get as much nutrition as possible. Do feedings every 3 hours. Feed the infant soon after awakening so the infant doesn't cry
What is the FIRST thing we do when a patient has constipation
Increase their fresh fruits, veggies, and cereal Asking for a stool softener or laxative is a last resort
SIADH (Syndrome of Inappropriate Anti-Diuretic Hormone)
Increased ADH Change in LOC Decreased DTRs Tachycardia N/V/A Headache
Diet for a patient with abdominal aortic aneurysm
Increased fiber and increased fluid intake so you don't have to strain when you are having a bowel movement which can increase pressure and lead to rupture of the aneurysm
Trachea deviation signifies what
Increased pressure on one side of the lungs aka pneumothorax
Hypovolemia
Increased temp Rapid/weak pulse Increased respirations Decrease BP Anxiety Urine specific gravity >1.030
Hypernatremia
Increased temp Weakness Disorientation/delusions Hypotension Tachycardia
Why do we do active assistive range of motion
Increases motion of the joint Performed by the client with the assistance of then nurse
Meningitis causes
Infections (viral, bacteria, fungal) Neurosurgical procedure, basilar-skull fracture Otitis media, mastoiditis
Cystitis
Inflammation of the bladder Urinary frequency, burning on urination, cloudy/foul smelling odor
What is keratitis and what do we do for it
Inflammation of the cornea Antibiotics Hot compresses Steroids, except with Herpes Simplex
What is uveitis and what do we do for it
Inflammation of the iris, ciliary body, and choroid Warm compresses Dark glasses Antibiotics, analgesis, sedatives
Pyelonephritis
Inflammation of the kidney caused by a bacteria Chills, fever, malaise, flank pain, urinary frequency, dysuria, CVA tenderness
What is the main cause of asthma
Inhaled allergens like animal dander, mold, pollen, and dust
What sign and symptom will we see in an infant that has a mom on heroin
Irritable, poor sucking
what meds are used in black people with heart failure
Isosorbide (nitrate) and hydralazine
Hantavirus
It is a disease from rodents/rodent droppings that can cause hematuria, hematemesis, bleeding gums, etc
Why is tea a problem in graves disease
It is a stimulant and in graves disease your body is already in hyperactive hyper metabolism mode
right side heart failure
JVD, hepatomegaly, splenomegaly, ascites, edema
Position of a patient after a laminectomy
Keep the body straight Pillow should be placed longitudinally between the legs to prevent adduction and spinal torque
When someone has a spinal cord injury, what is very important
Keeping the spine in alignment. Prevent flexion or hyperextension
Drug of choice for treatment of candidasis
Ketoconazole
Position for a mom with a prolapsed cord
Knee-chest position or trendelenburg
what is one golden sign of diabetic ketoacidosis related to breath?
Kussmaul respirations (fruity smell)
watch our for what organ when taking acetaminophen?
LIVER
what is trismus?
LOCKJAW inablity to open the mouth due to a tonic contraction of the chewing muscles
Obstructive sleep apnea
Lack of airflow due to the occlusion of pharynx
What type of syringe to we use to aspirate an NG tube
Large Barrel syringe
Signs and symptoms of a woman in labor with a baby who has an unreassuring FHR
Late decels Fetal bradycardia Decreased variability
What drug do we give for PVCs
Lidocaine
What do we do as the nurse during the oliguric stage
Limit fluids Diet adjustment (restrict protein, sodium, and potassium) Meds as needed (Kayexalate for high K) Dialysis (hemodialysis or peritoneal)
Introducing a child to table foods: 1-4 months they can have
Liquid vitamins only (A, C, D, and fluoride if indicated)
How do we know that our suctioning of an ETT was effective?
Listen to breath sounds when you are done and make sure it is clear and that there are no more adventitious breath sounds
When a mom comes in in active labor, what is the first thing we do for them?
Listen to fetal heart sounds
S&S of a hemolytic reaction
Low back pain Fever Bach ache Hypotension Chills
Diet for prevention of stones
Low calcium Low sodium Low in oxylates (spinach, cola, tea, chocolate) No vitamin D (increases calcium absorption) Low organ meats
Position of a patient after a thyroidectomy
Low or semi-fowlers. Support the head, neck, and shoulders. Have a trach at the bedside
Diet for a patient with Menieres disease
Low sodium (2000mg/day) Avoid caffeine, nicotine, and alcohol
What lab values to we expect to see with adrenocortical insuffiency
Low sodium and glucose High potassium
Heatstroke
MEDICAL EMERGENCY o Symptoms: 1. *Temperature ≥ 104 F (40 C)* 2. *Hot, dry skin* 3. Hemodynamic instability *(tachycardia, hypotension)* 4. *Altered mental status/neurologic symptoms* (confusion, lethargy, coma) o Treatment 1. Stabilization of *ABCs* 2. *Rapid cooling interventions* (eg cool water immersion, cool IV fluid infusion) Note: antipyretics are ineffective
some examples of live vaccines are:
MMR and varicella
For what diseases do we use contact precautions
MRS.WEE M:multi drug resistant organism R: Respiratory infection (RSV) S: Skin infections (varicella zoster, cutaneous diptheria, herpes simplex, impetigo, pediculosis, scabies) W:wound infection E: Enteric infection (C Diff) E: eye infection (pink eye)
examples of contact precautions
MRSA, VRE, cdiff, scabies
Hyperkalemia
MURDER Muscle weakness Urine (oliguria/anuria) Respiratory depression Decreased cardiac contractility ECG changes Reflexes depressed
If we suspect digoxin toxicity, what lab value should we check as a hidden sign
Magnesium could be low causing this!
Why do we do isometric exercises
Maintenance of muscle strength when the joint is immobilized Performed by the client. Alternate contraction and relaxation of the muscle without moving the joint
What is the priority when a client returns from a scleral bucking procedure
Make sure the client is not nauseated or vomiting as this can increase intraocular pressure and mess up the surgery
When someone has a head injury, what medication are we likely to give
Mannitol. An osmotic diuretic that decreases ICP and increase urine output. This crystallizes at room temperature so ALWAYS use a FILTER NEEDLE
Rules for crutches
Measure two fingers below axilla Client should support weight on handpick not axilla Crutches are kept 8-10 inchses out to the side Elbows are flexed at 20-30 degrees Stop and rest if diaphoretic and short of breath
What do we do for a patient with glaucoma
Meds! (Prostaglandin agonists, adrenergic agonists, beta-adrenergic blockers, cholinergic agonists, carbonic anhydrase inhibitors) Surgery (laser trabeculoplasty) Avoid tight clothing Avoid use of mydriatics (Atropine)
contact precautions
Methods of infection control that must be used for patients known or suspected to be infected with epidemiological microorganisms that can be transmitted by either direct or indirect contact.
Drug of choice for trichromonias, IBD, and intestinal amebiasis
Metronidazole
What do you NOT take tetracycline with
Milk or antacids It inhibits the med from working
Position for a patient in shock
Modified trendelenberg (extremities elevated 20 degrees) with the knees straight and head slightly elevated
What do we do as the nurse for kidney stones
Monitor I&O and temp Avoid over hydration and under hydration Strain the urine and check the PH Give analgesics
Care of the patient with Peripheral Artery disease
Monitor peripheral pulses Good foot care Do not cross legs Stop smoking/regular exercise
Care of the patient with peripheral venous disease (varicose veins or thrombophlebitis)
Monitor peripheral pulses Thrombectomy Avoid extreme temps SCDs/tedhose/elastic stockings Bedrest 4-7 days Elevate legs Warm moist packs Anticoagulants
Hypokalemia
Muscle weakness Dysrhythmias Increase K intake (raisins, bananas, apricots, oranges, beans, potatos, carrots, celery)
Hypercalcemia
Muscle weakness Lack of coordination Abdominal pain Confusion Absent DTRs Sedative effect on CNS
What is myasthenia gravis
Muscular weakness produced by repeated movements. Disappears when the patient rests. No problems with CNS or PNS just random. We see diplopia, ptosis, impaired speech, dysphagia, respiratory distress
For what diseases do we use airborne precautions
My (measles) Chicken (chicken pox/varicella) Hez (disseminated herpes zoster, shingles) TB (TB)
Myopia Hyperopia Presbyopia Astigmatism
Myopia: nearsightedness (can see near things well) Hyperopia: far-sightedness (can see things far well) Presbyopia: blurry vision of near things due to age Astigmatism: Blurry vision from an uneven curving of the cornea
S&S of Menieres disease
N&V Intolerable vertigo and tinnitus Pressure / fullness in the ear Fluctuating/progressive decreased hearing on the involved side Nystagmus/headache
S&S of opioid withdrawal
N&V Restlesness Abdominal cramping
Do we massage the site after IM shots
NO
after an amputation, should the residual limb be elevated?
NO, to prevent hip flexion contractures
bipolar pt comes in and is experiencing acute mania. what is the priority?
NOT risk prone behavior bc physiological needs like food take priority (remember maslows). so imbalanced nutrition would be the priority
nursing care for acute pancreatitis
NPO IV opioids IV fluids NG tube for suction
Salicylate
NSAID Therapeutic Level: 100-250 mcg/mL Toxic Level: >300 mcg/mL
what is Ketarolac?
NSAID analgesic used for short term pain relief- usage should not exceed 5 days due to kidney injury, gi ulcers, and bleeding
what is Toradol?
NSAID used for inflammation and pain
contraindication meds for heart failure
NSAIDS
which 2 groups of drugs can cause problems for those with asthma?
NSAIDS and beta blockers bc they can cause bronchospasm
Things to remember about Native American culture
Native americans do not rely on the clock, they used to complete their days by the sun, so they may be late to an appointment
Hyponatremia
Nausea Muscle cramps Increased ICP Muscle twitching Convulsions
Airborne Precautions
Needed to prevent transmission from particles so small the can float in the air and travel long distances. ex) chickenpox, measles, Tuberculosis, SARS Minimal PPE: Well fitting mask *Use respirator mask for TB and SARS **Negative Pressure room
Toilet training time schedule
Never begin before 18th month 2-3 years: bladder control reflex achieved 3 years: regular voiding habits establisted 4 years: independent bathroom activity 5 years: night time control expected
Sleep apnea features
Nighttime: - *periods of apnea* - *loud snoring* - *interrupted sleep* Daytime - *morning headaches* - *irritability* - *excessive sleepiness* Other - *difficulty concentrating* - *forgetfulness* - *mood changes* - *depression*
When a woman is pregnant and having breast discomfort, do we recommend that the massage them?
No
For Muslim people, what do we have to remember about their diets
No Pork, Alcohol, fermented fruits/veggies Meat must be Halal (drained of blood) Foods with special value: Figs, olives, dates, honey, milk and buttermilk
Rate for potassium infusion
No faster than 10 MEQ per hour
For Jewish people, what do we have to remember about their diets
No meat and milk together (must be 6 hours apart, but they have two meals with dairy and one meal with meat). Meat must be Kosher (drained of blood)
When you have a colostomy, what are the restrictions of your new activities
No restrictions You can return to all normal activities after the stoma/incision is healed
Can we ever remove bucks traction weights?
No! Not without a doctors order. We must reposition the client in bed with the weights still on. If we take them off we are inturrupting the line of pull
Do we aspirate the syringe when administering Heparin?
No, it can cause bruising
Extracorporeal Shock wave therapy
Non-invasive treatment of the kidney using an acoustic pulse. Teach patient to report fever, decreased UO and pain Hematuria is expected but should clear within 24 hours
Main two signs of meningitis
Nuchal ridigity Photophobia
Effective handoff communication components
Nurse should: 1. Provide *identifying information* (eg client's name and room number) 2. Note *care priorities* and upcoming or outstanding tasks (eg time to replace medication infusion bag, need to perform delayed wound care and cause of delay) 3. Provide *exact, pertinent information* (eg medication dose, time, measurable outcomes) 4. Include *multidisciplinary plans* (eg radiology examinations, family meetings, physical therapy) 5. Relay significant client changes in a clear manner
What patient needs Fluvoxamine
OCD Side effect dry mouth
what is topical capsaicin cream (Zostrix)?
OTC analgesic that relived minor pain like osteoarthritis special instrution: wait 30 mins after massaging cream into hands before washing
Causes of kidney/ureter stones
Obstruction and urinary stasis Hypercalcemia Dehydration Immobility Gout
Phases of acute kidney injury
Oliguric Diuretic Chronic
Position during internal radiation
On bedrest while the implant is in place
Position for an infant with a cleft lip
On their back or in an infant seat to prevent trauma to the suture line. If feeding, hold in an upright position
Hep B vaccine series
One shot, then additional shots at 1 and 6 months
Describe the RH incombatibility
Only RH negative mothers have a problem is their baby is positive and they are negative
What can long term steroid therapy cause
Osteoporosis and pathological fractures as well as muscle wasting
frontal lobe
PERSONALITY/BEHAVIOR
is reactive nonstress test positive or negative?
POSITIVE
what are the key signs of refeeding syndrome?
PPM rapid decline in phosphorus, potasium, magnesium also fluid overload
What lab value do we need to be aware of prior to a liver biopsy
PTT
heparin is measured thru what levels?
PTT
what is happening in ventricular trigeminy?
PVCs are occuring every third heartbeat
Hypercapnia
PaCO2 >45 mmHg
What to know about an EEG
Painless test that records electrical activity of the brain Wash hair before test to remove oils Restrict tranquilizer meds and stimulants 24-48 hours befit (stimulants include coffee, tea, smoking, soda) Instructed to stay awake late the night before so they can sleep through the test Maybe hyperventilate 3-4 times before the exam
What are cataracts
Partial or total opacity of the normally transparent lens (Caused by: congenital, trauma, again, diabetes, drugs like steroid therapy, exposure to radioactivity)
Position for administration of an enema
Patient should be LEFT side laying with the knee flexed (Sims position)
Position of a patient after cataract surgery
Patient should sleep on the UNAFFECTED side and have a night shield for 1-4 weeks
S&S of R sided heart failure
Peripheral edema and anorexia Distended neck veins Polycythemia
What drug do we use for DI
Pitressin
How to get a client to sit on the side of the bed
Place hands under knees and shoulders of client Have client push elbow into bed, while at the same time the nurse lifts the clients shoulders with one arm and swings the legs around with the other arm
Position if the patient has autonomic dysreflexia/hyperreflexia
Place the client in a sitting position (elevate the HOB to 90) FIRST before any other implementation S&S include: extreme HTN, pounding headache, profuse sweating, nasal congestion, goose flesh, bradycardia,)
What do we do if a patient has decreased LOC during tube feeding
Position the patient on the RIGHT side (to increase gastric emptying) and RAISE the head of the bed to at least 30 degrees (to prevent aspiration)
Position of a patient after a myringotomy
Position the patient on the side of the AFFECTED EAR after surgery to allow for drainage of secretions. This procedure is surgical incision into the eardrum (tympanic membrane), to relieve pressure or drain fluid.
common proton pump inhibitors PPIs
Prazoles: omeprazole, lansoprazole, etc
What do we do as the nurse for acoustic neuroma
Pre and post op care for posterior fossa craniotomy Assist with turning of the neck for comfort measures Treatment: surgical removal of tumor
Hip dysplasia in an older child
Preliminary traction Open reduction Hip spica cast
When implementing airborne precautions, what do we have to do
Private, negative pressure room Must wear mask Can cohort with patient who has same organism, but not if they have different organisms Place mask on client when they are being transported
How long to GB symptoms last for
Progress for 10 days and then last for 10 days
What is guillen barre syndrome
Progressive inflammatory autoimmune response resulting in a loss of motor fx symmetrically, starting from the lower extremities and working its way up. Also paresthesias and too much or too little autonomic dysfunction (hypotension, tachycardia, flushing, sweating)
What is Alzheimers disease
Progressive, irreversible, degenerative neurological disease characterized by loss of cognitive function and disturbed behavior. Forgetfulness progressing to inability to recognize familiar faces, places and objects
Why do we do active resistive range of motion
Provision of resistance to increase muscle strength 5 lb weights or bags may be used Performed by the client against manual or mechanical resistance
Time frame for checking pedal pulses when coming back from a cardiac cath
Pulses need to be checked immediately. And then every 15 minutes for the first few hours
How do we properly instill eardrops
Put the affected ear up Pull the ear up and back for an adult (greater than 3) Pull the ear down and back for children under 3
How often do we assess for suctioning with a vent
Q2
How often do we move the ETT from one side of the mouth to the other
Q24 hr to prevent ulcers
RACE for FIRES in a hospital
R: rescue any pts in immediate danger and move them to safety A: alarm- sound alarm C: confine fire by closing all doors to all rooms E: extinguish fire with extinguisher
symptoms of acute appendicitis
RLQ pain continuous anorexia, n/v rebound tenderness and gaurding prevent abdomen pressure by not coughing sneezing or breathing deep
orienting client to the bedside unit is the job or RN or UAP?
