NCLEX

Sexual harrassment in healthcare

1. Confront 2. Report 3. Document 4. Support

Subarachnoid hemorrhage

A subarachnoid intercerebral bleed is an emergent, serious presentation often described as the "worst headache of my life." The onset is usually abrupt due to rupture of the vessel. Subarachnoid hemorrhage has a high mortality from recurrent bleeding and is the highest priority presentation.

Down Syndrome

Down syndrome (trisomy 21) is a chromosomal abnormality caused by an error in cell division that results in an extra copy of chromosome 21. Common physical features may include: A short, flattened nasal bridge A single transverse palmar crease Upward slanting, almond-shaped eyes A wide separation between the first and second toes (ie, sandal-toe deformity) Protruding tongue Decreased muscle tone Down syndrome is typically associated with internal manifestations (eg, congenital heart malformations, decreased muscle tone of the chest and abdominal muscles, hypothyroidism) and a predisposition for complications (eg, respiratory tract infections). The nurse should recognize the external features of Down syndrome and report them to the health care provider so that diagnostic testing can be performed to evaluate the extent of internal manifestations.

Fibromyalgia

Fibromyalgia involves neuroendocrine/neurotransmitter dysregulation. Fibromyalgia is a chronic, nonspecific pain disorder. Common sequelae include fatigue, sleep disturbances, emotional distress (eg, anxiety, depression), and even mild cognitive impairments (eg, forgetfulness, difficulty concentrating). Treatment is focused on symptom management and often includes: Muscle relaxers (eg, cyclobenzaprine) Narcotic analgesics (eg, tramadol, hydrocodone) Nonsteroidal anti-inflammatory drugs (eg, ibuprofen, naproxen, celecoxib) Neuropathic pain relievers (eg, pregabalin, gabapentin) Antidepressants such as selective serotonin reuptake inhibitors (eg, fluoxetine, duloxetine) and tricyclic antidepressants (eg, amitriptyline). Antidepressants can cause suicidal ideation and behaviors, especially during the initial few weeks of therapy. This risk is even higher for young adults (age 18-24). The nurse must assess for this adverse effect and alert the provider

Heart Failure from Tetralogy of Fallot

Following repair of tetralogy of Fallot, clients often develop chronic pulmonary regurgitation. Insufficient flow into the pulmonary vasculature causes the right ventricle to work harder, leading to right ventricular hypertrophy and a subsequent reduction in right ventricular function and cardiac output. The decrease in forward blood flow causes blood to back up into venous circulation, resulting in heart failure. Clinical manifestations of heart failure include: Pale, cool extremities due to reduced perfusion to the systemic circulation Periorbital edema (puffiness around the eyes) and rapid weight gain due to systemic venous congestion and fluid retention Reduction in the number of wet diapers due to reduced perfusion to the kidneys

Hirschsprung Disease

Hirschsprung disease (HD) occurs when a child is born with some sections of the distal large intestine missing nerve cells, rendering the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. These newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They also have difficulty feeding and often vomit green bile. Surgical removal of the defective section of bowel is necessary and colostomy may be required. A potentially fatal complication is Hirschsprung enterocolitis, an inflammation of the colon, which can lead to sepsis and death. Enterocolitis will present with fever; lethargy; explosive, foul-smelling diarrhea; and rapidly worsening abdominal distension. Mild to moderate abdominal distension is an expected finding with a diagnosis of HD; however, increasing abdominal girth is a serious finding that must be reported. Failure to pass meconium or stool within 24-48 hours after birth is an expected finding of HD. Bilious vomiting and excessive crying are expected findings of HD. In enterocolitis, vomiting can occur more frequently and the client appears more ill.

Hyperthyroidism

Hyperthyroidism (Graves disease) is an autoimmune condition related to increased production of TH. Neonatal Graves disease is uncommon and usually occurs secondary to maternal hyperthyroidism. Tachycardia and increased bowel motility (frequent or loose stools) are features of hyperthyroidism and are related to an increase in metabolic processes. Thyroid storm is a serious and potentially life-threatening emergency for clients with Graves disease. This condition occurs when the thyroid gland releases large amounts of thyroid hormone in response to stress (eg, trauma, surgery, infection). Characteristic features include tachycardia, hypertension, cardiac arrhythmias (eg, atrial fibrillation), and fever up to 104-106 F (40-41 C). Other findings include severe nausea, vomiting, anxiety, altered mentation, and seizures. Weight loss and warm, moist skin are characteristic of an increased metabolic rate, as found in clients with hyperthyroidism. Interventions include reducing fever, maintaining hydration, and preventing cardiac compromise (i.e. heart failure) Hyperthyroidism (Graves Disease) Hyperthyroidism refers to sustained hyperfunctioning of the thyroid gland due to excessive secretion thyroid hormones (T3, T4); this leads to an increased metabolic rate. Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are used to relieve some of the symptoms of thyrotoxicosis (thyroid storm), a complication of hyperthyroidism in which excessive thyroid hormones are released into the circulation. Beta blockers block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in hyperthyroidism. In clients with hyperthyroidism, teaching and learning objectives to satisfy hunger and prevent weight loss and tissue wasting include: Adherence to a high calorie diet (4000-5000 calories per day). Consumption of approximately 6 full meals and snacks per day. These should be packed with protein (1-2 g/kg of ideal body weight), carbohydrates, and be full of vitamins and minerals Avoidance of high-fiber foods due to the constant hyperstimulation of the gastrointestinal (GI) tract. High-fiber foods may increase GI symptoms (eg, diarrhea)However, high-fiber diets are recommended if the client with hyperthyroidism has constipation. Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft drinks). Avoidance of spicy foods as these can also increase GI stimulation. Thyroid storm: life threatening condition that can occur in uncontrolled hyperthyroidism Manifestations of thyroid storm include a rapid onset of fever, tachycardia, and elevated blood pressure. The client often feels anxious, tremulous, or restless. Confusion and psychosis can occur, as can seizures and coma. Rapid treatment is necessary. Most commonly, thyrotoxicosis occurs as an exacerbation of hyperthyroidism and is treated with antithyroid medications and/or surgical removal of the thyroid (thyroidectomy). However, thyrotoxicosis may also occur due to excess thyroid hormone intake from medications and physical manipulation of the thyroid gland. The nurse caring for a client after thyroidectomy must closely monitor for and immediately report any clinical manifestations of thyrotoxicosis (eg, fever, chills, tachycardia), including small rises in body temperature After surgery, thyroid hormone levels can remain elevated for several days and may even increase from intraoperative thyroid gland manipulation. Without treatment, thyrotoxicosis can rapidly progress to lethal complications (eg, hyperthermia, ventricular tachycardia).

low molecular weight heparin

Low-molecular-weight heparins (LMWHs) (eg, enoxaparin, dalteparin) are anticoagulants commonly used for prevention and treatment of deep venous thrombosis and pulmonary embolism. LMWH is administered subcutaneously and is often available in a prefilled syringe, which contains an air bubble to ensure delivery of the entire dose. During injection, the air bubble follows the medication out of the syringe, ensuring that no medication is left behind. The nurse should not expel the air bubble prior to administration as this could result in an incomplete dose and medication error

Mechanical Ventilation

Mechanical ventilator alarms (eg, high- or low-pressure limit) alert the nurse to potential problems caused by a change in the client's condition, a problem with the artificial airway (eg, endotracheal or tracheostomy tube), and/or a problem with the ventilator. Peak airway pressure is the amount of pressure required to deliver a tidal volume. Any condition that increases the peak airway pressure can trigger the ventilator high-pressure limit alarm. When this alarm sounds, the nurse should assess for conditions that increase airway resistance and/or decrease lung compliance, such as: Excessive secretions: Obstruct the airway, increasing resistance Biting the endotracheal tube and kinked ventilator tubing: Air flow is obstructed, increasing resistance Any condition that decreases airway resistance (eg, tubing disconnect, extubation, endotracheal or tracheostomy tube cuff leak) can trigger the low-pressure limit alarm. When the mechanical ventilator high-pressure limit alarm sounds, the nurse should assess for causes of increased airway resistance in the client (eg, bronchospasm), artificial airway (eg, excessive secretions, biting the endotracheal tube), and/or ventilator system (eg, kinked tubing), as well as for causes of decreased lung compliance (eg, pneumothorax).

Neurogenic Shock

Neurogenic shock belongs to the group of distributive (vasodilatory) shock. It affects the vasomotor center in the medulla and causes a disruption in the sympathetic nervous system (SNS); the parasympathetic nervous system (PNS) remains intact. The imbalance of activity between the SNS and PNS results in massive vasodilation and pooling of blood in the venous circulation, causing hypotension and bradycardia, the characteristic manifestations of neurogenic shock.Neurogenic shock is a complication of traumatic brain injuries and spinal cord injuries (SCIs) at or above T6 that causes hemodynamic decompensation due to loss of sympathetic nervous response. This leads to bradycardia, systemic vasodilation, and pooling of blood in the extremities, reducing venous return and cardiac output (CO) and ultimately causing impaired tissue perfusion. The normal compensatory mechanism of tachycardia to raise CO cannot occur due to unopposed parasympathetic nervous activity. The nurse should protect the client's airway and provide supplemental oxygen as needed. The client's cervical spine must be kept immobilized in a rigid collar to prevent SCI exacerbation and permanent disability and should not be discontinued until the SCI is radiographically evaluated and cleared by the health care provider IV fluid boluses may be given, along with vasopressors (eg, norepinephrine) to keep the systolic blood pressure >90 mm Hg and mean arterial pressure >60 mm Hg. Positive chronotropes (eg, atropine) may also be needed to increase heart rate. The nurse should perform and record Glasgow coma scale (GCS) scores to monitor level of consciousness. Decreasing GCS may indicate a need for endotracheal intubation and mechanical ventilation. This presentation is classic for neurogenic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from the spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin from the vasodilation. Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of isotonic fluids is a priority to ensure adequate kidney and other organ perfusion.

Nitroglycerin

Nitroglycerin is a nitrate that causes vasodilation and relaxation of vascular smooth muscle. In clients with acute coronary syndrome, it is administered by IV infusion to decrease preload and prevent spasm of the coronary arteries, thereby increasing perfusion and oxygen supply to the cardiac muscle. Due to systemic vasodilation, this client is at risk for significant hypotension. The nurse should follow up immediately if the client reports dizziness or lightheadedness, which may indicate profound hypotension If the client is found to be hypotensive, the nurse may need to decrease or discontinue the infusion. Headache is a common side effect of nitroglycerin therapy and is often a sign that the medication is working properly. It is not a priority, although acetaminophen may be given for pain relief. Systemic vasodilation and decreased cardiac preload may cause the client to feel flushed and nervous during infusion. However, reports of dizziness and lightheadedness should take priority. Current evidence indicates that up to 50% of clients lack knowledge about administration procedures, storage, and side effects of NTG. Proper teaching can prevent many hospital visits for chest pain from stable angina. The client should be instructed to take 1 pill (or 1 spray) every 5 minutes for up to 3 doses, but emergency medical services (EMS) should be called if pain is unimproved or worsening 5 minutes after the first tablet. Previously, clients were taught to call EMS after the third dose, but newer studies suggest that this causes a significant delay in treatment NTG should cause a slight tingling sensation under the tongue if it is potent; otherwise, the medication is likely outdated. The oral mucosa needs to be moist for adequate absorption of NTG, and clients should be instructed to take a drink of water before administration if needed for dry mouth. Sublingual tablets should never be swallowed ​​​​​​​ If using a spray, the client should not inhale it but direct it onto/under the tongue instead.

