NCLEX-RN Review

Drooling in infants

drooling occurs at 3 months if it occurs before it may indicate a blockage

Fertilization

occurs in the third distal end of the Fallopian tubes

Hbg A1C

Blood test when elevated BS causes glucose attach to hemoglobin in RBC <7% for DM pt 4-6% for non-DM pt Assess pt glucose control over 3 month period (prior) *can detect if pt is compliant with DM tx

compression fracture

occurs when the bone is pressed together (compressed) on itself NSG INTV: No ambulation (unless brace is present) ENCOURAGE PT TO WEAR BRACE Lie FLAT

Kawasaki's leads to?

Cardiac problems. Also anurysms

AMA (against medical advice)

Against medical advice IF pt request to leave AMA Notify physician and explain situation and interventions taken (SBAR) Follow any MD orders (if any) Have pt sign AMA form (d/c any IV and take VS (if necessary)) DOCUMENT

Defense Mechanisms

Compensation: attempt to make up for real or imagined weakness Denial: refusal to acknowledge a real situation Displacement: transferring the feelings associated from one source to another that is considered less threatening Identification: the emulation of admirable qualities in another to enhance one's self-esteem Rationalization or intellectualization: use of logic, reasoning, and analysis to avoid unacceptable feelings Introjection: internalizing or taking on the values and beliefs of another person Isolation: separation of emotion from an associated thought or memory Projection: unacceptable feelings or impulses transferred to another Reaction formation: avoidance of unacceptable thoughts/behaviors by expressing opposing thoughts/behaviors Regression: withdrawing to an earlier level of development to benefit from the associated comfort levels of the previous level Repression: unconscious defense mechanism in which unacceptable ideas, impulses, and memories are kept out of consciousness Somatization: transfer of painful feelings to body parts, thus person's feelings expressed as a physical symptom Sublimation: transformation of unacceptable impulses or drives into constructive or more acceptable behavior Suppression: conscious or voluntary inhibition of unacceptable ideas, impulses, and memories Undoing: actually or symbolically attempting to cancel out an action that was unacceptable Substitution: individual replaces a highly valued, unattainable object with a less valued, attainable object

Endocrine treatment

LIFE LONG MEDICATION TREATMENT IS USUALLY STANDARD FOR MOST IF NOT ALL ENDOCRINE DISORDER. Teach pt the reason for taking the medication Teach the effects of not taking medication r/t disease Teach pt the side effects of medication Teach pt to always take medication

Hormones that increase blood [glucose]

"STENGG" Somatotropin (growth hormone) Thyroid hormones (thyroxine and triiodothyronine) Epinephrine Norepinephrine Glucagon Glucocorticosteroids

Any procedure/surgery involving the NECK, HEAD, THORAX region

*MUST HAVE AT BEDSIDE* INTUBATION KIT AMBU BAG SUCTION O2 (mask better but have NC and MASK) Elevate HOB ASSESS RESPIRATORY STATUS Assess lung sounds Incentive spirometer (unless contradicted)

Calcitonin

*responds when Ca levels are high in the blood. decrease Ca levels when Ca levels are high and causes increase Ca to be deposited into the bone.

Aldosterone

"salt-retaining hormone" which promotes the retention of Na+ by the kidneys. Increased aldosterone =less Na+ excreted. (Na+ retained, water follows= increased BP.

Depression

#1 sign is sleep disturbance

Hemorrhagic stroke

*#1 CAUSE IS HTN* occurs when a blood vessel in the brain leaks or ruptures; also known as a bleed s/s: Exploding headache decreased LOC N/V Stiff neck Focal seizures hemiparesis visual disturbance dizziness/tinnitus coma/death NSG INTV: Provide a pureed, soft, or semi-soft food r/t hemiplagia/paresis due to dysphagia=aspiration risk Elevated HOB (especially when eating) Monitor VS/LOC Provide safety Speech consult if dysphagia present Anticoagulation tx decrease sensory stimuli (do multiple tasks at once (ex.VS and AM/PM care) provide rest periods

*A*rteries *V*eins

*A*way from the heart To the heart

Addisons: Down, Down, Down, Up, Down Cushings: Up, Up, Up, Down, Up

*Addisons*: Hyponatremia, Hypotension, Decreased blood volume, *Hyperkalemia*, Hypoglycemia *Cushings*: Hypernatremia, Hypertension, Increased Blood Volume, *Hypokalemia*, Hyperglycemia

NG TUBE/PEG TUBE

*Have suction equipment at bedside (hooked up and ready)* HOB always elevated during feedings (bolus or continuous) New tube placement CXR should be done to confirm placement. If continous suction follow MD order. Check for residual prior to feedings and medication administration. If residual is 150 ml or more (based on MD order) hold feeding contact HCP or follow orders provided. (ex.hold feed for 30min to 1hr and reacheck residual) Check placement by aspiration of contents prior to medication administration. Crush each medication in individual med cup with 5 ml of water and place 5-10 ml of water between each medication. Flush with 30-60ml of water pre and post medication administration. Flush tube per order ex flush with 100ml every 4 hours. Peg tube dressing should be performed every night shift or PRN if soiled.

Post op SURGERY OR PROCEDURE NSG INTV

*Low grade fever is common* Monitor VS frequent Encourage PO fluids RX: tylenol to reduce fever Encourage ambulation *Encourage use of incentive spirometer (10x/hr)* Assess pain medication prior (assess prior to incentive spirometer use) Splint any incision with pillow prior to TCDB TCDB TQ2H Teach pt to avoid picking up heavy objects Assess site operated (COCA* on any drainage) DVT prophylaxis, SCD, TED hose r/t risk of PE Monitor for s/s of an infection (temp, warmth, redness, drainage) Incision itching means healing is occuring *but continue to monitor.

Acute Epiglottis

*MEDICAL EMERGENCY* *MAINTAIN AIRWAY* inflammation of larynx caused by bacterial/viral infection can be dangerous when it closes glottis and causes suffocation Usually occurs in ages 2-5yrs. Cause: H.influenzae S/S: cough drool fever sore throat resp. stridor child position themselves in tripod position to help breathing. NSG INTV: Humidified O2 ABT (usually IV for 7-10days) Steroids Position in upright position Have intubation equipment at bedside. decrease anxiety NPO Dx: x-ray of neck AVOID EXAMINATION OF THROAT r/t spasm and airway compromise. *may intubate or trach if continuous resp distress.

CAD RISK FACTORS

*Modifiable risks:* -cholesterol (elevated LDL) -tobacco/cigarette use -HTN -DM -Obesity -Physical Activity *Nonmodifiable risk* -Family HX -Adv. Age -Gender (male develop earlier) -Race (prevalent in african american) Control: Stop smoking, manage HTN and DM, control diet and physical activity and medication (ex: Lipitor)

CAD

*Most common cardiovascular disease r/t abnormal accumulation of lipid in arterial blood vessel which causes blockage and narrowing of artery and reduce blood flow to myocardium. S/S: *Chest pain (angina pectoris) r/t myocardial ischemia -MI r/t decrease blood supply -HR r/t myocardial damage=low CO -Sudden death r/t decrease blood supply tx: use aspirin due to it antiPLT action, HTN med, Nitrates, cholesterol lowering med (-statin) Diet: low fat NSG INTV: monitor VS Monitor LOC Monitor EKG Monitor respiratory status

FIRE (and fire extinguisher) procedure

*R*escue pt (check room and bathroom) *A*ctivate emergency response *C*onfine the fire *E*xtinguish fire *P*ull *A*im *S*queeze *S*weep

Cirrhosis

*common cause: alcohol abuse, Hep. B/C (screen) s/s MNEUMONIC: THE LIVER IS SCARRED Tremors (astrexis: flapping for hands) Hepatic foetor Eye and skin yellow (jaundice) Loss of appetite Increased in ammonia and bilirubin levels Varices Edema (lower extremities) Reduced WBC and PLT (risk for infection and bleeding) Itchy skin (r/t increased bilirubin) Spider angioma Spenoglomegaly, stool clay color Confusion (COMA) (r/t increase of toxins in the body) Ascities Redness of palms (r/t increase estrogen level) Renal failure Enlargement of breast (r/t increase estrogen unable to be excreted) Deficient in vitamins (B12, C, E,A, D,K), dark color urine Complication: portal HTN, hepatic encephalopathy, ascities RX: Beta-blocker, Nitrates, Diuretics vitamin replacement Lactulose to decrease ammonia levels Paracentesis (to decrease fluid in abdomen) Liver transplant NSG INTV: Rest -O2 -monitor for s/s of infection -Assess jaundice -Assess Resp. function -Reduce itching (creams or meds per order) -small frequent meals -fluids restriction -assess urinary output -Diet: high protein, carb, calorie. (if pt is confused avoid high protein diet) -elevated HOB -Monitor VS, LOC, I&O, daily weight -assess abdominal girth -monitor liver enzymes, PT/INR, Hepatitis -TQ2H -FALL PRECAUTION -BLEEDING PRECAUTION (soft toothbrush, pressure post veni-puncture site, electric razor) -Teach pt to avoid alcohol and alcohol products

Esophageal varices

*common in pt with cirrhosis enlarged and swollen veins at the lower end of the esophagus s/s HAMS -Hematemesis -AMS -Melena -s/s of shock tx: electrolyte and volume replacement blood transfusion urinary catheter SURGERY NSG INTV: assess for bleeding -montior VS -quiet environment -oral care -assess LOC

3 C's for TEF

*coughing* *chocking* during feedings unexplained *cyanosis* Monitor VS NOTIFY MD of any abnormalities NSG INTV: -admin morphine -IV fluids -100% O2 mask -Position infant or child in the knee chest position to increase blood flow 4 defects present: VSD Right ventricular hypertrophy overriding aorta Pulmonary stenosis-

Insulin storage

- Do not heat/freeze - In use vials may be left at room temp up to 4 weeks - Extra insulin should be refrigerated - Avoid exposure to direct sunlight or freeze Store insulin IN USE for 28 days to one month at room temp *Refrigerate any insulin NOT IN USE.* Insulin syringe used common areas for injection: abdomen, uppe arm, anterior thigh, hips Rotate injection sites to prevent lipoatrophy

Enteral routes of drug administration

- oral (PO): can be pills or liquid *usually the safest route - sublingual: under the tongue - buccal: between gum and cheek - PEG/NG tube

Immobile pt care

-2-3L of fluids (PO/IV) daily to prevent renal calculi, UTI, constipation, and DVT formation -use trochanter rolls to prevent external rotation and abduction of the hips which will maintain correct body alignment SCD/ROM Anticoagulant/prophylatic med Incentive spirometer TCDB Q2H r/t pneumonia risk and pressure ulcer risk *DO NOT* -massage lower extremities to prevent dislodging a thrombus -place pillow under the knees bc it can impede venous return and contribute to thrombus formation

HTN risk factors

-ADV AGE -Family hx -Obesity -Smoking -Stress -Sleep apnea -Lazy -Poor diet

ADL

-Activities of Daily Living -bathing/hygiene dressing mobility/ambulation eating bed mobility (transfer) elimination bed making cleaning rooms oral care medication management driving

Leadership Styles

-Authoritarian- makes all decision without input from other people/staff -Democratic- makes decision based on input of other people/staff -Laissez-faire- passive, provide no clear direction.

Respiratory Assessment

LOC ABG* when indicated Lung sounds (auscultate) Respiration patterns or effort Inspect chest symmetry pulse oximetry VS (specifically O2, RR and HR) NSG INTV: Check physiotherapy TCDB Q2H Incentive spirometer (10x/hr) oral care Elevate HOB

Preventing a UTI (cystitis)

-Avoid caffeine and alcohol -Avoid tight fitting clothing -Void before/after sex -Avoid bubble baths -Void q2-3 hrs -Sitz bath -Wipe front to back -Avoid coffee, tea, citrus, alcohol, colas r/t cause spasm -Drink Cranberry/apple Juice (helps to maintain acidity of urine) -Void frequently -Drink plenty of fluids. (1-3L) -Take PO ABT as ordered if DX.

Renal Labs

-BUN & Creatinine -GFR -BNP -U/A -Calcium/electrolytes (BGB UC)

DIGOXIN

-Check pulse, it is < 60 in adults, < 100 in children, <70 for older child, you must hold medication *Check pulse via Apical Pulse* -Check dig levels and K+ levels (low K+ levels can increase risk of digoxin toxicity) Normal level: 0.5-2 *Action of medication: increased strength of heart contraction and slow down HR*

Fetal Accelerations

-Increase in Heart Rate of 15 Beats/Min or More For 15 Seconds -Usually indicate fetal movement and can occur with or without contractions -REASSURING: NO INTV required -continue to montior FHR and mother VS

Peritonitis

-Inflammation of the peritoneum S/S: abd. pain and distention n/v weakness profuse sweating tachycardia fever *CAN LEAD TO SEPTIC SHOCK NSG INTV: -monitor VS -I&O and weights NPO or NG tube PRN Abd. assessment

Snake Bite

-Move the pt to a safe environment away from snake -Have the pt lie down -removing constrictive items -providing warmth, cleansing the wound, covering with sterile dsg -immobilizing limb below the level of the heart.

MAOI's are used as antidepressants

-Parnate -Marplan -Nardil *avoid food high in thyramine (ex: aged cheese, smoked meat, red wine, salami) Avoid with concurrent use with SSRI r/t to risk of serotonin syndrome Medication may have a metallic taste

Vistaril is for the:

-Tx of anxiety and also itching -Watch for dry mouth -Given preop commonly

Variable Deceleration

-deceleration of FHR r/t cord compression -Have a U or V shape apperance -occur with or without connection to a contraction NSG INTV: STOP Stop pitocin infusion Turn to left side O2: 8-10L via non re-breather mask Push IV fluids -continue to monitor FHR -monitor mother VS -notify HCP

Early Deceleration

-deceleration of FHR r/t cord compression that mirror contraction -REASSURING: NO INTV required -Continue to monitor FHR and mother VS

Cardioversion- PULSE

-returning a heart to normal rhythm for pt with s/s and have a PULSE; shock delivered at the peak or R of the QRS complex -Elective procedure that can be done at bedside with informed consent. -TEE must be performed to assess for clots *SYNC ON* -use conducting gel and sedation prior -Call "CLEAR" 3x, no one touch pt -Supplement O2 (ambu), monitor RR and O2 sat -admin sedation and anticoag -Inspect skin after to assess for burns -Continous EKG monitoring (during and after) for dysrhythmias -NO O2 during procedure r/t fire hazard -Admin antiarrhythmic medication post Stable SUPRAVENTRICULAR TACHYCARDIA A-FIB A-FLUTTER Unstable pulse V-TACH

Dysrhythmias

-sinus bradycardia and tachycardia -atrioventricular blocks -atrial fibrillation -ventricular asystole -premature atrial complexes (PACs) and premature ventricular complexes (PVCs) -supraventricular tachycardia -ventricular tachycardia -ventricular fibrillation

Drugs that cause ototoxicity

-specific antibiotics (-mycin) -loop diuretics (ex: Lasix) -nonsteroidal anti-inflammatory agents (NSAID) (Aspirin) -specific chemotherapy agents.

Cardiovascular assessment

LOC VS (HR and BP) *apical pulse Assess pulses ( grading of pulse (+1,+2)) (regular, irregular) Heart sounds Cap refill Assess CMS

1 gram

1 ml

Maslow's Hierachy

1. Physiological Needs (ex: airway, nutrition, pain) 2. Safety and Security (ex: trust, protection, and security) 3. Love and Belonging (ex: love and support) 4. Self- Esteem (ex: control, acceptance, competence) 5. Self- Actualization (ex: hope, spirituality, and personal growth) *each level must be satisfied first prior to moving to the next stage

Discontinue herbal remedies (preop)

1-2 weeks prior to surgery *Discontinue aspirin 48-72 hrs preop

No immunization or vaccines

1. After admin of antiviral med for 9 months 2. Steroid therapy (immunosuppressive thearpy) and active disease 3. pregnant women

1. IV inflammation 2. IV infiltration 3. IV itching

1. D/C the IV and start a new IV site. 2. D/C IV, elevate (above the heart) the site, apply warm compress, and restart the IV new site 3. Give benadryl (usually given 30min to 1hr prior if pt has hx) and monitor site for infection. Inform pt to try and avoid itching site r/t risk of skin breakdown. Change IV site if skin becomes broken due to itching.

Stages of Grief

1. Denial 2. Anger 3. Barganing 4. Depression 5. Acceptance

Management of DM

1. Nutrition 2. Excercise 3. Monitoring BS 4. Pharm tx 5. Education Nutrition: maintain proper body weight, control BS, BP, and lipids *increase fiber intake to decrease fat absorption -equal gram of protein, fat, and carb *obtain diet hx of pt based on favorite food, culture, and meal patterns Exercise: lowers BS and reduce CV risk, help with wt loss, exercise should be slow and gradual. *no insulin injection in limb exercising -proper foot wear and inspect foot pre/post -avoid extreme cold/heat -eat snack pre/post or reduce insulin dose prior to prevent hypoglycemia -monitor BS (pre,post, during) NSG INTV: assess pt self-care function Provide education on insulin tx, injection, glucose monitoring Assess pt understanding of education (feedback great indicator)

HIV/AIDS (3 stages)

1. Primary HIV infection Viral replication; High viral loads (1 mil/mL+); Decrease in CD4+ cells (but still >500 cells) No s/s or flu-like s/s: Fever, malaise, muscle aches, sore throat, night sweats 2. Latency phase No sign or symptoms Can last up to 10 years CD4+ cells fall gradually 200-499 Contagious s/s begin to occur while going into stage 3 3. Overt AIDS CD4+ drops to low 200 High viral loads AIDS defining illness Leads to death within 2-3 years s/s: Chills, fever, sweats, swollen lymph nodes, weakness, weight loss. Risk of opportunistic infection & death increases Wasting syndrome may occurs (lose 10% of body weight) AIDS dementia: deficit of memory, concentration, comprehension, & executive planning; apathy/depression/agitation; motor issues. *normal CD4 level: 500-1500 cells

1. Subjective data 2. Objective Data

1. Symptoms can only be described by the person feeling them. What the pt *S*ay 2. Signs are just what they sound like: indicators of a problem. (Usually visible, imaging, VS, labs) *Objective data*

AMA (2)

1. a form to allow discharge when a patient is leaving against medical advice. (contact nursing supervisor or HCP) 2. Advanced maternal age (OB)

1. Ice compress (cold compress) 2. Warm/hot compress

1. causes vasoconstriction which decrease bleeding 2. cause vasodialation which promotes circulation *must have an order for MD to use. *must cover or wrap to prevent injury to pt *Avoid/Limit in children and elderly *Assess skin pre and post application

Foot care for diabetics

1. inspect feet daily 2. wash feet daily, dry between toes 3. use lotion, but don't get in between toes 4. foot powder for sweaty feet 5. don't clip nails if you can, Cut nail across and then smooth corners 6. avoid open-toe, open-heeled shoes, wear slippers around the house to prevent scraps or cuts 7. avoid prolonged sitting/standing/crossing of legs #1 priority is foot care: pt should report any opening on foot that won't heal.

1. PAD (peripheral arterial disease) 2. PVD (peripheral vascular disease)

1. lower the extremities 2. elevate the extremities

COMMUNICATION 1. Interview admission questions 2. Pt to express themselves

1. use close-ended question 2. Use open ended questions *ALWAYS WANT TO CLARIFY WHAT A PATIENT HAS SAID (ex: what I hear you saying is?) Restate, listen, never ask "why", never give your opinion or be judgemental You want the pt to express themselves (especially with concerns/confusion) "Tell me...." NEVER PICK WHY IN AN ANSWER r/t never as the pt WHY

Specific Gravity

1.010-1.030 Measures concentration of urine Dehydration= increased SG Fluids overload=decreased SG (ex: diabetes insipidus)

Magnesium Levels

1.6-2.6 mg/dL Low mg can lead to *Torsades de pointes* which is ventricular dysrhythmia.

Acetaminophen therapeutic range:

10-20 *Can cause liver damage* Monitor liver function Antidote: N-acystecycline (mucomyst)

Normal IOP

10-21 mm Hg *for measurement use a topical anesthetic prior to use s/s: eye pain with n/v *report s/s to RN or HCP

Normal urinary output

1000 to 2000 mL per 24 hours Oliguria: less than 0.5ml/kg/hr or <400ml/24hr Anuria: less than 50ml/24hr

PO fluid replacement in infant/peds

10ml/ 1 kg

Incentive Spirometer

10x an hour while awake Indicated post op pt. to increase resp. function *assess pain prior to use.

AA meetings

12 step program with a spiritual basis

Sodium

135-145

Fundus

16 weeks- halfway between symphysis pubis and umbilicus 20-22 weeks- at the umbilicus 36 weeks- at the xiphoid process

Fibrinogen Levels

180 to 340 mg/dL for men and 190 to 420 mg/dL for women. A critical value is less than 100 mg/dL.

Glucose-6-phosphate dehydrogenase deficiency

A hereditary, sex-linked (X linked) Deficiency results in the breakdown of red blood cells (hemolysis) when they are exposed to fever or some medications => Anemia. s/s: NO S/S until exposure (normal H&H) AFTER EXPOSURE (fever, meds): Pallor jaundice high reticulocyte count hemoglobinuria

Stages of Labor

1st Stage: Dilation (0-10cm) (3 stages: early, active, transition) *if mother want to push prior to 10cm encourage pant-blow technique to prevent mother from pushing 2nd Stage: Pushing stage -crowning and mother has urge to push 3rd Stage: Placental Delivery -s/s: gush of blood umbilical cord lengthen uterus form globular shape with rise of fundus in abdomen 4th Stage: Uterus contracted midline of abdomen NSG INTV (4th Stage) -frequent fundal check (fundus should be firm) every 15min for 1 hr. *if boggy message until firm* -Uterus: if displaced to right or left check for bladder distention or hematoma/edema -assess vaginal bleeding and perineum -provide peri care -monitor VS (BP/HR/T) -Encourage voiding (normal or via cath) -encourage bonding and breastfeeding

HTN treatment

1st line: Lifestyle modification (weight loss, reduce salt and fat intake, stop smoking, reduce alcohol intake) -Look for secondary cause in young patients 2nd line: medications -ARB -ACE -Beta-blockers -CCB -Thiazide diuretic *NSG intv:* -Educate pt on lifestyle changes, follow up care, and medication regimen -Monitor VS and EKG -Monitor for neg effects of HTN

Calcium

8.6-10.6 Helps with bone coagulation

1 liter of fluid/1 kg

2.2 lbs

Phosphorus level

2.5-4.5

Legally Blind Patients

20/200 Position things based on clock-face image to help them locate items on a food plate or room.

Tube feeding with decreased LOC (unconscious)

Position on *right* side (promotes emptying of the stomach) with *HOB elevated* (to prevent aspiration) Have suction equipment at bedside Have O2 and intubation equipment at bedside

Infant with Cleft lip

Position on back or in infant seat to prevent trauma to suture line. While feeding, hold in upright position Usually performed 18 months to 2 years.