RN
When drawing up regular insulin with NPH, which order do you draw them up?
RN!! Regular before NPH
what are some symptoms that a pregnant woman has HELLP?
RUQ pain, nausea, vomiting, malaise
Dumping syndrome
Rapid emptying of gastric contents into small intestines. Client experience: -*abdominal cramping* -*nausea, vomiting* -*diarrhea* -*dizziness* -*generalized sweating* -*tachycardia*
What do we do when a baby has club foot
Reposition the foot to normal position Q4 Casts and splints correct the deformity if placed early (change casts every few days for the first 1-2 weeks and then every 1-2 weeks after that) Surgery is usually required for older children
3rd degree AV heart block
Results in disassociation of atrial & ventricular contraction due to blocked electrical activity → *decreased cardiac output* (dizziness, syncope, mental status changes, HF, hypotension, bradycardia)
giving aspirin to children can cuase what
Reyes syndrome
Methotraxate treats what?
Rheumatoid arthritis
Drug of choice for treatment of TB
Rifampin
When we have appendicitis, where is the pain
Right lower quadrant. Rebound tenderness
what is the only med approved for ALS?
Riluzule (Rilotek)
Signs of complications post tonsillectomy & adenoidectomy
Risk for *hemorrhage* up to 14 days after surgery and *life-threatening airway compromise* Signs of Hemorrhage: 1. *Restlessness* 2. *Frequent swallowing or clearing of throat* 3. *Vomiting of blood* 4. *Pallor* May require surgery to cauterize bleeding vessels
S&S when a client is withdrawing from heroin
Runny nose Yawning Fever Muscle and joint pain Diarrhea (A lot like S&S of the flu)
preeclampsia can lead to what severe thing?
SEIZURES
what can hyponatremia cause?
SEIZURES, confusion, neurologic complications institute seizure precautions
order of progression from sirs to mods
SIRS--> sepsis --> septic shock --> MODS
What is a detached retina
Separation of the retina from the choroid caused by trauma, gain, diabetes or tumors Patient will see flashes of light, floaters, curtain coming down, confusion/apprehension
How long is the GB recovery period
Several months to a year, normal loss of fx is 10% at the end of recovery
Continuous Ambulatory Peritoneal Dialysis
Should check weight daily Do not milk catheter, drain by gravity Eat a high protein diet as CAPD has taken out protein while flushing out the cells Use strict aseptic technique
What position is someone in for an epidural puncture
Side-lying
Where should the nurse be positioned when helping a client learn to walk with a cane
Slightly behind the client on the good leg side
When taking lithium, what lab value do we need to monitor
Sodium The excretion of lithium is dependent upon normal sodium levels in the body. If there is too low sodium, lithium will not excrete and we can get lithium toxicity
As the nurse, what do we do for GB patients
Steroids in acute phase Mechanical ventilation, elevate HOB, suctioning Plasmapheresis treatment! High dose IV immunoglobiluns Physical therapy and ROM Paid reducing measures Eye care Prevent complications (URI, aspiration, constipation, urinary retention)
When you have medication-induced Cushing syndrome, what is causing this
Steroids! they need to be tapered off! Never stop them automatically even when you are having a bad reaction because you can die from acute adrenal insuffiency
What do you need to caution a client about when taking tetracycline
Sun is HOT and skin is sensitive so wear hats and sunscreen
Position for a patient during the acute phase of a stroke
Supine with the head elevated 15-30 degrees Facilitates venous drainage from the brain and decreases ICP
When a patient has a phobic disorder, what is the best thing to do for them
Systematic desensitization
what does TORCH stand for?
T: *toxoplasmosis* O: *other parvo- b 19, varicella zoster* R: *rubella* C: *cytomeglovirus* H: *herpes*
What test do we use to diagnose people with Myasthenia Gravis
Tensilon test. Where we inject tensilon and ask you to do activities like stand up and sit down and stand up and sit down. If you get tired we inject another dose. If you can stand up again, you probably have MG. MG is susceptible to the Tensilon test
Position for a patient with a CBI
The catheter is taped to the patients leg so the leg should be kept straight, but there are no other positioning limitations
Sleep apnea syndrome
The client snores loudly, stops breathing for 10 seconds or more and then awakens abruptly with a loud snort (multiple times throughout the night) Often in older, overweight men, elderly, and people with thick necks, smokers
What is strabismus
The eyes do not function as a unit because there is an imbalance of extra ocular muscles
Insulin with a fetus right after birth
The fetus produces insulin to match the mother during pregnancy (which is high). When the baby comes out, it is still producing a lot of insulin which can cause hypoglycemia. Must monitor for hypoglycemia
Things to note about using a walker
The nurse should be behind the client with hold of their gait belt The client should sit down by grasping the armrest on the affected side and then shift weight to the good leg and hand and then lower themselves into the chair
What is abruptio placentae
The premature separation of the placenta which leads to hemorrhage. Biggest concern is fluid volume deficit related to bleeding
When undergoing a transplant, what do we need to remind visitors of
They can't be in the room for the first 72 hours
What is the primary problem for a client diagnosed with schizophrenia
They have difficulty forming relationships
What do we need to remember about potassium and people on "-pril" meds
They want low potassium! No bananas, no salt substitutes, etc
What do we need to teach the client about Menineres disease
To slow down their body movements as jerking or sudden movements can cause an attack Need to lie down when an attack occurs If driving, pull over and stop the car
Treatment for Premature atrial contraction
Treat the underlying cause (alcohol, tobacco, caffeine)
Treatment for sinus tachycardia
Treat underlying problem Beta blockers Calcium channel blockers or Cardioversion
What are Eriksons developmental stages and the ages for each
Trust/mistrust=birth to 1 year Autonomy/Shame and doubt = 1 yr to 3 yrs Initiative/Guilt = 3 to 6 yrs Industry/Inferiority = 6 to 12 yrs Identity/ Role confusion = 12 to 20 yrs Intimacy/Isolation = 20 to 45 yrs Generativity/Stagnation = 45 to 65 yrs Integrity/Despair = 65+ yrs
If someone was hurt and now is returning to the job but they are impaired forever (walk with a limp, hurt back can't lift) what do we do for them
Try to reassign them a job that is more feasible and fitting for them
What do we do as the nurse for air/pulmonary embolism
Turn patient to the LEFT side and LOWER the head of the bed
Position for a patient with peritoneal dialysis when the outflow is inadequate
Turn the patient from side to side BEFORE checking the tube for kinking
What do we do for a woman in labor who has an unreassuring FHR
Turn to the LEFT side Give O2 Stop the Pitocin Increase IV fluids (LR and NS)
How often do we provide oral hygeine for someone with an ETT
Twice a shift
Diuretic phase of AKI
UO 4000-5000 ml /day Increased BUN Loss of Na and K in urine Increased mental and physical activity
Oliguric phase of AKI
UO less than .5 ml/kg/hr N&V Increased Serum K, BUN, and creatinine Increased Ca, Na Decreased PH Anemia Pulmonary edema, CHF Hypertension Albuminuria
IVPB Potassium Chloride (KCl) - route & method
Use: *treatment of hypokalemia* Infusion rate: *should not exceed 10 mEq/hr* Give via *infusion pump*
Positive Pressure Ventilation (PPV)
Used most commonly in acute respiratory failure causes *increased intrathoracic pressure* - leads to *reduced venous return, ventricular preload* and *cardiac output*, which results in *hypotension* - effect is greater in presence of *hypovolemia (eg hemorrhage, hypovolemic shock)* and *decreased venous tone (eg septic shock, neurogenic shock)*
Droplet Precautions
Used to prevent contact with mucus and other secretions from nose, sinuses, throat, airway, and lungs. Use when contact will be within 3 ft or less ex) infulenza, mumps, pertussis Minimal PPE: Mask
Kegel exercises
Used to strengthen muscles of pelvic floor Tighten pelvic muscles for a count of 3, then relax for a count of 3. Do this lying down, sitting, and standing for a total of 45
Sucralfate
Used to treat duodenal ulcers Best results if taken on an empty stomach
Contact Precautions
Used when germs are spread by touching ex) C. Difficile, Norovirus Minimal PPE: Gloves and Gown
Automated peritoneal dialysis
Uses a machine with a warming chamber for the dialysate infusion, dwell and outflow The times and volumes are preset (10 mins infusion, 10 mins dwell, 10 min outflow) and they do this for 8-10 hours
Treatment for Atrial Flutter
Vagal maneuvers Adenosine Cardioversion/ablation
vagal maneuvers examples
Valsalva, coughing, carotid massage
When we have a bunch of clients getting blood transfusions, all with reactions who is the most crucial to see first
Vomiting is first JVD second Itching third Headache fourth
what is the best indicator of treatment effectiveness of antibiotics?
WBC count
What do we do for styes
Warm compresses Antibiotics I&D Caused by a staphylococcal organism
What do we do for conjunctivitis
Warm, moist complexes Topical antibiotics Hydrocortisone ophthalmic ointment Caused by virus, bacteria, and allergies
What to remember when someone is in a crisis psychologically
We have to ask them what they have done in the past to cope, since this is a crisis. If it is just a normal situation, we do not focus on what has worked in the past because the past is the past
What do we need to remember about Prochlorperazine
We must draw it up in a separate syringe than all other medications It is an anti-psychotic and treats schizophrenia and anxiety as well as N&V
If we have a client who is withdrawing from alcohol, and their vital signs continue to creep up, what do we do
We need more sedation, these patients are approaching delirium tremens
Diet for a patient after an appendectomy
We need wound healing so we need high protein and high vitamin C and high calories
How do we diagnose Menieres disease
Weber and Rinne test CT scan
what can inadequate thiamine lead to?
Wernicke encephalopathy- altered mental status, oculomotor dysfunction, and ataxia. can lead to seizures
When are we going to administer an anti anxiety
When a client is restless and has an increased heart rate
What is the Somogyi effect
When blood glucose levels drop too low in the middle of the night, the body tries to compensate by rebounding into hyperglycemia, so you think you are high blood sugars in the morning when it is all just a facade
Standard Precautions
When handling blood, bodily fluid, bodily tissue, mucous membranes, open skin PPE: depends on type of exposure (minimal is nothing)
After having an MI, when can sexual activity be resumed
When the client can walk two flights of stairs or one city block with no SOB or chest pain
When do we assume a baby has developmental hip dysplasia
When the head of the femur does not fit in the acetabulum Uneven gluteal folds and thigh creases Infant lays on back with legs flexed Click sound when legs are moved to abduction Delays in walking/limping with older children
When can we give TPA in an MI
Within 6 hours
Orders and re-evaluation for wrist restraints
Wrist restraints need to be re-evaluated every 4 hours and a new order for a wrist restraint needs to be obtained every 4 hours
even after the diagnosis of a DVT, is walking suggested?
YES
Is it okay to instill 30 ml of air into the stomach before aspirating fluid out of an NG tube?
Yes
If you are having a bad reaction to a DtAP vaccine, when will you see the side effects
You will see a low-grade fever and it will be about 48 hours after the injection
what is transferrence?
a client unconscioulsy transfers feelings and behaviors related to a person in the clients past onto the nurse examples: a client states that the nurse reminds them of their sister
what are some risk factors for postpartum hemorrhage?
a hx of PPH uterine distension uterine fatigue high parity certain meds
what is creatinine clearance>
a measure of glomerular function and an indicator for renal disease progression it is a 24 HOUR URINE COLLECTION. the test must be started again if all urine in the 24 hours period is not collected when the test begins, the first urine is taken and thrown away
what does an absent babinski or weak reflex indicate?
a neurological deficit
no lasix to what kind of patient
a pneumonia patient with fine crackles bc they dont result from heart failure or edema
the use of radioactive iodine is contraindicated in
a pregnant client. all females should be tested before
what kind of environment do autistic kids need?
a private calming one with minimal stimulation
what is the Simian crease and what is it seen in?
a single transverse crease across the entire palm of the hand; seen in down syndrome
what is uterine atony?
a soft boggy poorly contracted uterus and most commonly causes early PPH
what does torsades de pointes look like
a strand of dna
what is an amnioinfusion?
a transvaginal infusion of a crystallid fluid to compensate for the loss of amniotic fluid (oligohydramnios)
what does a pulsatile mass in periumbilical area with back pain indicate?
abdominal aneuryism
what are signs of perforation?
abdominal pain (with shoulder tip pain), positive rebound tenderness, gaurding, abdominal distension, boardlike/rigid abdomen
what is a pleural effusion?
abnomral collection of fluid >15-20 mls in the pleural space btwn parietal and visceral preventing th lung ffrom expanding ffully results in: dec lung volume, atelactasis, and ineffective gas exchange
Age when *head lag* is *abnormal finding*
abnormal = remaining *after age 6 months* often associated with *cerebral palsy* or *autism*
what are the 2 core symptoms of ASD? autism?
abnormalities in social interaction and communication and patterns of behavior interests and activities
HYPERnatremia
abnormally high sodium level (>145) in the blood, which helps regulate the amount of H2O in and around the cells.
HYPOnatremia
abnormally low sodium level (<135) in the blood, which helps regulate the amount of H2O in and around the cells
atrial septal defect (ASD)
abnromal opening btwn the L and R atria that causes a murmur from blood flowing in btwn
for all pregnant clients, weight gain in the first trimester shold be what?
about 1.1-4 lbs
fall risk factors
above age 60 previous fall bowel/bladder incontinence or urinary freuqency sedatives, diuretics, ntihypertensives, CNS drugs unsteady gait weakness, limited mobility hypotension visual/auditory impairments dementia tubes med equipment scds restraints
symptoms of an aortic dissection
abrupt, worst ever tearing ripping moving from upper to lower back epigastric and abdominal pain- life threatening. surgery and lowering the BP which is a contributing factor
what is typically seen in a retinoblastoma?
absence of red reflex. the pupil reflects a white color
abdominal surgery and other procedures with bowel manipulation cause what for the bowels for the first 24-48 hours?
absent bowel sounds
what is the earlisest sugn of magnesium toxicty>
absent or decreased deep tendon reflexes (normal 2+) and should be assesed during magnesium infusion
what combination durgs are normally used to treat heart failure?
ace inhibitor and lasix
treatement for aspiriin poisoning
activated charcoal, and then IV sodium barcarbonate
when is the rapid response team notified?
acute significant changes in heart rate, systolic BP, RR, o2 sat, LOC, and urine output
lithium toxicity symptoms
acute: GI disturbances: nausea, vomiting, diarrhea neuro finding can occur later chronic- neurologic ataxia, confusion, tremors
Naegele's rule
add 9 months and 7 days to LMP
what is the priority intervention for pain with sickle cell crisis and why?
administer IV fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion
addisons disease-wat is it?
adrenal glands not producing enough steroids
what is the strongest risk factor for late onset Alzeimers?
advancing age
how to calculate the # of teeth a child should have in the first 24 months?
age of child in months minus 6
quick formula to calculate number of teeth in the first 2 years of life?
age of child in months- 6= expected number of teeth
if a chest tube gets dislodged, immediately cover with something sterile or clean if you dont have sterile. what are we trying to prevent here?
air from getting into the pleural cavity
pt with measles precautions
airborne and neg pressure room n95 respirators
what is peak expiratpry flow?
airflow out of the lungs
what does a peak flow meter measure in a person with asthma?
airflow ut of the lungs
first level priority problems
airway breathing circulation & cardiac (become first priority in cardiac arrest) vital signs
near-dorwning victim managemeent
airway management- mechanical ventilation warm blankets warm IV fluids dont necessairyl need to give blood only if blood loss has occured but not just cux of dorwning
what lab levels will be seen in abnormal liver function?
albumin, ammonia, platelets, INR, and bilirubin
treat asthma with
albuterol. SE: n/v, insomnia, palpitations, tremor
following hip repacement, place an abducter pillow btwen a pts legs to maintain hip in straight and neutral position
aldo dont bend at the hip for more than 90 deg or cross the legs or ankles
guidelines for the pneumococcal vaccination
all adults 65 or above should get 2 pneumonococcal vaccines
who should get the flu vaccine?
all pts 6 months old or greater unless pt has life threatening allergy to the vaccine or one of its ingredients
what to remember when introducing new foods to a baby?
allow 5-7 days btwn introduction of new food to see allergies
what are some early symptoms of Increased Cranial Pressure?
altered LOC, headache, abnormal breathing, rise in bp, slow pulse, vomiting
second level priority problems
altered mental status acute pain untreated medical problems (like hyperglycemia in client with diabetes) chronic pain acute elimination problems abnormal lab results risk for infection, safety
wheezing indicates what in a respiratory issue?
an *obstructive process* like *asthma, copd*
continuous bublling in a chest tube inicates what
an air leak in the chest tube system section C
Quantiferon-TB (QFT) blood test is what?
an alternative to the Mantoux test. it too only indicates tht the individual has been infected with TB. the test is more expensive but it only requires a single visit rather than having the person coming back in 48-72 hours to have their TBT test read.