Peka Expiratory Flow Rate

Peak expiratory flow rate (PEFR) is the peak velocity of exhaled air during forced exhalation. Clients with asthma use a peak flow meter to monitor their PEFR and determine their level of asthma control. An optimal PEFR is determined by recording the client's personal best peak flow number during 2 weeks of well-controlled asthma symptoms. Guided by their personal best, clients are taught asthma self-care using peak flow "zones": Green zone (≥80% of personal best): no intervention needed Yellow zone (50%-79% of personal best): intervention needed (eg, short-acting bronchodilator [eg, albuterol]) and/or treatment plan modification by the health care provider) Red zone (<50% of personal best): emergency medical care and short-acting bronchodilators required and hospital admission possible A peak flow meter is a handheld device that measures the client's ability to push air out of the lungs. Measurements from a peak flow meter often guide the client's use of respiratory medications and the need to schedule an appointment with a health care provider. To obtain the most accurate readings to help guide, maintain, and evaluate treatment in clients with asthma, the procedure is performed in the following order: Before each use, slide the indicator on the numbered scale on the flow meter to 0 (or the lowest value), and stand or sit as upright as possible Inhale deeply, place the mouthpiece in the mouth, and close the lips tightly around the mouthpiece to form a seal Exhale as quickly and completely as possible and note the reading on the numbered scale Repeat the procedure 2 more times, with a 5- to 10-second rest period between exhalations Record the highest reading (ie, personal best) in the peak flow log

Postpartum Psychosis

Postpartum psychosis is a rare but serious perinatal mood disorder. Research suggests a multifactorial etiology, including genetic predisposition and hormone fluctuation after birth. Risk factors include history of bipolar disorder and previous discontinuation of mood-stabilizing medications (eg, lithium). Signs appear within 2 weeks after birth and include hallucinations, delusions, paranoia, severe mood changes, delirium, and feelings that someone will harm the baby Postpartum psychosis is a psychiatric emergency requiring hospitalization, pharmacologic intervention, and long-term supportive care. Women exhibiting signs of postpartum psychosis are at increased risk of suicide and infanticide, and their assessment should take priority to ensure the safety of mother and baby.

Pediculosis Capitis

Preventing the spread of pediculosis capitis (head lice) may be accomplished by using hot water to launder clothing, sheets, and towels in the washing machine; these items should then be placed in a hot dryer for 20 minutes. Treatment of head lice consists of the use of pediculicides and the removal of nits (eggs). Items that cannot be washed or dry cleaned may be placed in sealed plastic bags for 14 days to kill active lice or lice that hatch from the nits in 7-10 days. Vacuuming of furniture, carpets, stuffed toys, rugs, and mattresses is also recommended to prevent the spread of lice and nits. Pediculosis capitis (head lice) is a common parasitic infestation of the scalp that is typically seen in school-aged children. It is spread by contact with personal items such as clothing, combs, and bedding.

Scarlet Fever

Scarlet fever (ie, scarlatina), a complication of group A streptococcal infection (eg, streptococcal pharyngitis), is common in early childhood and is characterized by a distinctive red rash. The rash begins on the neck and chest and spreads to the extremities, resembles a bad sunburn, blanches with pressure, and has fine bumps like sandpaper. Additional manifestations of streptococcal pharyngitis (eg, exudative pharyngitis, fever, swollen anterior cervical lymph nodes) are typically present. Because the clinical presentation (ie, rash plus sore throat) is characteristic, but not diagnostic, of scarlet fever, the health care provider will prescribe a rapid streptococcal antigen test to confirm symptom etiology. Swabbing the posterior pharynx and tonsils provides test results within minutes. Throat culture may be necessary to verify results.

Maturation in males

Testicular enlargement, including scrotal changes, is the first manifestation of puberty and sexual maturation. This typically occurs at age 9½-14. It is followed by the appearance of pubic, axillary, facial, and body hair. The penis increases in size and the voice changes. Some boys also experience an increase in breast size. Growth spurt changes of increased height and weight may not be apparent until mid-puberty. Sexual maturation in boys begins with an increase in testicular size, followed by changes in the scrotum, appearance of pubic, axillary, facial, and body hair, and voice changes.

Delusions from Schizophrenia

Tactile hallucination, which gives the client the sensation of being touched. Auditory hallucination, specifically a command hallucination. Clients experiencing auditory hallucinations hear sounds and voices others do not. Persecutory (paranoid) delusion. Clients with such delusions believe that they are being threatened or treated unfairly in some way. Delusions are one of the positive symptoms of schizophrenia. Delusions are false beliefs that have no basis in reality and are unrelated to a client's culture or intelligence. When presented with proof that the delusion is irrational or untrue, the client continues to believe it is real. Clients experiencing delusions of reference will believe that songs, newspaper articles, and other events are personal and significant to them. Other examples of delusions are below: Grandeur - "I need to get to Washington for my meeting with the president." Control - "Don't drink the tap water. That's how the government controls us." Nihilistic - "It doesn't matter if I take my medicine. I'm already dead." Somatic - "The doctor said I'm fine, but I really have lung cancer." Tactile hallucination, which gives the client the sensation of being touched. Auditory hallucination, specifically a command hallucination. Clients experiencing auditory hallucinations hear sounds and voices others do not. Persecutory (paranoid) delusion. Clients with such delusions believe that they are being threatened or treated unfairly in some way. Clients with persecutory delusions (paranoid delusions) believe that they are being persecuted or harmed (eg, spied on, cheated, followed, poisoned). Focusing on the client's feelings secondary to the delusion is an example of empathy, one of the most important parts of the therapeutic nurse-client relationship. When nurses attempt to understand clients' feelings and their meaning, clients realize that someone is trying to understand them and the nurse-client relationship grows Focusing on reality and verbally reinforcing it will decrease the time that the client spends thinking about the delusions For example, the nurse may focus on the client's feelings by stating, "I understand that it is frightening to know that someone is trying to poison you." Reality orientation may also be helpful by telling the client, "What you are thinking is part of your disease and not real." The priority nursing action is to explore the content of the hallucinations. This client may be experiencing command auditory hallucinations that could lead to self-directed or other-directed injury and harm. After the content of the hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence. Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any of the 5 senses. Auditory hallucinations are the most common, followed by visual, tactile (touch), olfactory (smell), and gustatory (taste). Additional ways to deal with hallucinations include the following: Telling the client that you know they are real to the client but that you do not hear the voices (or see the vision, feel the sensation) Not arguing with or challenging the client about the hallucinations Directing the client to a reality-oriented topic of conversation or activity Nursing interventions: Not arguing or challenging the belief Reinforcing reality by talking about and encouraging the client to participate in real events. The nurse should not delve into or have long conversations about the delusional belief system.

Fundal Height

The fundus rises above the symphysis pubis at approximately 12 weeks gestation, reaches the umbilicus at 20-22 weeks gestation, and reaches the xyphoid process at 36 weeks gestation. After 20 weeks gestation, the fundal height in centimeters correlates closely to the weeks of gestation. A fundal height measurement that does not match the expected height for the current gestational age requires priority assessment by the nurse and health care provider because it may indicate an incorrect gestational age, a multifetal gestation (eg, twins), or a molar pregnancy

Peripheral IV complications

The nurse should also monitor for edema related to infiltration under the involved limb. Infiltrated fluid may leak into loose skin, causing edema in dependent areas without obvious signs of infiltration at the PIV site, particularly in the elderly. If a PIV site is leaking fluid, the tubing and catheter connections should be assessed. If all connections are intact, possible problems include infiltration/extravasation, a thrombus at the catheter tip, or damage to the catheter; all of these issues require a site change Infiltration, Phlebitis

Nurse Ethics

The nurse violated the ethical principle "nonmaleficence" (ie, do no harm). It is rare to see a nurse inflict intentional harm. However, problems do occur due to unintentional harm, which is usually a result of poor clinical judgment. Beneficence is a nurse's duty to promote good and do what is best for the client. Autonomy is allowing the clients to choose the direction of their care. This is accomplished with advanced directives along with informed consent and choices regarding proposed treatments. Paternalism is a type of beneficence whereby clients are treated as children. The nurse claims to know what is best for the client and coerces the client to act as the nurse wishes without considering the client's autonomy. Veracity refers to the duty to tell the truth. This principle should always be applied to client care and documentation. Fidelity is exhibiting loyalty and fulfilling commitments made to oneself and others. It includes meeting the expected responsibilities of professional nursing practice and provides the basis of accountability (taking responsibility for one's actions) The principle of justice refers to treating all clients fairly (ie, without bias). Veracity is telling the truth as a fundamental part of building a trusting relationship.

Inhaler Spacer

The proper method of delivering a dose via MDI includes the following steps: First shake MDI and attach it to the spacer. Exhale completely to optimize inhalation of the medication. Place lips tightly around the mouth piece. Deliver a single puff of medication into spacer. Take a slow, deep breath and hold it for 10 seconds to allow for effective medication distribution. After the dose, rinse mouth with water to remove any left-over medication from oral mucous membranes. Spit out the water to ensure no medication is swallowed.

Pulse oximetry

The sensor relies on adequate tissue perfusion, so low blood flow or decreased perfusion can decrease SpO2 readings. Conditions associated with low blood flow or decreased perfusion states include cardiac dysrhythmias, heart failure, peripheral vascular disease, edema, hypotension, hypovolemic shock, and vasoconstriction (eg, hypothermia, smoking, drugs). Other factors affecting accuracy of the reading include improper positioning or fit of the sensor, excessive movement, smoke inhalation, and carbon monoxide poisoning.

Third-spacing

Third-spacing of fluids can occur 24-72 hours after extensive abdominal surgery as a result of increased capillary permeability due to tissue trauma. It occurs when too much fluid moves from the intravascular into the interstitial or third space, a place between cells where fluid does not normally collect (ie, injured site, peritoneal cavity). This fluid serves no physiologic purpose, cannot be measured, and leads to decreased circulating volume (hypovolemia) and cardiac output. The priority intervention is to assess vital signs as the manifestations associated with third-spacing include weight gain, decreased urinary output, and signs of hypovolemia, such as tachycardia and hypotension. If third-spacing is not recognized and corrected early on, postoperative hypotension can lead to decreased renal perfusion, prerenal failure, and hypovolemic shock

Leaving Against Medical Advice

To leave against medical advice (AMA), a client must have the risks explained and be able to understand them (ie, competent). Issues that can make a client ineligible to leave AMA include danger to self or others, lack of consciousness, altered consciousness, mental illness, being under chemical influence, or a court decision.

Infant CPR

Two techniques are acceptable for performing chest compressions on a newborn or infant. In the first, two thumbs are placed on the middle third of the sternum, with the fingers encircling the chest and supporting the back. The thumbs should be positioned side by side, just below the nipple line. This technique is preferred because it may result in improved cardiac perfusion. If the newborn or infant is extremely small or the rescuer's thumbs are extremely large, the thumbs may be superimposed (one on top of the other). The xiphoid portion of the sternum should not be compressed because this may damage the liver. The alternate method, especially if the resuscitator's hands are too small to encircle the chest, is to place only the index and middle fingers of one hand on the sternum just below the nipple line. The other hand should support the back. This technique is preferred if umbilical cord access is needed or in single rescuer situations. During compressions, the sternum is compressed approximately one-third of the anteroposterior chest diameter at a rate of 100-120/min (compression-ventilation ratio: 30:2 for 1 rescuer and 15:2 for 2 rescuers). The thumbs or fingers should not be lifted from the sternum during the relaxation phase. The rescuer should check for brachial pulse no more than 10 seconds​​​​​​​

Child Abuse

Typical characteristics of child abuse perpetrators include: Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly critical of the child Confusion between punishment and discipline; having a stern, authoritative approach to discipline Having to cope with ongoing stress and crises such as poverty, violence, illness, lack of social support, and isolation Low self-esteem—a sense of incompetence or unworthiness as a parent A history of substance abuse; use of alcohol or drugs at the time the abuse occurs Punitive treatment and/or abuse as a child Lack of parenting skills, inexperience, minimal knowledge about child care and child development, and young parental age Resentment or rejection of the child Low tolerance for frustration and poor impulse control Attempts to conceal the child's injury or being evasive about an injury; shows little concern about the child's injury When speaking with a child about abuse, the nurse should be direct and honest. The nurse should allow the child to disclose the abuse at a comfortable pace, rather than probe for additional information. The nurse should use open-ended questions and avoid leading questions and statements. Guidelines for the interview: Speak with the child in private Be honest about reporting requirements Use language appropriate to the child's age Avoid making assumptions or communicating anger, shock, or disapproval Reassure the child about not being at fault or in trouble

Ventricular Septal Defect

Ventricular septal defect (VSD) is a congenital abnormality in which a septal opening between ventricles causes left-to-right shunting, leading to excess blood flow to the lungs. This places the client at risk for congestive heart failure (CHF) and pulmonary hypertension. Clinical manifestations of VSD include a systolic murmur auscultated near the sternal border at the third or fourth intercostal spaces, and hallmark CHF signs (eg, diaphoresis, tachypnea, dyspnea). The client is currently showing signs of increased respiratory exertion (eg, grunting) and requires further assessment for CHF

Anencephaly

Anencephaly is a severe neural tube defect resulting in little to no brain tissue or skull formation in utero. The newborn may be stillborn or born alive, although death occurs shortly thereafter. Nurses should facilitate a therapeutic environment for grieving parents and provide newborn comfort care such as warmth and oxygen.