Amniocentesis

<20 wks bladder must be full prior >20 wks empty bladder Used to detect hemolytic disease of the newborn and detect neural tube defect

Albumin levels

3.5-5.0 g/dl <3.5= edema present (dependent, orbital)

Triglyceride level

30-150

WBC count

4,000 - 10,000 /mm3 White blood cells are the body's primary defense against disease. White blood cells help fight infection. > 10,000 indicates systemic infection (more than just local colonization) Chemotherapy : < 5,000: use reverse isolation, see patient in room, careful hygiene, hold aerobic exercise

1 pound

453.6 grams

BUN

7-22 or 10-20 Causes of elevated BUN -dehydration -renal disease -need for steroid theapy

Clotting time Bleeding time

8-15 minutes 1-6 minutes

Umbilical Cord (AVA)

A V A (2 arteries and 1 vein) Provides an exchange of nutrients and waste products between the mother and the fetus

Oxytocin

A hormone released by the posterior pituitary that stimulates uterine contractions during childbirth and milk ejection during breastfeeding. *nursing consideration* assess the frequency and intensity of uterine contractions. STOP OR SLOW OXYTOCIN -contractions last longer than 60 sec. -contractions consistently occur more often than every 2 minutes. -pt experience uterine tetany (continuous uterine contractions)

After an Myringotomy-(surgical incision into the eardrum, to relieve pressure or drain fluid)

Position on side of *affected ear* after surgery (allows drainage of secretions) Avoid getting wet M.D removes the first packing

Asthma

A chronic allergic disorder characterized by episodes of severe breathing difficulty, coughing, and wheezing. Triggers: allergens (ex.dust), weather changes, meds (ex.beta blockers, aspirin), pregnancy, menses, smoking, exercise. DX: Based on s/s, PFT (pulmonary function test) S/S: SOB tachycardia tachypnea use of accessory muscle *infants* dyspnea wheezing coughing TX:O2 -long acting b2 antagonist to prevent an episode or short acting b2 antagonist to rescue from an onset on s/s -corticosteroids NSG INTV: monitor pulse ox/VS encourage pursed lip breathing teach pt to carry inhaler and rinse mouth post use teach to avoid triggers Sports recommended: swimming, gymnastics, baseball

oxygen toxicity

A condition of excessive oxygen consumption resulting in cellular and tissue damage. EARLY s/s: non productive cough Nasal congestion sore throat substernal pain GI upset dyspnea LATE: seizure changes in LOC tinnitus drowsiness N/V twitching NSG INTV Remove O2 Elevated HOB Monitor VS/LOC Notify MD

Parkinson's Disease

A disorder of the central nervous system that affects movement, often including tremors. s/s: TRAP *Tremors (risk for burns with hot fluids; risk for injury with sharp tools)* *Rigidity (poor ROM)* *Akinesia (impaired mobility)* *Postural instability (risk for falls)* other s/s: Excessive sweating Flushing Gastric urinary retention Constipation, drooling Depression Dementia Dysphagia Dysphonia Micrographia DX: based on s/s PET scan for levadopa levels *autopsy is true dx of parkinsons TX/NSG INTV *allow pt to perform ADL based on limitations *note tremors may decrease in severity when attention is focused on a task (ex. buttoning a shirt) Pharm tx (levadopa is most common) avoid thin liquids r/t aspiration risk PLACE ON FALL PRECAUTION BED/CHAIR ALARM!! DIET: thicken liquid, soft, purred diet Improve mobility (ROM) Improve nutrition Improve communication Supporting coping abilities Patient/family education Home care considerations Assess for dyskinesias COMPLICATIONS Immobility Pneumonia UTI Consequences of falls -accidents major cause of death

STOMA CARE (SITE)

A prolapsed stoma is one in which bowel protrudes through the stoma, with an elongated and swollen appearance. Ischemia of the stoma would be associated with dusky or bluish color. A stoma with a narrowed opening, either at the level of the skin or fascia, is stenosed. Normal color is red/pink. *NEWLY FORMED STOMA: scant amount of bright red bleeding is expected. IF EXCESSIVE AMOUNT OF BLEEDING NOTED: NOTIFY MD

APGAR Score

A= appearance (color all pink, pink and blue, blue P= pulse (>100, <100, absent) G= grimace (cough, grimace, no response) A= activity (flexed, flaccid, limp) R= respirations (strong cry, weak cry, absent) *Taken 1 min after birth and 5 min after birth* Score of (out of 10) Each section 0-2 <3 CPR is needed to be performed 4-6 Stimulation is needed *tap sole of foot to stimulate 8-10 Acceptable *Completed 1 min and 5 min after birth* NSG INTV: maintain patent airway dry and provide warmth to baby skin to skin with mother/parent

Anything in the airway area

ABC Monitor O2 sat, Resp, lung sounds Early s/s: restlessness, tachycardia, and inspiratory stidor. Late: Cyanosis and decreased LOC *avoid sedation med if necessary Chronic: clubbing

Risk factors for osteoporosis

ACCESS Alcohol use Corticosteroid (long term use) Calcium low (intake) Estrogen low (post menopause women, advance age, a hysterectomy) Smoking Sedentary lifestyle/ family hx *PT WITH OSTEOPOROSIS ARE AT INCREASED RISK FOR FRACTURES

Oral hypoglycemia meds (DM Type 2 pt)

ACTION: STIMULATE BETA CELLS IN PANCREAS TO RELEASE ENDOGENOUS INSULIN. PHARM: Action of sulfa: stimulate beta cells in pancreas to secrete insulin *AVOID TAKING NSAIDS r/t low blood glucose effect Biguanide (ex:METFORMIN): reduces hepatic glucose production, intestinal glucose absorption, improves insulin sensitivity in body. *AVOID in pt with HF and renal failure (monitor BUN and creation) Thiazolidinedione (ex: Actos): increase insulin sensitivity *MONITOR LIVER ENZYMES

PANCREATITIS (ACUTE/CHRONIC)

ACUTE: Abd. pain, LUQ pain radiating to back or shoulder Pain aggravated by a fatty meal, alcohol, or lying supine Abd. tenderness and guarding N/V Absent or decreased bowel sounds Elevated white blood cell count, and glucose, bilirubin, alkaline phosphatase, and urinary amylase levels, lipase CHRONIC: (similar to acute plus:) weight loss Steatorrhea (frequent, frothy, foul-smelling, greasy stool) NSG INTV *NPO status to rest the pancreas and decrease GI secretion* Monitor VS TUBE feeding PRN Side-lying position with HOB elevated 45 degrees decreases tension on the abdomen Resp. and abd. assessment Encourage bed rest IV hydration Encourage TCDB and incentive spirometer Avoid position flat or supine r/t pain. Monitor pancreas lab test tx: enzyme replacement must be given prior to meals Rx: Antacids and anticholinergics. (acetazolamide) RX: pain management: Demorol NOT morphine sulfate

Liver test

ALT AST GGT Bilirubin (0.2-1.0) Alkaline Phosphate

Criteria for t-PA

Age over 18 years DX: ischemic stroke Onset of stroke less than 3 hours INR less than 1.7 PT less than 15 sec No seizure on onset of sroke BP less than 185/110 No anticoag recieved in past 48 hr PLT <100,000 No major surgery in 2 weeks No GI or GU bleeding in 3 weeks No pregnancy No intracranial hemorrhage, neoplasm, aneurysm

Fetal Bradycardia or Tachycardia

Bradycardia: FHR <110 cause: maternal hypotension, fetal hypoxemia, drugs Tachycardia: FHR >160 cause: maternal fever, terbutaline, fetal hypoxia, infection NSG INTV: -change mother position to *left* side -monitor any changes to FHR -Assess mother VS -notify HCP

Postpartum Assessment (BUBBLE)

Breast Uterus Bowel function Bladder function Lochia Episiotomy/C- sect incision (assess every 15 min for 1hr.) -EPISIOTOMY: use ice pack for 30 min, sitz bath post 24hr, peri-care, assess for infection or redness, monitor VS and WBC

Traction for children

Bryant's traction Buck's extension Russell's traction CHECK NEUROVASCULAR ASSESSMENT

Application of topical medication

Apply with gloved hand Assess skin prior to admin Have pt take a warm bath prior to application Patch: date/time and initial If a patch: remove any previous patches prior to reapplication of new patch

If you see the word "initial or first or priority" in a question?

Look in the answers for words "Assess, Ask, Check" ADPIE Safety Maslow Hierarchy *physiological needs need to be met first (eating, breathing, pain) *meaning what are you going to do in the room for the pt to *provide safety.* 'OBSERVATION': what you see

ARF (Acute Respiratory Failure) Diagnosed

Parameters to dx: 1. Decrease in PaO2 to less than 60 mm Hg (hypoxemia) 2.- Increase in PaCO2 greater than 50 mm Hg (hypercapnia) 3.- Arterial pH of less than 7.35 (acidemia, acidosis) 4.- O2 Sat less than 89%

Delegation to LPN's/LVN's. LPNs can

Are technical doer's NO E.A.T -Can give PO, SubQ, IM, Topical meds -Sterile procedures such as foley cath -IV's but can not give IV meds (IV push) -REINFORCE teaching (not initial) -Tube feeding -ostomy care -monitor RN findings -focused assessments (not initial assessments) -should be given the most stable pt

Stroke/CVA

ASSESS LOC sudden loss of brain function r/t disruption of blood supply FAST Face droop Arm (drift present) Speech (slurr?) *Time (notify 911 or code)* TIME IS ESSENTIAL 2 TYPES 1. ischemic r/t vascular occlusion (thrombosis r/t a-fib) and hypoperfusion 2. Hemorrhagic #1 CAUSE UNCONTROLLED HTN, atherosclerosis, tumor, meds, illegal drugs

Junctional Dysrhythmias

AV node become the heart pacemaker which leads to bradycardia which causes decreased perfusion.

HEART FAILURE NSG INTV

Admin med and assess side effects monitor electrolytes (especially potassium) EGK monitoring Assess I&O Daily weights (monitor for 2-3lb/daily or 5lb/weekly *notify HCP) Ascultate lung sounds Provide O2 Assess JVD Assess edema Monitor VS Assess skin turgor and mucous membrane Montior for s/s of fluid overload (dyspnea, orthopnea) *COMPLICATIONS* -Hypokalemia/hyponatremia r/t diuretic use -Dysrhythmias r/t dig toxicity, hypokalemia/hypomagnesemia, hyperkalemia (ACE inhibitors) -O2 sat/ cyanosis (2L but may increase in emergency) CALL CODE

Thrombocytopenia

Abnormal decrease in the number of platelets caused by decreased production, increased destruction, or increased consumption. Cause: leukemia, sepsis (TB, HEP C), DIC, lupus, aplastic anemia, anemia, chronic alcohol use CAUSES BLEEDING s/s: based on PLT count PLT <20,000: petechiae, nasal/gingival bleeding, excessive menstruation, excessive bleeding after Sx & dental extractions. PLT <5,000: Spontaneous CNS (severe headache; potentially fatal complication) or GI bleeding AVOID: Valsalva maneuver Avoid anticoag (ASA, heparin, etc) Avoid razor blade Avoid IM injection or frequent needle sticks NSG INTV: Monitor VS/LOC MONITOR FOR S/S OF INFECTION AND BLEEDING Avoid anticoag (ASA, heparin, etc) Avoid razor blade, use ELECTRIC razors Avoid IM injection or frequent needle sticks Apply pressure for 5 min. Use a small gauge needle FALL RISK and RISK FOR INJURY

Placenta Previa

Abnormal implantation of placenta s/s: Bright red bleeding, usually painless PREVIA Painless bright red bag bleeding Relaxed uterus (non tender) Episodes of bleeding Visible bleeding Intercourse post bleeding Abnormal fetal position NSG INTV: Bed rest and L side lying *NOTHING IN THE VAGINA (SVE, SEX, etc)* Monitor FHR and contraction C-section

EMERGENCY ADMIN

Activate agency disaster plan prior to pt intake Establish an airway (admin opiods *AFTER* establish airway r/t resp distress.)

Otitis media (OM) pediatric

Acute: an inflammation of the middle ear usually caused by short, straight Eustachian tube. Cause: strep pneumoniae s/s: fever crying, irritability roll head side to side *infant decreased appetite purulent discharge from ear Dx: visual inspection of ear (appears red) TX: ABT Acetaminophen Surgery tx: myringotomy NSG INTV: avoid swimming or get water in ear. Use ABT for full course Sit or hold upright during feeding auditory evaluation *chronic OM can cause hearing loss* PREVENTION: breastfeeding immunization no bottle propping d/c pacifier at 6 months

HTN crisis

Admin Direct Vasodiolators Ex. Hydralazine works in 3 min. Take BP with in 3 min of administration

Bronchodilator and Steroids

Admin a bronchodilateor prior to a steroid. Bronchodilator open airways which when used with a steroid allow drugs to reduce the inflammation. Rinse mouth after admin of inhale steroid r/t risk of fungus (candidasis)

C&S test

Always do the culture before the administration of the antibiotic Broad specturm ABT usually given then narrow ABT

ASSESSMENT

Always done at the beginning of the shift. ALWAYS ASSESS YOUR PT WHEN PROVIDING ANY TYPE OF NSG CARE (ex: pt c/o pain perform a pain assessment) Head to Toe at the beginning of shift and systems or focused assessment at least every hour during the shift *questions: always think what you can do right then and there for the pt.

Peptic ulcer

An circumscibed lesion in mucus membrane of GI tract. Causes: long term NSAID use, *H.pylori*, smoking, genetic, zollinger-ellison syndrome 2 types: gastric or duodenal (main s/s both: indigestion and epigastric pain) S/S gastric: -food makes worse -dull pain -wt lose -*if severe: vomit blood (coffee ground emesis) S/S duodenal: -food makes better - abd. pain (usually at night) and tenderness -normal weight -*if severe: tarry, dark stool (hematemesis may be present) *think duodenal is closer to anus thus stool changes, gastric is close to mouth thus vomit blood.* NSG INTV Monitor VS Abdominal assessment Monitor for complication (gastric bleeding: high HR, Low BP, low H&H, dark stool, vomit blood, bright red bleeding) Monitor for perforation/peritonitis (abd. pain, abd. tenderness and distention, vomiting, elevated HR&RR&temp, low BP) Monitor for s/s of intestinal obstruction (N/V, abd.pain, bloating/abd. distention) Check gag reflex *based on procedure done *RISK FOR DUMPING SYNDROME (common when resection was done) *TEACH TEACH TEACH PT

Cystic Fibrosis

An genetic disorder that causes thick mucus to occur in multiple organs. It's an autosomal recessive trait so both parents must be carrying the recessive gene/trait. s/s: wheezing dry nonproductive cough cyanosis clubbing of fingers and toes repeated bronchitis and pneumonia "salty taste" Delayed puberty in females and sterility in males. bulk, foul smelling frothy stools dx test: sweat chloride test CXR PFT (pulmonary function test) enzyme analysis Newborn: if no meconium for first 24 hr may have CF. Diet: provide high Na, protien, calorie diet r/t the risk of hyponatremia NSG INTV: Repeated CPT -bronchodilators -pancreatic enzymes taken WITH food or snacks. -mucolytic -BS monitoring -ABT tx -Vitamin supplement -chest-physiotherapy post nebulizer tx to encourage drainage

PNEUMONIA

An inflammation of lung tissue, where the alveoli in the affected areas fill with fluid lying on affected side increase T of 103-104 degrees Resp 40-80 in infants and 30-50 in children nasal flaring MNEUMONIC S/S PNEUMONIA Productive cough (pleuritic cough=chest pain) Neuro changes (common in older adults) Elevated labs Unsuaul breath sounds (crackles) Mild to high fever (at least 104F) O2 Nausea and vomiting Increased HR and RR (can lead to fatigue) Aching all over dx: sputum culture, CXR (will show infiltration* usually in lower lobes) Labs: increase WBC and ESR NSG INTV: Monitor VS/LOC Admin ABT tx Himidified O2 Elevated HOB Incentive spriometer Increase fluids due to increase sputum production to thin fluids Bronchodilator Monitor lung sounds Respiratory assessment

How to treat a patient with dermatitis?

An oatmeal bath

Acquired Immunity

An specific against a foreign antigen. Active immunity- defenses developed by own body; lasts many years or a lifetime. (r/t exposure from immunization or contract disease) Passive immunity- temporary; the source is from outside the body (IV immune globulin or mother to infant).

Seizure Aura

An unusual sensation prior to a seizure Ask the pt what that aura is and if pt verbalize they have it then provide an benzo, anticonvulant, etc to prevent a possible seizure

Anaphylatic Reaction

Anaphylactic (Type I): Instantaneous & the most severe. S/S: edema in many tissues, bronchospasm, hypotension, & can lead to cardiovascular collapse. Cause: peanut, shellfish, milk, eggs, soy, wheat, insect stings, latex (ask if allergy to bananas, avocado, kiwi), penicillin, contrast, ASA, NSAIDS s/s: *MILD (within 2 hours)* Peripheral tingling Sensation of warmth Sensation of fullness in the mouth and throat Nasal congestion Periorbital swelling Pruritus Sneezing Tearing of the eyes *MODERATE* Flushing Warmth Anxiety Itching Bronchospasm Edema of airways/larynx Cough, dyspnea, wheezing *SEVERE* (immediate medical tx) Bronchospasm, laryngeal edema Severe dyspnea, cyanosis, tachypnea Hypotension, tachycardia Dysphagia Abdominal cramping, vomiting, diarrhea Seizures, Cardiac arrest, Coma TX: maintain airway Admin epinepharine (IM/SQ in UE and thigh) (monitor for rebound effect 4-8hr post) Benadryl Steroids (solumedrol) IV fluids NSG INTV: *Assess respiratory status (elevate HOB, O2)* *AIRWAY* Position pt in trendelenburg or elevated HOB Decrease pt anxiety RAPID RESPONSE DOCUMENT

Nitroglycerin

Sublingual q5 min for 3 doses. If chest pain isnt relieves after 3rd time of medication dose or rest contact 911 or M.D. (ED for evaluation) Check BP after each admin of nitro. *Affect of medication: it reduces preload due to dilation of peripheral blood vessels.*

jaw-thrust maneuver

Technique to open the airway by placing the fingers behind the angle of the jaw and bringing the jaw forward; used for patients who may have a *cervical spine injury*.

VS (normal values) ADULT

Temp (normal: 98.6) Pulse (adult:60-100 infant: 110-160) *Apical pulse *left* midclavicular, fifth intercostal space. (use bell for infants and diaphragm for adults (sethoscope)) Resp (normal: 12-20) BP Pain (1-10) O2 (normal: 95-100%)

Pulse point

Temporal Carotid Apical ( Apex of heart 5th intercostal space at the midclavicular line for 1 min) Brachial Radial Femoral Popliteal Posterior tibial Dorsalis pedis CARDIAC OUTPUT is 5L

Indication of a premature baby

The more hairier (lanugo) and cheesier(vernix caseosa) the baby. Appearance is transparent

*Nationality/Religious Food Preference*

Asian-American food preferences include raw fish, rice, and soy sauce. African-American food preferences include chicken, pork, greens, rice, and fried foods. Hispanic Americans prefer beans, fried foods, spicy foods, chili, and carbonated beverages. European Americans prefer carbohydrates and red meat. Jewish: avoid mix of meat and milk (KOSHER foods) Hindu- No food containing beef or gelatin Seven Day Adventist: no pork Hebrew Isrealities: no pork

Priority care in nursing

Assessment of patient, invasive sites, bleeding Provide O2 (usually 2L via NC) Monitor VS Elevate HOB Check any tubes for kinks

disulfiram (antabuse) *SAME WITH Metronidazole (FLAGYL)

Avoid ALCOHOL products ex: mouthwash, alcohol swabs because it *WILL* cause severe vomiting. Take at bedtime

Antifungal (-azole)

Avoid alcohol Monitor liver function Avoid sun exposure Take with food and glass of water

Any procedure on femoral artery or vein (-graphy, catherization, -gram)

Avoid bending the knee and hip Assess CMS and pulse Monitor I&O r/t may use contrast during procedure Assess doppler every hour Keep limb straight Full supine position

Respiratory disorders

Avoid dairy products (ex:milk and cheese) because it produces additional mucus or thicken secretion. Pt with resp disorders it difficult to expel mucus.

Tonsillectomy (postop)

Avoid red, brown, purple fluids, and dairy products Provide popsicles or jell-o Posistion prone or side-lying Assess for s/s of bleeding (excessive swallowing) Monitor PLT ct Apply ice or cold compress Check for any loose tooth for the risk of aspiration

VERTIGO tx

Avoid sudden head movements. Orthostatic BP

Celiac Disease (gluten allergy)

Avoid: wheat, barley, rye, and oats Can eat: rice, corn

Hematological toxicity

Low-bacteria diet. Remove fresh fruits and vegetables.

Heroin pt

Any s/s of respiratory depression give NARCAN to reverse effects

Fontanels

Anterior fontanel - diamond shape, 5 cm avg. -close at 12-18 months Posterior fontanel - smaller, triangle shaped -close at 2-3 months Fontanels should be soft Flat when newborn is quiet May bulge when newborn cries, coughs, or vomits Bulging may indicate increased ICP, infection, hemorrhage. Depressed may indicate dehydration

If during daily prenatal visits

Any significant increase in weight check BP to see if HTN r/t fluid overload or retention

Check HR of infants

Apical Pulse is taken until the age of 5 years

Legal Nursing Considerations

Ask unemancipated minors about heathcare treatment they seeking r/t birth control, pregnancy, STI doesn't require parental consent.

Legal Principles

Assault- threat a person in fear of harm, verbal threat to cause harm. Libel- Written defamation Slander- Verbal defamation Battery- physical harm Good Samaritan- protect HCP if assist a person medically that result in death unless compensation is received it's invalid. Malpractice- professional negligence Negligence- conduct below the standard of care DNR orders- must follow and reviewed regularly Durable (PPOA)- person chosen by pt to make health decision if pt is unable to. Tort- civil wrong against a person or property CONSENT MUST BE VOLUNTARY.

antihypertensive

Assess and monitor VS prior to giving medication a medication administered to lower blood pressure Monitor VS after med admin (usually 1hr) ASK MD FOR PARAMETERS WHEN ANTI-HYPERTENSIVE MED IS RX pt of medication must see MD on regular basis and take medication for life. Have pt change position slowly Monitor and teach pt for first dose orthostatic BP

Skin assessment

Assess for color, moisture, temperature, texture, turgor, vascularity, edema, lesions, rash Assess hair and scalp Assess for bruising, wounds, and pressures Assess mucosas and oral cavity (pink, most, lesions) Assess extremities Assess bony parts for breakdown r/t high risk areas of pressure ulcer formation

C-section postpartum

Assess fundus by running fingers through the side to the center of the abdomen. Monitor respiratory system by TCDB, incentive spirometer, and lung sounds especially if on opioids such as MORPHINE. Monitor urinary catheter. (C-SECTION ALWAYS HAVE A FOLEY CATH)

Any procedure ending in -scopy (in the mouth)

Assess pt pre/post Monitor for GAG REFLEX post op. Monitor VS/LOC DONT offer any PO food or liquids until gag reflex return. Ask pt to cough, speak, or use tongue depressor to check gag reflex.

Suspect domestic violence

Assess the pt interaction with significant other Ask the pt about abuse privately (have significant other go somewhere or move the pt to a private area) Document the client's statement and injuries *if bruising or injuries noted and ask pt about them and consistencies of injuries Ask pt about medications that may cause injuries (anti-platelet) Never give pt a written paper or document about help rather give number verbally

Positioning Clients

Asthma/COPD/Chronic bronchitis, Emphysema- orthopneic position Post Bronchoscopy- flat with head hyperextended Cerebral Aneurysm- high fowlers Hemmorrhagic stroke- HOB 30 degrees Ischemic Stroke- HOB flat Epistaxis- lean foward with applied pressure for 5-15 min AKA (above the knee amputation)- elevated on pillow 24 hr then flat with HOB elevated after *some sources say not to elevate at all BKA (below the knee amputation)- Foot of bed elevated on pillow 24 hr then flat with HOB elevated after *some sources say not to elevate at all *Tube feeding on pt with decreased LOC- right side with HOB elevated* Cholecystectomy- semi-fowler Air Embolism- L side tendelenburg LP (lumbar puncture)- Pre: knee chest Post: flat 4-12 hrs. CBI- cath to thigh and leg straight Post myringotomy- affected side Post cataract- sleep on unaffected side with night eye shield Detached retina- dependent position Post thyroidectomy- semi fowler with pillow behind neck and support neck Thoracentesis- orthopneic position or upright (post: unaffected side) Spina bifida- prone (to prevent rupture of sac) Buck's traction- elevated FOB Post hip replace- unaffected side, maintain abduction Prolapsed cord- knee-chest or tendelenburg Cleft lip- supine or infant seat (feeding: upright) Cleft palate- prone Hemmorhoidectomy- side-lying Hiatal Hernia- upright Post supratentorial- HOB elevated 30-45 deg. Post infratentorial- flat and lateral Increased ICP- high fowlers 30 degrees with head midline, exhale when turning to prevent increased ICP Paracentesis- flat or sitting NG tube- HOB elevated 30 deg., low intermittent suctioning Head injury- HOB elevated 30 deg. Autonomic Dysreflexia- elevated HOB 90 degrees Shock- trendelenburg Liver biopsy- on right side with pillow or rolled blanket under right side Bone biospy (post op)- leave limb dependent for 24 hrs Hypotension- Lay flat Hypertension- Raise HOB

Atrial Dysrhythmias

Atrial flutter Atrial fibrillation

Schizophrenia

Auditory hallucinations Occurs in adolescence or early adulthood

Bryant's traction Russell's traction Buck's traction

Butt sightly elevated and hips flexed. Weights hang freely weights hang freely

Water soluble Vitamins

B1: thiamine which helps with carbohydrate metabolism (*common deficiency in alcoholic) B2: Riboflavin which helps with nutrient oxidant (*found in dairy products and whole grain) B3: Niacin which helps with nutrient oxidant (*found in dairy products and whole grain)(side effect: flushing of the face and neck, rash, diarrhea, cough, pruritus, hypotention, hyperglycemia. TAKE WITH ASPIRIN) B5: pantothenic acid which helps with nutrient oxidant (*found in dairy products and whole grain) B6: pyridoxine B7: biotin which helps with the growth of hair and nails B9: Folic acid which helps with the prevention of spina bifida B12: Cobalamin which helps with RBC formation and nerve cell maintenance C: Ascorbic acid which is an antioxidant and helps with collagen formation. (*found in citrus fruits) *help with the absorption of iron

Orthostatic hypotension

BP check standing, lying, and sitting. Wait 2-3 mins in between each position change to check BP Observe pt for low BP and/or increased pulse (drop SBP 20 and DBP 5) RISK FOR INJURY AND FALL PRECAUTION Indicated for at risk pt (ex: syncope)

HTN

BP: 140-90 Common in African Americans and Hispanics Prolonged HTN can damage blood vessel and affect heart, kidney, eyes, and brains. Lead to: HF, HF, hemorrhagic stroke, renal failure, peripheral arterial disease Lab test: U/A with protein noted, blood chemistry, and cholesterol levels, 12 lead EKG, ECHO, renal labs.

Circumcision

Baby or pt MUST void prior. No full retraction until puberty. infant or pt must have voided prior to the procedure. Apply Vaseline to the site. Monitor site for bleeding. *Yellow crust on penis DO NOT remove the crust* *If any penile abnormalities no circumcision is performed until corrects (ex. epispadias and hypospadias) Monitor site post op for s/s of infection or hemorrhage Monitor infant for void post. Monitor VS

Mechanical Ventilator Complications

Bacrotrauma/Pneumothorax: prep for a chest tube, ambu bag, notify HCP Atelectasis: use incentive spirometer, suction, ventilation (if severe) Pulmonary infection: use aseptic technique, oral care, proper nutritional status Bucking- pt inhale at the same time as vent breath occur; tx: muscle relaxant, tranquilizers, paralytic Pulmonary embolism: ROM, SCD, TED hose, DVT prophylaxis, TQ2H Gastric ulcers- treat with PPI, H2 antagonist, etc Weaning off vent: (3 stages) -Remove from vent, then remove from ET or trach, remove from O2 *pt VS and ABG must be stable

ANEMIA NSG INTV

Balance physical activity, exercise, and rest. Maintain adequate nutrition. Patient education to promote compliance with medications and nutrition. Monitor VS and pulse oximetry, provide supplemental oxygen as needed. Monitor for potential complications.

BRAT diet for Gastritis

Bananas Rice Applesauce Toast ABT tx for gastritis

Foods high in K+

Bananas Plums (prunes) Oranges Potatoes Milk

Delegation to UAP's. UAPs can

Bathing Transfer with or without assist. Ambulation *RN assess pt first* Feeding Toileting Obtain VS Nonsterile dressing change with instruction from RN/LPN repositioning and reapply (ex.ted hose, SCD) Height and weight I&O Transfer stable pt (ex. d/c) Housekeeping (linen change) Stock supplies

Ele*V*ate *V*eins & D*A*ngle *A*rteries for

Better perfusion so as not to have impaired tissue perfusion

Immunization schedule

Birth: Hep B 2 mos: Hep B, Rotavirus, DTaP, Hib, Pneumococcal, Poliovirus 4 mos: Rotavirus, DTaP, Hib, Pneum, Poliovirus 6 mos: Hep B, DTaP, Hib, Pneum, Poliovirus 12 mos: MMR, VAR, Hep A, Influenza, Hib 11-12 YEARS: Tdap, Meningococcal, HPV*encouraged Hep B vaccine given in 3 doses. First dose then second dose in a month then third dose given in 6 months from first dose.