if pt comes into ER and says they have the worst HeadAche of their life what could it be
an aneurysm
metronidazole (Flagyl)
an antibiotic
pinworm infection
anal itching thats worse at night
what are the signs?
anemia (pallor), low platelets (petechiae and purpura, and acute kidney injury (low UO)
bone marrow suppression can lead to what?
anemia, thrombocytopenia, and leukopenia
what meds can precipitate malignant hyperthermia?
anesthesia
what are the sartan drugs like losartan, valsartan, and candesartan
angiotension II recprot blockers used for pateitns that cant take ACE inhibitors
"sartans"
angiotension receptor blockers like valsartan
nitroglycerin is why type of drug?
antianginal vasodilator that may cause a headache
Quinidine
antiarrhythmic/anti-parasite Therapeutic Level: 2-5 mcg/mL Toxic Level: >10 mcg/mL
Levofloxacin (Levaquin)
antibiotic
Gentamicin
antibiotic (renal/oto toxic) Therapeutic Level: 0.5-0.8 mcg/mL Toxic Level: >12mcg/mL
Magnesium Sulfate
anticonvulsant Therapeutic Level: 4-8 mg/dL Toxic Level: >9mg/dL Antidote/Reversal: calcium gluconate 10% (Kalcinate)
Carbamazepine
anticonvulsant Therapeutic Level: 5-12 mcg/mL
phenytoin
anticonvulsant used for seizers
Amitriptyline
antidepressant and nerve pain med Toxic Level: >500 ng/ML
Loperamide (Imodium)
antidiarrheal
what is Amphotericin B?
antifungal med used to treat systemic fungal infections severe adverse reactions like hypotension, fever, chills, and nephrotoxicity
Loratidine (claritin)
antihistamine
what can treat thet death rattle?
antihlinergic bc they will DRY the secretions and atropine will decrease saliva production
orthostatic hypertension is a common side effect of most of what type of meds?
antihypertensives
ondesetron (zofran)
antinausea
what is methotrexate?
antineoplastic, immunosuppressant to treat malignancies chemotherapy, rheumatoid arthritis, psoriasis, and for abortions
Aripiprazole (abillify)
antipsychotic for dementia
risperidone- what class and what is it used to treat?
antipsychotic used to treat schizophrenia and bipolar
Phenytoin (Dilantin)
antiseizure
why is putting an IV in the arm of a mastectomy contraindicated?
any trauma to the arm on the operative side can cause lymphedema with painful and lengthy swelling
avoid what after open radical prostatectomy
anything that could cause strain on the rectal area
Postpartum psychosis - signs
appear *within 2 weeks after birth* include: - *hallucinations* - *delusions* - *paranoia* - *severe mood changes* - *delirium* - *feelings that someone will harm baby*
what is acute RLQ pain, n/v, and a high WBC count most likely?
appendicitis. emergency surgery bc appendix could rupture. if it ruptures, the pain will subside temporarily (until peritonitis/sepsis develops)
late signs of dig toxicty
arrhythmias
what is an amniotomy?
artificial rupture of the membranes (AROM) -induces labor -watch for cord prolapse -assess fetal heart rate -characteristics of amniotic fluid. once ruptured this inc risk for infection -check patients temp every 2 hours after rupturing assist client to an upright position after the procedure
what is significant about guillian baree syndrome?
ascending symmetricl paralysis
if a client complains about a staff member mistreating them ,what is the first thing the nurse does?
ask patient to describe what happened so the nurse can assess then choose a chourse of action
how to measure how to safely transfer a pt the first time
assess if they can bear weight assess whether they are cooperative
suicidal ideations
assess if they had thoughts of self harm. find out if they have a plan and if they have one then ask about the details
care of infant wearing pavlik hanress
assess skin 2-3 times daily put shirt and socks under harness put diapers underneath straps leave harness on at all times adjusting of straps should onlt be done by HCP, not nurse or parent
first thing to do if a pt is in ventricular tachycardia?
assess them for a pulse (bc they can either have a pulse or not)
what is the Bishop score?
assesses and rates cervical favorability and readiness for induction of labor. a score above 8 is good
nurse actions during a seizure
assist them to lie down is standing/sitting, put them on side for patent airway, loosen tight clothing, give oxygen as needed, remove objects from immediate area, document time and duration of seizure (for tests are done later to see which type of seizure and maybe what exacerates it) never put anything in mouth or restrain them since muscle contractions can occur during a seizure
shortness of breath and high pitched expiratory wheezing are expected side effects of what
asthma
latent vs active TB
asymptomatic/cant spread vs symptomatic and can spread
borderline personality disorder
at a very high risk for suicide. often make suicide threats if they feel abandonment
phenytoin toxicity
ataxia (gait disturbance)
signs of phenytoin toxicity
ataxia, nystagmus, slurred speech, decreased mentation
clozapine
atypical antipsychotic used to treat schizophrenia
assessing a sleeping infant
auscultate first the palpate/percuss from head to toe then traumatic procedures like eyes, ears, mouth then moro reflex (this is the last step)
if the child swallowed something and is conscious and abke to cough or make sounds, what should the nurse do first
ave them try to cough it up, but signs of respiraotory distress require immediate ijtervention
how to prevent hemorrhage after a tonsillectomy
avoid clearing the throat, blowing the nose, or coughing
tet spell where they become cyanotic
baby will squat knee to chest
if a child under 1 years of age is choking, what do you do
back blows and chest thrusts
what foods to think when you see latex allergy*
bananas, avocados, tomatoes
which foods may cause a latex-food syndrome in pts with a latex allergy?
bananas, avocados, tomatoes, kiwi, potatoes, peaches, grapes, apricots
what are some foods that are high in potassium?
bananas, strawberries, legumes, green leafy veggies, potatoes, carrots, tomatoes, melons, avocados, whole grains, most fish, beef, pork
amoxicillan is the standard treatment for acute otis media. if symptoms dont mprove within 48-72 hours, the client shoudl return for further assessment,
basically if antibiotics arent treating the infection, this may mean your body is resistant to the antibiotic and you need a different one in order to treat.
where is a PICC line inserted into?
basilic or cephalic veins which go into the superior vena cava
why does tension pneumothorax cause hypotension?
bc the heart and great vessels are compressed/shifted and cardiac output is reduced it is LIFE THREATENING
whyi s vfib more lethal than vtach?
becuase there is no pulse with vfib. no pulse calls for immediate CPR and defibrillation
atrial pacemaker spikes before P waves and ventricular pacemaker spikes
before QRS complexes
an atrial pacemaker shows a spike when?
before the P wave
At what *age* can infants *roll*
begin at *4-5 months*
bronchiolitits
begins with upper respiratory symptoms like rhinorrhea/congestion and then goes to lower respiratory symptoms like tachypnea, cough and weezing
reaction formtion
behaving in a manner or expressing a feeling opposite of ones true feelings
delerium in older adults
behavior chnges and confusion that require assessment by the nurse. they have acute onset and are usually reversible often caused by meds, infection, and hypoxia
red asthma
below 500 medical alert
what temp means hypothermia?
below 95
a chest tube and catheter should both be placed
below chest and bladder
what is the brudzinski sign?
bending of neck causes flexion of knee and hip
what are mongolian spots?
benign discoloration bluish gray but usually fades
what are some meds that treat EPS?
benzos like "pam" drugs and benadryl
gross tremors and seizures from acute alcohol withdrawal are treated with what?
benzos like lorazepam and diazepam
what 2 races have a high incidence of getting a cough from ace inhibitors?
blacks and asians
what are common triggers of this?
bladder or rectum distention. treat the trigger
PTSD patients tend to
blame themselves. make sure to tell them it wasnt their fault
cephalohematoma
bleed that does NOT cross suture lines
kidney and liver biopsy what to watch out for
bleeding
when do you not give a vaginal exam for a pregnant woman?
bleeding with unknown origin
signs of complications after a prostatectomy
bleeding, passing blood clots, a decrease in urinary stream, urinary retention, symptoms of a uti and should al be reported
stage 2 ulcer
blister, abrasion, shallow open ulcer red pink wound with no sloughing
in leukemia, bone marrow activity is depressed and so what does this result in
blood cancer *infection low RBC production= *anemia decreased making of platelets= *bleeding
d-dimer
blood clot test
before starting broad spectrum antibiotics, what must be done?
blood culture and sensitivity
what should be checked before giving erythropoietin?
blood pressure
what do you closely monitor when giving furosemide?
blood pressure potassium BUN creatinine
when a pt is on methylphenidate, what do you measure
blood pressure and weight/height cuz can cause lack of appetitie leading to weight los and can also cause hypertension an tachycardia
what is the trousseau sign
blood pressure cuff is inflated and the wrist spasms
what is an advantage of having an insulin pump?
blood sugras wont go way up and down they will stay at more of a steady rate. you stil have to test your blood sugar when you have this
how is hep B transmitted?
blood, semen, vaginal secretions "B" for body fluids
high reticulocytes inicate what
bone marrow is producing RBCs fast
what are adverse affects of methotrexate?
bone marrow suppression, hepatotoxicity, and GI irritation
what are the major side effects with methotrexate?
bone marrow suppression, hepatotoxicity, fetal death. you dont need monthly eye exams when taking it
what kind of precautions do you need for open lesions from shingles?
both *contact* and *airborne* precautions and a negative airflow room
infants should not be throwing up green vomit, this could indicate what?
bowel obstruction
symptoms of hypothyroidism
bradycardia dry skin weight gain
beta blockers major side effects
bradycardia, bronchospasm, hypotension, depression, impotence
cushings triad
bradycardia, slowed RR, widened pulse pressure
symptoms of hypothyroidism- "everything is slow" lump, lackluster mood
bradycardia, weight gain, constipation, cold intolerance, dry/thick skin, cool, pale, brittle nails/hair, hair loss, generalized edema, fatigue, anemia muscle/joint pain, lethargy, forgetfulness, depression, dec libido, none little or a lot of menstrual bleeding,
laser lithotripsy
breaks down stones. burning on urination and hematuria are expected SE
post extracorpeal shock wave lithotripsy for kidney stones instructions
brsuing on back or abdomen is norma increase fluid to flush out fragments ambulate to remove fragments blood in urine is normal
what is the battle sign?
bruising behind the ear; indicates skull fracture that could cause brain injury if not treated
what is the grey-turner sign and what is it a sign of?
bruising of the flanks and retroperitoneal hemorrhage and is a bluish color
elevates INR/ prolonged PT
bruising, bleeding bc it is taking the blood longer to clot
pericardial effusion
build up of fluid between the layers of the pericaridum
what is paricardial effusion?
build-up of fluid in the pericardium
lactated ringers is often used for
burns
infants dont have complete closure of the esophageal sphincter therefore they are prone to gastroesophageal reflux. this is why they spit up after feeds. how can this be reduced?
burp during and after feeds to get air out, hold baby upright for 20-30 after feeding, and smaller more frequent meals
if a patient cant ingest a simple oral carb, they are given dextrose or glucagon
but these can cause rebound hypoglycemia by stimulating more insulin release from the body in response to increased glucose levels
amoxicillan can cause what super infection?
c diff. watch out for a fever and abdominal pain that develops with diarrhea
Nifedipine (Procardia) is what?
calcium channel blocker antihypertensive- dont give if hypotensive
what is nifedipine?
calcium channel blocker antihypertensive. do not give if bp on the lower end range
amlodipine, nifedipine
calcium chennal blcokers
what drugs is kept at bedside when getting magnesium sulfate to reverse the event of megnesium toxicity?
calcium gluconate
what is given to hyerkalemic patients to stabilize the myocardium?
calcium gluconate
what is the antidote for magnesium toxicity?
calcium gluconate
calcium carbonate drug is what?
calcium supplement
nutrients in cows milk
calcum and vitamin D not vit k, iron, or fiber
nursing intervetions for a child with ADHD in hospital
calm, structured, organized, consistent enviornment written chart or list of daily activities
EpiPen delivery
can be delivered through clothing in the out thigh hold for 10 scds so all med goes in then massage the thigh for 10 more scds
metoclopramide
can cause tardive dyskinesia
what does atropne treat?
can decrease saliva and also used for bradycardia
burning at the IV site can indicate and lead to what?
can indicate phlebitis which can lead to thrombophlebitis (blood clot)
be careful for giving too much oxytocin why
can lead to uterine tachysystole, decreased placental perfusion, and fetal distress. this is why its given via an infusion pump so there are no med errors
why do we monitor intake and output during oxytocin infusion?
can lead to water intoxication
when is epinephrine given?
cardiac arrest, anaphylactic reactions, severe asthma attack
muffled heart tones are headr in?
cardiac tamponade
x linked recessive
carried by females and affects males
what are TORCH infections
cause *fetal abnormalities in pregnant women*
what is clonus?
cause is neurological; it is rhythmic muscle spasms
mastitis
caused by staph frequent feeding and appropriate latching to prevent
mitral valve regurgitation does what?
causes a backflow of blood from the L ventricle theu the mitral valve and into the L atrium. the backflow can lead to dilation of L atrium and pulmonary edema. -make sure to report any digns of heart failure
rice, corn, and potatoes are gluten free and are allowed in what type of diet?
celiac gluten free BROW diet barley, rye, oats, wheat
theophylline toxicity presents as what symptoms?
central nervous stuff- HA, insomnia, seizures, gi disturbances, and cardiac toxicity
what does magnesium toxicty cause?
central nervous system depresion
what type of device would be placed in a client with sudden kidney failure requiring immediate dialysis?
central venous catheter
what is CVP and what does it monitor?
central venous pressure measuring right ventricular preload and reflects fluid volume status connect it to the proximal port to pressure monitoring system; normal range 2-8
what is Ancef?
cephalosporin antibiotic thats active against skin flora like staff, given before and after surgery
immediate client care for basilar skull fracture
cervical spine immobilization, close neurologic monitoring, and support of ABCs
postprocedure instructions for barium enema
chalky white stool until barium passes take a laxative like milk of magnesia to help expel barium drink plenty of fluids to promote hydration and eat a high fiber diet
low platelets= ICP bleeding=
change in LOC
indicatrs of increased ICP
change in LOC (often the first sign), cushings triad, and pupillary changes)
what is the standard treatment for overdose?
charcoal (but its inneffective for lithium, iron, and alcohol)
basically what 2 things do you do before and after wach feeding or medication giving thru an ng tube?
check placement and flush tube with sterile water
what is the priority when giving 2 neds at the smae time?
checking for drug compatibility
acute pericarditis
chest pain worse on inspiration pericardial friction rub
s/s of myocardial infarction
chest pain, diaphoresis, dyspnea, anxiety
myocardial infarction symptoms
chest pain, dizziness, sweating, sob, n/v, pain radiation to neck, jaw, left shoulder, arms, epigastrum
the varicella zoster virus can cause what 2 things?
chicken pox and shingles
what is Duchenne muscular dystrophy?
childhood form of MD x linked recessive lacks protein called dystrophin for proper muscle stabliizing mucles of proximal lower extremities are affected first they do the gower sign to help them stand remove clutter to prevent falls
24 guage
childrne and elderly with frail veins
about eczema
chronic skin disroder with pruriti, erythema, and dry skin -goal: DO NOT SCRATCH- leads to more infections -alleviate the itching and keep skin hydrated -moisturize, keep nails short, dont wear wool or rough fabrics, gloves or cotton stockings over the hands
Peripheral Arterial Disease (PAD)
chronic, *atherosclerotic* disease caused by buildup of plaque in arteries
intractible diarrhea
chronic, diarrhea that is hard to control
what to do if an air embolus is expected?
clamp the tubing, turn the pt on the left side and put them in trendelenburg to trap air in the right atrium
if asked to float to an unfamiliar unit, you cant refuse. but you can
clarify the skills that you are unable to perform
negativism
client resists instructions or atempts to be moved
client self determination act
clients must be given info about their rights to identify written directions about the care that they wish to get in the enent they become incapacitated and are unabe to make healthcare decisions.asked about advance directive on admission
general rule of thumb for engaging in sexual activity in cardiac clients
climb 2 flights of stairs without symptms then youre good
RN scope of practice
clinical assessment initial client education discharge education clinical judgement initiating blood transfusion
what type of meds should be stopped 7 days before surgery?
clopidogrel,antiplatelet, NSAIDS to prevent excess bleeding
vitamin K is a/w what
clotting factors
what does normal CSF look like/contain?
colorless and odorless a little protein, glucose, minimal wbcs, no rbcs, and no microorganisms
hepatic encephalopathy symtpoms
compliction of ESRD build up ammonia in the blood lethary, confusion, slurred speech, can lead to coma watch for asterixis- flapping hand tremors
emtpy a JP drain every 4-12 hrs or when its 1/2 to 2/3 full, same thing as an ostomy
compress the empty bulb rom side to side
how to close a hemovac
compress to create negative suction pressure and APPLY PLUG BEFORE RELEASING THE PRESSURE
UTI and the elderly
confusion may be a sign of a UTI, but still be addressed to R/O other possible causes
what is an arteriovenous malformation (AVM)?