Legal Terms

Assault is an act that threatens the client and causes the client to fear harm, but without the client being touched False imprisonment is the confinement of a client against the client's will or without legal justification (eg, client is not a threat to self or others) Invasion of privacy includes disclosing medical information to others without client consent. Under the Health Insurance Portability and Accountability Act (HIPAA), a client's information regarding medical treatment is private and cannot be released without the client's permission Battery involves making physical contact with the client without permission. This includes harmful acts or acts that the client refuses (eg, performing a procedure). When interacting with the client, it is important to practice veracity, the ethical principle of being truthful. An emancipated minor is an individual under the age of legal responsibility who has been legally freed from parental control through a court order (eg, due to enlistment in the military, marriage, pregnancy). The parent in this situation would not need to be called. Clients have the right to be informed of risks and benefits of procedures prior to care and to give informed consent.

Serotonin Syndrome

Can occur when pt. is on linezolid (has MAOI-type properties) therapy and takes an SSRI (paroxetine, fluoxetine, sertraline). SSRIs can be resumed 24 hours after linezolid therapy has been d/c. Serotonin syndrome, a potentially life-threatening condition, develops when drugs affecting the body's serotonin levels are administered simultaneously or in overdose. Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol. The diagnosis is primarily clinical and based on medication history and clinical findings. Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia). The client experiencing serotonin syndrome would exhibit hyperreflexia. The client experiencing serotonin syndrome would exhibit warm moist skin and a fever. COMMON S/S: TACHYCARDIA, DIAPHORESIS, AGITATION, MYDRIASIS (PUPIL DILATION), HYPERREFLEXIA, CLONUS, TREMOR, DIARRHEA AND HYPERACTIVE BOWEL SOUNDS, AUTONOMIC INSTABILITY AND HYPERTENSION Serotonin can be increased by the addition or high doses of serotonergic medication, or by some herbal medications (St. John's Wort) Selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram) cannot be combined with monoamine oxidase inhibitors (MAOIs) (eg, phenelzine) as there is a risk of serotonin syndrome. MAOI effects persist long after dosing stops. An MAOI should be withdrawn at least 14 days before starting an SSRI.

Uterine Rupture

Clients attempting vaginal birth after cesarean (VBAC) have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus. Clients desiring VBAC are usually encouraged to wait for spontaneous onset of labor rather than undergo induction and are monitored closely throughout labor and delivery. The first sign of uterine rupture is usually abnormal fetal heart rate (FHR) patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if severe rupture occurs unrecognized. Most commonly, FHR decelerations followed by fetal bradycardia are indicative of uterine rupture. Fetal tachycardia may be caused by infection, maternal fever, or stimulant drugs. Contractions normally grow more intense as labor progresses, and increasing anxiety and discomfort are common. However, the nurse should monitor the client for constant, severe abdominal pain, which may indicate uterine rupture. The nurse should be hypervigilant for tachysystole (> 5 ctx in 10 min) , which increases the risk for uterine rupture. Strong contractions every 3-4 minutes are probably indicative of a normal labor contraction pattern.

Cognitive Impairment

Clients with cognitive impairment (intellectual disability) are diagnosed prior to adulthood and have limited levels of intellectual functioning and adaptive skills for their chronological age. Manifestations may include a decreased ability to perform abstract or logical reasoning, interpret complex ideas, and learn by experience. Cognitive impairment results in developmental delays of varying levels (eg, mild, moderate) and types (eg, cognitive, physical, social, emotional, behavioral) and requires the nurse to assess the client's skills and abilities and provide individualized care. Appropriate nursing interventions for a client with cognitive impairment include: Promoting the staff's understanding of client behavior/needs and maintaining a familiar environment for the client by consistently assigning the same staff (eg, nurse) for care Fostering playtime by providing toys that are developmentally appropriate, not necessarily age appropriate Preventing self-injury by reinforcing the parents' limit-setting measures (eg, time-outs) and positively reinforcing good behavior Facilitating communication and learning by using visual demonstration (eg, picture board) rather than complex explanations The nurse should involve parents in preprocedural education but avoid excluding the client; explaining procedures using methods appropriate for the client's cognitive ability is encouraged.

Infant Botulism

Clostridium botulinum spores in honey or soil can colonize an infant's immature gastrointestinal system and release a toxin that causes botulism, a rare but serious illness. The toxin attacks the neuromuscular system, causing progressive muscle paralysis that can potentially lead to respiratory failure and death. Initial manifestations may include constipation, generalized weakness, difficulty feeding, and decreased gag reflex. Iron-fortified infant cereals (eg, oatmeal) mixed with formula or breastmilk are appropriate for infants >6 months; however, honey (especially raw or wild) is not recommended for infants age <12 months due to the risk of botulism Botulism is caused by the gastrointestinal absorption of the neurotoxin produced by Clostridium botulinum. The neurotoxin blocks acetylcholine at the neuromuscular junction, resulting in muscle paralysis. The organism is found in the soil and can grow in any food contaminated with the spores. Manifestations include descending flaccid paralysis (starting from the face), dysphagia, and constipation (smooth muscle paralysis). The main source is improperly canned or stored food. A metal can's swollen/bulging end can be caused by the gases from C botulinum and should be discarded. The infant form of botulism can occur in children under age 1 year if they eat honey, particularly raw (wild) honey. The immature gut system in these children makes them more susceptible. Infant botulism is food poisoning that occurs after consuming Clostridium botulinum, a bacteria found in soil and animal products (eg, raw honey, milk). In infants, the bacteria often colonize the gastrointestinal tract and release an exotoxin that causes rapid, life-threatening paralysis. In addition to young age, absence of competitive bowel flora predisposes infants (age <1 year) to this infection. Therefore, infants should not be fed honey. Early clinical manifestations of infant botulism often include constipation, difficulty feeding, decreased head control, and diminished deep-tendon reflexes It is essential to recognize symptoms early, because botulism progresses rapidly to respiratory failure and arrest. Management of infant botulism often includes administering intravenous botulism immune globulin (BIG-IV), which reduces severity and duration of symptoms by improving immune response. In addition, close monitoring and supportive care (eg, mechanical ventilation, enteral tube feedings) are provided.

Complete Atrioventricular Canal Defect

Commonly associated with Trisomy 21 (Down Syndrome)

Restraints

When caring for a client in restraints, the nurse should implement these interventions at regular intervals, according to agency policy (eg, every 2 hours): Provide skin care and range-of-motion exercises; ensure basic needs are met (eg, fluids, nutrition, elimination). Assess skin integrity and neurovascular status of restrained extremities; pad bony prominences under restraints, if necessary, to protect skin Determine the need for continued restraint by releasing restraints briefly and assessing the client's reaction; regularly assessing the need for restraints promotes discontinuation as soon as possible Supine positioning increases aspiration risk as the client may be unable to self-reposition if vomiting occurs. Side-lying or semi-Fowler position promotes drainage of emesis or oral secretions. Restraint straps should be tied in a quick-release knot, in case of emergency, and never in a square knot, which is difficult to release quickly. When physical restraints are applied to a client, the nurse is responsible for the primary and ongoing assessments (eg, skin integrity, peripheral pulses, neurovascular status), determining appropriateness of restraint type, need for continued use, and psychological response. These tasks may not be delegated to the UAP. The UAP may report changes in these areas if noted but must not be expected to monitor for changes.

Wilms tumor (nephroblastoma)

Wilms tumor (nephroblastoma) is a kidney tumor that usually occurs in children age <5. Most often it involves only one kidney, and the prognosis is good if the tumor has not metastasized. Wilms tumor is usually diagnosed after caregivers observe an unusual contour in the child's abdomen. Once the diagnosis is suspected or confirmed, the abdomen should not be palpated, as this can disrupt the encapsulated tumor. It is important to post the sign "DO NOT PALPATE ABDOMEN" at the bedside. It is also essential that the child be handled carefully during bathing.

Abdominal Aortic Aneurysm

With either procedure, postoperative monitoring for graft leakage or separation is a priority. Manifestations of graft leakage include ecchymosis of the groin, penis, scrotum, or perineum; increased abdominal girth; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased pain in the pelvis, back, or groin; and decreased urinary output Abdominal aneurysms may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. A bruit may be auscultated over the site. Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). Rupture of an abdominal aneurysm can quickly cause exsanguination and death. This client may need emergency surgery to repair the aneurysm. An abdominal aortic aneurysm (AAA) is a blood-filled bulge in the abdominal aorta caused by weakening in the vessel wall due to increased pressure. Risk factors include - male sex - age >65 - coronary artery and peripheral vascular diseases - hypertension - family - smoking history AAA dissection (blood leakage into a vessel tear) or rupture may manifest as acute-onset abdominal pain radiating to the back and is typically associated with symptoms of hemorrhagic shock (eg, decreased systolic pressure; increased, weak pulses; pallor). Open aneurysm repair involves a large abdominal incision and requires cross-clamping the aorta proximally and distally to the aneurysm. Establishing baseline data is essential for comparison with postoperative assessments. The nurse should pay special attention to the character and quality of peripheral pulses and renal and neurologic status. Dorsalis pedis and posterior tibial pulse sites should be marked for easy location postoperatively. A decreased or absent pulse with cool, pale, mottled, or painful extremity postoperatively can indicate embolization or graft occlusion. Renal perfusion status is monitored closely in a client who has had abdominal aneurysm repair. Hypotension, dehydration, prolonged aortic clamping during surgery, blood loss, or embolization can lead to decreased renal perfusion and potential kidney injury. The nurse should routinely monitor the client's blood urea nitrogen (BUN) and creatinine levels as well as urine output. Urine output should be at least 30 mL/hr. This client should have an output of at least 120 mL of urine in a 4-hour period.

DVT and PE risks for pregnant women

Women who give birth by cesarean section are at particularly increased risk for deep venous thrombosis (DVT). Additional risk factors for DVT include obesity, smoking, and genetic predisposition. If unrecognized, DVT may progress to pulmonary embolism (PE), often characterized by anxiety/restlessness, pleuritic chest pain/tightness, shortness of breath, tachycardia, hypoxemia, and hemoptysis. The nurse's priority is rapidly identifying symptoms, assessing respiratory status, administering supplemental oxygen, and notifying the health care provider (HCP) Pregnancy is a hypercoagulable state that increases risk for deep venous thrombosis and pulmonary embolism (PE). Signs and symptoms of PE include anxiety/restlessness, pleuritic chest pain/tightness, shortness of breath, tachycardia, hypoxemia, and hemoptysis. Priorities are rapid symptom identification, assessment of oxygenation, and notification of the health care provider.

ABGs

pH. 7.35-7.45 PaO280-100 mm Hg (10.7-13.3 kPa) PaCO2. 35-45 mm Hg (4.66-5.98) Bicarbonate (HCO3-). 22-26 mEq/L (22-26 mmol/L) O2 Saturation (SaO2)95%-99%

Vancomycin

- Draw the prescribed trough level prior to administration. Therapeutic vancomycin levels range from 20-40 /L for hemodynamically stable clients. Adverse effects of vancomycin toxicity include nephrotoxicity (eg, elevated creatinine levels) and ototoxicity (eg, hearing loss, vertigo, tinnitus). Infuse medication over at least 60 minutes (≤10 mg/min). Faster rates increase the likelihood of complications Monitor blood pressure during the infusion. Hypotension is a possible adverse effect Assess for hypersensitivity. Red man syndrome is a nonallergic histamine reaction characterized by sudden onset of severe hypotension, flushing, and/or maculopapular rash of the face, neck, chest, and upper extremities Monitor for anaphylaxis (eg, rash, pruritus, laryngeal edema, wheezing). Observe IV site every 30 minutes for pain, redness, or swelling. Vancomycin is a vesicant and may cause thrombophlebitis or, if extravasation occurs, tissue necrosis. Administration using a central venous catheter is preferred; however, a peripheral IV may be used for short-term therapy Red man syndrome (RMS) is a condition that can occur with rapid IV vancomycin administration. It is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest. Muscle pain, spasms, dyspnea, and hypotension may also occur. RMS is usually a rate-related infusion reaction and not an allergic reaction. It can be reduced by infusing vancomycin over a minimum of 60 minutes. It can be difficult to differentiate severe RMS from anaphylaxis as flushing and hypotension can occur in both conditions. However, hives, angioedema (lip swelling), wheezing, and respiratory distress are more suggestive of anaphylaxis. The client exhibiting signs and symptoms suggestive of anaphylaxis should have the vancomycin infusion stopped immediately and be treated with intramuscular (IM) epinephrine. The infusion must not be restarted if anaphylaxis is suspected. A slowed infusion rate or pre-medications will not prevent a future anaphylactic response. Flushing and pruritus may also be symptoms of RMS. The nurse should further assess the client's airway for possible anaphylaxis.