Done by RN

Blood Transfusion Initial Assessment of pt Seculsions Chemotherapy IV *LPN's can perform if IV certified

Avoid BP extremities with:

Mastectomy (post op squeeze ball to reduce edema) serious injury to extremity lymph node IV line (piccline, IV) Dialysis (AV fistula)

Decreased LOC

May need NG tube placment Perform a Glascow coma score assessment Admin via other routes (rectal, *IV*, IM, subQ) NO PO ROUTE Have suction equipment at bedside Have intubation (trach) equipment at bedside Have O2 equipment

neurogenic shock (early phase)

Circulatory failure caused by paralysis of the nerves that control the size of the blood vessels, leading to widespread dilation; seen in patients with spinal cord injuries. COMMON IN SPINAL CORD INJURIES S/S: HYPOTENSION *orthostatic BRADYCARDIA Decreased cardiac output No sweating on paralyzed part Venous pooling NSG INTV IV fluids: 0.9% or LR Vasopressors and atropine Lovenox, SCD, TED hose, TQ2H, assess skin and keep dry Observe for abrupt fever Monitor VS changes

Post-op Patient positioning

Conscious: Semi or High Fowler's, Bed low, Side rails up x2, and call bell in reach. Unconscious: Side *due to risk of aspiration, Bed low, side rails up x2. INTV: monitor RR *Have emergency equipment at bedside (O2, trach kit, suction)* VS

Postsurgical patient (Procedure -scopy)

Monitor airway (gag reflex, NPO until gag reflex return) Check gag reflex with tongue depressor Fresh postop is a priority pt Obtain VS Check operative site DOCUMENT FINDINGS

Organ Transplant pt

Monitor for rejection. Monitor VS closely. Monitor incision site and dressing care per MD order. Pt take immunosupressant for the rest of their life. Take medication every 12 hours at the same time to prevent the risk of rejection.

Hypoparathyroid

CATSS: Convulsions Arrhythmias Tetany (decreased calcium) Spasms Stridor NSG INTV Assess resp. status closely High calcium, low phosphorus diet Monitor Ca and phosphorus levels Monitor muscle strength Monitor EKG

Reye's syndrome

CAUSED BY ASPIRIN SO AVOID WITH CHILDREN. Cause: aspirin toxicity, viral illness, gastroenteritis. s/s: MNEUMONIC REYE'S Reduced LOC (coma) Elevated temp and ICP Young children r/t aspirin or viral infection Encephalopathy, elevated labs (liver) Seizures other s/s: -frequent vomiting DX: liver biopsy, labs, LP NSG INTV: Monitor VS/LOC Monitor for s/s of increased ICP Neuro checks (frequently) Maintain hydration and electrolytes (IV) Respiration device PRN HOB elevated Decreasing stimuli in the environment. Admin Vit. K Monitor I&O Monitor labs (bleeding, liver, and BS levels) Avoid ASA in children <18yr to tx viral infection

Myasthenia Gravis Crisis

CAUSED BY: disease progression stress increased physical activity infection surgery/trauma Medications Noncompliance of tx S/S: Increased BP/HR Resp. distress (tachypnea, dyspnea, anoxia, cyanosis) Bulbar weakness (dysphonia, swallowing & chewing difficulty, speech difficulty, impaired cough & gag reflex) Bowel & bladder incontinence Decreased urine output (UO) Increased secretions; absent cough & swallow reflex *Mechanical ventilation PRN/emergency AVOID SEDATION OR OPIOID USE IN PT r/t RESP. disteress PT MAY HAVE SUDDEN RESP DISTRESS DUE TO MUSCLE WEAKNESS AND DYSPHAGIA SO MECHANICAL VENTILATION MAY BE NEEDED.

Cancer warning signs

CAUTION Change in bowel/bladder A sore that doesnt heal Unusual bleeding/discharge Thicken/lump in breast Indigestion/difficulty swallowing Obvious change in wart/mole Nagging cough, hoarseness

Bowel obstruction

Monitor for s/s of electrolyte imbalance. Monitor I&O and PO intake. PT MAY BE NPO IF OBSTRUCTION IS SUSPECTED

Assessment of any drainage or bodily fluids

COCA color odor consistency amount

DX test in neurological

CT brain scan MRI PET scan Cerebral angiography Myelography EEG EMG LP Nerve conduction test

Hypocalcemia

Ca level <8.6 Cause: idiopathic, surgery (parathyroid gland), renal failure, pancreatitis, hypoalbuminemia S/S: CRAMPS Confusion Reflex hyperactive Arrhythmias Muscle spasm (tetany, seizure, stridor) Positive Trousseau (BP) Sign of Chvostek (facial nerve tap) DX: Ca, PTH, Mg, P, and *albumin level* (Ca bind to albumin so correct Ca to correct albumin level) TX: 10% Ca gluconate or Ca chloride IV Ca must dilute in D5W *slow IV or pump via central line PO Ca supplement with Vit D to increase absorption given after food or bedtime Increase Ca intake (milk, green veg, can salmon, sardine, oysters) *NO IV Ca to pt on dig r/t toxicity risk* NSG INTV: VS/EKG Monitor labs (albumin, P, Ca, Mg) Monitor RR and cardiac function *(have suction, trach kit, and O2 at bedside)* Monitor IV site for phlebitis Seizure precaution Fall risk (safety precations) No alcohol, laxative, and antacid

Hypercalcemia

Ca level >10.6 cause: (HIGH CALM) Hyperparathyroidism Increase Ca intake (food, supplements) Glucocorticoids (r/t it suppress Ca absorption so increase Ca in blood) Hyperthyroidism Ca excretion decrease (r/t kidney failure, bone cancer, diuretic) Adrenal insufficency Lack of mobilization, lithium use Multiple myeloma (malignancies) s/s: WEAK Weakness of muscles EKG changes (Short QT interval and ST interval prolonged), excessive urination (to remove Ca) Absent of reflexes, AMS Kidney stone formation DX: serum Ca level, X-ray of bone, UA, EKG TX: Phosphate, Calcitonin, Lasix, Steroid, ASA/NSAIDS, or Dialysis *severe IV fluids (0.9%) NSG INTV: PO/IV fluids (0.9% to dilute Ca) Encourage fluids to prevent renal calculi formation monitor for abd or flank pain r/t possible kidney stone formation; strain urine Encourage mobilization and fiber (r/t constipation risk) Assess dig level Restrict med and food with Ca Assess reflexes Assess VS/EKG Safety measures *DIALYSIS IF Ca LEVELS ARE TOO HIGH/SEVERE

INCREASED ICP

Can cause decreased cerebral perfusion= swelling=herniation Cause: head injury, tumor, hemorrhage, encephalitis S/S: *EARLY* Change in LOC Restlessness Irritability Confusion impaired EOM Unequal pupil size Headache *LATE: (cushing triad)* *HTN* *Bradycardia* *Bradypnea* -Projectile vomiting Speech changes Elevated Temp Infants: high pitch cry irritable difficult to feed bulging fontanels MNEUMONIC FOR S/S (MIND CRUSHED) Mental status change decreased LOC (EARLY) Irregular breathing Nerve change optic to oculomotor "papilledema" Decorticate or decerebrate or flaccid postures Cushing Triad (hyperbradybrady) *HTN *BRADYCARDIA *BRADYPNEA Reflex positive Babinski Unconscious (late) Seizures Headache Emesis no nausea (projectile vomiting), eye pupil changes Deterioration of motor function Normal Range Adults: 10-15mm Infant: 5-10 mm Positions: Comatose (flaccid) Decorticate Decerebrate *AVOID LP IN PT WITH INCREASED ICP* Use GLASCOW COMA SCALE RX: mannitol to reduce fluid volume corticosteroids (dexamethazone) to decrease cerebral edema antiseziure (ex. -pam, phenytoin, phenobaribital) Colace or stool softner NSG INTV: HOB elevated 30 degree with head midline reduce stimuli avoid activities that increase ICP (valsalva maneuver, hip flex) avoid sx and neck compression seizure precaution O2/VS monitor airway Aseptic technique Control fever Avoid abd. distention via NG tube *Have pt exhale when turning to prevent increased ICP* MNEUMONIC (PRESSURES) Position HOB 30-35 degrees Respiratory intervention (Sx PRN, O2, monitor ABG, mechanical vent) Elevated temp prevent (antipyretics, cool baths, remove extra blankets, cool baths) Systems to monitor (glascow, Neuro check) Straining activities avoid (coughing, sneezing, vomiting, valsalva, calm environment) Unconscious pt (avoid over sedation, assess lung sounds, immobile, kidney stones, ROM, oral/eye care, constipation -prevent all these through medication) Rx Barbiturate (anticonvulants, vassopressure, antihypertensives based on BP) Edema management (careful in pt with HTN and renal failure) rx: mannitol Stop fluids via fluid restriction (IV/PO) COMPLICATIONS: SIADH DI (diabetes insipidus) Brain stem herniation

CAST CARE NSG INTV

Cast used to immobilize device to contour body used to tx fractures elevate on a pillow for 24-48 hrs. CMS check Pulse check Explain to pt not to put anything in cast r/t risk of infection or scrap of skin Itching: use hair dryer on cool or RX: for benadryl REPORT TO MD: "Hot spots" and foul odor indicates an infection notify MD Cap refill *if refill is longer than 3 sec notify charge nurse or HCP Cast wet: use pillow to support and handle with palms Avoid getting it wet (use a plastic or garbage bag to cover) or avoid showers (sponge bath) *Don't put anything in the cast!!* Monitor s/s of infection and VS

During Continuous Bladder Irrigation (CBI)

Catheter is taped to thigh so leg should be kept straight. No other positioning restrictions. Catheter size 14-16 fr. Use aseptic technique Monitor output (COCA)

Decongestants

Cause HTN so contradicted to a pt with HTN May cause a rebound effect don't use longer than 48 hrs. Avoid use longer than 3-5 days.

Diabetes Insipidus (decreased ADH)

Cause: Head traums, brain tumor, surgery, CNS infection, kidney failure, craniotomy s/s: Excessive urine output increase thirst (2-20L) dehydration weakness decreased specific gravity hypotension Dx: ADH levels, fluids deprive test NSG INTV: *Administer Pitressin or vasopressin via intranasal. (monitor for runny nose or nasal congestion)* *taken for rest of life* Encourage fluid intake Identify undelying cause Replace ADH monitor daily weight and I&O (STRICT) Monitor VS and LOC SEIZURE PRECAUTION r/t the s/s of hyponatemia and side effects of med. monitor children who take in fluids from weird sources (toilet bowls, flower vase, etc) monitor skin turgor or fluids overload due to tx *rare

Skull Fractures

Cause: MVA, fall, blunt trauma s/s: AMS: restlessness and confusion, nystagmus Battle's sign- ecchymosis behind ear Raccoon eyes- bruising around eyes CNS fluid leak from ear and nose (test to confirm) DX: MRI, CT scan, x-ray, cerebral angiography NSG INTV: Assess VS/LOC Neuro Check

Superior Vena Cava Syndrome

Cause: Tumor (common in lung cancer) can compress SVC Pregnant mother positioned supine s/s: -swelling of face (periorbital) -swelling to extremities (upper) -JVD -visible chest veins INTV: Tumor: notify HCP Pregnant: position mother to left side to relieve pressure and monitor VS

Compartment syndrome

Cause: cast, burn injury s/s: deep & throbbing pain, not controlled by opioids Passive stretching of muscle causes pain Nerve ischemia & edema Pressure increases Paresthesias (early sign of nerve compromise) 5Ps (pain, pallor, pulselessness, paresthesia, and paralysis) From hypoesthesia to complete numbness From paresis to paralysis NSG INTV Neurovascular assessment Assess for CMS, Color, Swelling, Cyanosis of extremity No elevation of extremity Notify MD Bivalve the cast or splint

Hydrocephalus

Cause: impaired production and absorption of CSF *CSF produced in choroid plexus s/s: increased head circumference bulging fontanels sun setting eyes high pitch cry irritability DX: measure head circumference CT scan MRI NSG INTV: *avoid any IV placement in scalp* assess fontanels check head circumference until 2-3y seizure precautions HOB elevated assess for s/s of increased ICP TX: VP shunt which is done after 6months -post op: position infant flat

Hypoglycemia

Cause: too much insulin or exercise or not eating enough s/s: shakiness, double vision, tremors, cool, clammy tx: provide OJ, sugar cubes, honey Concious pt give 15G of carbs (sugar, honey, carb) *if unconscious give glucagon or 50% dextrose IV (*give carb if BS isn't controlled) *IV Dextrose given slowly over 2-5 min via IV push. Once pt regain consciousness give a carb snack to prevent secondary hypoglycemia episode Recheck BS 15 min after tx and continue to monitor BS frequently notify MD NSG INTV: Monitor BS *frequently and VS Monitor LOC

Toxoplasmosis

Caused by: undercooked meat, cat feces, soil

Cholelithiases

Caused when a gallstone is formed in the gallbladder Obstruction caused by stone in bile duct: jaundice, clay color stool, dark urine, puritis *puritis occurs r/t high bilirubin levels with breakdown. dx: ABD. x-ray -US (low fat diet prior) TX: laparscopic cholecystectomy or traditional cholecystectomy NSG INTV: TCDB Admin pain med Incentive spirometer Assess wound (COCA if drainage) Wound care if needed Encourage ambulation ABD. assessment Encourage low fat, high crab and protein diet Monitor VS/LOC Postop: drain may be inserted (usually JP) expect serosanguieous drainage 24hr post.

Elevated Ammonia levels Normal: 9.5 and 49 mcg/dl (adults)

Causes LIVER failure and is an indicated of kidney problems TX with Lactulose

Monitor for decrease Temperature

Causes hypoglycemia and respiratory distress.

UNRESPONSIVE PT

Check pulse to know if pt should defibrillation or cardiovert

S/S of Air/Pulmonary Embolism

Chest pain Difficulty breathing/tachypnea Tachycardia Pale/Cyanotic hemoptysis sweating petechiae on chest and axilla Sense of impending doom hypoxemia s/s NSG INTV: Call RAPID RESPONSE Semi-fowler Pain management *IV morphine* Urinary catheter Monitor VS/ EKG

Prevent bacotrauma (think: pop of ears on an airplane)

Chewing gum Yawning occasionally Swallowing a few times Sucking on a piece of hard candy

Low Back pain

Chronic Low Back Pain s/s: decreased reflexes decrease motor strength decrease posture muscle spasm tingling, numbness TX/NSG INTV: Monitor VS per/post pain med administration Rest periods Decrease stress Relaxation techniques Heat/cold application per MD order Position pt in semi-fowler with knee flex Assess and administer pain medication Teach proper body mechanics Teach pt to avoid prolong standing

Dementia

Chronic state of confusion and is irreversible

Ulcertive Colitis/Crohn's disease

Chronis inflammation of the rectum and large intestines S/S: Wt loss, jaundice, diarrhea (10-20times), fever, join pain, GI bleeding, anorexia, dehydration, RLQ abd pain, steatorrhea Tx: corticosteroids, mesalamine, surgery, ostomy, Azathioprine Nutrition: low residure, high protien and calorie diet. Avoid milk, cold food, and smoking ACUTE EXACERBATION: NPO, IV hydration, TPN Monitor for ankylosing spondylitis, liver disease, carcinoma, pyoderma gangrenosum, hemorrhage, perforated colon NSG INTV: Assess for s/s Admin pain med Monitor weight Give TPN per order Promote rest Monitor skin breakdown Monitor VS and I&O

CMS assessment

Circulation: capillary refill (normal < 3 seconds) Color distal to affected site Pulse distal to affected site Temperature Motion: Assess joint mobility and motor nerves Assess: ROM, deformity, stability, tenderness, nodules Sensation- Assessing for peripheral sensory nerve function (paresthesias or pain) Feeling CMS abnormalities Distal pulses absent Capillary refill longer Temperature increased Edema Skin Discoloration Movement Tingling, Numbness, Pain

IM injection

Common sites: Newborn: vast lateralis Toddlers: dorsal gluteal Adults: deltoid, gluteal Use a TB syringe Do not rub or message the injection site

Hip fracture

Common: In the elderly More common in females r/t osteoporosis S/S: Shortening and adduction of the affected limb Pain at the fractured site External rotation of the foot on the affected side Dx: X-ray Tx: surgery NSG INTV: PREOP IMMOBILIZE Assess pain and admin pain PRN Traction NPO AE hose *Abduction pillow Turn patient to unaffected side OOB ASAP (keep operative leg extended, supported, & elevated (prevent hip flexion)); turn to unaffected side Weight bearing status as per MD order Maintain alignment Prevent: internal or external rotation; hip flexion, or crossing the legs Use high chair/ elevated commode Neurovascular assessment Elevate HOB 30-45 degrees only for meals Avoid hip flexion greater than 90 degrees. use an abductor splint pre/post overhead trapeze pre/post Fracture pan Monitor pt for any s/s of an fat embolism

Complication of iron deficiency anemia

Complications: HF Bleeding NSG INTV FOR COMPLICATION -assess GI system (N/V, diarrhea, dark stool, anorexia) DX: occult blood test

Fracture Types

Compound (open)- broken bone that protrudes through skin (risk for infection) tx: splint and apply NS, surgery Closed: skin isn't broke and can be reduced manual by MD Communited- bone crushed into multiple fragments Complete- complete break of the bone Greenstick- one side of bone is broken and the other is bent (common in children) Impact- fractured bone driven into another bone Spiral- break partially encircles the bone Patho- fracture r/t a weakening of the bone (osteoporosis) *HIP* fracture is risk for hemmorage and *FEMUR* fracture risk for fat emboli.

Any VS that is abnormal.

Continue to monitor and compare with pt baseline Assess for s/s NOTIFY MD

Diabetes (DM) Sick Day Management

Continue to take oral meds and insulin even if not eating normally (give insulin coverage based on BS level) stop taking metformin if dehydrated Follow regular meal plan if able with 1 cup of noncaloric fluid/hr if NPO drink 1/2 to 1 cup sugar containing fluid per hour Check blood sugar every 2-4 hours while awake Call MD for persistent vomiting/diarrhea, blood sugar consistently >300, temp >101, ketonuria

*Airborne Precautions* C MTV

Coronavirus Measles TB Varicella-Chicken Pox/Herpes Zoster-Shingles Private room-negative pressure with 6-12 air exchanges/hr *Must wear gloves, gown, N95 mask along with standard precaution*

Adrenal gland

Cortex: secrete steriod hormones -glucocorticoids (helps convert fat and protein into glucose) -aldosterone -adrogens Medulla -epinephrine and norepinephrine

NEVER DISCONTINUE MEDS

Corticosteroids Thyroid meds TB meds *meds should be D/C gradually ABT *until complete specific days stated.

Lab test: PT and INR

Coumadin (Warfrin) *Admin in the late afternoon Antidote is Vitamin K *avoid food high in vitamin K ex: green leafy veg. Levels: The normal PT is 9.6 to 11.8 sec. for the adult male and 9.5 to 11.3 sec. for the adult female. PT 1.5-2 times the INR. INR: 2-3

CABG (Coronary Artery Bypass Graft)

Creation of a new blood supply to an area of the heart with a clotted/blocked artery by inserting a graft. Site is anastomosed distally and proximal to bypass obstruction and create blood flow. Complication: cardiac tamponade

Children and herbal drugs

DO NOT ADMINISTER TO CHILDREN

Pulmonary embolism DX and TX

DX: D-dimer (shows that a clot is present but not location) CXR EKG ABG V/Q scan Pulmonary angio *most accurate dx* TX: -Supplemental "oxygen" is mandatory. -Position comfortably. -Anticoagulants (reduce of course of treatment) -Thrombolytics -IVC filter

GI assessment

Observe abdomen shape and contour (flat, round, distended) Palpate for pain or tenderness Percussion Auscultate: Bowel sounds *Assess girth measurement if indicated. Assess last BM

Administration of Enema

Position pt in *left side-lying* (Sim's) with knees flexed Avoid 3+ enema at once r/t cause F&E imbalance. Monitor VS Lubricate tip of tube with water soluble lubricant May warm solution for pt comfort Avoid overuse of enema due to throwing off the electrolyte balance of the body. ASSESS PT DURING AND POST PROCEDURE

DKA vs HHNS

DKA No insulin production (think type I diabetic) Breakdown of stored glucose, protein, & fat Ketone bodies & ketoacidosis type 1; onset rapid; >250 BS; serum & urine ketones; BUN/CRT elevated HHNS Insulin level too low to prevent hyperglycemia, but high enough to prevent fat breakdown (think type II diabetic) NO ketosis related GI symptoms Polyuria & polydipsia type 2; onset slower; >600 BS; NO serum & urine ketones; BUN/CRT elevated (higher mortality rate b/c slow onset delays therapy=hyperglycemia, dehydration, and hyperosmolarity becomes more severe

Tetralogy of fallot; remember DROP (child drops to floor or squats or knee chest position)

Defect, ventricular septal Right ventricular hypertrophy Overriding aorts Pulmonary stenosis s/s: child in squat or knee-chest position fatigue during feeding or activity NSG INTV: USE SOFT NIPPLE WITH BOTTLE RX: digoxin

Hemophilia

Deficiency or absence of a blood clotting factor impairing the body's ability to control blood clotting or coagulation (hereditary x-linked) Affect factor 8 (hemophilia A) and 9 (hemophilia B) *usually from mother to son r/t x-linked Causes: Bruising, spontaneous bleeding, bleeding into joints (75%) with pain and swelling, GI and GU hemorrhage, blood in the urine or stool, prolonged bleeding from cuts, tooth extraction, and surgery s/s: bruising hemearthrosis (bleeding in joints) spontaneous bleeding GI/GU hemorrhage prolong bleeding pain hematuria melena DX: Prolonged PTT but normal PT Tx: replace clotting factors (especially prior to surgery and dental procedures) DDAVP which stimulate coagulation factor Pain meds Genetic counseling NSG INTV: Prevent injury Apply ice to site Elevate leg affected Avoid contact sports Monitor VS/LOC Assess the pt for any bleeding and apply prolonged pressure Avoid NSAIDS, ASA, anticoag, use electric razor etc If hemoarthrosis occurs use R.I.C.E Avoid frequent IM or needle sticks r/t risk of bleeding FALL RISK AND RISK FOR INJURY SAFETY PRECAUTIONS

Diarrhea and Vomiting precautions

Diarrhea: give pt Gatorade due to the throw off the the electrolyte in the body Vomiting: give patient ginger ale (stir the bubbles) or ginger base products. NSG INTV: Monitor for fluid and electrolyte imbalance. Monitor skin tugor, mucous membranes Give PO/IV fluids

Inhaler medication

Different med take med within 5 min of each other. Same med take med within 1-2 min of each other Rinse mouth post if a steroid inhaler medication r/t risk of fungus Give broncodilator prior to a steroid inhaler medication

Hypotensive shock

Dizzy Blurred vision syncope Hypotension (decrease 10-15 mmhg from baseline) Tachycardia NSG INTV: IV fluids (ISOTONIC OR HYPERTONIC) Foot of bed elevated or trendelengburg Monitor VS/LOC

Documentation

Documentation on the incident report allows the nurse and administration to review the quality of care and determine any potential risks present. DOCUMENT after assessment not later DOCUMENT any treatment provided Any doctor order

Do not delegate what you can EAT

Don't delegate what you can: E- Evaluate A- Assess T- Teach *if unsure ask charge nurse Follow up with performed task that has been delegated.

No Pee, No K

Don't give potassium without adequate urine output. (ADV: Adult: 30 ml/hr Child: 20-30 ml/hr) Monitor I&O

After Total Hip Replacement

Don't sleep on operated side, don't flex hip more than 90 degrees. NEVER crossing legs Assess for pain and medicate per order *ABDUCTION with pillow between legs* not adduction Internal rotation not external *RISK FOR INFECTION Keep heels off bed to prevent pressure ulcer Assess CMS and Pulse DVT prophylaxis Monitor for s/s of fat embolism or PE

Ace inhibitor side effects

Dry cough. Increased blood-potassium level (hyperkalemia) Fatigue. Dizziness. Headaches. Loss of taste. Ex: lisinopril *If the cough persists switch resident to a ARB (-sartan) MNEUMONIC for side effects CAPTOPRIL Cough Angioedema Potassium excess Taste changes (loss) Orthostatic hypotension Pressure drop Renal failure, rash Indomethacin inhibition Leukopenia

Nutrition intake of Mothers

During pregnancy: an additional 300 calories Breastfeeding: an additional 500 calories Protein: 60g Ca: 1200 mg Iron: 30 mg Folic Acid: 400 mcg

Sign of resp obstruction/distress

EARLY: RESTLESSNESS/AMS LATE: CYANOSIS

TRACTION

EFFECTIVE: Continuous, never interrupted (maintain same degree of traction even if repositioning pt), good body alignment, ropes not obstructed, weights hang freely, knots must not touch pulley or foot of bed. USE OF TRACTION PURPOSE Used to reduce pain Reduce muscle spasm Proper alignment Immobilize fracture Reduce deformity Increase space between the opposing forces Complications of tractions: Skin breakdown Nerve pressure Circulatory impairment DVT Elderly at higher risk PERFORM NEUROVASCULAR ASSESSMENT

myocardial infarction (MI)

EKG/ECG: ST segment elevation, T-wave inversion cause: stress, overweight, DM, HTN s/s: CRUSHING Chest pain (intense,heavy) Radiating chest pain (to left arm, neck, and jaw) Un-relieved by rest or NITRATES Sweating (cold) Hard to breath (SOB) Increased HR and RR and irregular HR N/V Going to be anxious and scared Take VS, *O2 and EKG* and assess pain level (chest pain) tx: M.O.N.A -Morphine *priority r/t chest pain -O2 -Nitro -Aspirin (usually 162-325mg) Insert IV line NSG INTV: Assess LOC and resp. status Assess VS Assess/admin pain level obtain cardiac monitor and monitor IV access Allow bed rest (Beta-blockers and ACE inhibitor within 24hr). *IV heparin or lovenox if indicated. Explain to pt to reduce stress, change diet, and activity Lab Values: *all elevated* Troponin (T/I), WBC, CK-MB, CBC, ESR, myoglobin

Pressure areas

Elbow and heel (extremity pt its the UNaffected leg)

Buck's Traction (skin traction)

Elevate foot of bed for counter-traction Inspect the skin every 8 hrs. PREOP assess skin, check CMS, pulse prior *RISK FOR INFECTION Applied preop r/t prevent or reduce pain and muscle spasms NSG INTV: nurse inspect skin: clean, dry, abrasions, circulation prior to traction implementation Avoid wrinkles and slipping of bandages and snug wrapped bandage Maintain counter balance/continuous traction applied Proper positioning PRN No turning (slight weight shift) Monitor: CMS* and pulse Remove the boot or bandages to inspect the skin three times a day (have another person supports the limb) Reposition patient to prevent decubitus ulcer Higher-specification foam mattress *AVOID SIDE TO SIDE POSITION r/t injury risk*

Fundal Location

Elevated and to the right or left: indicates a full bladder or active bleeding (ex. hematoma) Have the pt void or monitor VS Immediately after delivery: between the umbilicus and pubic symphysis 4-6 hrs post delivery: fundus at umbilicus *fundus height reduce 1cm or 1 finger breath per day

Defribrillation- NO PULSE

Emergency Procedure action: allows SA node to resume role of pacemaker in the heart use conducting gel call "CLEAR" 3x No O2 during procedure r/t fire hazard *SYNC OFF* Defib, CPR, meds (epi, antiarrhythmic), defib, CPR until stable rhythm USE: *PULSELESS* V-TACH VENTRICULAR FIBRILLATION

CAST (before application) NSG INTV

Explain procedure to the patient Perform assessment of the body part for Edema, skin abrasions, bruising, etc. Baseline CMS and Pulse check Educate pt on need of cast Treat any skin lesions (promote healing) before applying cast & cover with sterile dressing.