congenital deformity of tangled BVs occuring in brain. usually found in the brain and can cause headaches, seizures, and neurological deficits. -BLOOD PRESSURE CONTROL IS CRUCUIAL -at high risk for having an intracranical bleed due to the weak vessels -any neurological changes like sudden severe HA, nausea, vomiting should be assessed immediately as these are symptoms of a hemorrhage -do not perform heavy exercising as this increases BP
what happens to the body in botulism?
constipation, respiratory failure and neurologic decline. infants usualy have costipaiton , generalized weakness, and diminshed deep tendon reflexes IV human derived botulism immune globin is given asap to reduce severity
what are some common side effects of anticholinergics?
constipation, urinary retention, flushing, dry mouth, and heat intolerance
what could be causing insufficient outflow in PD and what to do?
constipation. assess bowel pattern and give stool softener, assess for abdominal distention and constipation, check tubing for kinks, reposition client to side lying or walk with them keep drainage bag below abdomen
what are wheezes?
continuous, high pitched musical adventitious sounds caused by air movement through narrow bronchi and bronchioles
what do yo do if there is itching under a cast?
cool air from an air dryer
chemical burn to the eye is an emergency- priority is what?
copious eye irrigation (water at home and NS or LR at hospital)- eye must remain open
what re the primary drugs to treat addison's disease
corticosteroids
what is Dexamethasone?
corticosteroudoid that reduced inflammation and cerebral edema with brain injury and tumors
symptoms of active tuberculosis
cough, ,fever/chills, malaise, weight loss, night sweats, anorexia, fatigue positive T skin test abnormal chest xray can transmit
what is the nurses priority action when she hears a sucking chest wound?
cover with petroleum gauze and tape on three sides
what are normal expected findings after a colonoscopy?
cramping, gas, and watery stools
if myopathy is present, what will be very elevated?
creatinine kinase
what is strabismus?
cross eyes eyes dont look in the same directon at once closing one eye when viewing objects is a sign
strabismus
cross eyes misalignment of the eyes eyes looking in dfferent directions
catatonic
ct remians in a fixed stupor and refuses to move about or do adls, remaining mute, bizarre postures -they are unable to meet thier basic needs for adequate fluid and food intake and are at risk for dehydration and malnutrition
how often and where is growth hormone replacement given to a child?
daily sub q injections tretment is most successful when it begins early in a child's life, as soon as growth delays are noted; it stops when bone growth finishes or when parents decide
what is the most accurate indicator of fluid loss or gain?
daily weight
ventricular bigemy must be assessed rapidly because it can lead to what?
deadly arrythmias like vtach or vfib
autopsies are typically required when?
death by suicide, homicide, accident, or within 24 hrs of admission to facility. in these cases consent from family is not required when required dont remove any tubes or lines from deceased patient
clients with hypertension should take decongestantss why?
decongestants can contain a vasoconstrictor and exacerbate hypertension
long term use of PPIs can cause what?
decrased bone density which incrases the risk for fractures and can also cause cdiff
morphine can do what to the urine output?
decrease
raising the HOB causes BP to do what?
decrease
beta clokers like the lols do what
decrease HR and decrease cardiac workload
common expected findings in peripheral arterial disease
decrease blood supply from plaque buildup (watch lipid levels), lack of hair, decrease peripheral pulses, thick brittle nails, cool, dry, shiny skin, skin atrophy, toe ulcers, gangrene
what is presbyopia?
decrease in ability to see objects close up
dont take nsaids on lithium or with heart failure bc nsaids do what?
decrease renal blood flow
what does the nurse do if fluid over load occurs?
decrease the rate to a min or at KVO rate, elevate HOB, assess lung sounds and edema
signs of cold stress
decreased temp, altered mental status, bradycardia, hypoxia, weak cry
whend oes lithium toxicity usuallly occur?
dehydration decreased renal function (elderly) diet low in sodium drud-drug interactions- nsaids and thiazide diuertics
what can cause lithium toxicity in a pt taking lithium?
dehydration decreased renal function, diet low in sodium, and drug-drug interactions like nsaids
venturi mask
delivers a guaranteed oxygen concentrationto pts with unstable COPD
simple face mask
delivers higher concentration than cannula about 40-60. can be used if hypoxemia doesnt resolve
delrium vs dementia
dementia has a slow onset usually with normal attention
Normal amount of *drainage* in *first 24 hours following surgery*
depends on type of procedure performed, but about *80-120 mL/hour* of *serosanguineous or sanguineous drainge* can be expected
st johns wort used to treat what?
depression but interacts with many prescription meds
radioactive iodine
destroys the thyroid gland
what is the Allen's test?
determines patency of the ulnar artery. pt makes a fist and radial and ulnar arteries are occluded. pt opens fist and pallor is shown on hand from non blood flow. nurse releases pressure on arteries and blood flow is returned to hand. allens test should be positive and if negative, another artery should be used
what happens in peritoneal dialysis?
dialysate is infused into the abdominal cavity and the tubing is clapmed to allow the dialysate to dwell. after the dwell time, tubing is unclamped and the fluid drains out
antihypertensives are held before
dialysis
thyrpid replcement can give symptoms of hyperthyroidism like
diarrhea wt loss, palpitations, tachycardia, sweating, heat intolerance
what are soe ways iron deficiency can happen?
diets low in iron like vegetarian iron not being absorebd like after abdomal surgery or malabsorption syndrome increasd iron requirement blood loss
take pulse and withold which med if less than 60?
digoxin
ACE inhibitors do what main thing?
dilate blood vessels
how to give morphine iv push
dilute and give slowly over 3-5 mins
what is osteoarthritis?
disorder of the synovial joints (knee, hip, fingers) that causes erosion of joint cartilage and bone beneath cartilage
classic heart attack symptoms
dizziness, sweating cold clammy skin, sob, n/v, ischemic chest pain, pain radiating to neck, jaw, left shoulder, arms, epigastrum
what to dw tih client with positive orthstatic vitals?`
dnt complete if feel dizzy/weak give fluids
UAP soft wrist restraints can:
do ROM exercises reapply wrist restraints report changes in skin to nurse turn/reposition client in bed
what does nonmaleficience mean?
do no harm
important teaching for tiotropium
do not take the capsule orally even though it comes in a capsule and look slike you do. the buttom must also be pushed on the inhaler for the med to be dispersed
screening for latex question
do your lips swell when blowing up balloons or do your hands get itchy when you put on rubber gloves
so a pt with SIADH
does not need extra fluid needs salt seizure precautions strict I/Os
cardiac cath
done via artery arterial bleed can lead to shock and death ifnot treated quick kee them flat after procedure to not dislodge clot should not be bleeding at puncture site. this means no clot formed then
how to help improve sleep
dont nap during day physical activity at least 5 hours before bed 20 mins of natural sunlight avoid caffeine after noon avoid alcohol or smoking at bedtime relaxing activity before bed decrease environmental stimuli avoid heavy meals or large amounts of fluid at bedtime warm milk or small carbs before bed
pad position
dont raide legs above heart level like you would for veins/edema
drug of choice for symptomatic hypotension?
dopamine
at 6 mo what should baby weigh?
double birth weight
do you tilit your head up or down during a nosebleed?
down
which way to pull pinna for a child?
down and back
advanced age and pregnent a/w with what?
down syndrome
teaching when on lithium
drink 1-2 L of fluid daily blood levels checked periodically get adequate sodium
while taking lithium clients should:
drink 1-2 L of fluid daily maintain normal sodium levels have their blood drawn regularly for therapeutic levels
lithium toxicity occurs with dehydration and hyponatreima so why should you do if taking?
drink lots of fluid (2 L?) per day and get adequate salt. and dont take nsaids or thiazide
influenza is transmitted how?
droplet
pertussis and influenze precaution
droplet
patient with the flu precautions
droplet be in 3 ft when coughing or sneezing place mask on pt when transporting
expected side effects of lithium
droswniess, weight gain, dry mouth, gi upset
anticholinergic effects
dry mouth and constipation
drug for fibromyalgia
duluxetene (cymbalta) it has both antidepressant and pain relieving affects its also prescribed for MDD
jaundice in a newborn
during first 24 hours: jaundice is pathological (r/t liver problems) after 24 hours: physiological jaundice r/t inc amount of unconjugated bilirubin in system
UAPs CAN perform oral suction for pts
during oral care
LP positioning
during side lying, fetal knees up after supine
lumbar puncture poditioning
during- side lying after- supine
symptoms of a pleural effusion
dyspnea on exertion, non-productive cough, diminshed breath sounds, dullness to percussion, dec tactile fremitus
signs of heart failure
dyspnea, orthopnea, weight gain, cough, fatigue
pulmonary embolus symptoms
dyspnea, sob, tachycardia, pleuritic chest pain, severe anxiety, impending doom
acute lithium toxicity presents early with what and later with what
early/acute: GI disturbances later/chronic: neurologic like ataxia, confusion, tremor, or diabetes insipidus manifestations like polyuria, polydipsia
complications of preeclampsia?
eclampsia, placental abruption, and HELLP
atopic dermatitis aka what?
eczema
cognitive behavioral therapy (CBT) 5 basic components
education about pts disorder self observing and monitoring relaxation techniques cognitive restructuring behavioral strategies
what are some tings that put patients at risk for respiratory depression?
elderly age, underlying pulmonary condition, hx of snoring, obesity, cigarette smokers, opiate naive, post surgery within 24 hours
who to watch for while taking digoxin?
elderly and those with kidney injury bc they have decreased kidney function and digoxin can build up so they must be monitored frequently
heart failure patient having trouble breathing, what to do first?
elevate HOB
ways to reduce ICP
elevate HOB maintain head/neck in neutral midline position give stool softener manage pain/fever cal dark quiet environment give oxygen hyperventilate before suctioning dont suction too much (not longer than 10 scds) as this increases ICP
what is expected with a lupus pt?
elevated ESR, positive antinuclear body test, anemai, mild leukopenia, and thrombocytopenia
what are lab results that support a vaso-occlusive crisis (pain crisis) in sickle cell patients?
elevated reticulocytes elevated bilirubin anemia (Hgb <10 g/dL)
what is the treatment for tension pneumothorax?
emergency large bore needle decompression chest tube
before a lumbar puncture teaching
empty bladder lateral recumbent (fetal position) or sitting pain may be felt radiating down leg but should be temporary
what are the most important adverse effects of calcium channel blockers?
end in -pine; dizziness, flushing, HA, peripheral edema, and constipation
symptoms of acromegaly (overproduction of growth hormone)
enlarged face, hands, feet, and organs like tongue, spleen, kidney, thyroid hypertension, heart failure joint pain skin changes hyperglycemia
graves disease
enlarged thyroid gland & excessive thyroid hormone secretion, bounding rapid pulse is expected
stress ulcers can develop in critically ill patients so what helps with this?
enterel feedings
where should the nurse listen for a bruit in abdominal aneyurism
epigastric/periumbilical area
behaviors of bulimic person
episodes of binge eating followed by self induced vomiting using enemas/laxatives intense frequent exercise
TIPS procedure is used for what?
esophageal varices
how often should ostomy bags be changed?
every 5-10 days
opiate withdrawal
everything is increased
symptoms of hyperthyroidism
everything is increased! like if someone is moving around a lot they would get all sweating and tired and lose weight anxiety/insomnia palpitations heat intolerance sweating weight loss w/out decreased appetite goiter hypertension hand/finger tremors eyeball protrusion
narcotics like morphine can do what with obstructive sleep apnea symptoms
exacerbate them
tetraology of fallot
exacerbation can happen when infant or child cries, becomes upset, or is feeding you immediately place them in KNEE CHEST position
what are some seizure triggers?
excess caffeine, alcohol, sleep deprivation, and stress
symptoms of RSV in infants
excessive mucous production, rhinorrhea, fever, cough, lethargy, irritability, poor feeding
how to use the peak flow meter for asthma
exhale quickly and forcibly thru the mouthpiece
guaifenesin (Mucinex)
expectorant med that thins secretions to facilitate expectoration
what is Guaifenesin (Mucinex)?
expectorant to facilitate mobilization of mucus
How is *toxoplasmosis acquired*?
exposure to infected *cat feces* or ingestion of *undercooked meat* or *soil contaminated fruits/vegetables*
remember that kids under 2 have shorter Eustachian tubes therefore more prone to respirator infections that may cause otitis media
exposure to smoke, pacifiers, and drinking from a bottle when lying down are all causes
pressure ulcer develop how?
external pressure compressing capillaries and underlying soft tissue- occurs mainly over bony prominences
what does the FLACC scale stand for?
facial grimace, leg movement, activity, crying, consolibility
what is the chvostek sign
facial twitch after tapping nerve on side of head
risks for colon cancer?
family hx if you have ibd, crohns, or ulcerative colitits diet high in red meat obesity alcohol smoking
ppl with long bone or pelvic fractures are at risk for developing what?
fat embolism
symptoms of mono?
fatigue, fever, sore throat, splenomegaly, hepatomegaly, swollen lymoh nodes contact sports should be avoided; caused by the epstein barr virus
acute pancreatitis stool
fatty and foul smelling
how is hep A transmitted?
fecal-oral route
cardiac cath position
femoral approach- bed rest 4-6 hrs and client can turn from side to side. keep extremity straight and hob no more than 30 deg
where is amniotic fluid produced?
fetal kidney
characteristics of neuroleptic malignant syndrome
fever, muscle rigidity, altered mental status, sweating, hypertension, and tachycardia
client identifiers
first and last name medical record number DOB
asterixis
flapping tremors of the hands to assess, have pt extend the arms and dorsiflex the wrist
PTSD characteristics in people
flashbacks of the traumatic event persistent angry, fearful mood difficulty concentrating feeling detached from others
AFTER cardiac catheterization position
flat and keep extremity straight
Delirium signs and symptoms
fluctuating acute mental status changes inattention with disorganized thinking like hallucinations altered level of consciousness and the presence of infection can cause delirium
what do rales (crackles) indicate?
fluid in the lungs
bounding pulses may be present in
fluid overload r hypertensoin
low albumin can cause what
fluid overload, edema, weight gain, ascites
treatment of SIADH
fluid restriction less than 1000 ml per day oral salt tablets to increase serum sodium hypertonic saline (3%) or NS IV and/or vasopressin receptor antagonists to decrease renal response to ADH
14 gauge catheter
fluids and drugs in pre hospital or emergency setting or hypovolemic shock
while talking with a delusional pt,
focus on the pts feelings and reinforce reality
what should someone take methotrexate with to help with adverse affects?
folic acid supplement
When do we give glucagon
for SEVERE hypoglycemia or if the client cannot take oral fluids
14 guage (large bore)
for giving fluids/drugs in prehospital emergecy setting or for hypovolemic shock
peritoneal dualysis
for someone with insufficient renal function a catheter goes into peritoneal cavity and dialysite is infused then clamped off for 30 mins. then its unclamped for the dialysite to drain via gravity
if a child is suddenly in distress and cant speak what should you suspect
forein body aspiraion
head njury
fowlers or high to reduce ICP
signs of DIC
frank external bleeding like venipuncture site bleeding and internal bleeding like petechiae, ecchymosis, hematuria, and bloody stools, also respiratory distress from bleeding into the lungs what to do? replace clotting factors fresh frozen plasma and platelets
what are some symptoms of placental abruption?
frequent contractions, abdom pain, dark red vaginal bleeding
asthma
frequent cough at night
DASH diet
fruite/veggies/fat free/low fat dairy whole grains, fish, poltry, beans, seeds, nuts limit intake of sodium, sweets, sugary beverages, and red meats low in saturated and trans fats and rich in potassium, calcium, magnesium, fiber, and protein
stage 4
full thickness skin loss exposed muscle tendon or bone
unstageable pressure ulcer
full thickness skin loss ulcer base covered by slough and eschar that needs to be removed to stage
stage 3
full thickness skin loss with visible sub q fat
a patient with a total knee arthroplasty should be what by discharge?
fully weight bearing
IV proton pump inhibitors are given for
gastric ulcer bleeding
SIRS
generalized inflammatory response to an infectious or noninfectious insult to the body (fever, tachycardia, tachypnea)
milking chest tubes
generally contraindicated bc it messes with the pressure changes in the pleural space
copd teaching
get pneumonococcal and flu vaccine and report any signs of infection
what should nurse do before giving vancomycin?
get trough levels
phenytoin side effect
gingival hyperplasia
RSV interventions
give oxygen elevate HOB airway suction give antipyretics IV fluids CONTACT AND DROPLET isolation
how to administer oral liquid med to a child?
give small amounts into the back of the cheek
if a diabetic patient shows symptoms of hypoglycemia, what does the nurse do after checking the blood glucose?
give them a carbohydrate snack!
if someone is having hypoglycemic reaction and glucose is below 70, what is the first thing to do?