Carotid Endarectomy

A carotid endarterectomy is a surgical procedure that removes atherosclerotic plaque from the carotid artery. Clients with carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding. Blood pressure is closely monitored during the first 24 hours post surgery. Hypertension may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain. Clients having undergone a carotid endarterectomy, a surgical procedure removing plaque from carotid arteries, would be expected to show no evidence of hemorrhage (eg, hypotension, tachycardia) or neurological impairment (eg, decreased level of consciousness, altered mental status)

Central line/Central venous catheter

A central line or central venous catheter (CVC) is inserted by the health care provider in a "central" vein (eg, subclavian, internal jugular, femoral) and is used to administer fluids, medications, and parenteral nutrition and for hemodynamic monitoring. Proper hand hygiene should be performed when caring for a CVC to prevent infection, and nonsterile gloves should be worn to protect the nurse from blood or body fluids at the port site as one or more lumens are often used to draw blood The Centers for Disease Control and Prevention recommend that catheter hubs always be handled aseptically to prevent catheter-associated infections. The hubs should be disinfected with a hospital-approved antiseptic (eg, 70% alcohol sterile pads; > 0.5% chlorhexidine with alcohol; 10% povidone-iodine). Always allow the antiseptic to dry before using the hub/port ( A central venous catheter is used to administer fluids, for simultaneous infusion of incompatible drugs, for parenteral nutrition, and for hemodynamic monitoring. The nurse should always handle the lumen ports and hubs aseptically with facility-approved antiseptics to prevent catheter-associated infections.

Central Venous Catheter

A central line or central venous catheter (CVC) is inserted by the health care provider in a "central" vein (eg, subclavian, internal jugular, femoral) and is used to administer fluids, medications, and parenteral nutrition and for hemodynamic monitoring. Proper hand hygiene should be performed when caring for a CVC to prevent infection, and nonsterile gloves should be worn to protect the nurse from blood or body fluids at the port site as one or more lumens are often used to draw blood The Centers for Disease Control and Prevention recommend that catheter hubs always be handled aseptically to prevent catheter-associated infections. The hubs should be disinfected with a hospital-approved antiseptic (eg, 70% alcohol sterile pads; > 0.5% chlorhexidine with alcohol; 10% povidone-iodine). Always allow the antiseptic to dry before using the hub/port ( A central venous catheter is used to administer fluids, for simultaneous infusion of incompatible drugs, for parenteral nutrition, and for hemodynamic monitoring. The nurse should always handle the lumen ports and hubs aseptically with facility-approved antiseptics to prevent catheter-associated infections. To prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions: Instruct the client to lie in a supine position. This will increase the central venous pressure and decrease the possibility of air getting into the vessel Instruct the client to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vessel

Tonsillectomy/Adenoidectomy

A client who is status post tonsillectomy and adenoidectomy is at risk for hemorrhage up to 14 days after surgery. Because of the location of the surgery, hemorrhage can lead to life-threatening airway compromise. The client who had a tonsillectomy 3 days ago and has signs of hemorrhage (eg, restlessness, frequent swallowing or clearing of the throat, vomiting of blood, pallor) should be seen first. The client may require surgery to cauterize the bleeding vessel(s). To decrease the risk of hemorrhage, the nurse should educate the client to limit coughing, gargling, and clearing of the throat.

Hypertensive Crisis

A hypertensive crisis is an elevation in blood pressure (BP) >180 mm Hg systolic and/or >120 mm Hg diastolic with evidence of organ damage (eg, kidney damage, retinopathy). The goal of treatment is to slowly lower BP using IV antihypertensive medications (eg, vasodilators) to limit end-organ damage. Once the client's condition is stabilized, oral antihypertensives are prescribed and IV medications are titrated off. The client may have symptoms of hypertensive encephalopathy, including severe headache, confusion, nausea/vomiting, and seizure. Hypertensive crisis poses a high risk for end-organ damage (eg, hemorrhagic stroke, kidney injury, heart failure, papilledema). The nurse should prioritize neurological assessment (eg, level of consciousness [LOC], cranial nerves) as decreased LOC may indicate onset of hemorrhagic stroke, which requires immediate surgical intervention Treatment for hypertensive crisis typically includes IV nitrates or antihypertensives (eg, nitroprusside, labetalol, nicardipine) and continuous monitoring (eg, blood pressure, telemetry, urine output) in a critical care setting. Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure (SBP) and double the diastolic blood pressure (DBP), and then dividing the resulting value by 3. MAP = (2 x DBP + SBP) / 3 TX: HYDRALAZINE - Take with food - Do not take OTC drugs unless otherwise stated - Get up slowly: at RF orthostatic HYPOTN - Observe for any weight gain/loss

PICC lines

A peripherally inserted central catheter (PICC) is a venous access device that is inserted via the cephalic or basilic vein and terminates in the superior vena cava. It is indicated for administration of noxious medications (eg, parenteral nutrition, chemotherapy), for long-term IV therapy, or in clients with poor venous access. Proper care and aseptic technique are important to maintain lumen patency and eliminate the risk of life-threatening central line-associated bloodstream infection (CLABSI). The nurse should inspect the insertion site for signs of infection (redness, drainage) and dressing integrity. Routine care includes sterile dressing changes every 48 hours with a gauze dressing or 7 days with a transparent semipermeable dressing (biopatch) as well as immediately if dressing is loose/torn, soiled, or damp. The line should be flushed before and after medication administration and per facility protocol Blood pressure and venipuncture should not be performed on the affected arm as compression of the vein can alter its integrity All infusing medications (except vasopressors) must be paused before drawing blood from the PICC to prevent false interpretation of the client's serum levels

Acne Vulgaris

Acne vulgaris is a skin disorder characterized by obstructed sebaceous glands, which form comedones (ie, blackheads, whiteheads). Bacteria consume and metabolize the obstructed sebum, and the metabolic products cause inflammation, pustules, papules, and nodules. Acne usually develops during puberty, and multiple factors influence its development (eg, overgrowth of normal bacteria, heredity, stress, hormones). Treatment includes topical and oral medications such as tretinoin (Retin-A), benzoyl peroxide, isotretinoin (Accutane), and oral contraceptives. Antibacterial soaps are harsh and ineffective, increase the pH of the skin, and can dry the skin. The client should instead gently wash the face with a mild facial cleanser. Additional self-care measures include: Using noncomedogenic skin care products (ie, products that do not clog pores) to avoid creating new lesions Maintaining a healthy lifestyle (eg, moderate exercise, balanced diet, adequate sleep) to reduce stress and promote healing Refraining from squeezing, picking, and vigorously scrubbing lesions to prevent additional inflammation and worsening the acne

Acute Stress Disorder

Acute stress disorder (ASD) occurs following a traumatic or extremely stressful event. ASD is characterized by intrusive memories of the event, negative mood, dissociative symptoms (eg, altered sense of reality), and arousal and reactivity symptoms (eg, hyperactive sensory state, sleep disturbances, difficulty concentrating, easily startled). If these symptoms continue beyond a month after the event, the diagnosis becomes post-traumatic stress disorder. Nursing interventions for a client with ASD include: Assessing for ideas and plans to commit self-harm Assessing for ineffective coping (eg, use of drugs and alcohol) Assessing impact of ASD on the client's job performance, relationships, sleep pattern, and ability to perform activities of daily living Explaining that feelings and/or symptoms occurring after traumatic events are normal, as this can help alleviate the client's anxiety Exploring coping strategies used in previous stressful situations

Adolescents and depression

Adolescent clients are at increased risk for developing depressive and anxiety-related mood disorders as they begin to identify their role in adult life and develop new personal relationships. However, they frequently report vague somatic symptoms (eg, headache, stomachache) and may exhibit an irritable or cranky mood rather than a sad or dejected mood. Signs of depression in adolescent clients include: Hypersomnolence or insomnia; napping during daily activities Low self-esteem; withdrawal from previously enjoyable activities Outbursts of angry, aggressive, or delinquent behavior (eg, vandalism, absenteeism); inappropriate sexual behavior Weight gain or loss; increased food intake or lack of interest in eating Depression is also a significant cause of suicide in adolescents.

Advanced Care Planning

Advance care planning documents may include the following: A health care proxy (durable power of attorney for health care or medical power of attorney) is a person appointed by the client to make decisions on behalf of the client. The proxy document only goes into effect when the health care team determines that the client lacks the capacity to make decisions. This should be deactivated if the client regains decision-making capacity. A living will is an advanced directive describing the type of life-sustaining treatments (eg, cardiopulmonary resuscitation, intubation, mechanical ventilation, feeding tube) that the client wants initiated if unable to make decisions. Advance care planning is an ongoing process that should be revisited yearly and after changes in condition. Legal documentation is needed to ensure that the client's advance care plan is carried out correctly. Advance care planning allows the client to determine desired treatments (eg, cardiopulmonary resuscitation, intubation, mechanical ventilation) and decision makers in the event the client is unable to do so. Advanced directives are legal documents outlining these wishes and include living wills and health care proxies (durable powers of attorney for health care or medical power or attorney). Advance care planning is a process that includes: Considering treatments that may be needed in the future Making decisions to guide future treatments, particularly if the client is no longer able to make own decisions Ensuring that treatment decisions are legally documented on the appropriate forms, such as the advance directive, and in the medical record Ensuring that advance directive documents are in the medical record so that they are available to HCPs who care for the client in the future Ensuring that the health care proxy (or durable power of attorney for health care) has information and documentation to support that role if this person needs to make decisions for the client The nurse's role as advocate includes discussing options with the client and ensuring that the client's wishes are communicated and documented appropriately so that the health care proxy and health care team will have the necessary information. An advance directive makes clear a client's health care wishes (eg, do not resuscitate). A power of attorney (POA) designates a representative to act on a person's behalf. It is important to clarify that the client has the type of POA who can make health care decisions (durable POA for health care, POA for health care [Canada]).

Ileostomy

An ileostomy is a surgically created opening (stoma) in the abdominal wall that connects the small intestine to the external abdomen. Stool from the small intestine bypasses the colon and exits through the ileostomy. Functions of the colon (eg, fluid and electrolyte absorption, vitamin K production) do not occur, resulting in liquid stool that drains into an external ostomy appliance attached to the skin. In the immediate postoperative period of an ileostomy, a low-residue diet (low-fiber) is prescribed to prevent obstruction of the narrow lumen of the small intestine and stoma (1-in [2.54-cm] diameter or less). After the ileostomy heals, the client reintroduces fibrous foods one at a time. The client is instructed to thoroughly chew food and monitor for changes in stool output. Foods to be avoided include: High fiber: popcorn, coconut, brown rice, multigrain bread Stringy vegetables: celery, broccoli, asparagus Seeds or pits: strawberries, raspberries, olives Edible peels: apple slices, cucumber, dried fruit After an ileostomy, a client may consume fruits and vegetables that are pitted, peeled, and/or cooked (eg, peaches, bananas, potatoes). Low-fiber carbohydrate options include white rice, refined grains, and pasta. Nausea, vomiting, abdominal distension, and decreased stool production may signal a bowel obstruction or obstructed ileostomy. Bowel obstruction can lead to electrolyte disturbances, dehydration, bowel perforation and infection (eg, peritonitis), and/or tissue necrosis. It is urgent and potentially life-threatening. The client must be evaluated by the health care provider in a timely manner.