Complication of DM (long term)

Eye disease Peripheral neuropathy PVD Renal failure CAD MI INSULIN COMPLICATIONS: -allergic reactions (systemic or local) -INSULIN LIPODYSTROPHY -insulin resistance -hypo/hyperglycemia

Ear irrigation

Prior to irrigation inspect the ear and insure it's intact. warm to 98.6 degrees. Place on affected ear with a emesis basin near ear area

Phases of Burn

Emergent (resuscitative phase): greatest period of fluid leak occurs first 24 to 48 hr after the burn occurs -s/s: pitting edema, hypErkalemia, hypOnatremia -TX/NSG INTV: ABC: maintain airway (100% humidified O2) IV fluids (LR) via 2 large bore IV guage Cover wound with guaze, clean sheets above/below pt Cool compress monitor urinary output *foley cath Irrigate any chemical burns EDEMA: elevate above heart monitor for s/s of compartment syndrome (s/s: pain, numbness, decrease cap refill) TX COMPARTMENT SYNDROME: NO ELEVATION OF EXTREMITY, NO PAIN MED OR COOL COMPRESS. EKG/VS/ABG CMS check, Pulse check Acute phase: fluid return to vascular compartment as capillaries regain integrity; phase complete when the wound is covered by tissue -s/s: FVE *polyuria*, hypOkalemia, hypOnatremia, increase cardiac output -TX/NSG INTV: ABC maintain airway Monitor for s/s of FVE (fluids volume excess) Blood transfusion r/t blood loss (anemia) Assess for s/s of infection to site IV fluids (LR) I/O and daily weight Debridement (goal: remove burned eschar or contaminated tissue r/t bacteria) Assess COCA of wound and drainage Graft care Rehabilitative: begin when burn area is healed and can last yrs later TX/NSG INTV: PT/OT *Psych assistance* Monitor skin integrity

Most GI disorder interventions

Encourage small frequent meals and eat slowly Maintain proper body weight Avoid alcohol, caffeine, NSAIDS Encourage rest periods Avoid smoking, alcohol Reduce stress IV hydration Monitor VS and I&O Pain management

Blood cells

Erythrocyte: RBC last 120 days, Hemoglobin: O2 carrying protein Reticulocyte: Immature RBC located in bone marrow. They will become mature (erythrocyte) and will go out to the blood stream. Reticulocyte # : increases in blood stream (peripheral blood) when demands of blood increase during bleeding or some diseases (hemolytic anemias). Leukocyte—WBC (protect against infection and tissue injury) Neutrophil Monocyte Eosinophil Basophil Lymphocyte—T lymphocyte and B lymphocyte Thrombocyte—platelets

Cause of HF

FAILURE Faulty heart valves Arrhythmias, anemia Infarction (MI) Lineage (family hx) Uncontrolled HTN Recreational drug use Evaders (bacterial and viruses)

Causes of a pulmonary embolism (PE)

FAT BAT Fat Air Thrombus *most common Bacteria Amniotic fluid Tumor *Other risk factors are central lines, immobility, and hypercoagulation

Thyroid storm (severe hyperthyroidism)

FATAL if not tx Cause: PISI (pregnancy, infection, surgery, injury) s/s: HEAT High fever, HTN Exaggerated s/s of hyperthyroidism (hyperkinesis) AMS, N/V Tachycardia (extreme) tx: -PTU and Tapazole -hypothermia (low BP and HR) -IV dextrose -O2 -Hydrocortisone to tx shock -Tylenol -Iodine NSG INTV Environment cool and quiet Monitor VS and resp assessment (O2) Diet: low in iodine Monitor for s/s

FHR (fetal heart rate)

FHR begins to beat at 5 weeks gestation. 110-160 (100-160) Murmur in normal for 1-2 weeks. *If last longer report to HCP.

5 F's for increase risk of gallbladder infection (Cholecystitis)

Female Fat Fair Forty (40 years) Fertile *provide a low fat diet (and desert ex: cookie) *IF AN ULTRASOUND IS PERFORMED PLACES PT ON A FAT FREE DIET PRIOR* s/s: pain, tenderness, rigid RUQ, N/V, jaundice, dark urine, pale color stool, steaorrhea, positive murphy's sign, *usually due to a calculi which obstruct bile flow.

Composition of breastmilk

Foremilk- watery part Hindmilk- thick (meal-like) which helps to keep the baby full.

Digoxin toxicity s/s

GI effects - anorexia, nausea, vomiting, abdominal pain, diarrhea; CNS effects - fatigue, weakness, diplopia, blurred vision, yellow-green or white halos around objects ANTIDOTE: DIGIBIND (digoxin immune fab) ASSESS EKG r/t risk of cardiac abnormalities. Monitor VS/LOC MUST CHECK Apical Pulse for 1 full minute (if <60 bpm hold or <100 bpm infants or <70 for young children *clarify pulse hold with MD*) HOLD DOSE AND NOTIFY MD Monitor digoxin levels: 0.5-2.0

Blood Transfusion ADMINISTRATION AND REACTIONS

GIVEN ON COAGULATION ISSUES *PRIOR: INFORMED CONSENT* pt must be typed and crossed. Identify patient Two licensed nurses / MD Identify blood type/donor number/expiration date Explain the procedure to the patient and purpose Get baseline VS (if temp is >100 notify MD) Plasma given for fluid and blood loss s/s: chills, itching, fever, rash, headache, and *back pain* *repeated transfusions can cause hemosiderosis (r/t the excess iron deposits stored in tissue) *Remain with pt for first 15-20 min during blood admin.* Monitor VS immediately prior and 15 min during blood infusion. Hang RBC within 30 min from collection from blood bank. Infuse no longer than *4 hrs* r/t to the risk of bacterial growth in blood. *MUST BE HANG WITH 0.9% NS ALONG WITH BLOOD* Use 18G or 20G needle to prevent hemolysis of RBC Use Y tubing or tubing that has a filter Given in slow infusion *Warm blood prior to admin due the risk of cardiac arrhythmias (within 15-30min from blood bank)* PLT/FFP must be give STAT from blood bank. Have clean tubing at the bedside in the event of an reaction If another unit of blood is needed *CHANGE ENTIRE IV LINE!* MUST RUN AT 2-5ml/min RATE!! Observe for an increase in hbg and hct (H&H) Contamination through blood products: HIV/AIDS Hep B/C CMV CJD GVHD (graft vs host disease) Syphilis MNEUMONIC s/s: REACTION Rash (hives) Elevated Temp (1-2 degrees above baseline VS) Aching Chills Tachycardia Increased RR Oliguria *hematuria Nausea ACUTE HEMOLYTIC REACTION s/s: fever, chill, N/V, lower back pain, hypotension, dyspnea, DIC, bronchospasm Stop the infusion, remove tubing, run NS, and contact HCP/blood bank Send urine and blood samples to blood bank/lab Follow MD orders Document actions Monitor VS/LOC (temp) ALLERGIC REACTION s/s: hives (utica), itching (all over), flushing -*MILD* reaction; stop transfusion; call HCP for antihistamine (Benadryl), & then continue transfusion. -*SEVERE* reaction: (s/s: bronchospasm, laryngeal edema, shock). Treated with epinephrine, corticosteroids. D/C transfusion and call MD Monitor VS/LOC (temp) DOCUMENT BACTERIAL CONTAMINATION (septicemia) contamination of blood products (usually r/t blood out from blood bank >4hrs) s/s: fever, chills, hypotension, tachycardia, vomiting, diarrhea Discontinue blood immediately; keep IV on Connect saline Notify MD Collect blood cultures as ordered Monitor VS/LOC (temp) DOCUMENT OTHER COMPLICATIONS OF TRANSFUSION: Circulatory Overload: (s/s: Blood flow infused too rapidly, cough, tachycardia, dyspnea and edema.) -NSG INTV: Elevate HOB to high fowlers, stop infusion, notify HCP Air Emboli Febrile reaction Shock TRANSFUSIONS ARE AVOIDED BY JEHOVAH'S WITNESSES

GTPAL

GTPAL acronym: G = gravidity (number of pregnancies); T = term births (number born after 37 weeks); P = preterm births (number born before 37 weeks' gestation); A = abortions/miscarriages (number of abortions/miscarriages); L = live births (number of live births or living children). Therefore, a woman who is pregnant with twins and who already has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 0, and the number of term births is 1. The number of abortions is 0, and the number of live births is 1.

Herbs or herbal Remedy

Garlic interfere with platelet and clotting function. Black Cohosh- estrogen St. John wort- aid with depression GINKO increase bleeding risk for pt on anticoag

Peptic ulcer dx/tx

Gastroscopy, EGD -NPO, sedated -NPO until gag reflex returns -watch for perforation by watching for pain, bleeding, or dysphagia Upper GI -looks at esophagus and stomach with dye -check renal labs pre -NPO past midnight -NO: smoking, chewing gum, mints. -encourage PO fluids post op to excrete dye. -remove nicotine patch - smoking increases stomach motility and secretion which will affect test and aspiration risk CT scan with contrast TX: PPI, H2 antagonist, pepto bismol, ABT, antacids, surgery if severe

Premature Delivery

Given 2 injections of steroids (bethamethasone) within 24 hr to help increase lung function of surfactant which will help with fetal lung maturity.

Duramorph

Given for spinal/epidural. Last 24hrs. Monitor RR qh for the first 24 hrs. Monitor for itching (given benadryl or narcan) If RR is <12 give narcan

Rh Test: Rhogam

Given standard at 28 weeks if mother is negative. If mother is negative and when baby is born and is positive, mother gets another shot of Rhogam up to 72 hrs after birth. Also given after an abortion, eptopic pregnancy RH - mother was given in the past give again Must have a negative Coombs test

Procedures you DON'T COUGH, sneeze, strain, suck on straw

Glacoma or eye surgery Brain surgery Hernia Tonsillectomy Myringectomy Hypophysectomy Nasal surgery ENT procedures *unless ordered otherwise

SKIN GRAFT

Graft is the use skin (from pt, animal, or donor) to injury site to correct deformity. NSG INTV: elevate and immobilize (3-5 days) the affected leg postop to reduce edema and allow time to adhere to wound. Keep site free from pressure AVOID ROM r/t risk of pop sutures out Monitor for s/s of infection or bleeding Monitor VS Assess skin site frequently Sterile wound care PRN or per order *itching means healing* Cool, clammy skin means inadequate blood to site. Shock s/s (hypotension, tachycardia)

Causes of Ventricular Asystole

H: Hypoxia Hypovelemia Hypo/Hyperglycemia Hypo/Hyperkalemia Hyperthermia Hydrogen Ion T: Trauma Toxin (drug,poison) Tamponade, cardiac Tension pneumothorax Thrombus

Contusion

HEAD: s/s: decrease LOC, neuro defects, VS changes EYE AREA: Apply Ice on affected eyes and contact HCP If eye injury occurs cover both eyes. If any substance is in the eyes irrigate with STERILE saline.

Transdermal areas absorption

HIGHEST absorption: scalp, axillae, face, eyelids, neck, perineum, genitalia LOWEST absorption: back, palms, soles

DONT BREAST FEED IF

HIV HEPATITIS B/C *may if Hep B based on vaccination.

HIV/AIDS PREVENTION

HIV Testing Receive proper tx (ART) HIV teaching Standard precautions (wash hands before & after gloves!!!) -Safer sex practices and safer behaviors -Abstain from sharing sexual fluids -Reduce the number of sexual partners to one -Always use latex condoms *if allergic use non-latex but DOESN'T protect against HIV -Do not share drug injection equipment -Contact HCP if any new s/s develop -Avoid large crowds r/t infection risk Blood screening and treatment of blood products Risk of body fluids contact/splashes:Wear mask, gloves, and gown. Pre-exposure prophylaxis (PrEP)

Contributions to Glaucoma

HTN, cardiovascular disease, DM, and obesity

ANY artificial airway ex: trach, naso, oro

HYPER OXYGENATE THE pt before, after, and during (if possible) suctioning. Suctioning should be no more than 10-15 sec HAVE EXTRA TRACH EQUIPMENT AT BEDSIDE (1 size smaller or same size to potential swelling) IN THE EVENT OF AN EMERGENCY HAVE INTUBATION AND AMBU BAG AT BEDSIDE

Pt refusal (med, procedures, etc)

Have pt sign refusal of tx form. Document pt refusal, encourage at least 2 times, document NEURO status (AAO). Document additional relevant info (ex. pt refuse BP med document pt BP) EXPLAIN RISK Notify MD DOCUMENT

Rule of Nine

Head and neck, 9% anterior thorax, 18% posterior thorax, 18% arms, 9% each legs, 18% each perineum, 1%.

Complications of Anemia

Heart failure* Neurologic: neuropathy, decreased sensation to position & vibration, poor balance, unsteady gait, delirium Fatigue Altered nutrition (due to nausea, poor appetite, upset stomach) Altered tissue perfusion Noncompliance with prescribed therapy

Complication of amputations

Hemorrhage Infection Skin breakdown Phantom pain

Hepatitis (A, B, C, D, E)

Hep A: transmit fecal/water to oral contamination *Vaccine for A* Hep B: transmit blood, semen, saliva *Vaccine* Hep C: transmit by blood and semen *leading cause of liver transplant* Hep D: only occurs due to Hep B, transmit by blood or bodily fluids Hep E: transmit fecal/water to oral contamination S/S: JAUNDICE -Jaundice -Anorexia -Urine (dark color) -Nausea and vomiting (n/v) -Discomfort RUQ -Increasing temp (fever), itching -Chills, clay color stool, liver cirrhosis *chronic s/s* -Exposure (past) DX: blood test (hepatitis viral panel) Vaccine: only for A and B NSG INTV HEPATITIS Handwashing Eat low fat and high carb diet Personal hygiene product (DONT SHARE) Activity conservation (REST) Toxic substance AVOID (alcohol, ASA, tylenol) Individual bathroom Testing results Interferon (given SQ) Small, frequent meals Other NSG INTV: antihistamine or calamine lotion for itching corticosteroids Vit K Diet: low fat, high calorie, carb, and protein diet

Lab test: PTT

Heparin Antidote protamine sulfate Level of PTT: 20-36 sec Pt on continuous heparin aPTT is 60-80 sec. *if aPTT is low (<60) and pt is on heparin contact HCP to increase dose.

Sickle Cell Anemia

Hereditary trait when cells look sickle shaped. PT AT RISK FOR INFECTION (pneumonia, osteomylitis) s/s: pain in joints, respiratory issues, jaundice, low hbg, hypoxia NSG INTV: Monitor for s/s of infection NEURO CHECKS Hydration (1-2L) IV or PO HHOP (*H*eat administration *H*ydration, *O*2, *P*ain management *AVOID rx: demerol*) Monitor VS/LOC Monitor/admin pain med Assess respiratory status use warm compress Genetic: only of 50% chance of carrier common in African Americans. Monitor for s/s of gallstone formation (INCREASE FLUIDS INTAKE TO PREVENT) TX: hydroxurea or bone marrow transfusion Diet: high calorie and protein with folic acid Peds: receive all immunization and influenza vaccine Complications: INFECTION STROKE KIDNEY INJURY IMPOTENCE HF PULMONARY HTN ACUTE CHEST SYNDROME (s/s: fever, cough, low O2 sat, CXR shows infiltration)

Food to help with WOUND HEALING

High protein diet Zinc Vitamin C Iron High carb NORMAL WOUND HEALING -wound is red and warm approximated to site -surrounding skin intact -no abnormal draining (serosanguineous is normal)

Birth Contraceptives DON'T GIVE TO PT WITH HX

Hx of DVT or spontaneous bleeding Hepatitis COPD Cholecystitis *ABT decrease the effectiveness of contraceptives*

HHNS

Hyperosmolality and hyperglycemia occur due to lack of effective insulin. Ketosis is minimal or absent. Hyperglycemia causes osmotic diuresis with loss of water and electrolytes (risk of dehydration); Hypernatremia and increased osmolality occur. Lack of insulin effectiveness s/s: slow onset low BP and high HR Dehydration AMS hyperglycemia (BS 600-1200) elevated BUN and creat. TX: HIE Hydration (IV/PO) Insulin (regular) Electrolyte replacement

Pheochromocytoma is r/t

Hypersecretion of epi., persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA. Pt must avoid stress. Take frequent baths and rest breaks, and avoid cold and stimulating foods, and must have surgery to remove tumor. Tx: glucocorticoid

Allergic response

Hypersensitive reaction to an allergen initiated by immunological mechanisms which is usually mediated by IgE antibodies Cause: antigen (dust, pollen) TYPES: Anaphylactic (Type I): Instantaneous & the most severe. S/S: edema in many tissues, bronchospasm, hypotension, & can lead to cardiovascular collapse. Cause: peanut, shellfish, milk, eggs, soy, wheat, insect stings, latex (ask if allergy to bananas, avocado, kiwi), penicillin, contrast, ASA, NSAIDS Cytotoxic (Type II): body produces anti-bodies against itself (i.e. myasthenia gravis). Immune complex(Type III): Antigens bind to antibodies & form an immunocomplex that can deposit in tissues and cause tissue injury. Delayed-type (Type IV): Occurs 24- 72 hours after exposure to antigen. T cells cause tissue damage (itching, erythema, raised lesions).

Classifications of Anemia

Hypoproliferative: Deficit in production of RBCs Due to deficit of iron, vitamin B12, folic acid, or erythropoietin Marrow damage: medications, chemicals, cancer. Hemolytic: Excess destruction of RBCs Altered erythropoiesis (sickle cell anemia) Hypersplenism Drug-induced or autoimmune processes Mechanical heart valves Bleeding (blood loss):-- GI, epistaxis, GU, trauma. COMMON s/s: Fatigue, weakness, malaise Pallor or jaundice Cardiac and respiratory symptoms Tongue changes Nail changes Angular cheilosis (ulcers in angles of mouth) Pica (craving for non-nutritious substances: chalk, ice, clay). Frequent in severe iron-deficiency anemia.

Addison's Disease

Hyposecretion of adrenal hormone. Cause: adrenal gland removal, TB, corticosteroids tx s/s: STEROID Sodium and sugar low, salt craving Tired and weak Electrolyte imbalance (K and Ca) Reproductive changes O: lOw BP Increased pigmentation (brownish) Diarrhea, nausea, depression Diet: high in Na NSG INTV: Montior VS and LOC Assess for muscle weakness and fatigue Assess stress level (bed rest) Monitor for s/s of crisis *if increase heat weather increase Na and fluid intake *increase risk of dysrhythmias r/t low NA and *high K* tx: Mineralcorticoidsteriod to replace cortisol (monitor glucose for s/s of hyperglycemia) CRISIS: MEDICAL EMERGENCY s/s: CRISIS: 5 S' Sudden pain (back, stomach, legs) Syncope Shock Super low BP Severe vomiting, diarrhea

Post Op complication/NSG INTV

Hypovolemic shock-push IV fluids, monitor VS Thrombus formation- use ACE hose, dorsiflexion, SCDs, anticoagulants (Lovenox), mobility (ambulation hrs to 1 day post op) Pneumonia due immobility- TCDB, Incentive spirometer, suction UTI's- push fluids, remove catheter as soon as possible (bladder and bowel training until return to normal) Pressure Ulcers- sacrum, TQ2H Infection- aseptic technique, hand washing Dislocation Altered bowel/bladder function (constipation/urinary retention)

Kidney autoregulation

IF BP decreased (by dehydration, shock, vasodilation) causes renin-angiotension system to be activated =vasoconstriction and increased BP Normal BP= decreased renin secreted= angiotension production stop

Airway

IF any suspected airway obstruction AVOID placing anything into the airway. Monitor pain or discomfort levels. Elevate HOB and provide o2.

Suicidal pt

IF pt made threat of suicide assess if they have means to do so (ex. gun, pills) Monitor CLOSELY *Have someone with the pt at all times.*

suspected spinal injury

IMMOBILIZE HEAD AND NECK Make Sure to minimize movement to HEAD, NECK, TORSO, SPINE -no traction applied Use jaw thrust technique for CPR

Report Change/HAND OFF

INCLUDE: tests and treatments; as-needed medications given or therapies performed during the past 24 hours, including the client's response to them; changes in the client's condition; scheduled tests and treatments; current problems; and any other special concerns. Only significant vital signs changes need to be included.

Anything placed in causes a risk for (invasive)

INFECTION Check site (if applicable) Check VS/LOC CMS (if applicable)

Neurological assessment includes

LOC (especially in head injury, PE/DVT, and fat embolism) Mental Status Emotional status AAO x4 (person, place, time , and situation) Assess cranial nerves Assess sensory and motor reflex PERRLA Assess eye (sclera, conjunctiva, symmetry) Pupil size (normal 3-4mm) Monitor pain, temp, sensation, reflexes Assess motor function and balance/coordination *Infant or neonates: check fontanels

AIDS: Opportunistic infection and cancer

INFECTIONS: Oral Candidiasis (can be found in esophagus and stomach) (tx: Fluconazole PO, topical clotrimazole, miconazole, and nystatin) *Pneumocystis carinii pneumonia* (most common) (s/s: nonproductive cough, chills, fever, dyspnea, chest pain) TX: TMP-SMZ and early corticosteroids Cytomegalovirus (gastroenteritis, retinitis, pneumonia, encephalitis) Herpes simplex (pneumonia, bronchitis, esophagitis, blisters) Toxoplasmosis of brain TB* (if negative PPD then CXR to dx) Recurrent salmonella septicemia Recurrent pneumonia HIV-related encephalopathy CANCER: Invasive cervical cancer *Kaposi's sarcoma (lesions in skin & internal organs. It is diagnosed by skin biopsy and confirms the diagnosis of AIDS).* Types of lymphoma

transesophageal echocardiography (TEE)

INFORMED CONSENT procedure in which patient swallows ultrasound head in order to better visualize internal cardiac structures, especially cardiac valves and to check for clots in heart NSG INTV: NPO 6 hrs prior to prevent aspiration -Insert IV line -Assess for GAG reflex post op -Monitor VS, EKG, O2 sat, LOC -HOB elevated 45 degrees and bed rest.

Liver biopsy

INFORMED CONSENT Check coag and PTT, PT, PLT prior *Give Vitamin K prior r/t bleeding risk* Monitor VS Position PT: Lateral( right Side-Lying) with pillow or rolled up blanket under right side. due to risk of bleeding Monitor site post op

Preop Procedure

INFORMED CONSENT Collect labs If pt is on any type of anticoagulant -CHECK PT AND INR Usually on NPO status Clarify with MD on preop meds (especially if diabetic pt)

Pacemaker implantation

INFORMED CONSENT NPO prior to procedure CXR to confirm placement Assess site and surrounding skin. After implantation assess site for bleeding or hematoma. *report to HCP* Monitor VS closely (pulse and T) and EKG Assess LOC and pain. Change dressing Teach pt to carry medical ID, avoid MRI, explain pacemaker may be triggered at airport but wont affect it. *Assess when last time pacemaker was irrigated (first one should be done 6 weeks post)* Report abnormalities to MD *spike: atrial spike after p wave ventricular spike after QRS complex Failure to capture: bradycardia will occur Avoid contact sports, heavy lifting, and wearing tight clothing *NO MRI* Wear medical alert bracelt

Cardiac Catherization

INFORMED CONSENT (an invasive procedure) Use to dx: CAD and pulmonary arterial HTN Assess coronary artery prior Review labs (renal (due to dye), coag, electrolyte, PLT) Insert IV NPO 8-12 hr prior Assess for allergy to iodine or seafood HOB elevated 30 degrees Usually in the femoral artery. *Keep affected limb straight* *Immobilize limb for 4-6 hrs if venous or 8-10 arterial.* *Assess groin area and distal peripheral pulses frequently* *Report any chest pain* Assess temp and color of extremity Monitor VS and EKG DSG stay in place for first 24HR Bed rest 2-6hr post op Check dsg for bleeding (hemorrhage *if bleeding apply pressure 1 in above puncture site, monitor VS/LOC, CMS, Pulse and report to HCP*) Assess I&O PEDS: delay if a diaper rash is present

Colonoscopy

INFORMED CONSENT SIGNED NPO or clear liquid diet prior (per MD orders) Position pt on left knee and knee chest. Check coag labs Make sure pt understand procedure Provide bowel prep prior Allow pt to empty bladder Adjust DM tx if pt is DM (notify MD) post: monitor for perforation (s/s: n/v, chills, fever, abd. pain) Notify MD if occur. Monitor VS frequently Increase PO fluid Monitor for rectal bleeding after 2 days. (report any bright red bleeding to MD) Provide privacy r/t increase flatus Pt may return to normal diet, fluids, and ask MD about activity.