give them simple carbs like orange juice or low fat milk
the deluvery if oxytocin
given through an infusion pump into a proximal port (not distal) monitor FHR and uterine contraction pattern at least every 15 mins monitor intake and output continuous FHR monitoring
what does enteral mean?
given through the GI tract (orally or feeding tube)
which long acting insulins can you not mix?
glargine and detemir
important education for celiac disease
gluten-free diet for the rest of their lives. why? gluten damages intestines (small) thats needed to function properly for nutrient absorption rice, corn, and potatoes are allowed bc they are gluten free read food labels of all processed foods bc some may contain hidden gluten
physical assessment on a child
go from least invasive to most invasive bc once the child becomes upset its hard to finish the assessment so first interact with parents/then the kid and play with them get ht/wt then auscultate then get vitals
signs of bulimia someone may notice
going to bathroom after meals large amonts of food disappearing hidden wrappers/empty food containers like sweets intense physical exercise parotid gland enlargement calluses on hands preoccupation with weight food and dieting
what will chronic pancreatitis show in stool
greasy, foamy, foul-smelling, fatty
babinski sign for a child less than 1 year
great toe bends upward and smaller toes fan out. this is NORMAL
disaster traige
greatest good for the greatest number ppl with alterations in airway breathing and circulation who are likely to survive with timely interventions are given first priority
what do theh traffi signal colors mean in a peak flow meter?
green- asthma is under control. there are no worsening of cough, wheezing, or trouble breathing. yellow- means caution. symptoms are getting worse. even after reutn to the green zone after use of medication, further med or chane in treatment is needed. still take meds if you return to green zone after taking rescue meds. red- needs emrgency treatment if the level does not immediately return to yellow fafter taking resue meds.
what is hirsutism?
happens in women where they devlop male pattens of hair on the face, abdoen, chest and back cushings can cause this
what is an aura?
happens right before a seizure
if injury to the spinal cord, what important precaution to take?
hard cervical collar and backboard
someone sufferig from PTSD
has flashbakcs/nightmares of the event and their body responds with rapid hR, sweating, etc. they avoid reminders of the truma like places or activities, they feel detached and numb and are hypervigilant, cant sleep are mad, cant concentrate
is a child is having sepration anxiwty in the hospital, what are some things nurses can do to reduce the anxiety
have parent leave familiar objects in room, dont leave them alone when upset, establish daily schedule like one at home, give child time to play
rule of nines
head: 4.5 front 4.5 back torso: 18 front 18 back each arm: 4.5 front 4.5 back (each arm is 9 total) each leg: 9 front 8 back (each is 18 total) genitals: 1
what are some hings that happen with myopia?
headache, dizziness, poor school performac,e eye rubbing, frequent blinking.squinting when viewing bjects from afar
durable power of attorney
health care proxy chosen by client to make health care decision on clients behalf id client can no longer make decisons
directly observed therapy
health care worker or caregiver wacthes patient take every medication. helps prevent infection spread, adherence to drug therapy, and controls spraed worldwide
what do advanced care documents include?
healthy care proxy and living will
Crackles - when are they heard?
heard typically only during *inspiration*
cardiac tamponade
heart cant squeeze effectively muffled heart tones CO drops BP drops tachycardic JVD distant heart sounds requires pericardiocentesis (draining of fluid in pericardial sac)
an S3 heart sound is a sign of what?
heart failure
bumetanide (Bumex)
heart failure to diurese
dont take licorice root with that medications?
heart meds
what is a Holter monitor
heart monitors that we have at work, keep a diary of activities and any symptoms experienced and dont bathe or shower
what is pyrosis?
heartburn
cardiac catheterization
helps assess/diagnose CAD. catheter is placed in vein in leg up to heart. after, a pressure dressing is applied and client is places supine with affected extremity flat for 2-3 hours. if bleeding occurs, direct manual pressure is put above the puncture site. peripheral pulses and pulses distal to site should be checked routinely after to make sure adequate blood flow to extremities
after a thyroidectomy, there shouldnt be swelling of the neck or increased pain. what could this indicate?
hematoma formation or increased tissue inflammation which affect airway patency. this patient shoudl be seen first
what is important after an abdominal aortic aneurysm repair?
hemodynamic stability bc of graft leakage
what can cause pseudohyperkalemia?
hemolysis or clotting during the blood draw
what are preventatives given before and after surgery to prevent venous thromboembolism?
heparin, enoxaparin, lovenox
high ammonia can cause what
hepatic encephalopathy, confusion, lethargy, asterixis, coma
what is SIADH?
high antidiuretic hormone production leads to water retention increased total body water DILUTIONAL HYPONATREMIA -will see signs of fluid volume overload, changes in loc, weight gain w/o edema, hypertension, tachycardia -seizure precautions
HYPERcalcemia
high blood calcium level (>10.5)
preeclampsia 2 main things:
high blood pressure and protein in urine. edema is expected but not part of the criteria
cystic fibrosis diet
high calorie, high fat, high protein
how to fix ARF immediately?
high concentrations of O2
bacterial meningitis
high fever change in loc nuchal rigidity meningeal signs (positive kernig and brudzinski signs)-- treat with antibiotics
Scarlet fever symptoms
high fever, bright red "sandpaper" rash that begins on chest, strawberry tongue Treat with penicillin.
malignant hyperthermia symptoms
high fever, rigid jaw, tachynea, and tachycardia
body positioning for paracentesis
high fowlers
proper nasal spray administration
high fowlers and head bowed slightly forward occlude one nostril and put it in open one point tip toward side and away from center spray while inhaling deeply
how to improve oxygenation flow?
high fowlers and take slow deep breaths
metabolic alkalosis
high ph and low hco3
what will excess salt in diet do to BP?
higher BP
why is throwing up green vomit an emergency?
his is indicitaive of bile ad coule mean its a bowel obstruction
anaphlactic shock
hives, itching, skin rash, rapid swelling of the mouth and throat- give epi quick in the thigh- benadryl can be given for hives or rash. epinephrine is the only thing that can treat anaphlyaxis. if you have any kind of hx of severe allergic reaction then you should always carry an epi pen.
early signs of phenytoin toxicity
horizontal nystagmus and gait unsteadiness
what is the causitive agent of fifth disease?
human parvovirus
Trousseua and Chvosteks are signs of what
hyocalcemia
decreased sweat production can lead to what?
hyperthermia bc you arent sweating which naturally cools your body off
signs/symptoms of cardiac tamponade
hypotension (heart isnt contracting effectively), muffled or distant heart tones, JVD, dyspnea, tachynea, tachycardia, weak thready pulses
what can happen as a result of emergent catheterization from acute urinary retention?
hypotension and bradycardia
what are early signs of bleeding into the retroperitoneal space?
hypotension, back pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses
classic symptoms of neurogenic shock
hypotension, bradycardia, and pink an dry skin
rationalization
i di poorly on the test bc the questions were hard
what does frosstbite a ctually men
ice crystals form n the intracellular spaces causing peripheral vasoconstriction and reduced blood flow superficial frostbite looks: mottled, blue, or waxy yellow deeper frostibite looks: white heard and unable to sense touch leads to gangrene
sodium intake leads to fluid retention
if you restrict sodium this leads to a decrease in water retention
intussusception causes intestinal obstruction
ileum telescopes into cecum, pain obstruction, edema, bowel ischemia, rectal bleeding (CURRANT JELLY stools)
what are the 4 categories for triaging?
immediate (red tag)- life threatening injuries with good prognosis once treated delayed (yellow)- injuries requiring treatment within hours minimal (green tag)- injuries requiring treatment within a few days expectant (black tag)- extensive injuries, poor prognosis regardless of treatment
in bacterial meningitis, what is the priority of care?
immediate antibiotics LP with csf is done to find causative organism
what does tamponade require?
immediate pericardiocentesis
what does a STAT order mean?
immediately and only once
accidental exubation is a medical emergency. if it happens, what does the nurse do?
immediately deliver rescue breaths using a bag valve mask and 100% oxygen until they can be reintubated
Buck's traction
immobilizes a fractured hip and reduce pain/swelling skin/neurovascular assessments every 2-4 hrs weights should not touch the ground patient is supine
buck traction
immobilizes hip and femur fractures . the weight pulls the limb into traction. the foot of the bed is elevated
notify hcp if child temp is over 100.4 after
immunizations
Azathioprine
immunosuppressant drug causing bone marrow suppression and increases risk for infection
hepatic encephalopathy
impaired ammonia metabolism causes cerebral edema. s/s: change in LOC, memory loss, asterixis (flapping tremor) impaired handwriting, hyperventilation w/ resp alkalosis. treatment: lactulose-traps ammnia and lwoers pH, low protein, safety, rest
what is the desired effect of lactulose?
improve mental status lactulose reduces ammonia by trapping it in the gut then expelling it with a laxative
intermediate acting (NPH)
in 4 hours
when is digoxin used?
in heart failure to increase cardiac output and in afib to reduce the heart rate
opioid agonist-atagonist meds can be used when during labor?
in the active phase of stage 1 labor when labor contractions are well established and the cervix is dilated to atleast 4 cm
where should there NOT be continuous bubbling in the chest tube drainage system?
in the air leak monitor
inferior vena cava filter is placed where and does what?
in the femoral vein and catches blood clots from the legs from going to the lungs
aphasia
inability to express thoughts and comprehend language
what is presbyopia?
inability to see things close up
what is hyperthyroidism?
increased T3 and T4 hormones which increases the metabolic rate
circulatory (or fluid) overload sings
increased bp, distented jugular veins, rapid breathing, dyspnea, moist cough and crackles
lupus nephritis characteristics
increased creatinine and BUN, abnormal urinalysis (protein, rbcs)- can lead to irreversible kidney damage. recognize early. elevated kidney tests tells us which organ is being attacked by inflammation
glaucoma
increased intraocular pressure that can lead to severe eye pain, reduced central vision, blurred vision, ocular redness
digoxin function
increases cardiac contractility but slows heart rate EXCRETED BY THE KIDNEY
dopamine
increases heart rate and increases blood pressure
full weight bearing
independent; no assistance needed unless they are uncooperative or they are a fall risk, which is 1 person standby
what do late decelerations indicate in pregnancy and are they ever good>
indicate uteroplacental insufficiency and no
oxytocin
induction or augmentation of labor should be given by an electronic infusion pump requires frequent mother/fetal assessment adverse affects: maternal hypotension and water intoxication
what does a positive tuberculin skin test show?
induration (basically a white patch) surrounded by redness
increased c-reactive protein is a sign of what?
infection
just like chemotherapy, methotrexate causes bone marrow suppression which places patients at risk for what?
infection
once a woman's water breaks, this leaves her susceptible to what?
infection
what is a major adverse effect of TNF inhibitors like infliximab or adalimumab?
infection bc they cause immunsuppression
what puts a patient at risk for preterm labor?
infection like periodontal disease
if a patient gets a transplant, they are then given immunosuppressants to help prevent organ rejection. however what does this make them susceptible to ?
infections
ulcerative colitis
inflammation/ulcerations in the large intestines causing urgent, frequent, bloody diarrhea, abdominal pain, anorexia, and anemia-lower GI-rectum
what contains live vaccones?
influenza nasal spray, MMR, and varicella
18 gauge
infusing blood or large amounts of fluids in adults
what is the specific action of atropine?
inhibits the action of the vagus nerve (the vagus nerve slows the heart rate. this is why you do vagal nerve stimulation in hypertensive crisis.
signs of intussusception
initial periodic pain with legs drawn up to abdomen, pain is severe and progressive though, inconsolable crying, blood/mucousy stools "currant jelly"
lyme disease
initial symptoms: flu like headache, fever, myalgia, fatigue, bulls eye rash. give antibiotics to prevent it from spreading to heart brain or joints
cauda equina, amedical emergency
injury to L4-L5 causing motor/sensory deficits from pressure on spinal nerves acute spinal/lower back pain and bowel/bladder incontinence its a medical emergency to prevent permanent damage
stroke patients are at a high risk for
injury/falls bc of one sided paralysis and confusion
what is Meniere disease
inner ear disorder vertigo, tinnitis, and muffled hearing
side effects of albuterol
insomnia, n/v, palpitations (from tachycardia), and tremor
metaboli syndrome- what s it?
insulin resistance syndrome
stage 1 ulcer
intact skin non-blanchable with localized redness
fetal alcohl syndrome causes what?
intellectual disability and developmental delay
what are some physical signs of peripheral arterial disease?
intermittent calf muscle pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin, thick brittle nails, gangrene, ulcers (all of these are in the extremities)
3 classic symptoms of intusseception
intermittent severe crampy abdomonal pain sausage shaped mass currant jelly also inconsolble crying drying knees up to chest vomiting
what should always be at beside for a gastric lavage?
intubation and suction supplies; it removes toxins and irrigates stomach within one hour after overdose
symptoms of cold stress in a newborn
irritability, lethargy, decreased temp, hypoxia, bradycardia, weak suck and cry, emesis, hypoglycemia
what is expected during IV infusion of KCL?
irritation and discomfort at the site bc KCL irritates the vein
Ipratropium
is the short acting anticholinerguc used as a rescue med for COPD and asthma
bronchiolitis is a/w RSV
isolation low grade fever, tachypnea, wheezing, poor feeding
When you have a cast, which type of exercises should be performed
isometric exercises Contraction of the affected muscle without movement of the joint
what type of fluids would someone need while in hypovolemic shock?
isotonic like normal saline and lactated ringers
what type of fluids do pts in hypovolemic shock need?
isotonic solutions like NS, LR
a pt with diabetes does not get dextrose solutions why?
it can increase blood glucose levels
what is the purpose of continuous bladder irrigation?
it is prescribed after TURP to prevent obstruction of urine outflow by removing clotted blood from the bladder
what does an elevated PTT mean?
it is taking your blood way too long to clot therefore this is a problem bc you could bleed out- there may be a coagulation factor deficiency
what is nitroglycerin used for?
its a vasodilator that restores myocardial perfusion
what is the first line of treatment for torsades de pointes?
iv magnesium
increased bilirubin
jaundice, scleral icterus, itching
later signs of hep B?
jaundice, weight loss, clay colored stools, thrombocytopenia
if spine injury is suspected, do not use the head tilt chin lift method as this could damage the spine further. what do you use instead?
jaw thrust maneuver
position after a vascular graft of extremity
keep extremity straight and bed rest for 24 houra
where should NTG tabs be stores?
keep in original container stored away from light and heat sources but easily accessible
wilms tumor is on the
kidney presents as abnormal bulging on one side of child's abdomen DO NOT PALPATE ABDOMEN;fatigue in children - *kidney tumor* usually occurs in *children age <5* - usually discovered when caregivers note an *unusual bulging/swelling on one side of abdomen*
IV iodinated contrast used for ct scan can cause
kidney injury; metformin is discontinued on the day of IV iodine contrast exposure
if a child has an asthma exacerbation and there is no wheezing/breath sounds heard, this is an emergency priorty because it could indicate what?
lack of airflow so airway obstruction. this is called "silent chest"
best fluid solution to give after a burn
lactated ringers bc it most closely resembles blood than all of the others
what drug is goingn to decrease ammonia levels?
lactulose
when is stridor heard?
laryngospasm or edema of upper airway
what is "sunset eyes" in an infant a sign of?
late sign of increased intracranial pressure/hydrocephalus
what are foods high in vitamin k?
leafy green veggies, asparagus, brocoli, kale, brussel sprout, spinach
what position to place a oregnant woman in for seizure precautions?
left side
recal irrigation and enema position
left side lying for gravity flow natural direction of the colon
what is the kernig sign?
leg extension on 90deg flexed hip causes pain and resistance
what number is consididered a hypoglycemic neonate?
less than 40. feed them right away
what number is considered severe neutropenia?
less than 500
what is the care for acute diverticulitis?
let the BOWEL REST and let the inflammation go down IV antibiotics since bacteria may contribute to a flare up NPO IV fluids to prevent dehydration bed rest possibe NG suction any procedure that cuases abdom pressure or that increases peristalsis could perforate or rupture the diverticula and should be avoided
signs of severe dehydration in infants
lethargy, sunken fontanel, poor feeding, tachycardic, increased RR
location of the phlebostatic axis (for measuring continuours arterial bp readings)
level of atria at 4th ICS, 1/2 anterior/posterior diameter
body positioning after cardiac catherterization
lie flat
after a LP teaching
lie flat with no pillow for atleat 4 hours incrase fluid intake
trisomy 18 and trisomy 13
life expectancy is a few weeks after birth. discuss palliative/end of life care
hemolytic uremic syndrome
life threatening complication of e. coli diarrhea
when is the only time that procedures can be performed without getting informed consent first?
lifesaving procedures
how about biliary obstruction
light gray clay colored
in continuous bladder irrigation, what should the urine look like?