Anorexia Nervosa

Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include: Fear of weight gain - clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. Fluid and electrolyte imbalance - excessive vomiting can cause hypokalemia and metabolic alkalosis Amenorrhea - clients are often amenorrheic due to decreased body fat (low estrogen) Decreased metabolic rate - severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance Lanugo (fine terminal hair) can be seen in extreme cases Manifestations of anorexia nervosa will resolve after the weight loss is corrected, although the recovery process can take several months. Losing a significant amount of weight and hiding the weight loss (eg, wearing oversized, bulky clothing) are characteristics of clients with anorexia nervosa. Anorexia nervosa is a psychogenic eating disorder with potentially fatal physiological implications. Clients commonly become extremely underweight and protein-energy malnourished. Clients admitted for anorexia nervosa are typically in a crisis state, and the priority is restoring physiological integrity through appropriate weight gain and nutritional intake. Nursing care includes: Assisting the client in reflecting on triggers for dysfunctional eating and fears and feelings related to gaining weight Maintaining strict documentation of dietary protein and calorie intake to ensure healthy weight gain Remaining with the client during and 1 hour following meals to ensure intake and prevent purging behaviors Establishing a weekly weight-gain goal (typically 2-3 lb/wk [0.91-1.36 kg/wk]) Weighing the client at the same time each morning (after voiding and before any oral intake) and wearing the same clothing to assess efficacy of nutritional support Limiting physical activity initially and gradually increasing as oral intake improves Not focusing on food initially, but encouraging participation in meal planning as the client nears target weight

Bacterial Conjunctivitis

Bacterial conjunctivitis (pink eye) is highly contagious. The hands must be washed properly before and after instilling eye drops and after cleaning away eye drainage or crusting; this is the single best method to prevent the spread of infection to the other eye, the parents, other family members, or anyone else. Therefore, parents should ensure that affected children wash their hands frequently and discourage them from rubbing their eyes. Tissues used to clean the eye should be discarded. The child's washcloths and towels should be kept separate. Many schools and day care centers require that children be kept at home during the time when they are most contagious.

Cholinergic Allergic Rhinitis

Bronchiolitis is a lower respiratory tract infection most commonly caused by respiratory syncytial virus. It causes inflammation and obstruction of the lower respiratory tract. Depending on the severity of the infection, infants with bronchiolitis can experience mild cold symptoms or respiratory distress. The infant will have difficulty feeding and can become dehydrated. Medical care is supportive and includes suctioning, oxygen, and hydration. The infant with irritability may be exhibiting signs of hypoxia. The nurse should see this client first. A client with bronchiolitis will require frequent suctioning, especially before feeding. The nurse should use the ABC (airway, breathing, circulation) guidelines and see this client first.

Bronchiolitis

Bronchiolitis is a lower respiratory tract infection most commonly caused by respiratory syncytial virus. It causes inflammation and obstruction of the lower respiratory tract. Depending on the severity of the infection, infants with bronchiolitis can experience mild cold symptoms or respiratory distress. The infant will have difficulty feeding and can become dehydrated. Medical care is supportive and includes suctioning, oxygen, and hydration. The infant with irritability may be exhibiting signs of hypoxia. The nurse should see this client first. A client with bronchiolitis will require frequent suctioning, especially before feeding. The nurse should use the ABC (airway, breathing, circulation) guidelines and see this client first. Bronchiolitis is a common viral illness of childhood that is usually caused by RSV. It typically begins with viral upper respiratory symptoms (eg, rhinorrhea, congestion) that progress to lower respiratory tract symptoms such as tachypnea, cough, and wheezing. Bronchiolitis is a self-limited illness and supportive care is the mainstay of treatment. Most children can be managed in the home environment. Breastfeeding should be continued and additional fluids offered if there is a risk of dehydration due to frequent coughing and vomiting Parents should be instructed to use saline nose drops and then suction the nares with a bulb syringe to remove secretions prior to feedings and at bedtime (Medications such as cough suppressants, antihistamines, bronchodilators (eg, albuterol), and corticosteroids have not been found to be effective and are not recommended.

Bulimia Nervosa

Bulimia nervosa (BN) is an eating disorder characterized by episodes of uncontrollable binge-eating (consuming very large amounts of food, often in secret) followed by inappropriate compensatory behaviors to prevent weight gain. Compensatory behaviors may include laxative or diuretic use, self-induced vomiting, or excessive exercise 1-2 hours after binging; Other signs of BN may include: Physical changes related to self-induced vomiting (eg, scars or calluses on the hand, enlarged parotid glands, erosion of tooth enamel, dental caries) Preoccupation with body image, weight, food, and dieting

Cognitive Behavioral therapy

CBT teaches clients to reframe their thought processes and develop new adaptive approaches for coping with anxiety, stress, and conflict. CBT requires that the client learn about the disorder and engage in self-observation and monitoring, relaxation techniques, desensitization activities, and changing negative thoughts. Cognitive behavioral therapy (CBT) can be effective in treating anxiety disorders, eating disorders, depressive disorders, and medical conditions such as insomnia and smoking. These types of disorders are characterized by maladaptive reactions to stress, anxiety, and conflict. CBT requires that the client learn the skill of self-observation and to apply more adaptive coping interventions. CBT involves 5 basic components: Education about the client's specific disorder Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and assess the severity Physical control strategies - deep breathing and muscle relaxation exercises Cognitive restructuring - learning new ways to reframe thinking patterns, challenging negative thoughts Behavioral strategies - focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events

Ventilator Associated Complications

Clients requiring mechanical ventilation are at risk for a variety of ventilator-associated complications (eg, aspiration, pneumonia). When caring for a client receiving mechanical ventilation, the nurse should: Monitor respiratory status (eg, lung sounds, breathing pattern), airway patency, and ventilator functionality (eg, settings, alarm parameters). Maintain the head of the bed at 30-45 degrees to reduce aspiration risk Use the minimum amount of sedation necessary for client comfort (eg, compliant with ventilator, opens eyes to voice). Continuous IV sedation should be paused daily for evaluation of spontaneous respiratory effort and appropriateness for weaning off the ventilator Perform oral care with chlorhexidine oral solution every 2 hours, or per facility policy Perform tracheal suctioning as needed. Monitor correct endotracheal tube placement by noting insertion depth. Place emergency equipment at bedside (eg, manual resuscitation bag Although the client should have a quiet environment at night, ventilator alarms should never be muted, as they may indicate life-threatening complications (eg, accidental extubation, tubing disconnection).

Clubfoot

Clubfoot (ie, talipes equinovarus) is a congenital bone deformity and soft tissue contracture manifested by one or both feet being turned inward. The health care provider typically begins management of the deformity soon after birth by manipulation and stretching of the affected foot and placing a long-leg cast. Weekly recasting over 5-8 weeks (ie, Ponseti method) is necessary to gradually reposition the foot To maintain the correction after successful casting, the client commonly wears custom shoes secured to a bar brace. To prevent recurrence, long-term follow-up continues until the child attains skeletal maturity. The nurse should teach parents about cast care, which includes monitoring the client's circulation (eg, toes pink and warm) and keeping the cast dry during diapering and bathing to prevent skin irritation or infection

congenital hypothyroidism

Congenital hypothyroidism occurs when abnormal development of the thyroid gland causes complete or decreased secretion of thyroid hormone (TH). Untreated hypothyroidism can cause severe intellectual disability in infants if undetected. TH plays an important role in growth, development, and regulation of many bodily functions (eg, heat production, muscle tone, skin function, cardiac function, metabolism). Clinical manifestations in affected infants reflect the pathophysiology of decreased TH and may include: - Difficulty awakening, lethargy, or hyporeflexia due to alterations in central nervous system function - Dry skin due to alterations in skin function - Hoarse cry caused by swelling of the vocal cords due to fluid retention - Constipation due to slowed metabolism - Bradycardia due to the effect of TH on cardiac function

Pneumonia

Crackles - Fine or coarse crackling sounds caused by air passing through alveoli and small airways obstructed with mucus (Option 1) Fever, chills, productive cough, dyspnea, and pleuritic chest pain (Options 3 and 4) Increased vocal/tactile fremitus - Transmission of palpable vibrations (fremitus) is increased when transmitted through consolidated versus normal lung tissue. Bronchial breath sounds in peripheral lung fields - High-pitched, harsh sounds conducted through consolidated lung tissue, which are abnormal when heard in an area distant from where normally heard (ie, trachea); this finding can be an early sign of pneumonia. Unequal chest expansion - Decreased expansion of affected lung on palpation Dullness - Percussion of medium-pitched sounds over consolidated lung tissue (pneumonia) or fluid-filled space (eg, pleural effusion, a complication of pneumonia) Pleurisy is characterized by stabbing chest pain that usually increases on inspiration or with cough. It is caused by inflammation of the visceral pleura (over the lung) and the parietal pleura (over the chest cavity). The pleural space (between the 2 layers) normally contains about 10 mL of fluid to help the layers glide easily with respiration. When inflamed, they rub together, causing pleuritic pain. A pleural friction rub is auscultated in the lateral lung fields over the area of inflammation. The sound is produced by the 2 layers rubbing together and can indicate pleurisy, a complication of pneumonia. It is characterized by squeaking, crackling, or the sound heard when the palm is placed over the ear and the back of the hand is rubbed with the fingers. Complications of pneumonia are more prevalent in elderly clients with underlying chronic disease.

Peritonitis

Diffuse pain and a rigid abdomen indicate peritonitis (eg, from ruptured appendicitis or perforated bowel). Peritonitis is also an emergency but not immediately life-threatening like AAA rupture. This client should be seen next after the client with AAA. Peritonitis is a common but serious complication of peritoneal dialysis that typically occurs as a result of contamination during infusion connections or disconnections. Typically, the earliest indication of peritonitis is the presence of cloudy peritoneal effluent. Later manifestations include low-grade fever, tachycardia, chills, generalized abdominal pain, and rebound tenderness. To detect rebound tenderness, one hand is pressed firmly into the abdominal wall and quickly withdrawn. Rebound tenderness is present when there is pain on removal, indicating inflammation of the peritoneal cavity. The nurse should collect peritoneal effluent from the drainage bag for culture and sensitivity Treatment of peritonitis is antibiotic therapy based on the culture results. Antibiotics may be added to dialysate, given orally, or administered intravenously. Signs and symptoms of a failing pacemaker include failure to capture (pacer spikes without associated QRS complexes) with bradycardia and hypotension. The nurse should use a transcutaneous pacemaker to stabilize the client until the internal pacemaker can be repaired or replaced. During peritoneal dialysis, dialysate is infused into the abdominal cavity and the tubing is then clamped to allow the fluid to dwell for a specified period. After the dwell time, the catheter is unclamped and the fluid drains out via gravity. During the instillation and dwell portions of the cycle, clients are monitored closely for indications of respiratory distress (eg, difficulty breathing, rapid respirations, crackles) that can result from instilling the dialysate too rapidly, overfilling of the abdomen, or fluid entering the thoracic cavity. Crackles can also occur if over time there is more dialysate infused than is removed (fluid gain).

Aortacaval compression syndrome

During stabilization of a pregnant client after trauma (eg, motor vehicle collision, fall), uterine displacement is the first step to address supine hypotension (due to aortocaval compression and decreased venous return to the heart) and promote blood circulation to the fetus. The client should be tilted laterally while strapped on the backboard to promote venous return and protect the client from further potential spinal injury Manifestations of aortocaval compression (eg, hypotension, pallor, dizziness) may mimic those of other complications of trauma. It is therefore critical to reassess blood pressure after uterine displacement to identify persistent hypotension, which may indicate hemorrhage caused by trauma (eg, placental abruption).

Ear Irrigation

Ear irrigation may be prescribed to remove impacted or excess cerumen; the following steps describe this procedure: Assess client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify that the tympanic membrane is intact and ensure there are no foreign bodies. Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth). Place the client in a side-lying or sitting position with the head tilted toward the affected ear. Place a towel and an emesis basin under the ear. Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort. Straighten the ear canal, pulling the pinna up and back for adults or down and back for children age ≤3 years. Irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear cana. Avoid occluding the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if the client experiences severe pain, nausea, or dizziness. Repeat as tolerated until the ear canal is clear or the prescribed amount is instilled. Document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client teaching.