Coagulation Labs

INR/PT PTT H&H PLT Fibrinogen

Cholecystitis

INTV based on prep pt for surgery or just nsg care NSG INTV: GALLBLADDER GI rest (NPO until rested and advance nutrition per MD order) Analgesic and Antiemetic med (via IV best route for pain med and antiemetic (n/v) medication) Low fat diet (avoid fatty, spicy, gassy foods) Large bore IV for fluids to maintain hydration and electrolyte status Breathing stop by pt during abd palpation (positive murphy's sign) Lab assessment (liver, WBC, renal, electrolytes) ABT for infection Drain care (c-tube present) assess drainage COCA, keep drainage below insertion site, empty bag regularly Deteriation changes (decreased LOC, hypotention, increased HR, high WBC, N/V, elevated temp, Jaundice, steatorrhea) ERCP (surgery procedure) Removal of gallbladders (cholecystectomy)

REDUCE EDEMA

INTV: elevation contrast baths massage compression (unless contradicted) ROM ICE PACK (per MD order) Diuretics

IV SOLUTIONS

ISONTINIC: equal osmolarity (equal solutes) to serum (blood). -LR -0.9% NS -D5W *becomes hypotonic when in bloodstream HYPOTONIC: low osmolarity (less solutes) than to serum. Pull fluid OUT of cell via diffusion. -0.45% NS -0.225% NS -*D5W when in bloodstream* HYPERTONIC: high osmolarity (more solutes) than to serum. Pull fluid INTO cell via diffusion *very concentrated and given slow IV and via central line* -5% NS -3% NS -D10W -D545%NS -Hydroxyethal starch Isotonic: "I" no change, fluid stays IN the vascular space hypOtonic: "O" fluid runs OUT of vascular space (extracellular fluid) into the cells (lowers BP) hypErtonic: "E" fluid is pulled from cells and ENTERS the vascular space (extracellular) (increases BP)

Cholinergic Crisis and MG crisis

If the pt is in cholinergic crisis -Stop medication -*Giving Tensilon (edrophonium) will worsen s/s* If pt is in MG crisis -*giving tensilon will improve s/s*

ABC is #1 ADPIE

If the question ask for ABC. ALWAYS ASSESS YOUR PT Assessment Diagnosis (nsg) Planning Implementation Evaluation

Calcium and Phosphorus work hand in hand

If you have hypercalemia then you have hypophosphemia and vice versa. Ca level: 8.6-10.6 Phosphorus level: 2.5-4.5

Malabsortion

Impared gastrointestinal absorption s/s: diarrhea (usually steatorrhea-fat stool) Abd. distention and pain increase flatus weakness weight loss tx: antidiarrheal, probiotic, tx dehydration, ABT

eptopic pregnancy

Implantation of fertalized egg not in the uterus (common site: Fallopian tube) S/S: vag bleeding RLQ abdominal pain TX: Meds or surgery NSG INTV: NPO status *surgery assess COCA of vag bleeding Monitor VS Assess emotional status Check HCG levels frequently until decrease Admin Rhogam and methotrexate Post op care

SIADH

Increased amount of ADH so cells becomes diluted causing less electrolytes (ex. Na) cause: lung cancer, CNS (injury, tumor, infection) s/s: Change in LOC, decreased DTR, tachycardia, N/V, anorexia, headache. Place pt on fluid restriction *watch usage of irrigation fluids and meds mix with NS NSG INTV: Place pt on fluid restriction Increase Na intake (diet, IV solution, etc) Monitor I&O and daily weight Urine and blood tx Assess VS and LOC IV hypotonic solution Fall risk/SAFETY *Place pt on seizure precaution* CV assessment (edema, JV?, lung crackles r/t fluid overload) Monitor neuro status tx: Administer *Declomycin & diuretics*

Group B Streptococcus

Infection found in the lower GI or urinary tract, transmitted from the mother to baby can cause meningitis RISK: Premature Young maternal age African American or Hispanic Screen at 35-37 weeks if position TX with ABT (Penicillin or Clindamycin *if allergic to pen) TX done at onset of labor or ROM

Bursitis and Tendonitis

Inflammation of a bursa or the tendon sheath respectively s/s: Redness edema pain TX/NSG INTV Anti-Inflammatory Rest, ice, NSAIDs Arthroscopy Assess VS Monitor pain

Pyelonephritis

Inflammation of the renal pelvis and kidney; caused by bacterial infection. s/s: ACUTE: chills, fever, N/V, bacteriuria, pyruia, vertebral angle tenderness, headache TX: ABT and IV or PO hydration CHRONIC: fatigue, headache, poor appetite, increase thirst, wt loss, polyuria TX: long term ABT tx *teach pt need for follow up urine culture *NSG INTV:* encourage PO fluids (1-3L) Pain management Assess VS, LOC, WBC, and blood cultures *Avoid coffee, tea r/t bladder spasm Educate on prevention

PET scan

Informed consent NPO 4hr prior a visual display of brain activity that detects where a radioactive form of glucose goes while the brain performs a given task 24hr prior: pt on a low carb diet, no alcohol, caffeine, or tobacco. DM pt consult with MD on glucose control. NO INSULIN OR DM MED DAY OF EXAM Encourage PO fluid post op.

Trach Suctioning

Intermittent suction is applied while rotating the catheter for 10 to 15 seconds.* *Hyperoxygenate* the client with a resuscitator bag/Ambu-bag connected to an oxygen source before suctioning. Insert catheter gently until resistance is met or the client coughs, then pulled back 1 cm or ½ inch. Intermittent suction while rotating and withdrawing the catheter. Wall suction should be set to 80 to 120 mm Hg. *Suction is never applied when inserting the catheter. STERILE GLOVES MUST BE WORN. Trach Tube in place determine ability to swallow. *Removal of mechanical ventilation via trach monitor for spontaneous breathing STAT*. Have O2 sat meter on finger during sx Monitor VS and bradycardia HAVE EXTRA TRACH EQUIPMENT AT BEDSIDE (1 size smaller or same size to potential swelling) IN THE EVENT OF AN EMERGENCY HAVE INTUBATION AND AMBU BAG AT BEDSID

Injections (intradermal, SQ, and IM)

Intradermal: 15 degree angle (TB syringe) SQ: 45 or 90 degree angle (insulin syringe) IM: 90 degree angle Intrathecal- admin of CSF SYRINGE: (intradermal) TB syringe 26-27 gauge needle SQ (insulin) 28, 30, 31 gauge IM: 23-25 gauge

Dx procedures (surgery, imaging test, etc)

Invasive: INFORMED CONSENT Usually NPO or clear liquid diet 4-12 hours prior to procedure (per MD order) Assess for allergies (especially if contrast is used) Check renal, liver, and coagulation labs prior (especially if contrast is used) Encourage pt to void prior Assess any anticoagulation meds to stop (at least 1 week prior) Monitor VS frequently after procedure (15 min for 1 hour, then every 2 hours, then every 4 hours) Assess tempt frequent (q4h) Monitor T for s/s of infection

Hypoproliferative Anemias TYPES

Iron Deficiency Anemia Anemias in Renal Disease Anemia of Chronic Disease Aplastic Anemia Megaloblastic Anemia Myelodysplastic Syndrome (MDS)

Cellulitis

It is a skin infection that involves the deeper skin layers and subcutaneous fat tx: assess/admin pain management apply warm compress Monitor VS/LOC IV/PO ABT (usually IV) Assess skin site Monitor for s/s of infection and Temp.

Hyperkalemia

K level >5.0 Cause: Addison's disease, untx renal failure, Drugs ( potassium sparing diuretic, beta-blockers, NSAIDS, ACE inhibitor), burns s/s: MURDER Muscle weakness Urine (oliguria/anuria) Respiratory depression Dcreated cardiac contractility ECG changes (heart blocks, asystole, and v fib) Reflexes (muscle twitching) -increase bowel sounds Cardiac changes: a wide, flat P wave; a prolonged PR interval; a widened QRS complex; and *narrow, peaked T waves.* DX: EKG changes, ABG, K level TX: loop diuretic or Kayexalate to reduce potassium levels *monitor BM r/t diarrhea* IV Ca gluconate to protect heart for 30min Acidosis: sodium bicarb Dialysis Hypertonic IV solution NSG INTV: Monitor BP and s/s of dehydration Encourage PO/IV fluids *EKG: MUST BE ON A CARDIAC MONITOR* AVOID FOOD HIGH IN POTASSIUM and salt substitutes Monitor K and renal function SEVERE HYPERKALEMIA: *usually K+ level >7 TX: -*Reg insulin and D50 IV to place potassium back into the cells* -Dialysis

Skin and Stool/urine (most bodily fluid)

Keep skin free of stool r/t risk of skin irritation Cleanse area with soap and water. Sitz bath Use A&D ointment if irritation or redness.

Tx of Pelvic Floor Dysfunction

Kegal excersice Increase fluids Decrease constipation

Cholesterol Levels

LDL: lower than 130mg/dL; <160 HDL: 30-70 mg/dL Total <200 mg TX: diet with whole grain, fruit, vegetable, olive or canola oil

Hemispheric Stroke EFFECTS

LEFT -Paralysis or weakness on right side of body -Right visual field deficit -Aphasia (expressive, receptive, or global) -Altered intellectual ability -Slow, cautious behavior RIGHT -Paralysis or weakness on left side of body -Left visual field deficit -Spatial-perceptual deficits -Increased distractibility -Impulsive behavior and poor judgment -Lack of awareness of deficits

Living Will (sign)

Living wills are required to be in writing and signed by the client. The client's signature either must be witnessed by specified individuals or notarized. Talk to HCP. NURSES doesn't sign.

IV FLUIDS SITE/INFUSING

MAKE SURE OF RATE MONITOR IV SITE (for s/s of swelling or redness) *If a piggyback is present: the infusing IV fluids should be hung higher. Change IV site every 3-4 days or per facility policy. Monitor for s/s of infection

Foods rich in iron

MNEUMONIC EAT LOTS OF IRON Egg yolk Apricots Tofu Legumes, Leafy green vegetables Oysters Tuna Sardines, Seeds pOtatoes Fish (halibut, haddock, salmon) Iron-fortified cereal and breads Raisins, Red meats (beef) pOultry (turkey, chicken) Nuts

Medication RX

MUST HAVE: date/time, med name, dosage, route, and frequency (ex: metformin 50 mg PO Q8H) For ABT (antibiotics) there should be a stop date (ex: Amoxicillin 10 ml PO Q8H for 10 days)

ROM (rupture of membranes)

MUST deliver in 24 hr or increase risk of infection *Monitor FHR for a full minute* r/t risk for cord prolapse Assess COCA of fluids *observe for any meconium stained fluid

DM: hyperglycemia

Main s/s: 3 P's Polyuria- increased urine (excrete glucose) Polydypsia- increase thirst Polyphagia- increased hunger Other s/s: SUGAR Slow wound healing blUrred vision Glycosuria Acetone breath Recurrent yeast infection, Rash other s/s:tingling of extremities, dry skin, n/v DX: Based on ADA 1. s/s of DM and random BS >200 2. Fasting glucose level >126 3. 2hr postload >200 TX: Type 1: insulin Type 2: oral hypoglycemia (because some insulin is still being produced but not enough to be therapeutic level) and/or insulin (mainly sliding scale)

Head injury medication includes

Mannitol (osmotic diuretic) it crystallizes at cool temperature so ALWAYS use filter needle. If via IV place the solution in warm water

Anticonvulsant Therapy NSG INTV

Medications given depending on type of seizure May be changed PRN Don't withdraw rather slowly decrease dose (per MD) to prevent seizures Place pt on seizure precaution Have O2 and intubation equipment at bedside

megaloblastic anemia

Megaloblastic- Deficit of Vit.B12 & Folic Acid Folic acid - body stores very little Poor diet, overcooked veggies. Should eat green veggies & liver Pregnant - need to increase RBC production Drugs (contraceptives, antiseizure, methotrexate, sulfonamides) and alcohol reduce folic acid levels in plasma. *B12 - Found only in foods of animal origin (meats & dairy products). Body normally stores large amounts (Dx of deficit can take years to detect) Strict vegetarians have poor intake of Vit B12 GI issues---- Like: a)- Faulty absorption of Vit B12 (Crohn's) b)- Decreased intrinsic factor (in pernicious anemia)

From the ass (diarrhea) = ____________ From the mouth (vomit) = ____________

Metabolic acidosis Metabolic alkalosis

Antidotes

Mg Sulfate- Calcium Gluconate Coumadin- Vitamin K Heparin/Lovenox- Protamine Sulfate Hypoglycemia- sugar or glucagon 1mg or dextrose IV if pt is unconscious Lead/IRON Poisioning- Chelating Agents Acetaminophen- N-acetyclcystine (mix with juice) Digoxin- Digibind Opiate (Narco, Heroin, demerol, etc)- Narcan Hyperglycemia- Insulin Tensilon/pyridostigmine/pilocarpine- Atropine Sulfate (avoid with glacoma pt) Aspirin- active charcoal Methotrexate- folic acid or multivitamins Alcohol withdrawal- librium Narcotic addicts- methadone Benzo (ex; -pam/lam) - Flumazenil Beta-blocker toxicity: glucagon thrombolytics (tPa, reteplase, tenecteplase)- aminocaproic acid Penicillin allergic reaction- epinephrine Oxytocin- mg sulfate

Hypomagnesia

Mg level <1.3 Cause: LOW MAG Low Mg intake Other electrolytes low (K and Ca) Waste Mg via kidney (diuretic) Malabsorption (UC and Chron's) Alcohol, pancreatitis Glycemic issues (insulin, DKA) S/S: TWITCHING Trousseau's sign+ Weak RR Irritability *Torsades de pointes*, tetany Cardiac changes, Chvostek sign+ HTN, hyperflexia Nausea GI issues (decrease bowels and mobility) DX: Mg, K, Ca, and albumin levels EKG, UA TX: IV Mg sulfate, PO Mg salts, TPN, Food high in Mg (green veg, nuts, seeds, cocoa, seafood, peanut butter) NSG INTV: VS/EKG monitor urine output (pre/during/post) tx of IV Mg* if decreased output notify HCP *Antidote is Ca gluconate for IV Mg sulfate* monitor dig level (N/V, diarrhea, blurred vision) Seizure precaution Assess for dysphagia *If K levels are low (hypokalemia) it MUST be corrected prior to correct low Mg level (hypomagnesium)* TX: PO K+

Hypermagnesia

Mg level >3.0 Cause: MAG Mg meds (antacids and laxatives) Addison disease Glomerular insufficiency (renal failure) S/S: LETHARGIC Lethargy EKG changes *(tall T wave)* Tendon reflex decreased Hypotension Arrhythmia Resp. arrest GI issues (N/V) Impaired breathing Cardiac arrest DX: Mg, K, Ca level Creatinine clearance EKG changes *(tall T wave)* TX: avoid meds with Mg, Vent support IV Ca gluconate, Diuretic and 0.9% or LR Hemodialysis NSG INTV: VS/EKG LOC monitor Mg level monitor for decrease DTR (deep tendon reflex) NO med with Mg to renal pt avoid food high in Mg

Nagele's Rule for expected date of delivery

Minus 3 months and add 7 days (-3 months and +7 days) *remember months with 28 (leap year: 29), 30, 31 days*

Ascites pt: NSG INTV

Monitor VS Monitor LOC Monitor wt and I&O Perform abd assessment (measure girth of abdomen). Admin diuretic. Continue to monitor wt and abd. (reassess for effectiveness of diuretic about 1 hr after med) Usually in liver problem patients Diet: low NA (sodium) diet r/t fluid accumulation

SEDATIVE ADMINISTRATION

Monitor VS/LOC pre and post admin DON'T sign a CONSENT form MUST be done PRIOR to administration.

Spica cast

Monitor pt for bowel sounds

*Contact Precautions* *Mrs. Wee! M R S W E E

Multidrug resistant organism Respiratory infection Skin infections Wound infections Enteric infections-C. difficile Eye infection-Conjuctivitis *must wear gloves, gown, and standard precaution*

REPORTING

Must report any suspicion of substance abuse by the nurse to the nursing supervisor. Must report any elder or pediatric abuse. If nurse observes an error: Ask personnel involved and then report to nursing supervisor. *ASK THEN REPORT*

Hydatidiform Mole

Must take contraceptive for 1 year. MAY HAVE A D&C (D&E)

Pregnancy and Immunization

NEVER given live virus vaccines to pregnant women Ex: Rubella

Glacoma

Open- angle is an medical emergency. Eye medication for rest of life.

NG tube complications/NSG INTV

NG tube use: used to decompress stomach post op to prevent distention and wound opening. Placement: measure from tip of nose, tip of ear, xyphoid process. Confirm placement with x-ray Insert by having pt swallow or drink water via straw MARK insertion site and tape to nose of pt. PT with NG tube usually NPO *if pt complains of throat irritation or discomfort: spray viscous lidocane via order. Misplaced with vomiting. Sx: intermittent suctioning CHECK PLACEMENT PRIOR TO FEEDING (aspirate contents) *if excessive amount hold feed and notify MD Loss of potassium (hypokalemia) Replace fluids with LR Provide oral care tx: diluted mouthwash and water after brush teeth Monitor blood sugar if feeding is provided Daily weight I&O Monitor suctioning (must be low intermittent suctioning) Don't irrigate without MD order

MRI NSG INTV prior (with or without contrast)

NO CONTRAST: MUST HAVE A CONSENT SIGNED NO METAL OBJECTS (nurse must remove if possible and send it home with family if possible DOCUMENT IT) PREOP: NO METALS or PACEMAKER, orthopedic hardware, credit card, clips, IUD, artificial heart valve *NURSE MUST REMOVE METAL OBJECTS OR NOTIFY MD IF PT HAS METALS Teach relaxation techniques Inform pt that they must lie still during procedure Machine is noisy so may provide ear plugs Assess if pt is claustraphobic may be given a sedative. Have pt void prior *unless contraindicated WITH CONTRAST: (same as above and....) -assess renal function -assess for allergies (iodine or shellfish)

Ventricular Asystole

NO HB, PULSE, or RESPIRATION NO QRS complex s/s: hypoxia, acidosis, hypothermia, drug overdose TX: CPR MEDS: epinephrine, vasopression, atropine *FATAL IF NOT TX FAST

Postpartum (vag area)

NO sex or anything into the vagina for 6-8 weeks. Hours after birth monitor mother for possible hemorrhage r/t increase hemorrhage in recent birth (within hours)

gentamicin tobramycin meds ending with (-mycin or micin)

NORMAL LEVELS: 5 to 10 mcg/mL 5 to 10 mcg/mL. MONITOR PEAK AND TROUGH SE: ototoxicity and nephrotoxicity

Treat a nose bleed (epistaxis)

NOSE IS VASCULAR NSG INTV: Monitor VS Have the pt sit and lean foward. Apply pressure for 10-15 min with thumb Apply ice to site, place a gauze or cotton in nose

Renal biopsy nursing care

NPO 6-8 hr prior INFORMED CONSENT Collect urine pre and post biospy CHECK LABS AND ALLERGIES (monitor H&H) Monitor renal function Monitor VS and pain. Done on abdomen. Remain in bed for 2-6hrs. Maintain pressure on the biopsy site for 10-30 min or per MD order. ENCOURAGE PO FLUIDS 1500-200ml to flush renal clots. Educate pt reduced physical activity for 2 weeks. Observe site and s/s for bleeding. Infection: Elevated temperature, changes in UO

Pacifier to NPO infant

NPO infant give an pacifier. *NO pacifier or bottle for cleft lip pt postop.*

Cast Materials

NSG CONSIDERATIONS plaster Needs air exposure, 24-72 hrs to dry out. Full strength when dry (hard, firm, odorless, shinny white, resonant to percussion); Space Between cast & skin: space for one finger Elevate at heart level for edema prevention: Use a cloth-covered pillow (not plastic) To handle wet cast, use only palms of hands Petal the cast if needed Leave cast open to air circulation Not water resistant & heavy fiberglass Tepid water for activation; Full rigidity in 30 minutes Some are waterproof (Pt can shower, swim) Stockinette/cotton pad placed under cast Between cast & skin: space for one finger Allow air circulation Elevate at heart level to reduce edema CMS CHECK EVERY HOUR

Eye Foreign Bodies

NSG INTV Assess eye Assess visual acuity Apply eye shield on 1-2 eyes to prevent pain with EOM

Hip Replacement (POST OP)

NSG INTV/Goal- is to prevent dislocation & prevent DVT from forming - Pillow between legs, prevents Adduction & dislocation - Encourage fluid intake, prevents DVT - use SCD/AE hose - anticoagulant to prevent DVT - Assess for swelling, edema, pain, redness, hotness - Wear elastic stockings & perform leg exercises - Encourage Incentive Spirometer every 1-2 hrs -TCDB -TQ2H - use fx pan - raised toilet seat (commode with elevation) -avoid (Hip flexion > 90°, Crossing legs (adduction), Internal rotation, turning on affected side) -Assess VS/LOC -Assess for s/s of infection -dressing change per MD order -assess for pressure ulcers -Assess CMS and 5/6P (NEUROVASCULAR ASSESSMENT) -Assess ROM if possible Signs of Dislocation - Shortening of limb - Adduction

Bone biopsy

NSG INTV: Check site for edema, hematoma/bleeding, pain, ingection Ice per MD order Pain assessment and admin PRN Educate pt to report any s/s

Thyroidectomy (post op)

NSG INTV: -Semi Fowlers, neck neutral -*Monitor for respiratory distress* -*appparatus at bedside (trach set, ambu bag, intubation equipment, 02 tank and suction machine)* -*STRIDOR IS AN INDICATION OF RESP. DISTRESS r/t edema. (tx. nebulizer tx) -Check for edema and bleeding by noting dressing -monitor site for bleeding -encourage pt to whisper - limit talking, no cough - monitor for laryneal nerve damage - monitor for hypocalcemia and tentancy - prepare CALCIUM GLUCONATE - Monitor for thyroid storm -Monitor VS/LOC -Hoarseness is normal and will subside within a few days -Damage to parathyroid causing decreased Ca levels Assess signs: Trousseau's sign and Chvostek's sign Give iodine prior to surgery to reduce viscosity of thyroid and decrease risk of bleeding. Rx: levothyroxine for life

tic douloureux (trigeminal neuralgia)

Painful condition in which the trigeminal nerve (CN 5) is affected by pressure or degeneration. (mainly affects women over 50) S/S: severe stabbing nature and radiates from the jaw and along the face. facial pain Facial twitching TX/NSG INTV: surgery rx: admin carbamazepine (Tegretol) Avoid hot/cold food r/t trigger facial pain Reduce stimuli Assess and admin pain medication

Chest tube

NSG INTV: Never empty drainage system Assess tube for kinking Position tube below pt chest and secure tube Clamp momentarily to assess for airleaks and change drainage (kinked, clamped too long, obstruction can cause TENSION PNEUMOTHORAX) Check for fluctuation of fluid in chamber or chest for air leak. STOP If lung re-expand (CXR to confirm), tube obstructed, sx not working, loop below rest of tube Mark drainage (time and date) *drainage should decrease first 24hr; if >100ml/hr notify MD Never milk chest tube. *MUST HAVE AN OCCLUSIVE DRESSING, 18G needle, sterile connector AT THE BEDSIDE* *If CONTINUOUS bubbling in system: Assess pt and notify MD due to risk of tension pneumothorax* Perform resp. assesssment: RR, lung sounds, monitor for subq crepitus, cyanosis, VS changes, chest pressure. TCDB and TQ2H TIDLING: increases water level with inspiration and decrease with expiration NORMAL. -no tidling mean obstruction or lung re-expansion (perform CXR to confirm) *REMOVAL OF CHEST TUBE* BY MD Check that tidiling has stopped, no bubbling, CXRto confirm re-expansion of lungs. Teach pt to perform the valsalva maneuver prior and perform during removal. Position in Semi-fowler Apply an occlusive dressing to 3 sides CXR to assess post removal *DISLODGE OF CHEST TUBE* Apply bandage with petrolatum guaze covered by 4x4 guaze and nonporous tape (3 sides) Occlusive dressing NOTIFY HCP *DISCONNECTION OF CHEST TUBE* Cut contaminated end, Re-connect to sterile connector ASAP, then connect to system OR Clamp and Place chest tube in 2cm of sterile water *never clamp unless MD order

Seizure Precautions

NSG INTV: Padded side rails and an airway O2 at bedside MAINTAIN PATENT AIRWAY (turning to side) Side-lying position Loosen clothing Remove any objects near by r/t excessive reflexes O2 (mask or NC) and Suctioning equipment at bedside Position pt to side Monitor VS (temperature should be axillary not oral)/LOC Bed in the lowest Call bell in reach -if pt is standing: ease pt to floor to prevent injury and fall Note onset time, events prior, and behavior before and after seizure. Allow pt to rest post *NEVER PLACE ANYTHING IN MOUTH* *DO NOT RESTRAIN PT* PT AT RISK MUST HAVE IV PRN IV ATIVAN* *try to give benzo or anti-seizure medication prior if pt has hx of seizure to prevent. DOCUMENT: if pt had aura, trigger, length of seizure, characteristics of seizure, any tx given

Upper GI study (series)

NSG INTV: clear liquid diet and NPO night before Bowel prep (golytely) Advise pt no smoking, chewing gum, or mint Encourage increase fluid intake to eliminate stool and barium *stool may be clay color r/t barium

Urine contents

Na (135-145) Chloride (96-106) Bicarbonate K+ (3.5-5.0) Urea (7-22 or 10-20) Creatinine (0.6-1.2) Uric Acid *NOT* SUPPOSE TO BE IN URINE *protein *glucose *leukocytes *nitrites *ketones *bilibrubin *RBC

Hyponatremia

Na level <135 Cause: NO Na Na excreted via renal failure, GI suction, vomiting, diuretics Overload of fluid NPO (decrease Na intake) Antidiuretic hormone oversecreted *SIADH s/s: SALT LOSS Seizure/stupor Abdominal cramping/attitude changes Lethargy Tendon reflex decrease Limp muscles (weakness) Orthostatic hypotension Shallow RR Spasm muscle TX: Increase Na intake via diet *IV fluid replacement (LR or 0.9% NS to place Na into cell than HYPERTONIC solution (3% or 5%) to hydrate)* Fluid restriction NSG INTV: *Monitor lithium level* on pt taking due to risk of toxicity I/O, daily weight monitor Na levels Seizure precaution Monitor VS/LOC Monitor pt PO/IV fluid intake Watch for CNS changes (lethargy,confusion,muscle twitch, seizure) Decrease diuretic dose *if on diuretic

Hypernatremia

Na level >145 Cause: DI, watery diarrhea, initial kidney disease, kayexelate, prolong loop diuretic use S/S: FRIED Flushed skin, fever Restless, anxious, agitated Increase fluid retention and BP Edema, extremely confused Decreased urinary output, dry mouth DX: UA (increased specific gravity) and Na level TX: IV hypotonic solution (0.45) Diuretic DDVAP *if cause is DI Low Na diet NSG INTV: Monitor VS LOC/behavior changes Hypotonic solution (IV,PO,NG) Seizure precaution Mania pt: provide foods high in calories

EMG

Needle electrodes introduced into Skeletal Muscles to measure changes in electrical potential of the muscles & the nerves leading to them. Used to detect: 1. Neuromuscular disorder 2. Determines weakness from neuropathies

Neutropenia

Neutrophil count less than 2000/mm³ Decrease production or increased destruction *Increased risk of infection* Caused by immunologic disorder & corticosteroids use, chemotherapy. Absolute Neutrophil Count (ANC)& Risk of Infection

WBC

Neutrophils: Increase greatly in numbers when needed Most common cell seen in acute inflammation, comes in and kill foreign substance through phagocytosis First responders to microbial infection; they die in a short time & large numbers of dead neutrophils form pus Eosinophils: Participate in hypersensitivity reactions by neutralizing histamine. Increased in allergic states Basophils: Produce & store histamine Involved in hypersensitivity reactions Contain heparin and appear during the clot dissolution phase on an injury Monocyte: Largest leukocytes Have phagocytic function Present pathogens to T cells so that the pathogens may be recognized again and killed, or so that an antibody response may be mounted. Macrophages: Monocytes eventually leave the bloodstream to become tissue macrophages Remove dead cell debris as well as attacking microorganisms Lymphocytes: Produce antibodies and identify other cells as "foreign". They attack foreign material T lymphocyte (THYMUS: mature in thymus): Responsible for delayed allergic reaction, rejection of foreign tissue (ex: transplant organs), and destruction of tumor cells B lymphocyte (BONE MARROW): Produce antibodies (IBG) that destroy foreign material

ITP

No PLT infusion because they will be destroyed. Monitor glucose levels.