light pink with no clots bladder spasms are expected
Amyotrophic lateral sclerosis (ALS) typical symptoms
limb weakness, dysarthria (difficulty speaking), and dysphagia
instructional directive
lists medical treatment the client wants to omit or refuse if they become unable to make decision
what must be checked before starting statin drugs
liver function tests bc they can cause hepatotoxicity can cause muscle aches and weakness take with evening meal or at bedtime
septic arthritis symptoms
localized pain, limited ROM, and systemic infection symptoms like fever
after a splenectomy, pts are subject to what?
lofelong infections. minor infections can quickly become life threatening. report any signs asap.
what is tiotropium (Spiriva) and what/how is it used for?
long acting, 24 hour, anticholinergic inhaled med used to control COPD. given using capsule-inhaler system where the capsule is placed in the device and a buttom is pressed to put a hole in the capsule and the powder is dispered thru the inhaler. it should not be used as a rescue med for example if someone has trouble breathing, thats where you woulld use the short acting like albuterol
what to wear to ptrotect yourself from mosquites
long sleeve, long pants, and light colors
a porlonged QT interval is usually the result of electrolyte imbalances so what is usually the treatment?
look for electrolyte in the answer
most patients with heart failure take what kind of med
lopp diuretic that ends in "ide" like furosemide, torsemide, or bumetanide
homonymous hemianopsia
loss in half of the visual field on the same side
major depressive disorder demonstrates
loss of appetite, weight loss, and insomnia or hypersomnia sleep disturbances
symptom of macular degeneration
loss of central field of vision
what is the death rattle?
loud rattling sound when reathing in a person that is actively dying caused by secretions
what ABG values indicate ARF?
low PaO2 and high PaCo2
liver dysfunction abnormalities
low albumin, high ammonia, elevated INR/PT, increased bilirubin, low platelets
what causes oligohydramnios?
low amniotic fluid volume caused by fetal kidney anomalies or leaking fluid through the vagina
HYPOcalcemia
low blood calcium level (<4.0).
what is osteoporosis
low bone density
signs of hypoglycemic reaction
low glucose, shaking, sweating, pale
what are some expected symptoms in a TBI?
low grade constant HA, slowness in thinking, memory problems, loss of balance, poor coordination, constant exhaustion, inc sensitivity to light, and heightened irritability all symptoms that can last up to 6 weeks
it is normal for some children to have a reaction to MMRV vaccine 5-12 days after getting it symptoms like
low grade fever, mild rash, swelling/redness at injection site, irritable, restless. watch that their temp does not get too high bc this could lead to febrile seizures. tell them to give acetaminophen if temp over 102
respiratory acidosis
low pH, high PaCO2, normal HCO3
metabolic acidosis
low pH, low HCO3
PKU
low phenylalanine diet specal infant formula no meat eggs or dairy
kidney disorders diet
low phosphate
thrombocytopenia
low platelet count; so this increases risk for bleeding;<100,000 platelet count
ulcerative colitis diet
low residue, high protein high calorie
heart failure patients should be on a what type of diet?
low salt
heart failure, ascites, hypertension diet
low sodium (fluid overload states)
heart failure patinets must take which very important 2 actions?
low sodium diet and take medications
what is a barium enema
lower GI series used to visualize the colon outlined by contrast to detect polyps, ulcers, tumors, etc
hydralazine is a vasodilator usually given to what?
lower blood pressure
bile
made in liver and helps aid in digestion
whats given for preeclampsia?
magnesium sulfate to prevent seizures
tracheostomy allow for 1 finger to fit under the ties
main concern is to prevent dislodgement
most important thing to do t preent stroke in a patient with a ton of risk factors and hyoertension
make sure they take antihypertensives
what is palliative care?
manages symptoms, provide psychosial support, coordinate care to relieve suffering and improve quality of life for cts with serious illnesses
nursing interventions for necrotizing enterocolitis
measure abdominal girth daily NPO NG suction to decompress stomach/intestines parenteral hydration IV antibiotics place supine to avpid pressure on the abdomen avoid rectal temps in case perforation
what are some iron rich foods?
meats- beef, lamb, liver chicken, pork shellfish- oysters, clams, shrimp eggs, green leafy veggies, broccoli, dried fruits, dried beans, brown rice, oatmeal eating foods rich in vitamin c like citrus fruits potatoes and tomatoes and also orange juice can enhance the absorption of iron
Isotretinoin
med for severe acne- a HUGE teratogenic!! derived from vitamin A. dont take extra vit A as this could cause toxicity -required to enter risk management plan and also use 2 forms of birth control -cant give blood while on bc some could still be in blood
what is the classic sign of a tension pneumothorax?
mediastinal shift and tracheal deviation
bulging fontanel signifies
meningitis
droplet precautions
meningitis haemophilius influenza type b diptheria mumps rubellla pertussis strep group A viral influenza wat do yuo need? surgical mask and private room as needed for procedures that can splash, gloves, gown, goggles/shield
the herb black cohosh is uses for
menopausal hot flashes
hepatic encephalopathy is caused from high ammonia levels and elevated ammonia levels cause what?
mental confusion
sickle cell crisis cause excrutiating pain and they need large dose of narcotics. PCA pump is th best method with morphin or dilaudid
meperedine (Demerol) is contraindicated for
what is the ABG most consistent with diabetic ketoacidosis?
metabolic acidosis
what is an external fiaxtor
metal device with metal scerws placed into a bone to stabilize it. there is an adjustable external rod *infection with pins is a complication. antibiotics must be started right away to prevent osteomyelitis -nurse gives sterile pin care with 1/2strength hydrogen peroxide and NSS OR chlorhexidine -neurovascular assessment afterwards -with an external fixator early ambulation is key with device in place
characteristics of fetal alcohol syndrome
microcephaly, short eyelids (palpebral fissure), flat midface (cheekbones), smooth philtrun (btwn nose and upper lip), thin upper lip
symptoms of serotonin syndrome
mild (shivering and diarrhea) sever (muscle rigidity, fever, seizures) also tachycardia and hypertension also agitation/restlessness
what are common SE of immunizations?
mild fever and soreness and redness at injection site anorexia/fussiness in the first 24 hours
common side effects of immunizations
mild fever redness and soreness at the injection site apply a warm compress to the site
autistic kids
minimal stimulation and calming enviornment
hydrocdone/aceteminophen oral tablet is typically used for what type of pain?
moderate
what is in the lpn scope of practice?
monitor RN findings reinforce education routine procedures like catheterization most medication administrations ostomy care tube patency and enteral feeding specific assessments
what are the priorities of care for suspected placenta abrupto?
monitor mom for fluid status and fetal heart tones bc it can cause maternal hemorrhage and/or fetal oxygen supply interruption
what is a major complication of RA?
morning stiffness. how to fix? take a warm shower or bath
necrotizing enterocolitis
mostly preterm infants from underdeveloped intetestin/gut immunity so bacteria is introduced into bowel and get worse fast bc compromised immunity inflammation and ischemic necrosis of the intetsine pogression causes bowel congestion and gangrenous with gas forming inside bowel wall
no weight bearing
motorized assist device if cooperative and they have upper body strength 2 person assist with full body sling if uncooperative and/or has no upper body strength
what are some early signs of rhabdomyolysis?
muscle aches or weakness- immediately report to hcp!
use of dantrolene
muscles spasms/malignant hyperthermia!!!
what does botulism cause?
muslce paralysis
how should IV potassium be administered?
must be given in an infusion pump so the rate can be regulated. not by gravity infusion. it should also always be diluted
what does an ST elevation indicate?
myocardial infarction bc one or more of the coronary arteries that supply blood to the myocardium are occluded
what is the extreme thing that happens as a result of hypothyroidism?
myxedema coma like lethargy, mental slugglishness, and coma
post surgical pts are usually prescrbed which prn med to help from the opioid drugs they were on
naloxone (Narcan) but it wears off in 1-2 hours so be prepared to give more than once monitor RR and give oxygen
aortic stenosis-
narrowing of orifice btwn L ventricle and aorta aka blood is not properly pumped to body. patients may experience passing out and SOB and sudden death eith exertion thats why they should rest and not exericse before surgery
early signs of dig toxicity
nausea and vomiting
what are sigs of a bowel obstruction?
nausea, vomiting, abdominal distention, and dec stool production
what are some signs of a bowel obstruction?
nausea, vomiting, abdominal distention, dec stool
wat is the brudzinski sign?
neck flexion and exhibits pain and hip/knee flexion
transport techs need to/dont need to know which info
need:pertinent info to transport pt dont need: exact diagnosis
what can a baby born to an opioid dependent mom have?
neonatal abstinence syndrome. the baby experiences opiod withdrawal 24-48 hrs after birth
vancomycin can case what 2 tings
nephrotoxicity and ototoxicity
taking folic acid during pregnancy prevents what?
neural tube defects and spina bifida
what does lead poisoning cause?
neurological and motor impairment
parasthesia is an early sign of what?
neurovascular impairment
infant formula key points
never dilute or concentrate formula wash tops of forumla cans before opening unused prepare formula can be used for up tp 48 hours and then discarded after to warm prepared bottle, place in pan of hot water never microwave formula any forumula left over should be thrown out immediately when done
pre eclalpsio
new elevated bp aat 20 or more weeks adn proteinuria HA, visual disturbances, facial swelling
gestational diabetes
new onset of elevated bp at 20 or more weeks without proteinuria
what is preeclampsia?
new onset of hypertension PLUS proteinuria after 20 weeks gestation
is supine positioning good for pregnant lady
no bc it decreases uteroplacental blood flow and fetal oxygen
after abdominal surgery, do you expect to hear bowel sounds?
no because postop paralytic ileus
can UAP tell familes and alert other departments why patient is on precautions?
no this is for RN to do
prior to an EEG which diagnoses seizures:
non caffeine, stimulants or depressants wash hair
what is a magnetic resonance cholangiopancreatography
noninvasive diagnostic to see biliary, hepatic, and pancreativ ducts via MRI. contrast (IV gadolinium) given before contraindications of the procedure that should be assessed by nurse beforehand: -any metal/electrical implants -any allergic reaction to contrast -pregnancy- the conrast crosses the placenta
early symptoms of hepatitis B?
nonspecific like malaise, n/v, abdom pain
given what meds in hypovolemic shock (besides fluids) ?
norepinephrine and dopamine
blood transfusions can only be run with what other fluid?
normal saline
examples of isotonic solutions?
normal saline lactated ringers
measure NG tube
nose tip, to earlobe, down to the xiphoid process
cheyne strokes breathing
not a good sign. concerning in a TBI. tachypnea breathing followed by a gradual decrease that eventually results in apnea. this breathing cycle repeats. often seen in a pt dying
late or variable deceleration indicate what in pregnancy?
not good and need further teaching
nursing management for hemroidectomy- mainly provide pain relief and prevent constipation
nsaids, not so much opioids bc it will worsedn constipation, warm sitz baths, high fiber diet, lots of fluids, stool softener
how to assess for clonus?
nurse dorsiflexes the foot with one hand and supports the leg/ankle with the other. when positive clonus is shown, rhythmic jerking beats of the foot are present as the foot is released
how are bowel sounds determined absent
nurse listens for 2-5 mins in each quadrant
Addison's disease
occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone; hyperpigmentation of the skin
ptosis means injury to what nerve
oculomotoer nerve (cranial nerve III)
somatic delusion
of having some physical defect or disease
what patients are considered immunosuppressed?
on steroids/chemo, HIV pos, new post op, multiple chronic co morbidities, splenectomy, diabetes, very young/elderly
dementia
onset is gradual (months to years), consciousness intact, progressive, irreversible
a sucking chest wound indicates what and is caused from what?
open pneumothorax, air is rushing in with each inspiration and fills the pleural space
basically, lpns can give any medication that doesnt invovlve the veins right? so what can they give?
oral, sub q, IM
symptoms of anaphylaxis
oral/airway swelling dizziness tachycardic stridor/hoarseness wheezing rash pruritis flushing n/v abdom pain treat with IM epinephrine
gastric lavage "stomach pumped"
orogastric tube removes toxins and irrigates stomach rarely performed unless overdose could be lethal and if it can be done within ONE HOUR of the overdose. not done a lot bc of high risk for aspiration or esophageal/gastric perforation **intubation/suction should always be at bedside elevate HOB or put pt on side use large bore
Korsakoff syndrome
orsakoff syndrome causes problems learning new information, inability to remember recent events and long-term memory gaps. Memory problems may be strikingly severe while other thinking and social skills are relatively unaffected. For example, individuals may seem able to carry on a coherent conversation, but moments later be unable to recall that the conversation took place or to whom they spoke. Those with Korsakoff syndrome may "confabulate," or make up, information they can't remember. They are not "lying" but may actually believe their invented explanations.
swimming pool water does not cause otitis media. it causes
otitis externa (swimmers ear)
gentamycin
ototoxicity
advere reaction to gentamicin
ototoxicity and nephrotoxicity
meds should be stored specfcaly how when hiding from children?
out of sight up in a cabinet and locked
when is *hyperresonance* percussed?
over *hyperinflated lung (eg asthma, emphysema)* or in air in pleural space (eg *pneumothorax*)
how are late decels corrected?
oxygen, reposition on right or left side, stop oxytocin if on it, IV fluid bolus
what is failure to capture on a heart rhythm?
pacemaker spikes that are not followed by QRS complexes. the pacemaker may be malfunctioning related to the machine like battery or soemtibg. pt will be bradycardic and hypotensive. the nurse should put on transcutaneuous pacemaker pads to regulate the heart beat until the problem with the pacemaker is fixed. TP is uncomfy for the pt so give analgesia.
what are some symtpoms fo osteoarthritis?
pain exacerabetd by weight bearing crepitus morning stiffness 10-15 mins decrease joint mobility and ROM
manifestations of OsteoArthritis
pain exacerbated by weight bearing crepitus morning stiffness decreased joint mobility and range of motion atrophy of the muscles
if signs of phlebitis are present immediate removel of the catherter is done bc phlebitis can lead to clot formation (thrombophlebitis) or serious bloodstream infection
pain swelling warmth at site, redness
placenta previa symptoms
painless vaginal bleeding, ultrasound shows placenta covering cervical os
symptomatic bradycardia will present like what?
pale, cool skin, hypotension, weakness, confusion, dyspnea, chest pain, syncope
what is fremitus?
palpable vibration on the chest wall when talking
in cystic fibrosis, pancreatic ducts are blocked in the GI tract due to thick secretions that clog them. therefore they are deficient in what type of enxymes?
pancreatic enzymes that are given with meals
proton pump inhibitors examples
pantoprazole and omeprazole given for GERD, ulcer treatment and prophylaxis
flail chest what happens?
paradoxical breathing from multiple rib fractures- inspiration chest moves inward and expiration chest moves outwards. fx rubs can ouncture lung or vessels- can likely lead to hemo or pneumothorax
how do toddlers play?
parallel play- right alongside eachother but not with eachother
remember the 5Ps to compartment syndrome
paresthesia, pain, pressure, palor, pulselessness
remember with bulemia, which gland is swollen?
parotid gland
what is scanning speach?
pasues btwn syllables and is expected with MS
delusions of reference
patient believe songs newspaper articles the radio and other things are personal and significant to them
what is the kernig sign?
patient lies supine, thigh is flexed at right angle, and it hurts to extend leg
liver biopsy during and after
patient supine with right arm above head during after, right side lying and pillow under puncture site. the idea is to place pressure on th pincute site thats why you lie on right side
best indicator of moving air in an asthma pt is wha?
peak flow
testicular self examination
perform monthly and on same day perform while taking hot shower bc temps will relax scrotal tissue and make testis hang lower in scrotum use both hands to feel each testis separately palpate gently using thumb and first 2 fingers
cigarettas and pregnant can cause what things
perinatal loss, sids, low birth weight, premature
characteristics of a basilar skull fracture
periorbital hematomas (raccoon eyes), csf fluid rhinorrhea, and battle sign (behind the ear bruising)
calf pain that relives with rest is what
peripheral arterial disease
wht does failing the pinprick test indicate?
peripheral neuropathy
diffue abdominl pain and rigid abdomen coul indicate what?
peritonitis
what does thromboycytopenia (low platelets) present as?
petechiae, purpura, or bleeding
low platelets
petechiae, spontaneous bleeding
target therapy for polycythemia
phlebotomy to remove some of those RBCs
what is anormal after a cystocscopy
pink tinged urine, frequency, dysuria, abdom discomfort, bladder spasms
incentive spirometer use
piston rises with each deep inhalation; prevents atelectasis in post op patients; 5-10 breaths per session q hour patient is awake
patiets with alzheimers (and other forms of dementia) may wander or get lost so its important to take precautions in the home like
place locks above or below eye level bc they lose their peripheral vision, alrms on doors, disguising the doors, childproof dorrknobs. you want to take precautions to PREVEnt them actually leaving, not just what youd do if they leave
what to do if you need to use an aed on a child but there are only adult pads available not kids
place one on front and one on back to "sandwhich" the heart. just make sure they dont touch
to prevent hip fractures after leg amputaion
place pt prone with hip extension for 30 mins 3-4 times/day
what is suspected in a pregnant woman having painless vaginal bleeding after 20 weeks gestation?