Elder Abuse

Elder abuse or neglect occurs when caregivers intentionally or unintentionally fail to meet the older adult client's physical, emotional, or social needs. Approximately 1 in 10 older adult clients are victims of physical, psychological, or sexual abuse by a caregiver. Commonly neglected necessities include water, food, medication, hygiene, and clothing. The client's living conditions may be unsafe or have inadequate access to public utilities. Objective findings consistent with abuse or neglect include: Dehydration, malnutrition, and weight loss Poor hygiene, soiled bedding or clothing, and pressure ulcers Missing/broken assistive devices (eg, eyeglasses); medications withheld or expired Clients who have experienced abuse or neglect may find the situation difficult to discuss and display apprehension, restlessness, withdrawal, poor eye contact, shame, and despair. The client may also deny or minimize the extent of the abuse out of fear or embarrassment.

Endometrial Cancer

Endometrial cancer arises from the inner lining of the uterus and forms after the development of unregulated endometrial overgrowth (ie, hyperplasia). Although typically slow growing, it can metastasize to the myometrium (ie, uterine muscle tissue), cervix, and nearby lymph nodes and eventually beyond the pelvis. Many signs of endometrial cancer are nonspecific (eg, lower back or abdominal pain), but the hallmark symptom is abnormal uterine bleeding (eg, heavy, prolonged, intermenstrual, and/or postmenopausal bleeding). As with many cancers, the client's family and genetic history (eg, BRCA mutation carrier) are significant risk factors; however, prolonged estrogen exposure without adequate progesterone is the greatest risk factor for developing endometrial cancer. Factors increasing estrogen exposure and endometrial cancer risk include: - Conditions associated with infrequent or anovulatory menstrual cycles (eg, polycystic ovary syndrome, infertility, late menopause, early menarche) - Obesity - Tamoxifen (a medication given for breast cancer) - Tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive endometrial proliferation (endometrial hyperplasia). This hyperplasia can eventually lead to cancer. Irregular or excessive menstrual bleeding in premenopausal woman or any bleeding in postmenopausal women can be a sign of endometrial cancer Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke, pulmonary embolism, deep vein thrombosis).

Extravasation with Norepinephrine

Extravasation is the infiltration of a drug into the tissue surrounding the vein Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established. The nurse should implement the following interventions to manage norepinephrine extravasation: Stop the infusion immediately and disconnect the IV tubing Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating. Elevate the extremity above the heart to reduce edema Notify the health care provider and obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine)

Failure to Thrive

FTT is a state of undernutrition and inadequate growth found in infants and young children. Physiologic risk factors for FTT include preterm birth, breastfeeding difficulties, gastroesophageal reflux, and cleft palate. Socioeconomic risk factors include poverty, social or emotional isolation, caregivers with cognitive disabilities or mental health disorders, and lack of nutritional education. FTT, or growth failure, is a state of undernutrition and inadequate growth in infants and young children. Most cases of FTT are related to an inadequate intake of calories, which can be tied to many different etiologies. Physiologic risk factors for FTT include preterm birth, breastfeeding difficulties, gastroesophageal reflux, and cleft palate. Socioeconomic risk factors include: Poverty - most common Social or emotional isolation - parents may lack the support system needed to assist them with the problems of child rearing Cognitive disability or mental health disorder Lack of nutritional education - parents may not have knowledge of proper feeding techniques or appropriate calorie intake based on age and size of the child FTT is generally defined as weight less than 80% of ideal for age and/or depressed weight for length, correcting for gestational age, sex, and special medical conditions. The underlying cause of FTT is inadequate dietary intake; contributing factors include a disturbance in feeding behavior and psychosocial factors. Observing the child feeding or when hungry will provide the nurse the opportunity to identify potential factors contributing to insufficient intake. The nurse can observe the type of food being offered, the quantity of food consumed, how the child is held or positioned while being fed, the amount of time for feeding, the parent's response to the child's cues, the tone of the feeding, and the interaction between the child and the parent. As part of the home visit, the nurse will assess overall parenting skills. It is most important for the focus of the visit to be on the nutritional intake of the child and the feeding experience.

Fifth Disease

Fifth disease ("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces. The child may have general malaise and joint pain that are typically well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen. Affected children typically recover quickly, within 7-10 days. Once these children develop symptoms (eg, rash, joint pains), they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition. Symptoms, in addition to a bright-red facial rash, include fever and general flulike symptoms. It is harmless unless the client has a hemolytic/immunodeficient condition. Pregnant women should avoid contact with infected individuals as the virus can be transmitted to the fetus and cause anemia.

Bipolar D/O (Acute Mania)

In developing a care plan for a client experiencing acute mania, the nurse is aware that an acute manic episode is characterized by the following: Excessive psychomotor activity Euphoric mood Poor impulse control Flight of ideas, non-stop talking Poor attention span, distractibility Hallucinations and delusions Insomnia Wearing bizarre or inappropriate clothing, jewelry, and makeup Neglected hygiene and inadequate nutritional intake The care plan for a client experiencing an acute manic episode includes the following: Reduction of environmental stimuliProviding a quiet, calm environmentLimiting the number of people who come in contact with the clientOne-on-one interactions rather than group activitiesLow lighting A structured schedule of activities to help the client stay focused Physical activities to help relieve excess energy Providing high-protein, high-calorie meals and snacks that are easy to eat Setting limits on behavior

Diabetes

Insulin shifts glucose and potassium from the intravascular to the intracellular space. This shift of potassium into cells may cause or worsen hypokalemia (<3.5 mEq/L [3.5 mmol/L]) and place the client at risk for life-threatening dysrhythmias (eg, ventricular tachycardia, ventricular fibrillation). The nurse should notify the health care provider (HCP) before administering insulin to clients with hypokalemia, as supplemental potassium may be required to prevent cardiac dysrhythmias Clients experiencing hypoglycemia may develop shakiness, palpitations, sweating, pallor, diaphoresis, anxiety/arousal, and restlessness and altered mental status (eg, difficulty speaking, confusion). If manifestations of hypoglycemia are present, the nurse should check the client's blood glucose (BG) level immediately. A BG of <70 mg/dL (3.9 mmol/L) requires treatment; however, if glucose testing is not readily available, the client should be treated based on symptom Hypoglycemia treatment in a conscious client is the administration of 15 g of a quick-acting carbohydrate. After treatment, the nurse should recheck BG every 15 minutes, repeating treatment if it remains low. Quick-acting carbohydrate options include: 4 oz (120 mL) of a regular soft drink or fruit juice 8 oz (240 mL) of low-fat milk 1 tablespoon (15 mL) of honey or syrup 6 hard candies Commercial dextrose products An emergency glucagon IM injection is indicated if the client is somnolent, unconscious, seizing, or unable to swallow. An acute illness (eg, scarlet fever) in clients with type 1 diabetes may trigger the release of stress hormones, which leads to higher blood glucose and ketone levels (sometimes leading to ketoacidosis). Clients with type 1 diabetes do not produce any insulin (unlike those with type 2 diabetes), so clients should not skip administration of external insulin even if not eating. Insulin therapy should be continued as prescribed during an acute illness Additional sick-day management includes: - increasing the frequency of blood glucose level checks (every 1-4 hours) - Increasing or decreasing the dose of insulin as needed based on blood glucose levels - - Maintaining adequate hydration Testing for urinary ketones frequently

Iron Deficiency Anemia

Iron deficiency is the leading cause of anemia worldwide. Most cases of iron deficiency anemia (IDA) result from inadequate intake of foods high in iron. In IDA, red blood cells are small (microcytic) with reduced hemoglobin content, appearing paler (hypochromic) under a microscope. The richest dietary sources of iron include meat, fish, and poultry, which provide a form of iron that is easily absorbed by the body (Option 1). Plant-based foods (eg, dried fruits, nuts, legumes, green leafy vegetables, whole grains) are not as iron rich and contain a less bioavailable form of iron than animal-based foods. However, foods high in vitamin C (eg, tomatoes, potatoes, strawberries) may boost iron absorption when consumed with iron-rich foods.

Methadone

Methadone is a potent narcotic with a longer half-life than its duration of action due to its lipophilic properties. The risk for overdose exists as clients can inadvertently take too many tablets for additional pain relief even though fat cells will continue to release high amounts of the drug into circulation. Early signs of toxicity include nausea/vomiting and lethargy. A client who falls asleep with stimulation (ie, is obtunded) requires additional observation/monitoring. Sedation precedes respiratory depression, a life-threatening complication of severe toxicity

Near-drowning

Near-drowning occurs when a client is under water and unable to breathe for an extended period. In a matter of seconds, major body organs begin to shut down from lack of oxygen and permanent damage results. Decerebrate posturing is a sign of severe brain damage. During assessment, the nurse would observe arms and legs straight out, toes pointed down, and the head/neck arched back. These assessment findings indicate that severe injury has occurred. Hypothermia is generally seen in near-drowning victims. One of the first goals of treatment is to warm the client. This is done using warmed IV fluids, blankets, and air. Sustained hypothermia will eventually lead to organ failure, making this an urgent finding but not initially life-threatening. A weak and thready pulse is generally detected in near-drowning victims due to hypothermia. Once the client is properly warmed, the pulse generally returns to normal. Sometimes the client is so cold that a pulse cannot be detected; this is why a client is not dead until warm and dead. Such clients may require prolonged resuscitation. When wheezing is heard on auscultation after a near-drowning, the first observation would be that the client is still moving air and providing oxygen to the body. The wheezing may indicate that the client has bronchospasm. If the client has aspirated fluid, crackles would be heard. Most such clients will develop acute respiratory distress syndrome.

OCD

Obsessive-compulsive disorder is characterized by obsessions and/or compulsions engaged in to relieve anxiety. Treatment effectiveness is demonstrated by the client's ability to identify situations that increase anxiety and develop healthy coping techniques to manage anxiety (eg, deep breathing, exercise) that replace the ritualistic behaviors. Obsessive-compulsive disorder is characterized by obsessions (ie, persistent and intrusive thoughts, impulses, or images) and compulsions (ie, ritualistic, repetitive behaviors performed to reduce anxiety or prevent an adverse event). Clients are aware that such behavior is irrational, but performing the actions provides relief, which compels them to continue. Initially, nursing care includes: Assisting the client to identify circumstances that increase anxiety Offering positive feedback when the client engages in nonritualistic behavior (eg, group activities, board games) Remaining nonjudgmental and empathetic and using reflective communication Cognitive-behavioral therapy (eg, thought stopping) Clients with OCD engage in rituals and behaviors that help reduce the anxiety or stress rooted in their obsessions (recurrent thoughts, impulses, or images that cause notable distress). If the ritual is interrupted, the client will experience increased anxiety. A client with compulsive behavior often does not realize the amount of time or how many times the same activity has been performed. By providing reflective feedback about the client's behavior, the nurse is acknowledging the behavior in a nonjudgmental manner. The nurse should also help the client become involved in other activities and problem-solving skills.

Otic medication administration

Otic medications are used to treat infection, soften cerumen for later removal, and facilitate removal of an insect trapped in the ear canal. They are contraindicated in a client with a perforated eardrum. To administer otic medications in an adult client, follow these steps: (1) Perform hand hygiene, (2) position the client side-lying with the affected ear up, (3) pull pinna up and back, (4) administer prescribed number of ear drops, (5) instruct the client to remain side-lying for 2-3 minutes, and (6) place cotton ball loosely in the outer ear canal for 15 minutes (if needed).

Oxytocin

Oxytocin (Pitocin) stimulates contraction of the uterine smooth muscle. It is commonly administered to induce or augment labor and to prevent postpartum hemorrhage. Oxytocin, a high-alert medication, is administered cautiously to avoid potential adverse effects, including: Category II or III fetal heart rate (FHR) patterns (eg, late decelerations, bradycardia). Abnormal or indeterminate FHR patterns are very common when using oxytocin and may occur because of reduced blood flow to the fetus during contractions Emergency cesarean birth, which may be required due to persistent abnormal FHR pattern Postpartum hemorrhage - Uterine atony and uterine fatigue may occur if the client experiences prolonged exposure to exogenous oxytocin Water intoxication - Oxytocin has an antidiuretic effect when administered at high doses over prolonged periods. Uterine tachysystole (ie, >5 contractions in 10 minutes) Oxytocin (Pitocin) stimulates contraction of the uterine smooth muscle and is used to induce or augment labor and to prevent postpartum hemorrhage (PPH). Oxytocin administration increases the risk of abnormal fetal heart rate patterns, emergency cesarean birth, uterine tachysystole, placental abruption, and uterine rupture. Prolonged administration increases the risk of water intoxication and PPH.