COPD (respiratory acidosis) (CHRONIC BRONCHITIS AND EMPHYSEMA)

No more than 2-3 L of O2 or it will shut their respiratory drive r/t unable to release CO2 thus air trapping occurs. Instruct the pt to perform *pursed lip breathing* to reduce the CO2 in the lungs and avoid air trapping. Encourage deep breaths Avoid carb intake because can increase CO2 which a pt with COPD can't effectively exhale.

Preeclampsia Eclampsia

No seizures (s/s: protienuria and HTN) Seizures

ABG

No suctioning (gastric or oral) prior to drawing an ABG pH- 7.35 to 7.45 Pa02- 80 to 100 mmHg Sa02- 93 to 100% PaC02- 35 to 45 mmHg HC03- 22 to 26mEq/L Low pH- acidosis High pH- alkalosis HCO3: KIDNEY PaCO2: Lungs Perform an allen test Post ABG apply pressure to site for 5 minutes. Monitor VS and site CMS check on extremity

Hypertension

Normal BP: less than 120/80 PreHTN: 120/80-139/89 HTN 140/90 Stage 1 HTN: 140/90-159/99 Stage 2 HTN: greater than 160/100 *HTN is most common in African Americans and Hispanics* Primary HTN caused by non-identifiable causes Secondary HTN caused by identifiable causes (weight, disease process)

Abruptio Placentae

Normal implanation of placenta that detatch from the uterine wall. s/s: Dark-red bleeding with pain and fetal distress. (DIC MAY OCCUR r/t the blood clots) DETACHED Dark red bleeding Extended fundal height r/t bleeding Tender uterus Abd. pain/contraction Concealed bleeding at detached site Hard abdomen Experience DIC Distressed baby (late decelerations) NSG INTV: C-section (or vag based on stage of labor) Position mother to L side IV fluids (LR) Monitor mother VS and FHR Assess pad count Monitor abdominal girth

Fasting glucose

Normal level: 70-100 monitor glucose levels with no consumption of food for 6-8 hours.

Serum Lipase

Normal: 10-140 units/L

Total protein level

Normal: 6-8 g/dL

Troponin T Levels

Normal: less than 0.6 ng/mL

Chain of command

Nurse to Charge Nurse to Nursing supervisor and manager

Malignant Melanoma

Nurse pt Teaching -avoid exposure to sunlight from 10 am-4pm -Wear SPF 15 or greater -Wear a hat, opaque clothing, and sunglasses when in the sun -Examine body monthly for suspicious moles and yearly by a HCP -Reapply suncreeen q 2-3 hrs pre/post swimming

Blood administration

O neg is the universal donor AB+ is the universal recipient

Cranial Nerves (12)

Oh, Oh, Oh To Touch And Feel A Girl's Vagina, Ahhhh, Heaven 1. Olfactory 2. Optic 3. Oculomotor 4. Trochlear 5. Trigeminal 6. Abducens 7. Facial 8. Vetibulocochlear 9. Glossopharyngeal 10. Vagus 11. Accessory 12. Hypoglossal

Cushing's syndrome

Oversecretion of gluccocorticosteroids. s/s: STRESSED Skin fragile Trunk obesity (buffalo hump at neck) Rounded face (moon face); reproductive issues Ecchymosis (bruising), elevated BP (HTN) Sugar high (hyperglycemia) Striae on extremities and abdomen Excessive body hair (common in women) Depression -Fluid and Na retention, low K NSG INTV: Assess VS and LOC Assess blood sugar (esp. pre/post surgery) Encourage rest Promote skin integrity (no tape on skin) Monitor for addison's crisis r/t treatment Monitor labs Monitor daily weight fluid restriction Diet: high protein, Ca, and Vit D

Oxygen Delivery

Oxygen is a medication and mainly used for resp. distress. Types: NC, simple mask, non re-breather mask, venturi mask SE: -dry nasal/mucous membranes (correct with humidification) -skin irritation (apply padded gauze to cheek, behind ear, etc) -o2 toxicity (changes in vision, tinnitus, nausea, twitching, irritability) INTV: -place an OXYGEN IN USE sign outside pt room -Inform pt/family NO SMOKING or OPEN FLAME -Keep away from open sparks -Monitor RR and O2 sat *assess response to oxygen (improve or worsen) -monitor for s/s of o2 toxicity

Hypophosphatemia

P level <2.7 *Ca level elevated Cause: PHOS Pharm (antacid, decrease Vit D) Hyperparathyroid, Heat (burn) Osteomalacia Stroke (heat stroke) S/S: BROKEN Breathing problem r/t muscle weakness with nutrition loss Rhabdomyolysis Osteomalacia (soft bone) Kill immune system (decrease PLT) Extreme weakenss Neuro changes (confused, seizure, irritability) TX: *NO ca gluconate* IV phosphate (or PO/NG) *IV rate must 10mEq/hr Vit D supplement for absorption NSG INTV: -Monitor Ca levels (*may be elevated*) -Rest (no ROM) -Gradually intro PO/NG/IV solution to avoid P push into cell -Infection control r/t decrease immunity -Monitor P level -EKG/VS -Seizure precaution -Monitor renal function -Increase fluid intake as tolerated if high Ca level (decrease risk of renal calculi r/t high Ca) -Encourage food with P (organ meat, fish, nut, poultry, sardine)

Hyperphosphatemia

P level >4.5 *Ca level low Cause: PHOS HI Phosphate food (soda) Hypoparathyroid Overuse Vit D Syndrome of tumor lysis Hemolysis Insufficient kidney (acute or chronic) S/S: CRAMP Confusion Reflex hyperactive Anorexia Muscle spasm, tetany, seizures Positive Trousseau and Chvostek DX: P, Ca, and PTH level X-ray of bone, bone studies Renal function (BUN and creatinine) TX: VIt D prep, Ca and P binding meds (take with meals) Loop diuretic, IV solution Low P and High Ca diet Dialysis if severe NSG INTV: Avoid food high in P and meds high in P (laxatives and antacid) Monitor urine output Observe for s/s of hypocalcemia seizure precaution monitor renal function prior to med tx r/t pt must be able to excrete phosphate

PQRST

P wave: atrial depolarization, SA node impulse -SA node is the pacemaker of the heart QRS complex: ventricular depolarization T wave: ventricular repolarization

Lab test: PLT

PLT: 150,000-400,000 Monitor for occult blood and bleeding. Monitor VS Assess levels prior to administration of Heparin, Lovenox, anticoag (eliquis, xarelto, etc)

Wound Irrigation

PPE: gown, gloves, and eye wear

CPR (cardiopulmonary resuscitation)

PRIMARY GOAL IS TO MAINTAIN CIRCULATION TO VITAL ORGANS ADULT: CAB (compression, airway, breathing) Assess LOC Check carotid pulse in children,teens, and adults 100 compression per minute Adult: 30:2 (compression:breaths) INFANTS: Check brachial artery -use 2-3 fingers for compression with 1/2- 1 inch in deep -turn to back and perform 5 back blows 100 compression per minute

IMPORTANCE FOR MENTAL HEALTH PT

PROVIDE SAFETY Therapeutic communication

Pain assessment

Pain is an priority *if pain is relieved usually negative s/s decrease. ASSESS PT PRIOR TO ADMISSION (ASSESS SITE AND PAIN QUALITY (PQRST)) P.O medication reassess pt in 30-60 min IV pt reassess in 30 min-45min *PQRSTU* Provocative/palliative factors ; Quality of the pain; Region or Radiation of the pain(location); Severity of the pain (scale/facial grimace); Timing of the pain (continuous or intermittent); and how the pain affects yoU

Peak and trough

Peak is taken 1 hr after a dose is administered Trough is taken 30 min before the next dose *common in the aminoglycosides and Vancomycin drugs*

Antibiotics

Perform a Culture and Sensitivity test prior to admin of antibitotics. May be started on a broad spectrum ABT then switch to narrow spectrum when culture returns. Take for the full course or the bacteria will become more resistant. Cause GI s/s to occurs ex: N/V, abdominal pain, diarrhea, and cramping

Barium swallow

Perform an abd assessment. Observe last BM. Conduct a digital rectal exam for impaction. Increase fluid intake. Monitor renal function prior. RX: laxative Stool: chalky white

Patient Care NURE

Place all pt on bed alarm Give pt call bell and tell them to use it to call Perform a head to toe assessment of pt on beginning of shift Have necessary equipment at bedside (based on diagnosis) Build a raptor with pt Assess/view pt every hour at least Learn to delegate appropriate tasks TIME MANAGEMENT Receive parameters for needed medication (beta-blockers, HTN med)

Insect/worm in ear (mucous membranes)

Place mineral oil or diluted alcohol solution in ear and place pt on affected ear Use a flashlight to attract insect Assess ear drum for any damage

Any pt with brain/nuero disorders

Place pt on seizure precaution Monitor Neuro assessment (LOC, AAO)

Pt on O2

Place sign outside room of O2 use Monitor VS (especially O2 sat and RR) No smoking in or about room No flammable solutions (ex: nail polish, hairspray)

Catheter embolism r/t IV catheter

Place turniqute above the IV site Provide O2 Monitor VS Notify MD

Components of blood

Plasma 55% of blood blood cells 45% of blood 5-6L in body Make up 7-10% of person's weight FUNCTIONS Carries O2 from lungs and nutrients from GI to body tissues Carries metabolic waste from tissues to organs for transformation and elimination Carries hormones, antibodies and other substances to their site of action Gas exchange in alveoli of lungs

Thoracentesis

Position: over a bedside table or *if unable*: side-lying on the unaffected side with HOB elevated to 30-45 degrees. Monitor RR function *Complications:* SubQ emphysema Pneumothorax Bleeding Liver or spleen injury Infection

Paracentesis Nursing Care

Pre: INFORMED CONSENT Encourage client to void prior Monitor VS Measure abdominal girth I&O and daily weight During: VS q15 minutes POST: document discharge (COCA) Assess VS/LOC *fall risk pt r/t fluid loss Abd. assessment Elevate HOB

Iron needed for females

Pregnant: 30 mg Nonpregnant: 18 mg Take with citrus fruit/juice or Vitamin C to help absorb Liquid iron absorbs faster mix with juice.

Immune deficiency (primary and acquired (secondary))

Primary: usually occurs in infancy s/s: Multiple infections despite aggressive Tx, opportunistic infect., FTT, poor growth, & positive family hx. Secondary: disorders: HIV/AIDS, DM, undernutrition. Chemotherapy, long Tx with steroids, bone marrow ablation before transplantation, radiation Tx. Nephrotic syndrome, GI enteropathy NSG ASSESSMENT/NSG INTV/TEACH PT TO RECOGNIZE Assess lifestyle (smoking, alcohol) Monitor for s/s of infections Fever with or without chills, sweating Cough with or without sputum SOB Dyspena Dysphagia White patches in the oral cavity Swollen lymph nodes Nausea with or without vomiting Persistent diarrhea Frequency, urgency, or pain on urination Change in COCA of urine Lesions on the face, lips, or perianal area Redness, swelling, or drainage from skin lesions Persistent vaginal discharge with or without perianal itching Persistent abdominal pain Monitor lab values Promote good nutrition Provide oral care Address anxiety, stress, and coping STRICT STANDARD PRECAUTION AND ASEPTIC PRECAUTION Provide skin care, promote normal bowel and bladder function, pulmonary hygiene

C-Section is indicated

Prolapse Cord Breech Hepatitis/HIV (tx: zidorydine to prevent trans to infant) Placenta previa Genital warts

BPH

S/S: *-increased frequency of voiding w/ dec output* *-increased urinary urgency* *-low back pain* -nocturia -hesitancy/difficulty starting stream -acute urinary retention -bladder distention -frequent UTI -abdominal straining during urination DX: elevated PSA, ultrasound, PVR TX: relax smooth muscle -hormone to decrease prostate -TURP

DNR

Pt must have a wrist band that says DNR. CHECK CHART TO SEE THAT THERE IS A *SIGNED* DNR FORM.

Allergy to Pencillin

Pt should avoid Cepholosporins becuase they are a similar chemical composition to penicillin thus an allergic reaction can occus Avoid medication -cillin, cef-, ceph- An anaphylaxis reaction can occur: -Monitor VS -give epinephrine -notify MD

After Cataract Surgery

Pt will sleep on *unaffected side* with a night shield for 1-4 weeks DON'T COUGH, strain, bend over, or rub eye Elevate HOB (fowlers) SAFETY: SR up x2, bed low and locked, CB within reach.

Bleeding Precautions (RANDI)

R- Razor Electric/ Blades A- Aspirin N- No needles (esp. in small gauge) D- Do decrease in needle sticks) I - Injury (Protect from) *NSG INTV/INTV* Avoid hard foods Avoid blowing nose Avoid ASA, tPA, anticoagulants Maintain high fiber diet to prevent straining (constipation) Avoid rectal temp or enema Avoid tampons Monitor menses Monitor VS Monitor for bleeding everywhere Use Soft toothbrush Limit needle sticks (use smallest gauge) Use electric razor. Safety precaution to prevent bruising. RISK FOR INJURY

Renal Disorder labs

RBC BUN 10-20 Serum creatinine *normal 0.6-1.2mg/dL Creatinine Clearance: 125ml/min Renal concentration test (specific gravity: 1.010-1.030 and urine osmolatiry) *Assess prior to any/most dx test especially ones using contrast. *if level are elevated prior: IV hydration prior and acetycysteine

CBC Lab Values

RBC - (Red Blood Cells/erythrocytes) Ref. Range 4.20 - 5.70 Cells that deliver O2 throughout the body and make blood look red (bright red in arterial blood; dark red in venous blood). HGB - Hemoglobin Ref. Range 13.2 - 16.9 Hemoglobin is a protein used by RBC to distribute O2 to other tissues and cells in the body. HCT - Hematocrit Ref. Range 38.5 - 49.0% Percent of your blood that is occupied by RBC. Good indicator of anemia*

RF and strep infection

RF occurs 2-6 wks if strep is left untreated. love the mitral valve and cause endocarditis Initiate seizure precaution Notify HCP of any invasive procedures

Acne causes (long-term use)

RISKS: Long term use of: steroids, phenytoin, phenobarbital, lithium, vitamin B12 NO CLEAR REASON FOR THE CAUSE OF ACNE

MS assessment

ROM Assess Gait Assess posture Muscle strength symmetry (right and left extremities) Assess CMS Assess skin condition (for injuries) Assess pulses Assess functions (ADL) Assess for pain based on location

INSULIN

Rapid acting (-log) ONSET: 5-15 min *PEAK: 45-90 MIN*DURATION: 3-5 HRS SHORT ACTING (REGULAR/-lin R) ONSET: 30-60 MIN, *PEAK: 2-4 HRS* DURATION: 5-8 HRS INTERMEDIATE-ACTING (-NPH) ONSET: 1.5-2.5 HRS, *PEAK: 4-12 hrs*, DURATION: 24 HRS. LONG ACTING (EX:LANTUS) ONSET: 2-4 HRS, PEAK: NONE DURATION: 24 HRS. Hypoglycemic reaction occurs during the *peak* Short-acting insulin (regular) are the only one that can be given IV. Prefilled insulin syringe last 7 days. Insulin stored for 28-30 days after open at room temp. Refrigerate any insulin not in use. Rapid and short acting given to cover increase glucose levels after meals (after injection)

Atrial flutter

Rate:Atrial 250-350 Ventricular rate 75-150 P: Irregular or absent, often "saw tooth" QRS: Normal Rhythm: Regular (usually) S/S: SOB, chest pain, low BP Cause: COPD*, pulmonary HTN, thyrotoxcosis TX: unstable pt: *electric cardioversion or pacing* stable pt: adenosine, MG, beta-blocker, digoxin, diltiazem

Immune Response (4 stages)

Recognition stage- Initiation; immune system recognizes antigen as foreign by using lymph nodes & lymphocytes for surveillance. Proliferation stage - The lymphocytes send antigenic message to the nearest lymph node. They then stimulate the residing T or B cell to enlarge, divide, and proliferate. Lymph nodes enlarge. Response stage 1. Cellular: T cells turn into cytotoxic/killer cells that attack microbes directly 2. Humoral: B cells produce and release antibodies against specific antigens. Effector stage: antibodies (B cells) or the T cell attach to antigen on the surface of the foreign invader & the destruction start. IMMUNE RESPONSE Helper T cells (CD4+): activated when they recognize the antigen & stimulate the rest of the immune system through their production of cytokines. MEDICATIONS THAT AFFECT IMMUNE SYSTEM Antibiotics(in large doses): bone marrow suppression Antithyroid drugs: bone marrow suppression NSAIDs: inhibit prostaglandin synthesis or release Adrenal corticosteroids: immunosuppression Antineoplastic agents: immunosuppression

Intussusception

Red currant jelly stool r/t the mixture of stool, mucous, and blood

Intrauterine fetal demise

Regression of pregnancy symptoms and absence of fetal heart tones. *After birth allow parents to hold child

Gestational DM

Regular insulin given but NO ORAL HYPOGLYCEMIA due to crossing the placenta. GDM babies are usually macrosomia

Restraints

Remove device q2h to promote circulation Check for circulation q 15-30min Check pulse and color (CMS checks) Allow 2 fingers between limb and restraint Inform the family why the restraints are used. *Attach to bed frame NOT side rails* Restraints ARE A FINAL RESORT and need a order from HCP. Not a continuous order must have a stop time/date

Therapeutic Diets for disorders

Renal- High calorie, CARB. Low protein, potassium, and sodium. Fluid restriction *especially in kidney failure Gout- Low purine (like can foods) Heart Healthy Diet- Low fat HTN- low sodium Dialysis, Kidney failure, HF: fluid restriction SIADH: fluid restriction DI: increase fluids intake (PO/IV) IBS (crohn's disease and ulcertive colitis): low residue, high protein, and high calorie. Hyperthyroidism: High calorie and high protein, small frequent meals, decreased stimulants and spicy foods. Hypothyroidism: low calorie and low fat, high fiber and fluid intake r/t constipation risk Pancreas and gallbladder disorder: low fat diet, high protein and carb, small frequent meals. Cirrhosis: high protein and high carb. High calorie r/t risk of malabsoption Cholelithiasis: High protein (avoid food high in cholesterol, fat, gas forming veg.) Hepatic encephalopathy: low protein and high calorie Thyroid storm: low iodine Addison's: high sodium and low potassium Cushing's: low sodium and high potassium pt taking Doxazosin (cardura): low sodium diet

Coup

Resp: stridor tx: have the child take in the steam in a hot shower with the door closed.

Guillan Barre Syndrome Complications

Respiratory failure Autonomic dysfunction (unstable BP & dysrhythmias) Sepsis PE/DVT Pressure ulcers Severe nerve pain Urinary retention

RSV

Respiratory syncytial virus. Viral respiratory illness; can be severe in infants. Usually occurs after an URI s/s: fever N/V diarrhea poor feeding tachypnea tachycardia moist cough wheezing and/or diminished breath sounds sneezing INTV: manage fever with acetaminophen O2 albuterol (or another short-acting beta-antagonist) CONTACT PRECAUTION *separate rooms or room with another RSV pt* proper hydration (PO/IV) maintain proper nutrition RX; Palivizumab (prevention but given based on criteria)

Common Cold TX

Rest clear airway increase fluid intke prevention of fever (antipyretic) skin care Caused by a virus so is treated by an antiviral medication

Visual Changes

Retina Detachment- curtain over eyes vision (black spots may indicate a bleed) Macular Degeneration- loss of central vision (like a dot in the middle) Cataracts- blurry vision Glaucoma- tunnel vision r/t loss of peripheral vision *acute angle closure glaucoma is a med. emergency*

10 right to drug administration

Right drug Right Dose Right to refuse Right patient Right History and Physical (assessment) Right order Right route Right documentation Right education Right time

Third Spacing

Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.

BURN patient

Risk for compromise airway Risk of fluid loss Risk for compartment syndrome r/t edema S/S: -elevated H&H -shock s/s: hypotension and tachycardia -hyperkalemia/hypokalemia *based on phase of burn -hyponatremia -edema asphyxiation -low body Temp -paralytic ileus, stress ulcer -sepsis TX/NSG INTV: *Administer pain med 30 min prior to dressing change* BEST drug route: Warm IV fluid (LR) *2 large bore IV (18G) Vasopressors (albumin, dopamine, etc) Use warm blankets, heat room Irrigate any chemical burns NPO Frequent hand washing prior to enter room. Monitor urine output *Indwelling catheter USE STERILE TECHNIQUE (cover wound with clean guaze) WEAR: GLOVES, GOWN, CAP, MASK, SHOE COVERS to perform task (ex: wound care) *r/t increase risk of infection Psych assistance Monitor for s/s of fluid overload or dehydration Monitor weight and labs Monitor VS/LOC EKG Monitor labs (electrolytes) Diet: high calorie, carb, and protien diet

Hypovolemic Shock

S/S: FHR changes Rising, weak pulse and narrowing pulse pressure Rising RR Shallow, irregular respiration, air hunger Falling BP Decreased or absent urinary output (<30 ml/hr) Pale skin or mucous membranes Cold, clammy skin Faintness Thirst TX: Isotonic solution Blood products Albumin Position pt in modified Trendelenburg.

Hyper-parathhyroid is r/t

S/S: Fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium). NSG INTV Low calcium, high phosphorus diet Monitor Ca and phosphorus levels Monitor EKG Encourage fluids r/t risk of renal calculi Assess and admin pain medication PRN

Preeclampsia

S/S: HTN increase headache edema protienuria

HEART FAILURE (RIGHT SIDE)

S/S: Dependent edema (usually lower extremities) -Hepatomegaly or spleenmegaly -Ascites -Weight Gain -Anorexia, nausea, abd. pain - Generalized weakness -JVD s/s: MNEUMONIC SWELLING Swelling of hands, spleen, legs, liver Weight gain Edema (legs) *pitting Large neck vein (JVD) Lethargic Irregular HR (a-fib) Nocturia Girth (abdominal) Dx: ECHO, CXR, EKG, *BNP*, BUN, electrolytes, TSH, CBC, U/A, creatinine, cardiac stress test, cardiac catherization. *BNP level >100 indicate HF* TX: based on severity -Medication -decrease NA intake -Limit fluids intake -Daily weight -O2 *nursing consideration* Monitor ECG Observe for SE of medications Obtain daily weight Monitor serum drug levels (ex. digoxin) Monitor electrolyte levels (especially potassium)

SBAR

S: Situation B: Background A: Assessment R: Recommendation

Degree of Burns

SUPERFICAL PARTIAL THICKNESS: * 1'- Epidermis* usually sunburn s/s: dry and red skin blanches warm pain when skin peels TX: PO pain med, cool compress/aloe gel (cool) DEEP PARTIAL THICKNESS: *2'- Epidermis & Dermis* s/s: edema red and painful blisters TX: recovery 2-3 weeks, if last >3weeks grafting FULL THICKNESS(3): *3'- Epidermis, Dermis, & SQ* s/s: decrease sensation edema shock myoglobinuria sloughing eschar and scaring TX: grafting FULL THICKNESS (4): *4'- Epidermis, dermis, SQ, muscle, fascia, and bone s/s: charred skin shock s/s myoglobinuria TX: amputation, grafting

Myelography

Same NSG INTV as (dx ending in -graphy) Have pt change position frequent prior to distribute contrast added. Bed rest 2-4 hr post and HOB elevated (fowlers) PO/IV fluid to excrete dye Assess for abnormalities (fever, meningitis, photophobia)

CT scans with contrast

Scan gives a cross section view of brain Done first WITHOUT contrast then WITH contrast to detect abnormalities NSG INTV: INFORMED CONSENT *explain to pt the purpose of exam and what to potentially expect *explain pt that they must must lie still during testing and if unable then sedation may be used. Check for allergies- to iodine or shellfish Assess renal function prior/post NPO 4hr prior/ or clear liquids Have pt void prior *unless contradicted IV INSERT (usually 18-20G needle) Fasting 4 hours prior Check if pt is on iodine medication (ex.metformin stop 48hr prior) *NURSE: read impression by MD

Wound dehisence

Separation of wound edges tx: cover with sterile guaze/dressing with NS to keep moist Monitor VS NOTIFY MD

*Droplet Precautions* *Think, Spiderman! S S S P P P I D E R M M M An

Sepsis Scarlet fever Streptococcal pharyngitis Parvovirus B19 *Pneumonia* Pertussis Influenza Diphtheria (pharyngeal) Epiglottis Rubella Mumps Meningitis Mycoplasma or meningeal pneumonia Adenovirus Private room or cohort *wear gloves, gown, and mask along with standard precaution*

Septic Shock

Shock caused by severe infection, usually a bacterial infection. S/S: Hypotension Increased Pulse and RR Diapharetic, sweating Warm r/t fever May have dysrythmias NSG INTV: Assess resp. status Monitor VS/LOC IV fluids IV medication

fracture complications

Shock- Hypovolemic r/t blood loss Fat Embolism Syndrome* (AMS, respiratory distress, headache, tachycardia, agitation, confusion, chest pain) *common in long bone fx Compartment Syndrome* (severe ischemia of limb) DVT, PE* Osteomyelitis Avascular necrosis DELAYED Non Union/Mal Union Avascular Necrosis DVT/PE DIC Infections Reaction to Internal Fixation Devices Complex Regional Pain Syndrome Heterothrophic Ossificans

Spinal epidural

Side effects: hypotension and urinary retention Given for a schedules c-section. (FOLEY CATH!!) If maternal hypotension occurs perform STOP Stop pitocin infusion Turn to left side O2 Push IV fluids

During Epidural puncture pt is in what position?