placenta previa
projection
placing ones own thoughts, feelings, or impulses onto someone else
expected term newborn findings
plantar creases up entire sole presence of babinski Epstein's pearls
babinski sign for child more than 1 year and an adult
plantar flexion normal toe flexion (no babinski)
what is parallel play that toddlers do?
play alongside rather than with other children
decreased breath sounds on left side could indicate what
pleural effusion, pneumothorax, atelectasis
in all of these conditions, breath sounds are either decreased or absent AND decreased fremitus
pleural effusion, pneumothorax, emphysema, atelectasis
which lab results are expected for a patient with severe COPD: anemia, neutropenia, polycythemia, or thrombocytopenia?
polycythemia- pt is in hypoxemic state so body makes more RBCs to compensate
s/o dehydration
poor skin trger, dry mucous membranes, tachycardia, orthostatic hypotension, weakness, lethargy
nurse finds a client slumped over in resp distress with low sats and visible food in throat, steos of what to do
position to high fowlers oral suction oxygenate lung sounds notify hcp (usually always last)
latent TB infection
positive TST, neg chest xray, asymptomatic, cant transmit;steroids can convert latent to active TB
the positive babinski is normal in children under 1
positive means big toe moves up and other toes fan out
what does a cpap machine do
positive pressure opens the airway that was previously cut off
if a newborn's heart rate is below 100 bpm, what does the nurse immediately do?
positive pressure ventilation
lactated ringers contains what electrolyte?
potassium
what drug is given with furosemide to prevent electrolyte imbalances?
potassium chloride
spironolactone
potassium sparing diuretic
clients with ESRD are unable to excrete which electrolyte?
potassium; so they should eat a diet low in potassium
swelling of the hands feet and face are expected findings of what pregnant condition?
preeclampsia
ARBs and ACE inhibitors are contraindicated in
pregnancy
MMR is a live vaccine and live vaccines are contraindicated during what?
pregnancy
rubella titer is contraindicated in
pregnancy
if a female patient is getting radioactive iodine to treat hyperthyroidism, what should you get for her?
pregnancy test-after RAI, clients will take supplemental iodine for life
whos at a high risk fr cold stress and why?
premature babies due to decreased brown adipose tissue
sepsis
presence of infection along with systemic manifestations of infection
what things confirm an active TB infection?
presence of symptoms, positive sputum culture, and chest xray
3rd degree AV heart block ECG changes
presents as a *regular rate & rhythm* with *disassociated P waves and QRS complexes*
braden scale assess for what
pressure ulcer
trochanter rolls
prevent legs from turing out
priority intervention for excema
prevent scratching
when are rhonchi primarily heard?
primarily during *expiration* but also may be present during *inspiration*
bronchioltiis
priority as it requires frequent suctioning
high in sodium foods examples
processed meat, cheese, brea, canned soup/veggies, frozen dinners
when is IV epinephrine indicated?
profound hypotension or when a pt does not repsond to IM epinephrine and fluid resuscitation
ises heartburn in pregnancy?
progesterone
beneficience
promote good and do whats best for client
after feeding an infant, what does placing it in the side lying position do
promotes gastric emptying and reduces the risk of vomiting
if GBS status is unknown in a pregnant woman, always give what?
prophylactic antibiotics
diverticular disease causes what?
protrusions form off the large intestine- they can become inflamed and infected causing acute diverticulitis
acute onset dyspnea and cough with sgpink frothy sputum indicates what?
pulmonary edema
left side heart failure symptoms
pulmonary edema, dyspnea, orthopnea, crackles
when is digoxin held in kids?
pulse less than 90
how should a person with COPD breathe?
pursed lip breathing
what do to if pregnant client has prolapsed cord?
put client on their hands and knees in the knee-chest position
is a central venous catheter CVC?
put in a "central" vein (subclavian, internal jugular, femoral)
what helps minimize vertigo?
quiet dark environment
nursing care for pts in acute mania
quiet structured non stimulating envrionment one on one activities instead of group limiting contact with other people high protein high cal finger foods easy to eat
what is the first thing you do with autonomic dysreflexia?
raise the HOB then treat the cause
how to treat acute urinary retention?
rapid comeplete bladder decompression
what is red man syndrome and why does it happen
rapid infusion of vancomycin- flushing, erythema, pruritis on face neck and chest
acute asthma exacerbation
rapid labored respirations using accessory mmuscles
radiation and chemo affect what tpe of cells first?
rapidly dividing cells like oral mucosa, gi, and and bone marrow causing oral ulcerations, nausea and vomiting, and low blood counts of rbc, wbc, etc
reactive nonstress test vs nonreactive nonstress test
reactive nonstress test you have a baseline of 110-160/min, moderate variability and 2 or more accelerations in 20 mins and nonreactive does not meet criteria for reactivity
win disaster triage, what do red yellow green and black eman?
red- life threatening, significant impairement to the abcs, will likely survice if treated within an hour yellow- can wait 1-2 hours- like bone piercing thru skin, etc green- walking wounded- can wait hours black- exected to die
goals for IBS
reduce diarrhea or constipation, abdom pain, and stress. manage with diet, meds, exercise, and stress reduction
what is the nursing care focus opioid dependent newborns?
reduce stimulation promote nutrition and comfort
what is sodium polystyrene sulfonate?
reduces potassium levels
nursing interventions for pin care
regular assessmnt to make sure pins arent loose or showing signs of infection, notify HCP if either neuro checks clean with hydro perx/saline or chlorhexidine
so what to do with dehydrated infant?
rehydrate is priorty- bolus NS for an infant
incentive sprometry
remember *I for INHALE
LOWER UTI
remember FUB frequency, urgency, burning
treatment of frostbite
remove clothing/jewelry to prevent vasoconstriction do not massage rub or squeeze he affeected area immerse affected areas in warm water provide analgesia- rewarming is painful elevate affected areas let areas become dry then put loose nonadherent dressings
surgical wounds are re-dressed using sterile technique.
remove old dressing with clean gloves and apply new dressing with sterile gloves
if infiltration or phlebitis occur, what should the nurse do with either immediately?
remove the IV device
Billroth II surgery (Gastrojejunostomy)
removes part of the stomach and shortens upper GI tract *dumping syndrome* is possible post-op
hypothyrpidism is said to cause lethargy and depressin. so synthroid, the hormone replacement, is supposed to cause eleveated mood and more energy
report sumtoms like high heart rate or chest pain/tremors as this could mean that pt is getting too much hormone repacement so its causing symptoms of hyperthyroidism
Treatment/Interventions - 3rd degree AV heart block
requires temporary or permanent *pacing* to stabilize patient
any condition that causes a decrease in RR is at risk for developing
respiratory acidosis
hypoventilating can cause a buildup of carbon dioxide in the blood and can lead to
respiratory acidosis
if mg toxicity is not reconized early by the DTRs, what can it lead to ?
respiratory depressino and cardiac arrest
RSV/bronchiolitis causes what
respiratory secretions. use saline nose drops abd then suction the nares to remove secretions. give fluids
after thyroidectomy watch out for what
respirtory distress from neck compressing the ariway
what is akathisia?
restlessness with inability to sit still
diet for chronic kidney disease
restrict fluids, sodium, potassium, and phosphorus
what usually causes delayed postpartum hemorrhage?
retained placental fragments
what can cause atelectasis after surgery?
retained secretions
what does excess salt cause?
retention of water
seeing small flashes of light is a sign of
retinal detachment
back pain after catheterization could be what?
retroperitoneal bleeding
what is a serious complication of statin meds?
rhabdomyolysis
when doing compressions on an infant, where do you place your fingers?
right below imaginary horizontal line between the nipples
body positioning after liver biopsy
right side (to put pressure on the liver)
AFTER a liver biopsy positioning
right side lying to put pressure on liver to stop bleeding
who is at risk for circulatory overload?
rspiratorym cardiac, renal or liver disease, olrder clietns, and very young.
what causes pink frothy sputum?
ruptured bronchial veins from the mix of blood and airway fluids
Fourth-degree (full-thickness) burns
same as third-degree (dry & inelastic with waxy white, leathery, or charred black color) plus involvement of *fascia, muscle, and/or bone tissue* *Pain* is *NOT major feature* due to *nerve damage*
what does atrial flutter look like
saw tooth
with a balloon tamponade tube, what should always be kept at the bedside?
scissors
people with narcissistic personality disorder try to maintain what?
self esteem
childhood of someone with NPD
sense of inferiority, poor self esteem, and self criticism
septic shock
sepsis induced *hypotension* despite adequate fluid resuscitation
MODS
septic shock plus multiple organ system damage (2 or more organs)
what type of drainage is expected after a surgical procedure?
serosanguinous (pink)
morphine is typically used for what type of pain?
severe
delerium tremens
severe alcohol withdrawal symptoms like shaking, confusion, and hallucinations
when is atropine given?
severe bradycardia it will speed up heart rate
decerebrate posturing (toes point down and amrs/legs straight out) is a sign of
severe brain damage
infants have a higher body water precentage than adults so they can become dehydrated quickly with vomiting and diarrhea
severe dehydration occurs more rapidly in infants and young children
diabetic ketoacidosis
severe form of hyperglycemia, >250. glucose cant be taken out of the bloodstream withoutinsulin which they cant produce. the body begins to break down fat stores into ketones
epiglottis- what is it?
severe inflammatory obstruction caused by H. influenzae medical emergency!! symptoms progress fast from being asymptomatic to an occluded airway have emergency intubation available
what are the steps to deliver a dose via a metered dose inhaler MDI?
shake MDI and attach to spacer exhale completely place lips tightly around mouthpiece deliver one puff of med into spacer take a slow deep breath and hold it for 10 scds rinse mouth with water
if a pregnant women is positive for GBS, what happens?
she gets prophylactic antibiotics so that she doesnt pass it to her baby during labor bc it can cause harmful things like pneumonia or neonatal GBS sepsis
albuterol
short acting and immediate bronchodilation
Iprattropium
short acting inhaled anticholinergic to promote bronchodilation
albuterol
short term rescue inhaler that treats reversible airway obstruction a/w asthma if not effective, use an inhaled corticosteroid
nasal cannula
short term, allows to eat and drink- delivers oxygen up to 44%
classic presentation of a fracturesd hip
shortened, abducted externally rotated leg
PTT should be 1.5-2.0 times the control value
should not be equal to the control value
classic symptoms of a rotator cuff injury
shoulder pain & weakness, severe pain on arm abduction
body positioning for enema administration
sims
enema administration position
sims
c diff room needs
single
process for breathing from an incentive spirometer
sit in high fowlers or sitting seal lips tightly to prevent air leakage inhale deeply hold breath for 2-3 seconds exhale slowly breathe normal for several breaths before repeating the process cough at the end of the session
incentive spirometry steps
sit upright, exhale and seal lips tight on mouthpiec, inhale, hold breath, then exhale
what will a child with epiglottitis present like?
sitting in tripod position, be drooling, restless, anxious
what is acanthosis nigricans?
skin condition patches of darkened thick skin
parvo causes fifth disease
slapped cheek bright re facial rash, flu like smptoms
cardinal physical sign of Parvo aka fifth disease is what?
slapped cheek rash. spread person to person esp with respiratory secretions
protective factors for SIDS
sleep supine breastfeeding pacifier during sleep up to date vaccines appropriate clothing like sleep sack firm sleep surface remove loose items from bed like pillows toys blankets dont let them sleep in parent room
what are some common findings 5-10 days after a tonsillectomy?
slight ear pain, low grade fever, and bad breath
dementia characteristic
slow onset family members usually notice first gradual progressive inability to remember recent events
if there is discomfort when infusing KCL, what should the nurse do?
slow the rate. dont stop it bc they need their potassium replacement
chemotherapy results in bone marrow suppression
so low rbcs, wbcs, and platelets
why should a patient take diuretic in the morning and not at bedtime>
so they wont have to pee a lot at night
process for a burn at home
soak in cool water to stop buring process remove clothing around burn cover with a clean dry cloth dont put any meds or anything on the wound
cdiff and scabies sanitize isnt sufficient, you need
soap and water
18 guage
somwhat stable adults needing large amounts of fluid or blood
signs of Epiglottitis
sore throat, dyshagia, drooling, respiratory distress, and sitting up/leaning forward AN EMERGENCY- PREPARE FOR EMERGENCY AIRWAY- INTUBATION/TRACHEOSTOMY
what does DOPAMINE do?
speeds up the heart rate increases cardiac contractility
droplet precautions
spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask)
Birth defect associated with depakote during pregnancy
spina bifida
a tuft of hair at base of spine in a newborn indicates what?
spina bifida
what is spina bifida
spinal cord contents protrude through vertebrae an there is a tuft of hair
what to do first with an unrestrained pt invovled in a sudden deceleration accident during emergency trauma care?
spinal precautions are first!! before checking pulse AND opening their airway place cervical collar
how to asisst a falling client?
stand behind and let out leg for supporting them to ground
remember the SIRS continuum
starts with inflammatory rsponse (fever, tachycardia, tachypnea, and then when an infectious source is identified, this is considered sepsis. when they remain hypotensive despite 2L of fluids, this is septic shock. shock and 2 or more systems damaged, this is MODS
What to do if evisceration happens?
stay calm and remain with them notify HCP make them NPO cover wound with saturated dressings to not dry out place in low fowlers with knees flexed assess vitals every 15
steps after newborn is born
stimulate and if after 30 scds if hr remains <100 then start PPV. if after 30 scds still reminds <60 afterquality PPV then do chest compressions and if still <60 then give epinephrine
filgrastinm (Neupogen)
stimulates neutrophil prodctuon
epoetin is what?
stiumlates production of erthropoeitin (to make rbcs) that treats anemia in chronic kidney disease bc the kdineys have a big role in blood cell production
what is Docusate
stool softener
what is docusate?
stool softener
interventions to prevent abdominal wound dehiscence
stool softeners, antiemetics, use abdominal binder, monitor blood sugar to maintain tight glucose control to dec infection risk and promote wound healing, splint the abdomen with pillow when coughing of moving
while giving an enema if the patients reposrts cramping or pain, it is most likely being given too fast. what should the nurse do?
stop for 30 scds and then start at a slower rate
if mg toxicity occurs, what should be done?
stop infusion and give its antidote
coarction of the aorta
strong upper pulses and weak lower pulses
what about if a chest tube separates from the drainage tube and becomes contaminated?
submerge the distal end 1-2 cm below the surface of sterile water to create a water seal so that air does not get in. keep bottle of sterile water, clamps, and antiseptic wipes at the bedside
ovarian cancer symtpms
subtle abdom pain, pelvic pain or pressure, abdom girth inc, urinary urgency/frequency, gi disturbances
ovarian cancer
subtle symptoms at first which contribute to more deaths than any other gynecologic cancer lack of screening and vague symptoms may not be diagnosed until advanced stage
how to measure UO in diapers?
subtract the weight of the diaper when dry from its weight when wet
what to do whn the high pressure alarm on he MV sounds?
suction
where in the chest tube drainage system is gentle, continuous bubbling normal?
suction control chamber. if more water is needed, add sterile water
symptoms of addisonian crisis
sudden drop in bp, tachycardia, hypoglycemia, abdom pain, and weakness; treat with IV hydrocortisone
delirium signs
sudden onset of fluctuating mental status changes and inattention with disorganized thinking and/or altered level of consciousness. think of the patient that I had that was lying in bed and reaching up grabbing something in the air with her hand that wasnt there
placental abruption symptoms
sudden-onset vaginal bleeding, abdominal pain, frequent uterine contractions
20-22 guage
sufficient for giving general IV fluids an meds to adults
trimethoprim-sulfamethazle (Bactrim)
sulfa antibiotic
body positioning after a lumbar puncture
supine
how are orthostatic vitals taken?
supine, sitting, then standing with 2 minutes btewn each position change
symptoms of hypoglycemia
sweating and pallor, irritable, tremors/weakness, tachycardic, drowsiness, hunger. if the brain becomes glucose depleted, this could cause seizures anc coma
Nystatin given for oral candidiasis is given in liquid suspension form. not cream bc it goes inside the mouth.
swish it around in mouth and then swallow it
when is atropine given?
symptomatic bradycardia
rheumatoid arthritis
systemic inflammation of the synovial joints swollen and painful joints usually starts in smaller joints and affects clients ability to button clothing and etc making adls hard what to do? -moist heat for stiffness -rom exercises -ice on painful joints as needed -allow fro periods of rest in the afternoon
positive orthostatic vital signs are present when
systolic BP drops by at least 20 OR diastolic dops by at least 10 pulses usually rises about 20
orthostatic vitals are present when what happens to systolic/diastolic BP?