Palliative Care

Palliative care is a model of treatment that involves managing symptoms, providing psychosocial support, coordinating care, and assisting with decision making to relieve suffering and improve quality of life for clients and families facing serious illnesses. An interdisciplinary palliative assessment team often includes nursing staff, chaplains, social workers, therapists, and nutritionists who work together on a comprehensive treatment plan. This model of care has been found to decrease unnecessary medical interventions and reduce depressive symptoms. Families of clients who receive palliative care interventions also experience lower rates of prolonged grief and post-traumatic stress disorder. Palliative care is not limited to the last 6 months of life and can begin immediately after diagnosis of terminal disease (eg, advanced heart failure or cancer). The main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decides to forego curative treatment. Palliative care focuses on quality of life and symptom management (eg, pain, dyspnea, fatigue, constipation, nausea, loss of appetite, difficulty sleeping, depression). It can be given concurrently with life-prolonging treatment in the setting of terminal disease. Palliative care is provided by a multidisciplinary care team with a focus on the clients and their families.

Injection Angles/Instructions

Parenteral medications are administered via injection into body tissues using aseptic technique (eg, intradermal, intramuscular, subcutaneous, IV). Intradermal Administer injections at a 5- to 15-degree angle to reduce risk of injection into subcutaneous tissue Apply firm pressure to the injection site to reduce bleeding. Massaging the site introduces medication into deeper tissues and should be avoided Subcutaneous Administer injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped or at 45 degrees if only 1 in (2.5 cm) can be grasped Intramuscular Acceptable sites include the deltoid, vastus lateralis, and ventrogluteal. The ventrogluteal is preferred as fewer large blood vessels and nerves are present. Position the client supine, prone, or side-lying with the knee and hip flexed when administering ventrogluteal injections. Flexing the knee and hip reduces muscle tension, improves access, and promotes client comfort A filter needle must be used when withdrawing medication from a glass ampule to prevent aspiration and injection of glass shards. After the medication is withdrawn, the filter needle is discarded and an injection needle (eg, 20-gauge, 1-in [2.5-cm] needle) is attached to the syringe.

Tracheostomy suctioning

Preoxygenate with 100% oxygen and allow for reoxygenation periods between suction passes Suction only while withdrawing the catheter from the airway Use strict sterile technique throughout suctioning Limit suctioning to ≤10 seconds on each suction pass 1. insertion of suction catheter 2. intermittent suctioning in circular motion during withdrawal of catheter

Sepsis

Sepsis is an exaggerated response to an infection in the bloodstream, often originating from a local infection (eg, pressure injury), that results in potentially life-threatening organ impairment. Older adults are at increased risk for sepsis due to normal, age-related decreases in the immune and inflammatory response (ie, immunosenescence). Because of altered immune function, older adults often do not develop typical signs of infection (eg, fever, leukocytosis). Instead, nurses must observe for and immediately report atypical indicators of infection (eg, altered mental status, hypothermia, leukopenia) because early identification and intervention reduce mortality Clients with sepsis are at risk for developing disseminated intravascular coagulation (DIC), a condition that initially causes clotting within the microvessels. Platelets and clotting factors are consumed in clotting and become unavailable for body use, leading to bleeding complications. The initial clotting also disrupts blood flow to extremities and organs. Signs of DIC include frank external bleeding (eg, venipuncture site bleeding), signs of internal bleeding (petechiae, ecchymosis, hematuria, hematemesis, and bloody stools), and respiratory distress (eg, bleeding/clotting into lungs). Signs of DIC need immediate assessment and emergency intervention. Rapid replacement of clotting factors (fresh frozen plasma), platelets, and blood is needed to save the client from death. Sepsis is a condition associated with a serious infection in the bloodstream. Evidence-based guidelines recommend the early administration of antibiotic therapy to reduce mortality. Cultures should be obtained quickly and antibiotics administered as soon as possible. Failure to treat early sepsis can lead to septic shock (persistent hypotension) and multiorgan dysfunction syndrome.

Sepsis Neonatorum

Sepsis neonatorum is a medical emergency. Newborns may not exhibit obvious signs of infection but instead may have elevated temperature or be hypothermic. Subtle changes such as irritability, increased sleepiness, and poor feeding should be considered red flags. Blood, urine, and cerebrospinal fluid cultures should be obtained immediately and broad-spectrum antibiotics started.

Multidisciplinary Team

Several adjunctive professional services assist clients in the post-acute phase of their illness as part of an overall interdisciplinary team. Speech therapy focuses on speech and communication but also on swallowing/eating issues A client with a stroke will need to be evaluated for any aspiration risks and taught how to minimize those risks (eg, chin-down positioning, chewing on the non-affected side of the mouth). Social workers assist with developing coping skills, securing adequate financial resources or housing, and making referrals to volunteer organizations Wound care is a resource for assessing and planning the optimal care of any wound Occupational therapy emphasizes the skills necessary for activities of daily living (eg, dressing, bathing, cognitive or perception issues); however, walker training is performed by a physical therapist. An overly broad generalization is that occupational therapy is for "above the waist." Physical therapy focuses on mobility, ambulation, ability to transfer, and use of related equipment. An overly broad generalization is that physical therapy is for "below the waist." Dressing skills would be taught via occupational therapy.

Herpes Zoster (Shingles)

Shingles (herpes zoster) is a reactivation of the varicella-zoster (chicken pox) virus. It is more likely to occur when a client's immune system is compromised by disease (eg, HIV infection) or treatments (eg, chemotherapy). Shingles lesions that are open may transmit the infection by both air and contact. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital. Negative airflow pulls air from the hospital environment into the room, and the air from the hospital room then goes directly to the outside rather recirculating to the rest of the hospital. Localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions.

Types of Play

Solitary play is common in infants (birth to 1 year). Children at this stage are focused on their own activity and will play alone in the presence of others. Parallel play is more common in toddlers (age 1-3). During parallel play, these children play next to each other and are happy to be in the presence of peers, but they do not play directly with one another. Preschoolers (age 3-6) enjoy associative play, in which they engage in similar activities or play with the same or similar items, but the play is unorganized without specific goals or rules. They often borrow items from each other without directing each other's play. Preschoolers also enjoy play involving motor activities and imaginative, pretend play. Children age 3-6 (preschool) are in Piaget's preoperational stage of cognitive development. At age 5, children are not able to fully understand cause and effect and will therefore ascribe inappropriate causes to phenomena (eg, scraped knee was caused by earlier misbehavior). Five-year-olds are developmentally capable of understanding adoption on a basic level; however, it may be difficult for them to understand the concept of having another family. The child might notice that friends are not adopted. Preschool-age children may also believe they are responsible for being adopted and may develop separation issues and fear abandonment. Cooperative play is common in school-age children (age 6-12). These children play with one another with a specific goal (eg, building a castle from blocks), often within a rigid set of rules. Cooperative play is likely too advanced for preschool-age children, as it involves more organizational skills.

Somatic Symptom Disorder

Somatic symptom disorder (SSD) is a psychological disorder that develops from stress, resulting in medically unexplainable physical symptoms (eg, abdominal pain) that disrupt daily life. Clients with SSD focus an excessive amount of time, thought, and energy on the symptoms, often seeking medical care from multiple health care providers. Nursing interventions focus on minimizing indirect benefits and developing client insight. To minimize the indirect benefits from being "sick" (secondary gains), the nurse should: Redirect somatic complaints to unrelated, neutral topics Limit time spent discussing physical symptoms To promote insight and healthy coping mechanisms, the nurse should assist the client to: Identify secondary gains (eg, increased attention, freedom from responsibilities) Recognize factors that intensify symptoms (eg, increased stress, reminders of a deceased family member) Incorporate appropriate coping strategies (eg, relaxation training, physical activity) The client's symptoms are real despite the lack of diagnostic findings. The nurse should administer analgesics as prescribed. Disputing the validity of the client's symptoms may increase the client's stress level and exacerbate symptoms Somatic symptom disorder (SSD) is a psychological disorder in response to stress that results in symptoms of physical disorders (eg, chest pain, syncope) for which there is no identifiable medical source (eg, myocardial infarction, hypotension). Periods of increased stress (eg, work demands, family events) frequently precede the onset, or worsening, of physical symptoms and result in frequent requests for medical attention and treatment. SSD and care-seeking behaviors may then be reinforced and perpetuated by secondary gains (eg, social affirmation, "sick role," avoidance of unpleasant activities). When evaluating clients' responses to treatment for SSD, the nurse should monitor for the following indicators of positive progress: Identification of alternate support systems for stress (eg, spouse, friends) Identification of perceived benefits (ie, secondary gains) of behaviors Use of stress-reducing strategies (eg, drawing, meditating) rather than fixation on symptoms Verbalization of factors causing or worsening symptoms When medical treatment does not support a diagnosis for the physical symptoms, the client may become frustrated and seek the opinion of additional health care providers. This indicates a lack of treatment progress..

MMR vaccine complications

Some children have a mild reaction to the MMRV vaccine within 5-12 days after the first dose. Problems include low-grade fever, mild rash, swelling and erythema at the injection site, irritability, and restlessness. Although rare, fever after MMRV vaccination can lead to febrile seizures. Therefore, it is important for the nurse to determine the child's temperature to evaluate the risk for a febrile convulsion. It would also be important for the nurse to instruct the parent to monitor the child's temperature and administer acetaminophen for a fever above 102 F (38.9 C). Children with a history of seizures should be vaccinated with separate MMR and varicella vaccines instead of the combination MMRV vaccine.

Breastfeeding Instructions

Sore nipples and painful breastfeeding are common reasons clients discontinue breastfeeding. Teaching proper technique helps clients continue breastfeeding, promotes comfort for the mother, and ensures adequate newborn nutrition. Key principles of proper breastfeeding and latch technique include: Breastfeed every 2-3 hours on average (8-12 times/day) Breastfeed "on demand" whenever the newborn exhibits hunger cues (eg, sucking, rooting reflex) Position the newborn "tummy to tummy" with mouth in front of nipple and head in alignment with body Ensure a proper latch (ie, grasps both nipple and part of areola) Feed for at least 15-20 minutes per breast or until the newborn appears satisfied Insert a clean finger beside the newborn's gums to break suction before unlatching Alternate which breast is offered first at each feeding

Z-track technique

The Z-track technique prevents tracking (leakage) of the medication into the subcutaneous tissue and is universally recommended for the administration of IM injections. Displacing the skin while injecting the medication, and then releasing the skin back to its normal position after removing the needle creates a zigzag track. The procedure for administering an IM injection using the Z-track technique includes these steps: Pull the skin 1-1 ½" (2.5-3.5 cm) laterally away from the injection site (Option 4). Hold the skin taut with the nondominant hand, and insert the needle at a 90-degree angle - taut skin facilitates entry of the needle and this angle ensures that the needle will reach the muscle Inject the medication slowly into the muscle while maintaining traction - slow injection promotes comfort and allows time for tissue expansion to facilitate absorption of the medication Wait 10 seconds after injecting the medication and withdraw the needle while maintaining traction on the skin; this allows the medication to diffuse before needle removal and helps to prevent tracking Release the hold on the skin - this allows the tissue layers to slide back to their original position, sealing off the needle track Apply gentle pressure at the injection site, but do not massage as this can cause the medication to seep back up to the skin surface and cause local tissue irritation There is no clear evidence to support the need for aspiration prior to IM injection. Aspiration may be indicated if the dorsogluteal site (last resort) is used for IM injection due to its proximity to the gluteal artery. The preferred areas for IM injection are the ventrogluteal site in adults and the vastus lateralis site in children. the needle needs to be at least 1 - 1 1/2 inch to get to the muscle

ADHD

The core symptoms of ADHD include hyperactivity, impulsiveness, and inattention. Hyperactive children are restless; have difficulty remaining seated when required; and exhibit excessive talking, blurting out answers prematurely, and interrupting others. Inattention is characterized by reduced ability to focus and attention to detail, easy distractibility, and failure to follow through (eg, homework, chores). The primary symptoms of ADHD have a negative impact and can make life difficult for children in school, at work, and in social situations. Symptoms interfere with opportunities to acquire social skills and may also result in rejection and critical judgment by peers. The negative consequences of ADHD include: Poor self-esteem Increased risk for depression and anxiety Increased risk for substance abuse Academic or work failure Trouble interacting with peers and adults Children with ADHD are more likely to have a learning disability. Confusion is not a typical clinical finding. Although children with ADHD may appear to be emotionally immature for their age, ADHD is not associated with delayed physical growth. Children with ADHD are not disoriented. ADHD is associated with a range of cognitive impairments, but no single cognitive dysfunction typifies all children with the disorder. Some children have no impairment at all. Symptoms of ADHD usually continue into adulthood; current research indicates that children do not outgrow the condition. However, individuals with ADHD learn to cope with and manage the symptoms and achieve their full potential, leading healthy and satisfying lives. They may move into a condition of being "recovered," but this is usually a dynamic and ongoing state. Stimulant medications (eg, methylphenidate, dextroamphetamine, lisdexamfetamine) are first-line agents in the treatment of attention-deficit hyperactivity disorder (ADHD). Methylphenidate (Ritalin) is administered in divided doses 2 or 3 times daily, usually 30-45 minutes before meals. As a stimulant, methylphenidate may interfere with sleep and should be given no later than around 6 PM The sustained-release preparation should be given in the morning. The dosage in children is usually started low and titrated to the desired response.