Side-lying or upright hunch over to open the vertebral spaces PT MUST BE STILL

Infection in elderly

Sign of an infection either UTI or URI or (resp infection) *Continue to monitor temperature and additional s/s that may lead to temperature. Monitor lung sounds. (resp assessment) Encourage PO fluids (if UTI and no contradictions) -AMS, confusion -lethargy -low grade fever -hyperventilation -anorexia -new incontinence

psoriasis

Silvery-white scaly lesions. NSG INTV: Keep the skin dry. corticosteroids Can lead to psoriatic arthritis- inflammatory arthritis Affect age 30-50 years It's damage to ligaments, tendons, skin, nails S/S: synovitis back pain pain infection uveitis TX/NSG INTV: ROM NSAIDS Corticosteroids injections Methotrexate (rx) Listen to pt Encourage physical activity with rest periods Monitor VS/LOC Assess and admin pain med

CAST REMOVAL (NORMAL)

Skin dry and peeling Change in color Foul odor Muscle atrophy Joint stiffness Wash gently Apply lotion per MD order Physical/Occupational Therapy

phantom pain

Soon after surgery- 2-3 months later Pain, numbness, tingling, muscle cramp, feeling extremity present Priority: admin pain medication as ordered (scheduled or PRN) NSG INTV: Assess VS Assess pain level *assess VS pre and post pain medication administration

Pt goals should be S.M.A.R.T

Specific Measurable Attainable Reasonable Time-oriented

Logrolling

Spinal pt

HIV DX

Spread via bodily fluids (breast milk, vaginal secretions, blood, via placenta (mother to baby unless mother recieved tx during pregnancy)) HIV is not spread through casual contact Western Bolt (#1) Elisa WBC Antibody tests: Only detect antibodies Antigen/antibody tests: Directly detect HIV Nucleic acid tests (RNA): Directly detect HIV *IF a negative result retest in 3 months.

Test for TB

Sputum culture ( 3 sputums must be collected and test) PPD (mantoux) (if the PPD is positive a CXR is done) CXR Gold Test *If pt with TB leaves room provide a mask* (usually a surgical mask)

Crutches use

Stand tall with your shoes on. Make sure your shoes have low heels and good support. Put the crutches under your arms. Relax your arms and let them hang down over the crutches. There should be a two inch space between your armpit and the top of the crutch with your hands hanging relaxed. The hand grips should be at the level of your wrist when holding the hand grips. Your elbows should be bent slightly to about thirty degrees. Standing Up To stand up, hold both crutches by the hand grips in one hand and push up with the other hand on the chair. Then put one crutch under each arm. Sitting Down To sit down, place both crutches in one hand holding the hand grips together and reach for the chair with your other hand to lower yourself slowly. Walking To take a step, squeeze the crutches between your upper arms and ribs put the weight through your hands not your armpits. Move the crutches forward. Move your injured leg forward and put your foot even with the crutches. Put as much weight as you are allowed on the injured leg, taking the rest of the weight through your arms and hands. Step past with your stronger leg. In summary, move the crutches first, your injured leg next, and then your stronger leg. Going Up Stairs To go upstairs with a handrail, place one crutch under one arm and use the handrail with the other arm for support. Step up with the stronger leg, then the injured leg, and lastly bring up the crutch. Always make sure the crutch tip is completely on the stair. If you do not have a handrail be very careful as you could lose your balance. Have someone help you or avoid the stairs until you are stronger. Place one crutch under each arm. Step up with the stronger leg then, then bring the injured leg and your crutches up together. Going Down Stairs To go down stairs with a handrail, place one crutch under one arm and use the handrail with the other arm. For support, lower the crutch down to the step below and move your injured leg down and then bring your stronger leg down. Always make sure the crutch tip is completely on the stair. If you do not have a handrail, be very careful as you can lose your balance. Have someone help you or avoid the stairs until you are stronger. Place one crutch under each arm. Step down with your crutches and your injured leg. Together then bring your stronger leg down.

Discharge ASSESSMENT OF PT

Starts at admission Assess ADL function prior READ MEDICATION TO PT and VERBALIZE FEEDBACK FOR PT HAVE PT READ IMPORTANT INFORMATION FOR UNDERSTANDING *if pt still unclear re-educate* Provide written instructions as needed to patient DOCUMENT!

TPN formula/dressing

Sterile dressing and must be changed very 3-7 days. TPN placement in the subclavicular vein (central venous access) to allow distribution to the body. Monitor for s/s of hyperglycemia (pt may be on a sliding scale insulin) *Wean pt off slowly due to the risk for rebound hypoglycemia (diaphoretic, confusion, tachycardia, restlessness) . Monitor blood sugar levels and sliding scale insulin

Factors that affect glucose levels (hypo/hyperglycemia)

Stress Infection Excessive exercise (have a snack prior to prevent hypoglycemic episode)

ARF (Acute Respiratory Failure) HX

Sudden deterioration of gas exchange in the lung r/t lack of O2 in blood or unable to remove CO2 in blood or failure to compensate. Causes: COPD, ARDS, asthma, CF, PE, pneumonia, HF Post-op period - anesthetics, analgesics, sedatives, pain *Fluid in alveoli & resp distress (Ex. *pulmonary edema) Intubation & mechanical ventilation. S/S: Early signs: restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, increased BP Later signs - confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, respiratory arrest Physical signs - use of accessory muscles, decreased breath sounds, & signs related to specific cause NSG INTV Perform rapid assessment & Administer O2 (call a code; MD will order/arrange to transfer client to ICU) Fowler's position Encourage deep breathing Administer bronchodilators as ordered Hyperoxygenate before suctioning, and suction PRN Assist with intubation & Maintain mechanical vent EKG monitoring; Monitor for pneumothorax Continually monitor VS & O2 Sat; Monitor lung sounds Assess respiratory status: Level of responsiveness: ABGs Pulse oximetry 95-100% VS Mouth care, turning, skin care, ROM exercises Education - prevention

Chest Tube Dressing Change

Supplies: Dressing pack Alcohol wipe/swab Sterile gauze Antiseptic solution NS 0.9% Sterile gloves Occlusive dressing Adhesive tape STEPS: Dressing should be changed DAILY Remove the patient's old dressing and assess site for bleeding, redness, air leaks, skin discoloration, condition of sutures, and color and amount of drainage. Remove the old gloves and don a new pair of sterile gloves. Clean the site with ChloraPrep. Use an antiseptic to clean the first two inches of the patient's chest tube, beginning where the tube exits the skin. Repeat this process twice. Use Xeroform to create an air-tight seal at the insertion site Split the 4×4 dressing and place it around the patient's chest tube. Make sure that the opening slits do not overlap. Apply two additional 4×4 sponges over the previous layer of dressing that covers the chest tube. Apply tape over the dressing. Date and time dressing. NEVER CLAMP CHEST TUBE Except when drainage bottle needs to be replaced or testing system for air leaks. *MUST HAVE MD ORDER

POTASSIUM

THINK HEART *cardiac Monitor renal function prior to administration r/t kidney failure due to increased potassium due to kidney inability to excrete K+ Range: 3.5-5.0

Tonsillectomy

TONSILLECTOMY RECOMMENDED: -a malignancy and obstruction of the airway -child has hypertrophied adenoids that obstruct nasal breathing -child has 3 or more infections of the tonsils and or adenoids per year despite tx NSG POST OP INTV: position in prone or side-lying observe s/s of bleeding No suctioning Avoid coughing, clear throat, blow nose Ice collar avoid dairy products (r/t it's mucus producing) Use cool water, crushed ice, ice pop (AVOID RED OR BROWN color) observe for any s/s of bleeding -s/s: frequent swallowing or clearing throat -tachycardia, hypotension -pallor -vomit bright red blood *post op bleeding can be 14 days post surgery decrease activities until 14 days post op

Maternal History of Child birth

TPALM T: Term P: Preterm A: Abortions L: Living M: Multiple GTPAL Gravida- amount of pregnancy Term- number of pregnancy between 37-42 weeks Preterm- number of pregnancies between 20-36.6 weeks Abortion- pregnancies ended prior to 20 weeks Living- children living at home (remember twins or multiple pregnancies will count as 1 pregnancy but 2+ living)

Thyroid dx test

TSH *best screening to test thyroid function T3 and T4 Thyroid antibodies Serum thyroglobulin thyroid scan (cold and hot nodules) *hot nodules=increased malignant risk Fine needle biopsy (accurate for detecting malignancy) NSG INTV: See if pt has iodine allergy or take meds with iodine NOTIFY MD

Thyroid test

TSH is the best to assess thyroid function NSG INTV: assess any iodine or shellfish allergy Assess any med with iodine Monitor VS *NOTIFY MD IF ALLERGY OR MED WITH IODINE

SICKLE CELL CRISIS

TYPES: aplastic acute sequestration hyper-haemolytic vaso-occlusive crises* (most common) Vaso-occlusive crisis: r/t s/s: fever, severse pain, hypoxia, and necrosis. MNEUMONIC SICKLE Significant blood loss (trauma, surgery) Illness (infection URI) Climbing or flying in high altitudes (planes, cold climates) Keep stressing (stress) Low fluid intake (dehydration) Elevated temp (fever, exercise) or COLD Any pt with infection (ex: URI) must wear a mask TEACHING D/C: Teach pt the importance of adequate fluids intake Avoid triggers that can lead to sickle cell crisis Take medication per order Pain management PRN

bright red bleeding (urine or sanguineous)= active bleeding

Take VS and contact HCP Assess and stay with pt

Prenatal vitamin

Take with food and at night

Removal of Foley Catheter

Temporary incontinence is normal and should reverse. Encourage PO fluids. IV fluids Observe first void (COCA) Monitor I&O *if no void has occurred within 12-24 hr post removal, perform bladder scan, try to encourage urination (run water, place hand in warm water) if unsuccessful notify MD, may need to replace foley cath or straight cath.

Eliminate Answers NCLEX quest.

Terms: always, never, all, every, only, must, no, except, or none MAKE AN EDUCATED GUESS CHOOSE C or answer with more info.

Schillings test

Test used to dx pernicious anemia NPO for 12 hours prior Pt is given PO radioactive B12 . a)- If absence of radioactive B12 in urine in 24 hrs => It indicates malabsorption of B12 in GI tract. b)- If radioactive B12 is present in urine in 24 hrs => The cause of anemia isn't ileal disease or pernicious anemia. c)- Later: The patient is given PO radioactive B12 + Intrinsic factor. If radioactive B12 is detected in urine (Shilling Test + => It is diagnostic of pernicious anemia). 24 hr urine collection done prior to test

Leopold's maneuvers

The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.

Sterile gloves

The nurse opens and flattens the inner wrapper to expose the sterile gloves. The nondominant hand picks up the dominant hand's glove at the inner cuff and inserts the dominant hand. The gloved dominant hand reaches under the cuff of the nondominant glove, and the hand is inserted, carefully avoiding contamination of the dominant thumb. The glove cuffs are then pulled down maintaining sterility and adjusting fingers in gloves as necessary.

Never get pregnant with a German (rubella). Why?

When pt is pregnant German measles (rubella) is dangerous while regular measles (rubeola) is not. Avoid getting pregnant for 3 months.

Kidney Transplant

To transfer a kidney from one individual to another *NSG INTV* -admin medication -monitor for s/s of rejection -monitor site for s/s of infection and dressing change per MD order -monitor labs (BUN, creatinine, ESR, etc) -monitor VS/LOC frequently -monitor urinary output -monitor skin turgor, cap refill -educate pt to take medication as prescribed (q12h on time) to prevent risk of rejection

myxedema (severe hypothyroidism)

Too little TH in adulthood Fluid accumulation in facial tissues and AMS, body temperature, and heart rate

Cardiac enzymes (labs)

Troponin T and I *elevated 2-3hrs post MI CK-MB *elevated 3-6hrs post MI Myoglobin *elevated 1-3hrs post MI *commonly used to DX MI*

Erikson stages

Trust v Mistrust (Age: INFANCY 0-1 1/2 years) Autonomy v shame (Age: Early Childhood 1 1/2-3 years) Initiate v guilt (Age: Preschool 3-6 years) Industry v inferiority (Age: School Age 6-12 years) Identity v Role confusion (Age: Adolescence 12-19 years) Intimacy v Isolation (Ages: Early Adulthood 20-25 years) Generativity v stagnation (Ages: Middle Adulthood 26-64 years) Integrity v Despair (Age: Maturity/Death 65-death)

Wilms' Tumor

Tumor in the kidneys avoid palpation of the abdomen due to the risk of tumor spreading

DM types

Type 1: Acute onset, genetic destruction of beta cells ONLY TX: insulin injections Type 2: 90-95% of pt. Pt decreased sensitivity to insulin or decreased insulin production *PREVENTABLE *#1 cause: OBESITY -first tx: diet and exercise then oral hypoglycemics (and or insulin) Gestational DM: onset 2nd or 3rd trimester -at risk pt: glucose tolerance test (1hr or 3hr) *done at 24-28 weeks -increase waist circumference increases insulin resistance.

Theophylline therapeutic range:

Type of bronchodilator therapeutic level: 10-20 Action: is given to relax bronchial smooth muscle an broncodilator s/s of toxicity: stomache tachycardia sweating profusely *Avoid medication at least 24hr prior to a cardiac stress test*

SPLINT for extremities BRACE

USE OF SPLINT: Temporary and when swelling anticipated prior to cast, special skin conditions NSG INTV: Monitor VS/LOV Assess skin Monitor CMS and 5P Cause: Potential for nerve pressure=foot drop BRACE Support, movement control, injury prevention Custom fitted Assess skin Pt teaching: donning and doffing, skin care Monitor CMS

Renal Assessment

Urinary patterns (frequency, urgency) Monitor VS (BP AND WEIGHT) Assess hydration (skin turgor) Renal labs (BUN, creatinine, specific gravity, urea, albumin, UA C&S) Urinary output (assess for foley) Monitor I&O Daily weights *usually for renal failure and HF

Fluid Status Labs

Urine specific gravity: 1.010-1.030 BUN: 10-20 Creatinine: 0.7-1.4 Hematocrit: 35-50 (females: 37-47 and males: 40-54)

ECT therapy

Use: Bipolar Mania; Lasts 3x week anywhere between 6-12 treatments. INTV/NSG INTV: NPO 8-12 hrs prior EKG continuous monitoring Monitor VS pre, post, and DURING (BP, O2) Provide anesthetic medication used methohecital ( Brevital) then a muscle relaxant is given Succinylcholine (Anectine). Seizures are induced and lasts between 25 to 60 seconds. SE: N/V, short-term memory loss, confusion, headache, and muscle weakness can occur. Administer antiematic and analgesic medications PRN. Explain reason for symptoms to client

LP (lumbar puncture) test

Used by insert needle into subarachnoid space (usuaully L4/L5) to withdraw and examine CSF fluids -can measure or reduce CSF -determine if blood present -detect subarachnoid block -Admin chemo, pain med, ABT Have pt void prior to prevent puncture of bladder Complications: -post LP headache cause by leakage of CSF --*prevent headache by use small guage needle site and remain flat for 4-8 hr post., increase fluid, pain med.* Blood patch can be placed as site to relieve headache -Herniation of intercranial contents -Meningitis -Spinal epidural abscess/hematomas *AVOID IN PT WITH INCREASED ICP* Pt lay flat for 4-8hr post

EEG

Used to detect seizure disorders -used to determine brain death (especially in pt in coma) -may show that tumor, abscess, brain scar, blood clots, and infection present. NO PAIN PROCEDURE PT MUST LIE STILL AVOID STIMULANTS 1-2 days prior ex: -coffee -chocolate -tea -caffine

Crainotomy

Used to remove tumors, blood clot, relieve increased ICP, control hemorrhage Elevate HOB to 30-45 degrees Initiate seizure precaution

Radiation Therapy

Used to treat or slow progression of cancer SE: alopecia N/V, anorexia fatigue and malaise diarrhea alteration in oral mucosa (stomatitis) NSG INTV: Bed rest while implant on place (TQ2H, TCDB, ROM in bed, SCDs, TED hose to prevent pneumonia and DVT formation due to immobility) Private room with private bathroom Wear a lead shield Place a notice on door of radiation use Wear a dosimeter badge (to detect radiation exposure) Limit nursing care and visitors to 30min at a time Assess nutritional status and general well being Assess skin and mucosa regularly No pregnant women or children under 16yrs allowed in room Low fiber diet Avoid wash cloth to skin where external radiation is r/t skin irritation *IF radiation material is placed in pt body and becomes released or dislodged from body place material in a lead (shielded) container and pick up with tweezers (keep at a distance from material) or CALL NECESSARY PERSONEL*

Dilantin (phenytoin) therapeutic range:

Used to tx and prevent seizures 10-20 mcg/mL Monitor for gum hypertrophy IF given via IV (should be mixed with NS) Can cause depress of myocardium= dysrhythmias

CCB (calcium channel blocker)

Uses: HTN Side effect: headache, dizziness, edema, flushing, nausea, and gingival hyperplasia NSG INTV: Monitor VS and s/s of medication *Avoid grapefruit juice* Have pt change position slowly

Allergy Testing

Usually Intradermal or topical Assess skin condition prior to administration Observe the pt for 15-30min for any anaphalactic reaction. s/s: rash, hives, and itching *required STAT intervention and care Remain in house for 15-30 min after in case of anaphylatic reaction occurs Avoid antihistamines 48-72 hr prior to testing

Newborn Assessment VS

Usually NORMAL after birth 5-10% of birth weight is loss but regain in about 5-7 (or 10-14) days. Temp: NO RECTAL T unless ordered by a doctor otherwise usually done axillary. (usually once and thats it) Normal RR: 30-60 bpm. Synchronize chest and abdominal movements are normal

HEAD INJURY

Usually occurs post trauma (car accident, blunt-force) Monitor ear and nose for clear drainage r/t could be CSF fluids (perform a glucose test to confirm) DX: as a spinal injury (get an x-ray and immobilize neck) TX: immobilize neck (neutral position) NSG INTV: Monitor for s/s of increased ICP (bradycardia, bradypnea, HTN with wide pulse pressure, cheyene-strokes, rapid increase temp., decreased LOC) Neuro assessment (PERRLA *fixed and dilated: NOTIFY MD) Seizure precaution: (padded SR, anticonvulsants, bed low) Elevate HOB 30 degrees to decrease ICP Decrease night disturbances, cluster nursing activities Monitor VS (BP, HR, T) Provide Oxygen Immbolization intv: TQ2H, log-roll, TED hose, SCD, DVT prophylaxis, passive/active ROM Glascow Coma Scale assessment INFANTS:high shrill cry in an infant) *avoid sedation if necessary ICP occurs may give mannitol or hypertonic solution.(3-5%)

Dumping Syndrome

Usually occurs when a pt begins a PEG tube feeding. (or NG, TPN) S/S: Sweating and pallor TX/NSG INTV: Limit fluid with foods. *Avoid high-carbohydrate foods, including fluids such as fruit nectars* Eat small frequent meals Low-Fowler's position during meals; *Lie down for 30 minutes after eating* to delay gastric emptying; and take antispasmodics as prescribed.

Anything ending with -ase (enzymes)

Usually pertaining to the pancreas. Meds are usually given through juice or apple sauce and meals. Perform oral care around mouth after because the enzymes can breakdown skin.

Precipitous Labor

Usually up to 3 hrs. Stay with the pt and instruct her to breath with contraction.(use CB if needed) Position the mother into a side lying position.

Uterine palpation

Uterus is elevated and to the side. Indication of a full bladder or possible bleeding (hematoma).

*Contact Precautions* Skin Infections *VCHIPS V C H I P S

V-varicella zoster C-cutaneous diphtheria H-herpes simplex I-impetigo P-pediculosis S-scabies *must wear gloves, gown, and standard precaution*

Normal Blood Loss (delivery)

Vaginal- 500 ml C-Section- 1000 ml

FHR monitoring strips

Variables Cord Early Head Acceleration OK Lates Placenta Insufficency FHR drops at the end of pregnancy

Ventricular dysrhythmias

Ventricular tachycardia ventricular fibrillation premature ventricular complexes Ventricular Asystole

Medication Administration (all routes)

Verify medication order (EMR) *use 2 nurse identifier based on med (ex: insulin, blood) Wash hands and apply gloves (if needed) Assess for allergies Identify pt (name and DOB) *scan if available Inform the pt of medication with the purpose and possible side effects Position the pt if necessary DO NOT LEAVE MEDICATION AT THE BEDSIDE DOCUMENT

Time-out prior to surgery

Verify the correct procedure, for the correct patient, at the correct site. • When possible, involve the patient in the verification process. • Identify the items that must be available for the procedure. • Use a standardized list to verify the availability of items for the procedure. (It is not necessary to document that the list was used for each patient.) At a minimum, these items include: relevant documentation Examples: history and physical, signed consent form, preanesthesia assessment labeled diagnostic and radiology test results that are properly displayed Examples: radiology images and scans, pathology reports, biopsy reports, any required blood products, implants, devices, special equipment • Match the items that are to be available in the procedure area to the patient

Pernicious Anemia

Vit. B12 can't be absorbed r/t lack of intrinsic factor in stomach s/s: s/s develop over time weakness palpitations Neuro s/s are present - confusion, paresthesia (numbness & tingling in lower limbs), poor balance/gait; loss of position sense (proprioception). MNEUMONIC s/s: PERNICIOUS Pale, pallor Energy gone Red, smooth tonuge Numbness/tingling in UE and LE Intestinal issues (diarrhea, constipation, indigestion, weight loss) Confusion Increased sad (depression) lOss of appedite Unsteady gait SOB with activity DX: Schillings test (24hr urine collection done prior to test) TX: Vitamin B12 injection monthly IM (rest of life) folic acid, good mouth care, high protein diet, multiple vitamins and minerals.

Fat soluble vitamins

Vitamins A, D, E, and K, which are found in food containing fat. They're stored in the liver and body fat. The body draws on these stored vitamins when needed.

How to promote peristalsis post GI surgery and flatus? and Tx of vericose veins.

WALK pt (ambulation)

Mother and WBC

WBC will be elevated but by day 3 should decrease.

Bone marrow

Yellow marrow-fat red marrow- where cells are produced *replaced by fat as a person ages NEEDS: Iron Vitamin B12 Folic acid Vitamin B6 Protein & other factors

Paget's disease

a bone disease of unknown cause characterized by the excessive breakdown of bone tissue, followed by abnormal bone formation s/s: decrease height (1-2in)

Rib Fracture

a break in the bony structure of the thorax Cause: blunt trauma s/s: pain with movement, deep breathing, and coughing (worsen oxygen and ventilation=inadequate clearing of secretion) Pain and tenderness at injury site (increase with resp.) Shallow RR DX: CXR TX: Heal spontaneous Open reduction and internal fixation (if needed) NSG INTV: Splint chest during inspiration (pillow, hands, or arms) Place in fowler position Provide pain medication Monitor for increase resp. distress Prep for nerve block

rheumatoid arthritis

a chronic autoimmune disorder in which the joints and some organs of other body systems are attacked (SYSTEMIC AFFECT) Have periods of remission and exacerbation s/s: 7 S's Sunrise Stiffness (severe pain) Soft feeling in the joints Swelling in the joint (warm) Symmetrical Synovium (affected and inflamed) Systemic (affects not only the joints...patient will feel achy, tired, and it can affect the lungs, heart, anemia etc) Stages (synovitis, pannus, anklyosis) TX: NSAIDS, celecoxib, ASA, steroids (prednisone) DX: elevated ESR, X-ray NSG INTV: Monitor VS/LOC Perform ROM exercise Assess joint (movement, function) Provide rest periods Proper nutrition Use ice/heat application per MD order PRN Assess pain and admin pain PRN ADL retraining PRN

Angina

a condition of episodes of severe chest pain due to inadequate blood flow to the myocardium Medication: nitroglycerin is given sublingual TX: nitroglycerin (contraindicated for pt with low BP r/t to vasodilation) Rest can decrease angina Take nitroglycerin (3 times in 5 minutes) but call 911 after the first dose Pt can take nitroglycerin prior to an activity that may cause chest pain With tx: pt is able to return to activities that they are able to do (work, sex)

Spina Bifida

a congenital defect that occurs during early pregnancy when the spinal canal fails to close completely causing a protrusion of meninges, CSF, and nerve root. s/s: small tuff of hair on back (lower) sac on back (lower) RISK/Complication: UTI r/t neurogenic bladder, Hydrocephalus TX: surgery NSG INTV: Position *prone* so that sac does not rupture Apply sterile moist gauze to defect. IV fluids to maintain hydration Turn to one side when feeding Monitor for s/s of ICP or infection Prevent skin breakdown Note any physical movement Prone to a latex allergy

Retina Detatchment

a curtain falling over eyes s/s: Complaints of a burst of *black spots* or floaters

Laryngeal STRIDOR

a harsh, high-pitched sound heard on inspiration and expiration that is caused by the compression of the trachea and that leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway. NSG INTV: CALL A CODE Monitor resp. status administer nebulizer therapy *PROVIDE O2* (via mask) Elevate HOB

ADH (vasopressin)

a hormone that regulates water reabsorption Released when body is dehydrated=kidney conserve water so urine is concentrated and decreased urinary output Dehydration= high ADH= decreased urination Overhydration= low ADH= increased urination

Herniated Disk

a knifelike stab in the back area

Total Knee Replacement

a procedure in which all of the parts of the knee are replaced Cause: uncontrolled joint pain (can be caused by osteoarthritis and rheumatoid arthritis) TX/NSG INTV -Apply a knee immobilizer before getting the client up elevate the client's surgical leg/ICE per MD order -CPM (extremity maintained in neutral position) -Neurovascular assessment FREQUENTLY (q15 min 1hr, every 1 for 4 hours, then every 4 hours) -EARLY AMBULATION (receive weight bearing order from MD prior) -Compression bandage -Weight bearing per MD order -Limit flexion position of limb -ROM 24hr post op -DVT prophylaxis r/t thrombus risk -Monitor VS/LOC -Monitor pain and admin pain medication PRN Complication: Infection thrombus formation

Dialysis

a procedure to remove waste products from the blood of patients whose kidneys no longer function complications: NSG INTV: -*avoid BP or diuretic meds on dialysis days*

status epilepticus

a prolonged seizure or situation when a person suffers two or more convulsive seizures without regaining full consciousness *MEDICAL EMERGENCY* Cause: sudden withdraw from med -fever -infection TX/NSG INTV: -turn pt to side -remove objects -padded siderails and pillow under head -SX at bedside and O2 -maintain airway (intubate pt) -IV line -BENZO/anticonvulsant med -Monitor VS/LOC -Neuro assessment every 15 min for 1 hour, 30 min for 1 hr, every hour then on. -if hypoglycemia give IV D5 -check labs/eeg

Delirium

a short term confusional state that has a sudden onset and is typically reversible ex: temperature nurse: continue to orientate the patient to the surrounding and situation Avoid form of restraints which can lead to anxiety and agitation.