systolic drops at least 20 diastolic drops at least 10 pulse usually rises about 20
symptoms of malignant hyperthermia
tachycardia, tachypnea, rigid jaw, high fever. it is triggered by drugs used for anesthesia give them IV DANTROLENE
transplanted hearts are expected to be
tachycardic like 90-110
major complication of rheumatoid arthritis is morning stifness
take a warm shower or bath upon wakening
warfrain teachng
take at same time each day dont have a diet high in vitamin k
instructions for taking levothyroxine
take on empty stomach in the morning separate from other meds blood tests are done to determine accurate dose usually is lifelong therapy dont take with antacid, iron, or calcium
what does a pt with Marfan syndrome look like
tall and thin. they often have heart abnormalities so contact sports are discouraged
UAPS can assist with passive and active ROM exercises that were
taught by the nurse or PT
take slow deep breaths durig catheter insertion, dont hold breath.
tell pt to hold breath when changing caps or tubing during a CL dressing change to prevent air embolus
never clamp a chest tube during transport of a pt. what may it cause?
tension pneumothorax cuz the air has no way to escape
what is the first sign of puberty change in boys?
testicular enlargement
what does it mean when induration is shown?
that the person has been exposed to TB, has developed antibodies, and is infected with TB bacteria. however, this doesnt tell if the infection is active or latent so further testing is required.
what is phenylketonuria PKU?
the amino acid phenylaline is unconverted causing neurological damage
what is quickening?
the awareness of fetal movement
wht are symptoms of withdrawal from opioid in infants?
the baby is HYPERSENSITIVE irritability high pitched cry jitteriness sneezing diarrhea vomiting poor feeding tx: opioid therapy like methadone or morphine
persecutory (paranoid) delusion
the belief of being treated in a malicious way
what does fasting do to the body?
the body goes into starvation mode. metabolism slows down and cortisol (stress hormone) increases. body breaks down muscle and converts amino acids to glucose. -fluid loss -depletion of essential nutrients -fatigue, HA, deydration, dizziness, muscle weakness
what is rhabdomyolysis?
the breakdown of muscle tissue releases muscle fiber contents into the blood. these substances can cause kidney damage
what is a saline lock?
the cap that goes onto an iv insertion catheter. it allows you the ability to stop giving iv fluids and then start again at a later time without having to do another venipuncture
what is veracity?
the duty to tell the truth
during dressing changes of a PICC line, what should a nurse check?
the external length of the PICC
orthodox jews cant take capsules why?
the gelatin is not kosher (fit to be consumed)
most frequet sites of bleeding in a hemophiliac are where?
the joints
vitamin K would lower INR why
the more clotting factors, the faster it would take the blood to clot so the lower the INR
in a hypothermic patinet, make sure to put them on cardiac monitor and anticipate defibrillation bc they can easily go into v fib
the myocardim becomes cold and prone to dsrythmias
what is countertransferrence?
the nurse unknowingly displaces feelings and behaviors in the nurses past onto the client
what is wazy flexibility?
the patients limbs stay in the same position in which they are placed by another person
placental abruption
the placenta prematurely detaches from the uterine wall
what does an antinuclear body tell us?
the presense of ANAs which the body produces against its own DNA and material so this shoule be positive in autoimmune disorders
what is the moro reflex?
the startle reflex where the nurse holds the baby and lets it "drop" in her hands and the baby's legs and arms move up in a startle motion/crying
what is partial thromboplastin time (PTT)?
the time it takes your blod to clot
what are mongolian spots and are they normal?
they are bluish discoloration of the skin on newborns seen on darker skinned newborns on the back or butt. they isllay fade over 1-2 yrs of life. nurse shouls measure and document bc they look like bruises. they are normal
its dangerous when someone is throwing PVCs why?
they could go into a lethal dsrythmia
why do opioids cause hypotension?
they dilate peripheral BVs. if the pt stands it can cause orthostatic hypotension
antisocial personality disorder
they disregard rules, hx of irresponsible behavior, and blame others for their actions. SET LIMITS with them make them aware of the rules and acceptable behaviors
children 3-6 put inappropriate causes to things that happen for example
they were bad so their knee was scraped
chronic alcohol abusers suffer from poor nutrition from improper diet and altered nutrient absorption. which vitamin are they specifically at risk for deficiency in?
thiamine
clients with alcoholism are commonly deficient in which vitamin?
thiamine
when a patient is taking lithium, be careful when taking which medications in addition bc they can increase lithium levels and lead to toxicity?
thiazide diuretics, nsaids, and antidepressants
cystic fibrosis
thick mucus, lungs become clogged with mucus. the mucus eventually harbors bacteria and they have recurrent respiratory infections,. chest physiotherapy is used
signs of developmental dysplasia of the hip?
thigh folds laxity of the hip joint
muslim culture- cover up womans body when in the presence of a man not in her family. arrange for women staff for her care, or at least female nurse present
think of ROSE
what is Kawasaki disease and what are he symptoms?
think of it as one big body rash systemic vasculitis in children presenting with more than 5 day of a fever, conjuntivitis, lymphadenopathy, mucositis, hand and foot swelling, an a rash, can cause coronary artery aneurisms some skin peeling jpint pain and irritability
oral warfarin is started about 5 days before a continuous heparin infusion is discontinued. and why?
this is the time it takes warfarin to reach therapeutic level
assess implanted pacemakers for electrical capture of the heart rhythm but also mechanical capture of the heart rate by getting a central pulse like the APICAL pulse
this is to make sure that the pacemaker that is producing a rhythm actually corresponds with the body and giving a pulse therefore pumping blood thru the body
if there is a puncture wound to a person by an object, the nurse should not try to remove the object. instead, they should stabilize it with dressings
this my cause further trauma and bleeding
autonomic dysrefexia (hyperreflexia)
throbbing headache from uncontrolled hypertension nausea blurred vision sweating and skin flushing above level of injury
what are the contraindications for giving tPA?
thrombocytopenia coagulation disorders major surgery within the last 14 dayswha
having chest pain typical of acute MI for 6 hours or less and no absolute contraindications you can then be given what
thrombolytic therapy
what is hypothyroidism?
thyroid horome deficiency, low T3 and T4 levels which decreases the metabolic rate
how to stop epistaxis
tilt the head forward and apply direct continuous pressure on the alaes (sides) for about 5-20 mins can also hold a cold washcloth to the bridge of nose for vasoconstriction keep child calm and quiet
what are vegans at risk for since they dont eat animal products?
tingling and numbness from vit B 12 deficiency-affects the entire nervous system from peripheral nerves to spinal cord and brain
what is atropine used for?
to decrease saliva production before surgery
what is the purpose of hemoglobin?
to pick up oxygen in the lungs and carry it to the tissues
what is the purpose of the water seal chamber in a chest tube>
to prevent air from flowing to the client. up nd down movement here with inspiration and expiration is normal. as the ung re expands this will decrease
2 major purposes of amniotic fluid
to prevent cord compression and promote lung development
during pregnancy, why are women in a hypercoaguble state?
to protect them from hemorrhage but there is a risk for DVT ambulate the pt soon after childbirth
what is the purpose of unfractioned heparin?
to slow the time it takes the blood to clot thereby keeping the current clot from getting bigger and preventing new ones from forming
what is magnesium sulfate used for?
to stop seizures durin pregnancy therapeutic level is 4-7
what is polycythemia?
too many RBCs
polycythemia
too many rbcs, wbcs, and platelets leading to increased hematocrit and blood volume, thicker blood, and abnormal clotting. hct of 66 is an abnormal finding
SIADH
too much ADH is produced causing water retention, increased total body water, and dilutional hyponatremia -can be caused by some central nerve disorders -ADH can sometimes be secreted by lung cancer cells
what do you do if a tooth falls put
tooth death can occur in one hour so put the tooth in milk and get help
why should you not give a baby a bottle of milk or other sugary substance to go to bed?
tooth decay
what is wound evisceration?
total seperation of wound layers with internal organs protruding thru the wall of an incision. Place them in low fowlers with the knees bent helps reduce the tension on the wound
dispacement
transferring thought feelings toward one person to another- person mad at boss comes home and yells at wife
desmopressin
treat bedwetting
dopamine function
treat distributive shock and maintain cardiac output
metronidazole (Flagyl)
treatmemt for trichomoniasis. dont take with alcol or for 24 after coompleting. can cause a metallic taste and cause urine to change a deep red-brown color.
dopamine does what?
treats hypotension due to bradycardia
carbidopa-levodopa
treats parkinson's- improves spontaneous activity seen with this disease
what is Levetiracetam (Keppra) used for?
treats seizures the preferred antiepileptic med
side effects of albuterol and other beta 2 agonists
tremor, tachy, palpitations, restless, hypokalemia
hypoglycemia symptoms
tremors, palpitations, anxiety, restlessness, sweating, and pallor
Clozapine
tretment of schizophrenia *AGRANULOCYTOSIS MUST CHECK CBC AND ANC
at 1 year of age, what should an infant weigh?
triple their birth weight
at 12 months, an infants weight should be
tripled the birth weight
true or fale: antiiotics can affect INR value?
true
what does this cause them to do?
try to regulate their self esteem
airborne precautions
tuberculosis, varicella, and rubeola (measles) wear N95 respirator (and other as needed like for splashes) ALSO (neg pressure room and HEPA) clients suspected are to wear a surgical mask after triage
retinoblastoma
tumor of eye usually diagnoses in children under 2 the pupil will reflect a white color and the child will not have the normal red eye reflex radiation therapy or removal of the eye
glaucoma eye sees
tunnel vision
what med is Riluzole?
tx for ALS- slows progression of the disease
oligohydramnios increases the risk for what?
umbilical cord compression and pulmonary hypoplasia so needs additional personnel and continuous fetal monitoring
what are some classic signs of DVT?
unilateral leg edema, local warmth, erythema, low grade fever (PS a negative homan is normal)
characteristics of herpes zoster
unilateral linear pattern of fluid filled blisters patients report pain and itching
some symptoms of tardive dyskinesia
unusualy movements of arms, legs, face, body
which way to pull pinna in an adult?
up and back
black stools (melena) indicate what?
upper GI bleeding
what does coffee ground emesis indicate?
upper gi bleed
signs of croup
upper respiratory tract symptoms, hoarseness, barking cough, stridor, respiratory distress
how can pregnant women avoid heartburn?
upright position after meals small frequent meals keep HOB elevated drink smaller amounts of fluid while eating eliminate dietary trigger like cffeien, chocolate, fried/fatty foods, spciy foods , peppermint do not take Alka seltzer while pregnant
positioning for paracentesis
upright semi or high fowler
position during a thoracentesis
upright sitting pisition on side of bed, leaning forward over bedside table, arms on pillows
after a cystoscopy notify HCP if:
urinary retention, hemorrhage infection, bright redblood when urinating, blood clots, cant urinate, fever
when inserting a catheter into a male, put it in about 7-9 in. once you start to see urine drops, then advance about 1-2 in more to make sure you're in bladder then inflate balloon. if inflate balloon to early could urethral trauma
urine culd be in urethrea. so basically just bc you are getting drops of urine into the bag does not mean you are in bladder
Gabapentin (Neurontin)
used for neuropathic pain
non rebreather
used in emergencies, delivers high concentrations of oxygen up to 90-95
what is a barium enema aka lower GI series?
uses fluroscopy to visualize the colon outlined by contrast to detect abnormalities like polyps, ulcers, tumors, and diverticula
what is the gower sign?
uses ones hands to rise from sqaut to a chair
a peak flow meter
uses traffic control signals to recognize degree of asthma symptoms. an asthma action plan is individulaized and developed btwn pt and hcp.
following total hip replacement, how is hip dislocation prevented?
using an abductor pillow to maintain hip in a straight position. dont bend hip more than 90 deg avoid extreme internal and external rotation, tell them not to cross legs AVOID ADDUCTION and hip flexion client supine with hob elevated less than or equal to 45deg
what antibiotic is used for cdiff?
vancomycin
in terms of fetal heart rate, the only normal accelerations are accelerations. what are the abnornal ones?
variable, early, and late are all abnormal.
relation of varicella/chicken pox/herpes zoster
varicella causes *chickenpox in childhood* and then the virus goes *dormant.* *reactivation* occurs with *compromised immune system* (eg aging or immunosuppression) can get a *vaccination* to prevent *shingles*
what is the purpose of norepinephrine?
vasoconstriction and improved contractility/output
sodium nitroprusside
vasodilator used in hypertensive emergencies can produce a sudden and drastic drop in bp causing symptomatic hypotension monitor BP closely every 5-10 mins
what is NTG?
vasodilator usd to treat stable angina. sunblignual tablet or spray under tongue. relives pain in about 3 m ins and lasts 30-40 mins recommended dose: 1 tab or 1 spray every 5 minutes for a max of 3 doses. if chest pain continues after 5 mins after first dose, call 911.
iv hydralazine for hypertensive emergency
vasodilator. goal is to slowly drop bp but not to fast
norepinephrine (Levophed)
vasopresser used to increase stroke volume, CO, and MAP
best type of oxygen delivery for a COPD patient
venturi mask
what is ebola
viral hemorrhagic fever extremelt contagious high mortality rate standard, contact, airborne, and droplet precautions so for ppl entering room: impermeable gown/coveralls, N95 respirator, full face shield, dooubled gloves, boot covers, apron no current meds or vaccines to prevent prevention is key there is a strict glove removal process when degloving -client shold have airbonr isolation room, strict ppe use, restrict visitors, and log of ppl who enter room
croup
viral inflammation and edema pf epiglottis and larynx sx: runny nose, tachypnea, inspiratory stridor, seal like barking cough
dealing with a patient with hearing loss or deaf
visibly gain their attention before speaking directly face the client put up hearing impairment sign on hob or door keep lightd on so speakers face is well lit direct speach to least affected ear if partial hearing loss speak at a NORMAL volume
occipital lobe
vision
S/S of digoxin toxicity
visual changes n/v confusion lethargy weakness cardiac arrythmias
what will damage to the occipital lobe cause?
visual disturbances
kids with autism spectrum disorders are usually
visual. dont touch them or make eye contact
oral isoniazid (INH) interferes with what vitamin?
vitamin B6 resulting in peripheral neuropathy. if taking thise you should take a vit B supplement
stress incontinence teaching
void every 2 hours while awake and 4 hrs at night kegels to strengthen pelvic floor muscles
what can determine if a person with heart problems can resume sexual activity?
walking 1 block or climbing 2 flights of stairs without symptoms
near drowning hypothermia
warm iv fluids, blankets, and oxygen also will find weak and thready pulse
where should there be intermittent bubbling on a chest tube?
water-seal chamber
osteoporosis and the elderly
we want to prevent fractures especially hip bisphosphate, calcium and vit D suplment, stop smoking and alcohol, weight bearing exercises
physical findings of peripheral arterial disease
weak/absent peripheral pulses, poor wound healing, cool pallid skin, shiny skin, missing hair
what are some reasons for venipuncture to be contraindicted in upper extremities?
weakness paralysis infection av fistula or graft mastectomy
what is the most accurate indicator of fluid loss or gain?
weight measurements
poor thiamine consumption can lead to wernicke encephalopathy
wernicke encepalopathy
refeeding syndrome
what happens after a starved and severely malnourished person finally gets fed via any of the routes. electrolytes distubrnaces happen and declines in phosphorus, potassium, and magnesium happen
what are symptoms of an asthma exacerbation?
wheezing, coughing, chest tightness, dyspnea, retractions. cough may be the earliest sign
when should an ostomy bag be emptied? (when it is how full?)
when it is 1/3 full
When do *advanced directives* go into effect?
when person is *unable to speak for him/herself* due to either: 1. *Mental Incapacity* - *coma *(GCS score ≤ 7) 2. *Aphasia* (≠as soon as signed; directives can always be changed later by person)
placenta previa
when the placenta covers the opening of the mothers uterus it usually presents with painless vaginal bleeding
what are epsteins pearls?
white pearl like cysts on gum and palate that are benign and usually go away within a few weeks
what should the nurse do if the chest tube becomes separated from drainage tubing and is not contaminated?
wipe the end with antiseptic immediately reconnect it, and secure with tape
when walking stairs use the neumonic, up with the good and down with the bad
with injuries and a cane and going upstairs, always hold cane on the STRONG side and move cane before moving weak leg
when are pancreative supplements taken?
with or just before every meal
beta blockers, calcium channel blockers, and digoxin can all cause bradycaria
withhold beta blockers if hr below 60
when does the umbilical cord detach from body?
within 2 weeks
if patients are having an ischemic stroke, they are given tissue plasminogen activator tPA to dissolve the clot. how soon must tPA be given?
within 3-4.5 hours of onset of symptoms
what happens in diabetic ketoacidosis?
without insulin, the body breaks down fat for fuel, resulting in ketones, polyuria, rapid respirations (kussmauls sign) DKA is serious and can lead to death
what is dysarthria?
worsening ability to speak- can lead to respiratory distress
presence of neurological change in pregnant women may indicate what?
worsening preeclampsia