TB test

The correct procedure for administering a TB intradermal injection is as follows: 1. Choose a 1 mL tuberculin syringe with a 27-gauge 1/4 inch needle then don clean gloves - the syringe is calibrated in hundredths of a millimeter and the intradermal needle is short enough to remain in the dermis with length range of 1/4-5/8 inch 2. Position the left forearm to face upward, and cleanse site that is a hands width above the wrist - the left arm is commonly used for TB testing; the forearm has little hair and subcutaneous tissue and is readily accessible to observe a skin reaction. 3. Place non-dominant hand 1 inch below the insertion site and pull skin downward so that it is taut - taut skin makes it easier to insert the needle and promotes comfort. Insert the needle almost parallel to skin at a 10-degree angle with bevel up - this is important as the medication can enter the subcutaneous tissue if the angle is >15 degrees 4. Advance the tip of the needle through epidermis into dermis; outline of bevel should be visible under the skin - verify that the medication will be injected into dermis 5. Inject medication slowly while raising a small wheal (bleb) on the skin - verify that the medication is being deposited into the dermis 6. Remove needle and do not rub the area - rubbing promotes leakage through the insertion site and medication deposition into the tissue. 7. Circle the area with a pen to assess for redness and induration (according to institution policy) - this delineates the border for measurement of reaction

Burns

The greatest immediate threat to a client with severe and extensive burn injuries is hypovolemic shock and electrolyte imbalance. This is due to cellular damage and increased capillary permeability caused by direct thermal trauma, which result in fluid loss. In the emergent phase of burn management, it is critical to establish an airway and replenish lost intravascular fluid, proteins, and electrolytes. Lactated Ringer's (LR), also known as Ringer's lactate, is the solution of choice for fluid resuscitation of a burned client due to its similarity in chemical composition to human plasma LR remains in the intravascular space longer than other solutions, which helps to stabilize blood pressure and avert shock. Burn injuries cause tissue damage that leads to increased vascular permeability and fluid shifts (eg, second and third spacing). In the emergent phase after a burn (first 24-72 hours), fluid, proteins, and intravascular components leak into the surrounding interstitium, causing decreased intravascular oncotic pressure and decreased intravascular volume, and resulting in fluid shifts and hypovolemia. Potassium, the predominant intracellular cation, is released when cellular damage occurs, resulting in hyperkalemia (potassium >5.0 mEq [5.0 mmol/L]). Clients with hyperkalemia experience muscle weakness, ECG changes (tall, peaked T waves, shortened QT interval), and cardiac arrhythmias Burns cause large fluid shifts and can decrease perfusion to the gastrointestinal tract, resulting in inconsistent absorption of oral medications. Burns damage the muscle and subcutaneous tissue, causing generalized body edema and decreased circulating blood volume. These physiological changes reduce the absorption ability for the intramuscular and subcutaneous routes -- Medication administration is give through IVs

Thrombolytic Therapy

Thrombolytic therapy aims to stop the infarction process, dissolve the thrombus in the coronary artery, and reperfuse the myocardium. This treatment is used when facilities do not have an interventional cardiac catheterization laboratory or when such a facility is too far away to transfer the client safely. Client selection is important because all thrombolytics lyse the pathologic clot but may also lyse other clots (eg, at a postoperative site). Minor or major bleeding can be a complication. Inclusion criteria for thrombolytic therapy in clients with acute myocardial infarction include chest pain lasting ≤12 hours, 12-lead ECG findings indicating acute ST-elevation myocardial infarction, and no absolute contraindications (eg, history of cerebral arteriovenous malformation) Active menstruation is not a contraindication for thrombolytic therapy. Research shows that the risk of increased menstrual bleeding due to thrombolytic administration is low and not life-threatening. Physiologic menstrual bleeding is also not a contraindication for anticoagulation therapy. Chest pain is one of the inclusion criteria for thrombolytic therapy. Uncontrolled blood pressure of >180 mm Hg systolic or >110 mm Hg diastolic is a relative contraindication for thrombolytic therapy. This client's blood pressure (170/92 mm Hg) is elevated but not uncontrolled, which does not rule out this therapy.

Recommended bed-to-chair transfer method

To determine the most appropriate method to safely transfer a client for the first time, the nurse should assess: Whether the client can bear weight Whether the client is cooperative If the client is cooperative and able to partially bear weight, a safe transfer requires a 1-person stand and pivot technique with a gait belt or powered stand-assist lift. If the client can fully bear weight and is cooperative, the client will not require an assisted transfer. However, a caregiver should stand by during the first transfer for safety or for assistance.

Cane use

To prevent falls after a total knee replacement, clients should use a cane to provide maximum support when climbing up and down any stairs. Clients should hold the cane on the stronger side and move the cane before moving the weaker leg, regardless of the direction. Clients must also keep 2 points of support on the floor at all times (ie, both feet, foot and cane). When descending stairs, the client should: 1. Lead with the cane 2. Bring the weaker leg down next (in this client, it is the left leg) 3. Finally, step down with the stronger leg (Option 1) When ascending stairs, the client should: 1. Step up with the stronger leg first 2. Move the cane next, while bearing weight on the stronger leg 3. Finally, move the weaker leg T o remember the order, use the mnemonic "up with the good and down with the bad." The cane always moves before the weaker leg.

Reye Syndome

Total parenteral nutrition (TPN) is an IV nutrition solution containing carbohydrates, amino acids, vitamins, minerals, electrolytes, and lipids that is administered to clients who are unable to receive enteral nutrition. TPN is rich in glucose, which supplies caloric energy and stimulates the pancreas to secrete insulin. If TPN is stopped abruptly, the pancreas may continue to secrete increased amounts of insulin in anticipation of glucose metabolism, placing the client at risk for rapid-onset hypoglycemia. Therefore, clients whose TPN infusion has stopped or abruptly slowed should be

TPN

Total parenteral nutrition (TPN) is an IV nutrition solution containing carbohydrates, amino acids, vitamins, minerals, electrolytes, and lipids that is administered to clients who are unable to receive enteral nutrition. TPN is rich in glucose, which supplies caloric energy and stimulates the pancreas to secrete insulin. If TPN is stopped abruptly, the pancreas may continue to secrete increased amounts of insulin in anticipation of glucose metabolism, placing the client at risk for rapid-onset hypoglycemia. Therefore, clients whose TPN infusion has stopped or abruptly slowed should be assessed for signs of hypoglycemia and have blood glucose measured immediately, because hypoglycemia is associated with potentially life-threatening neurologic complications A complication of total parenteral nutrition (TPN) is hyperglycemia, as evidenced by excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision. The development of hyperglycemia is related to the following: Excessive dextrose infusion A low tolerance for dextrose in critically ill clients due to the inflammatory response and the resulting production of counterregulatory hormones High infusion rate Administration of medications such as steroids Infection Interventions to resolve TPN-associated hyperglycemia include reducing the amount of carbohydrate in the TPN solution, slowing down the infusion rate, and administering subcutaneous insulin. Total parenteral nutrition (TPN) is an IV nutrition solution containing carbohydrates, amino acids, vitamins, minerals, electrolytes, and lipids that is administered to clients who are unable to receive enteral nutrition. TPN is rich in glucose, which supplies caloric energy and stimulates the pancreas to secrete insulin. If TPN is stopped abruptly, the pancreas may continue to secrete increased amounts of insulin in anticipation of glucose metabolism, placing the client at risk for rapid-onset hypoglycemia. Therefore, clients whose TPN infusion has stopped or abruptly slowed should be assessed for signs of hypoglycemia and have blood glucose measured immediately, because hypoglycemia is associated with potentially life-threatening neurologic complications A complication of total parenteral nutrition (TPN) is hyperglycemia, as evidenced by excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision. The development of hyperglycemia is related to the following: Excessive dextrose infusion A low tolerance for dextrose in critically ill clients due to the inflammatory response and the resulting production of counterregulatory hormones High infusion rate Administration of medications such as steroids Infection Interventions to resolve TPN-associated hyperglycemia include reducing the amount of carbohydrate in the TPN solution, slowing down the infusion rate, and administering subcutaneous insulin. The American Society for Parenteral and Enteral Support (ASPEN) recommends 140-180 mg/dL (7.8-10.0 mmol/L) as the target range for glucose control in clients receiving nutritional support. Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) can be due to slowing the rate of the infusion. Although it occurs less frequently in clients receiving total parenteral nutrition (TPN) than hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) does, hypoglycemia can lead to life-threatening complications (eg, seizures, nervous system dysfunction). Therefore, the serum glucose of 68 mg/dL (3.8 mmol/L) is the laboratory finding of highest priority for the nurse to report to the health care provider (HCP).

Varicella

Varicella (chickenpox) is a highly contagious infection characterized by a generalized rash of itchy, vesicular lesions. Both chickenpox and shingles are caused by the varicella-zoster virus (VZV), which is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated (widespread) shingles, the nurse should use precautions for both airborne isolation (ie, N95 respirator mask), negative air pressure room) and contact isolation (eg, gown, gloves, disposable equipment) Once the vesicles have crusted, the client is no longer contagious, and isolation precautions may be discontinued Rooms with negative air pressure are equipped with specialized air equipment that continuously filters air out of the room and creates a negative pressure gradient that prevents infectious airborne particles from escaping through the doorway Pregnant health care workers should not be exposed to clients with TORCH infections (Toxoplasmosis, Other [VZV/parvovirus B19], Rubella, Cytomegalovirus, Herpes simplex virus), as these infections can cause fetal abnormalities Educational objective:Varicella-zoster virus (ie, chickenpox, shingles) is transmitted through airborne particles or contact with open vesicles. For chickenpox and disseminated shingles, the nurse should use precautions for both airborne isolation (ie, N95 particulate respirator mask, room with negative air pressure) and contact isolation (eg, gown, gloves, disposable equipment) until vesicles have crusted.

Nonutritive sucking

Violence (eg, offensive language, physical aggression) may be precipitated by substance abuse, emotional stress, mental instability, or altered mentation from medical conditions. To de-escalate a violent situation and ensure the safety of the client and others, the nurse should: Remove other clients from the area. Keep a safe distance from the client with a clear path to safety. Maintain a calm demeanor, keeping the hands visible. Use clear, nonthreatening communication focusing on mutual goals During periods of extreme anxiety and stress, clients are prone to irrational thinking. The nurse should avoid reasoning (eg, explaining the dangers of refusing treatment) until the situation has been de-escalated and the client is no longer in crisis.

Patient Violence d/t Substance Abuse

Violence (eg, offensive language, physical aggression) may be precipitated by substance abuse, emotional stress, mental instability, or altered mentation from medical conditions. To de-escalate a violent situation and ensure the safety of the client and others, the nurse should: Remove other clients from the area. Keep a safe distance from the client with a clear path to safety. Maintain a calm demeanor, keeping the hands visible. Use clear, nonthreatening communication focusing on mutual goals During periods of extreme anxiety and stress, clients are prone to irrational thinking. The nurse should avoid reasoning (eg, explaining the dangers of refusing treatment) until the situation has been de-escalated and the client is no longer in crisis.