Tardive dyskinesia

a side effects of continued use of neurleptic medications to control schizophrenia

Increasing hoarseness

a sign of resp depression. also a sign of laryngeal nerve damage NSG INTV: Assess resp. status Provide O2 Elevated HOB RAPID RESPONSE Monitor VS/O2 sat/ LOC

Amputation

a surgical removal of all or part of a limb. Level of amputation is based on adequacy of circulation and healing. Cause: Accident or trauma PVD (DM, HF, malignant tumors) Chronic bone infection Infected burns or damage bone Due to severe deformity NSG INTV Pre/post PRE; Psychological evaluation pre/post Avoid showing over enthusiasm Patient education- phantom pain Educate pt on wrapping stump POST: Monitor VS/LOV Check for bleeding/drainage Monitor for s/s of infection (ex: redness,pain, swelling) *NOTIFY MD IF S/S OF INFECTION Bed flat to prevent hip flexion Place pt in prone position to prevent flexure contracture of hip (20-30 min, several times a day) ROM exercises/stretching Massage stump Legs kept adduct Overhead trapeze *Surgical Tourniquet at the bedside table r/t bleeding risk* Elevate residual limb for first 24 hrs then flat with HOB elevated after (to prevent flexion contracture of hip) Wrapping stump with ace bandage to shape limb for prosthesis, reduce edema Frequently assess site (for s/s of bleeding or infection) wound care Not sitting for long periods Assess pain r/t phantom pain (admin pain med PRN) Expose residual limb to air to help facilitate healing Cast post op to control pain and prevent contracture

Ischemic stroke

a type of stroke that occurs when the flow of blood to the brain is blocked s/s: *depend on location of obstruction or area of decreased profusion Assess: maintain airway, RR, CV changes (HTN, dysrhythmias, bruit), Neuro deficits Numbness or weakness of extremities/ decreased sensation Decreased LOC, confused Loss of balance or coordination Sudden headache Dizziness and visual disturbance (hemianopsoa) Troubled speech (aphasia (expressive/receptive)) TX/NSG INTV *TIME IS ESSENTIAL (determine onset of s/s)* -anticoagulants -statins -tPA -elevated HOB 30 degrees -provide O2 -give mannitol -Hemodynamic monitoring -Monitor VS and neuro status frequently -Assist with nutrition r/t dysphagia -speech therapy consults -SAFETY -PT/OT -prevent deformities and shoulder pain (dislocation) -promote self care -decrease sensory stimuli (do multiple tasks at once (ex.VS and AM/PM care)

How to test for H. Pylori?

a urea breath test due to the release of bacteria and organism through breaths. Can also be stool or blood test Common cause of peptic ulcer disease Tx: PPI (short term use) ABT ( usually a combination of 2 ABT to decrease resistance and increase effectiveness of tx)

24 hr urine collection

a urine specimen in which all urine is collected for a 24 hour period and tested. Procedure: Discard first void in morning -Collection begins with second void (write time) -Keep container in *ICE* during collection process -Mark start time and end time. -Send collection to lab quickly *measures urea, nitrogen, Na+, creatinine, protiens, Ca+ Collection should have sterile precations

ventricular tachycardia (MEDICAL EMERGENCY)

a very rapid heartbeat that begins within the ventricles, 3 or more PVC with HR over 100 bpm Causes: stimulants, digitalis toxicity, hypokalemia, cardiac infarction/ischemia, MI TX: *SYMPTOMATIC PT WITH A PULSE* (pt who shows s/s) Cardiovert or defib (pulse or no pulse) Medication: epi, amioderone CPR TX: Medication: Adenosine with flush NS after. *(STABLE PULSE V-TACH)* -Cardioversion *UNSTABLE PULSE V-TACH* (s/s: decreased LOC, sweating, hypotensive) -Defibrilation *PULSELESS V-TACH*

Disseminated Intravascular Coagulation (DIC)

abnormal activation of the proteins involved in blood coagulation, causing small blood clots to form in vessels and cutting off the supply of oxygen to distal tissues BLEEDING CAUSE: STOP Making New Thrombi Sepsis Trauma Obstetrics complication Pancreatitis Malignancy NephrOtic syndrome Transfusion s/s: decreased LOC Petechiae, purapura, ecchymosis oozing from injection sites hematuria hypotension tachycardia tachypnea abd. distention shock head injury, burns placenta abrupto DX: increased PT, PTT and thrombin time Decreased PLT and fibrinogen TX/NSG INTV: TX underlying cause Strict bleeding precuation (RANDIS) Assess for s/s of bleeding Assess lung sounds provide O2 monitor VS monitor renal function increase fluids intake (PO/IV) oral care Assess skin Avoid straining/coughing IV blood given TRANSFUSION for serious bleeding (clotting factors) and give heparin therapy to prevent clotting of blood admin RANDIS (BLEEDING PRECAUTION) Razor (NO) ASA (NO) Needle sticks (small gauge) Decrease needle sticks (IM, IV) Injury protection (padded side rail, bed alarm, belongings within reach) Soft toothbrush, flossing (NO) COMPLICATIONS: Renal failure Gangrene PE or hemorrhage ARDS (acute respiratory distress syndrome) Stroke HF Shock SAFETY PRECAUTION FALL RISK AND RISK OF INJURY

Scoliosis

abnormal lateral curvature of the spine (s-shape) DX: standing radiograph screening of spine by bending over S/S: asymmetry of shoulder and hip height NSG INTV/TX: Surgery involving rod placement Pt may be advised to wear a brace for 23hr a day Assess skin Wear a cotton shirt under brace to prevent skin irritation Shower *-if surgery:* -assess VS, CMS -pain medication -skin care -*LOGROLLING* -ambulation 2-3days post op -TEACH parents about how to care once d/c

Herpes Simplex Virus Encephalitis

acute inflammatory process of the brain TYPE 1 affects children/adults TYPE 2 affects neonates S/S: Fever Headache Seizures Dysphasia Hemiparesis Altered LOC, confusion, behavior changes Dx: LP (assess CSF), MRI, EEG TX/NSG INTV Antiviral agents (acyclovir (Zoviraz) or Ganciclovir (cytovene)) *given for 3 weeks. *give slow IV push to prevent crystallization of urine Assess LOC Reduce stimuli (dim room, reduce noise, admin pain med, perform multiple task at one if possible) Safety precaution to prevent fall/injury Monitor LABS and urinary output EDUCATE PT/FAMILY

Administration of ear drops: Ear drops (ad*U*lts) Ear drops (chil*D*)

ad*U*lt: pull ear *u*p and back chil*d*: pull ear *d*own and back Have pt lay on unaffected side for 5-10 min.

Portal hypertension

affects the liver which causes the blood vessels to dilate. TEACHING: tell pt to avoid straining (an bearing down causing a reaction to the vagus nerve which causes the HR to decrease)

allergic rhinitis (hay fever)

affects the mucous membranes of the nasal cavity and throat Cause: pollen or animal dander s/s: sneezing and nasal congestion copious clear nasal discharge breating problems (dyspnea) nasal itching itching of throat watery eyes post-nasal drip headache hyposomnia. TX/NSG INTV: Identify antigen Maintian airway Assess respiratory status TCDB (frequently)

Pneumothorax

air in the pleural cavity caused by a puncture of the lung or chest wall cause: spontaneous, puncture by flail chest (ribs), procedure (thorocentesis), trauma (shooting or stabbing) TYPES: spontaneous, open, tension s/s MNEUMONIC COLLAPSED Chest pain, cough, cyanosis Overt tachycardia and tachypnea Low BP (hypotension) Low O2 sat *Absent or decreased breath sound on affected side (TENSION)* Pushing trachea to unaffected side SubQ emphysema, suckling sounds Expansion of chest unequal Dyspnea DX: CXR TX: Thorocentesis Chest tube NSG INTV: Apply nonporous dsg over open chest wound Prepare and monitor chest tube (leaking, bubbles, etc) Semi-fowler position Assess lung sounds, RR (depth, characteristics) Monitor ABG TCDB Humidified O2 Monitor for s/s of shock (AMS, decreased BP, increased pulse, cold, clammy) Assess/admin pain *careful with admin of pain medication r/t decreased resp. status Monitor for subq emphysema (body absorb but if severe trach)

Paraethesia

an abnormal sensation, such as burning or prickling Common: nerve damage (DM) and circulatory impairment (fracture, surgery, amputation, etc)

RDS (newborns)

an absent in production of pulmonary surfactant risk: premature (lack of surfactant) or surfactant deficiency S/S: WET FROGS Wheezing Effort Tachypnea Flaring (nasal) Retractions O2 Grunting TX: Betamethasone, surfactant replacement, VENT

Chemotherapy

an antineoplastic agent used to treat cancer or other systemic disease. VESICANT medication. Risk for infection r/t immunocopromised NSG INTV: GIVEN via PICC line or central line NOT PERIPHERAL *check IV for blood return prior to starting medication Monitor IV site for complication such as extravasation, hypersensitivity reaction If complication occur: STOP medication, notify HCP, restart at a lower dose or slower rate, apply warm or cold compress, premedicate with steroids, antihistamine, and antipyretics to prevent reaction Give pt antiemetic at least 30 min prior to tx of chemo. (N/V may last up to 48hr post tx) Monitor VS Avoid fresh fruits and vegetable No live vaccines (speak to HCP prior)

SLE

an autoimmune disorder that affects any organ. (multi organ system) Cause: sulfa meds, penicillin s/s: butterfly rash (avoid sunlight) hair loss oral ulcers Nephritis (risk of nephritic syndrome) HTN pericarditis depression stroke seizures arthritis pleural effusion and infiltration Dx: ANA (antinuclear antibody) TX: corticosteroids NSAIDS Pain management Antibodies antimalarial which decrease systemic flare ups Chemo (severe cases ex. methotrexate) NSG INTV: Sensitivity to Pt's psychological reactions Avoid sunlight / ultraviolet light Wear sunscreen / protective clothing Dietary instructions (atherosclerosis) Encourage periodic follow up with MD Encourage Medication compliance & education on side effects Monitor renal function r/t risk of renal failure Monitor labs Seizure precaution Low fat diet r/t atherosclerosis risk Educate Pt on smoking cessation

Dawn Phenomenon

an increase in blood glucose in the early morning due to spike in growth hormone at night (usually at 3am) *more insulin is needed in the morning Common in type 1 DM tx: intermediate acting insulin or long acting insulin (lantus) or change admin of insulin times per MD or increase insulin dose

Intramuscular injection

an injection into deep muscle tissue, usually of the buttock, thigh, or upper arm 1-1.5 inch needle with 20-23 gauge needle Locate and assess site Insert needle at a 90 degree angle *may aspirate based on agency policy 3 ml given max (adult) Inject med slowly with even pressure Remove needle quickly and apply pressure to site. MAY MASSAGE SITE DOCUMENT

Myelodysplatic syndrome

an insufficient production of one or more types of blood cells due to dysfunction of the bone marrow Common in elderly or toxic exposure PT AT RISK FOR INFECTION, BLEEDING, FATUGUE DX: bone marrow biopsy and CBC TX: PLT and blood transfusion

Drugs that can cause confusion (older adults)

anticholinergics, digoxin, histamine-2 receptor blockers, benzo, NSAIDS, antihypertensives,, antiarrhythmic.

Bee Sting

apply ice and elevate the site

thoracolumbosacral orthosis (TLSO)

apply prior to getting out the bed in the morning

Cocaine babies

are prone to neurological impairments and hyperactivity. Low birth weight. s/s: jittering

-gram/graphy (most procedure ending in -gram/graphy) NSG INTV

ask if pt has an allergy to shellfish or iodine Monitor renal function prior r/t dye excrete Obtain an *INFORMED CONSENT* Encourage fluids post op to excrete dyes. (if not contradicted) If hx of an allergic reaction (tachycardia and rash) tx with an antihistamine prior (ex. benadryl) Void prior *unless contradicted Assess if pt is taking any iodine medication (ex. metformin) POST OP: Encourage PO/IV fluids to excrete dye Assess distal pulses Monitor site for bleeding Assess VS/LOC CMS/weakness Keep limb straight and lie still (bed rest) 2-6hr post

Normal Urinary output postpartum

at least 400 ml or more an hr. Monitor the first 3 voids.

Myasthenia gravis

autoimmune neuromuscular disorder characterized by weakness of voluntary muscles (usually with exertion or exercise), fatigue s/s: WEAKNESS Weakness (neck, face, resp. muscles, and extremities) Eye dropping (ptosis and diplopia) Apperance mask-like (no expression, very sleepy look) Keep chocking and gagging when eating No energy (fatigue) EOM movement Slurred speech (hoarse voice) SOB DX: Crisis positive with Tensilon (edrophonium) test Edrophonium--- Is a medication cause impulses at the neuromuscular junction. Within 30 seconds of IV injection of Tensilon (2-10 mg), facial muscle weakness and ptosis should resolve for about 5 minutes (positive test). OR Ice Test is used in pt with cardiac issues or hx of asthma. Ice placed on pt eyes for 1 min & ptosis should resolve for a short time. *antidote* ATROPINE *have at bedside NSG INTV: Monitor VS/LOC Monitor RR r/t muscle weakness of respiratory muscles provide rest periods Monitor EKG and IV atropine PRN Admin rx: corticosteroids and anticholinesterase agents with milk or crackers to prevent GI upset Give med same time each day

Patch Testing

avoid any use of topical medication for at least 2 days prior to testing. Must stay at facility 15-30 min after administration. In case of an anaphalatic shock (epi is usually given) Monitor VS pre and post.

PUD

avoid caffine *will fill in more info later

Child/adult with 1 kidney

avoid contact sports Ex: football

Labor and pelvic exam

avoid doing OFTEN to decrease the risk of infection into the womb

juvenile idiopathic arthritis

avoid full ROM r/t increase pain.

Diverticulitis/IBS/Ulcerative Colitis (tx and information)

avoid seed, alcohol, corn, nuts and raw fruits and vegetables because trapped in the diverticula and cause irritation. s/s: n/v, constipation, LLQ pain Increase fluids intake. Avoid enema Diet: clear liquid diet until inflammation is relieved; then a high-fiber, low-fat diet Bulk-forming laxative as rx ABT NPO if high risk pt (chemo, older)

Check for Jaundice in a baby

begins from the head to the toes. Blanch the tip of the nose.

Surfactant

begins to develop at 28 weeks for the lungs to mature. Lungs are fully mature at 34 weeks.

Laceration Indication or active bleed

bight red trickle of blood

DVT

blood clot in a deep vein s/s: edema, swelling, warm in affected limb, tenderness *PREVENTION* OF DVT: Early mobility (especially post op), SCD, ROM TX: SQ low-weight heparin (lovenox) or anticoagulant NSG INTV: *STRICT BEDREST to prevent dislodge of clot* Elevate affected extremity to increase blood flow Moist, warm compress Ted hose VS Pain management (acetaminophen) Adequate hydration (unless contradicted) FOOT PUMP EVERY 1-2hr Monitor coag (PT, PTT, INR, H&H, PLT TX: Heparin (hospital)----Warfarin PO or SQ lovenox after heparin *monitor for bleeding (busing, gums, nosebleed, hematuria, thrombocytopenia)

Open fracture

bone fragments protruding through the skin. Cover with a moist sterile gauze. Monitor for s/s of infection. Monitor VS

Grapefruit juice effect

can inhibit the metabolism of certain drugs, thereby raising their blood levels AVOID!!!!

Thiamine deficiency

can lead to wernicke encephalopathy *must replace with thiamine which is common with alcoholics

Leukemia

cancer of white blood cells Abnormal delevopment of immature WBC affects the bone marrow s/s: *increase risk of infection (pneumonia)* bruising bleeding (r/t decrease PLT) anemia fatigue anorexia weight loss N/V bone pain DX: normal or high WBC count confirm by bone biopsy X-ray NSG INTV/TX: chemotherapy tx bleeding precaution (RANDIS) neutropenic precaution -strict aseptic technique bone marrow transplant/stem cell transplant blood transfusion monitor VS (especially temp) avoid fresh fruit, flowers Adequate nutrition avoid people visiting pt with infection or have them wear a mask RX: Imantinib

Uterine atony

cant be reversed MUST have SURGERY.

DKA (diabetic keido acidosis)

cause: increase breakdown of fat for energy=ketone production into blood= metabolic acidosis MAIN s/s: HAD Hyperglycemia* (BS 300-800) Dehydration and electrolyte loss Acidosis other s/s: polyuria, polydipsia, ortho BP, weak pulse, N/V, increase RR and pH, fruity breath tx: HIE HYDRATION INSULIN (regular via IV) ELECTROLYTE REPLACEMENT Common in type 1 DM r/t lack of insulin NSG INTV: Monitor BS Monitor renal function and urine output Monitor EKG and electrolyte changes Monitor VS and LOC Resp assess r/t fluid overload

Glomerulonephritis (acute nephritic syndrome)

caused by a strep infection or hx of tonsillitis or strep throat s/s: periorbital and facial edema, hematuria, HTN, pallor, lethargy, Increased BUN, creatinine, and O titer. INTV: Monitor VS, I&O, and daily weight, and COCA of urine. Diet: Low potassium and sodium. Low protein diet. Initiate seizure precaution Fluid restriction

Lyme disease

caused by a tick carried by deer. Can cause neurological disorders. s/s: -flu-like s/s -s/s of meningeal irritation (stiff neck, headache) -Rashes -Fatigue -Achy, stiff, or *swollen joints* -Headaches, dizziness, fever -Night sweats and sleep disturbances -Cognitive decline -Sensitivity to light and vision changes

CKD

causes HTN, cardiovascular problems, DM, obesity. s/s: -elevated BUN and CRE -Anemia -Metabolid acidosis r/t kidney unable to excrete acid or reabsord HCO3 -Low (Ca and Na) -High (phosphorus, K+, Mg) -fluid retention (CHF and edema) -HF -uncontrolled BP Monitor BP and P closely Monitor kidney function Monitor urinary output Monitor I&O Diet: low in protien, phosphorus, Na, and Ca.

Down Syndrome

defect in chromosome 21. s/s: protruding tounge, cardiac problems, crease in palm

Involution of uterus

changes in reproductive organs to return to prepregnancy size and condition.

nephrotic syndrome

characterized by massive proteinuria caused by glomerular damage. s/s: edema r/t low albumin, proteinuria, hypoalbuminemia, high LDL and cholesterol and edema TX: corticosterois, ACE inhibitor, control protienuria NSG INTV: Turn and reposition (risk for impaired skin integrity). TQ2H Monitor VS, I&O, and daily wt Low sodium diet and fluid restriction

Postpartum hemmorage

check lochia flow then VS RX: oxytocin

COPD

chronic obstructive pulmonary disease CAUSE: Cigarette smoking Occupational chemicals & dust Air pollution Infection Genetics (alpha 1 gene) Aging S/S: LUNG DAMAGE Lack of energy Unablity to tolerate activity (SOB) Nutrition poor (r/t wt loss) Gas abnormal (resp.acidosis) Dry or productive cough Accessory muscles used to breath Modification in skin color (pink or cyanosis *blue) Anteraposterior diameter of chest (barrel chest) Get in tripod position to breath (orthpneic position) Extreme dyspnea Other s/s: Sputum production Wheezing/chest tightness Clubbed nails Prolongued expiration Hypoxemia Hypercapnia Polycythemia DX: PFT ABG CBC (WBC *pneumonia risk and H&H) TX: Steroids *monitor BS, wound healing/skin breakdown, infection risk, cushing syndrome, fx risk* Bronchodilators ABT *monitor for C.diff NSG INTV: *-Low flow O2 or (2-3L O2)* -tripod position -pursed lip breathing (eliminate CO2) -CPT -VS -increase fluid intake as tolerated *PREVENTION* No smoking Reduce irritants Increase calorie intake (high fat, low carb) Immunization (flu and pneumococcal)

Hodgkin's disease

chronic, progressive neoplastic disorder of the lymphoid tissue s/s: painless enlargement of the lymph nodes enlarged spleen and liver weight loss fever night sweats DX: PET scan, biopsy, bone marrow examination

Wound cleaning

clean from clean to dirty

CSF

clear, colorless fluid produced by ventricles Content: proteins, glucose, elctrolytes, low # of WBC and no RBC *blockage lead to hydrocephalus Can leak from nose or ear during a head injury *bloody and yellow concentric rings on dressing material, which is known as the halo sign. It also tests positive for glucose. (If head injury and clear fluid is training test for CSF)*

Sputum Specimen

collect before starting antibiotic therapy Collected early morning or after resp tx Rinse mouth prior, take several deep breaths, and deep coughs Transport to lab STAT collect after or during ABT tx for effectiveness of ABT therapy

Von Willebrand Disease

common hereditary disorder, bleeding disorder caused by a deficiency of von Willebrand factor, a "sticky" protein that lines blood vessels and reacts with PLT to form a plug that leads to clot formation s/s: bleeding in the mucosa TX: Desmopressin (DDAVP) (not for pt with CAD r/t induce PLT aggregation and induce MI) Aminocaproic acid is useful in mild forms of mucosal bleeding NSG INTV: Monitor VS/LOC Assess pt for bleeding Assess coag. levels Avoid anticoag meds AVOID razors Avoid frequent injections (IM, IV) Avoid tube placements (foley, suppositories) Admin stool softener to prevent constipation Use soft toothbrush, no flossing Apply pressure for 5min. FALL RISK AND RISK FOR INJURY SAFETY

Fat Embolism

common in long bone, hip, and pelvis fx occurs 12-48 hr post injury s/s: EARLY s/s: decreased LOC or AMS Hypoxia Tachypnea hypotension Tachycardia Pyrexia Adventitous breath sounds (crackles, wheezes) Precordial chest pain Cough Increased pulmonary pressure Increased Temp AMS (restless, confusion) petechial rash on chest PREVENTION: IMMOBILIZE IMMOBILIZE Minimal Fracture manipulation Adequate support for fractured bones during turning and repositioning Adequate balance of fluid and electrolytes Respiratory support O2 high concentrations Report MD of any S/S tx/NSG INTV: Provide O2 IV fluids Monitor VS/LOC Notify MD

Loading dose of Medication

comparatively large dose given at the beginning of treatment to rapidly obtain the therapeutic effect of a drug ex: phenytoin (dilantin) to tx seizures

Strabismus

cover good eye to strengthen weak eye muscle. Surgery correction before 3 years old.

Crepitus

cracking noises

carpal tunnel syndrome

compression of the median nerve as it passes between the ligament and the bones and tendons of the wrist s/s: Pain numbness paresthesia weakness (thumb, index, & middle finger) TX/NSG INTV: Monitor VS Assess pain and admin pain med PRN Ergonomics changes, splint, oral or intrarticular corticosteroids, Surgery

polycythemia vera

condition characterized by too many erythrocytes; blood becomes too thick to flow easily through blood vessels Classification (primary and Secondary s/s: HTN dark and flushed face headache dizziness fatigue blurred vision NSG INTV: Monitor VS/LOC Admin anticoag per order Increase fluid intake Encourage physical activity Removal of blood per orders DVT/PE preventions (anticoag, SCD, fluids) DX: increased CBC HCT >55% RISK: HTN, THROMBUS FORMATION, CVA, MI

amyotrophic lateral sclerosis (ALS)

condition of progressive deterioration of motor nerve cells resulting in total loss of voluntary muscle control S/S:Depending on location of affected motor neurons Progressive muscle weakness Fatigue Twitching/fasciculation Spasticity Difficulty speaking Dyspnea Impaired ability to laugh/cough Atrophy/weakness of extremities and trunk Anal /bladder muscles intact Death r/t infection, resp. failure or aspiration. LOC intact Senses intact except feel/touch DX: based on S/S TX/NSG INTV Monitor VS/LOC mechanical ventilation tube feedings (NG/PEG) tx spacity (baclofen, benzo) Maximize independence ROM (prevent atrophy/contractures) Foot board Energy conservation for family/pt Walker Hand splints Handrails HOB standard (and pre, during, post feeding) AVOID LIQUID and SOFT FOOD DIET (IV fluids) THICKEN LIQUIDS Monitor respiratory status (CPAP, BiPAP, Mechanical ventilation) Communication support via alphabet board, yes or no quest. Breathing exercise Suction PRN CPT - maintain airway SCD/anticoagulant tx r/t risk of DVT/PE HAVE INTUBATION or TRACH SET, AMBU BAG, O2 AT BEDSIDE

Influenza vaccine (CONTRADICTAED IN PT)

contradicted for pt: -Allergic to eggs -Fever of 100.4 or sick in the last 10 days -Polio -Guillain barre syndrome. -Pregnant -Immunosuppressants (steroids) NSG INTV: assess if pt has following condition Assess TEMP prior to administration of med. Usually given IM *pt on steroids should receive flu shot yearly*

ACUTE ASTHMATIC ATTACK (STATUS ASTHMATICUS) *MEDICAL EMERGENCY*

cough wheezing air hunger RESTLESSNESS difficulty breathing MNEUMONIC for treatment: ASTHMA A- ALBUTEROL S- STEROID T- THEOPHYLLINE H- HYDRATION M-ASK O2 A- ANTICHOLENERGIC

ANY CLEAR FLUIDS FROM HEAD OR SPINAL REGION

could be CSF fluid so test fluid for glucose present NOTIFY MD

Paranoia pt

dont whisper or laugh around them because they think you against them.

Mixing Insulin (NPH and Regular)

draw *Clear* before *Cloudy* ex: Regular insulin before Insulin NPH Process: 1. Inject AIR in cloudy first 2. Inject AIR in clear 3. Draw clear 4. Draw cloudy

1. Raise HOB 2. Lay flat or supine

decrease BP increase BP

Chronic disorders

decrease immune system= increased risk of infections A disease last more than 6 months *Acute is less than 6 months

Late deceleration

decrease in FHR after the onset of a uterine contraction and persisting after the contraction ends caused by uteroplacental insufficiency NSG INTV: STOP or LIONS Stop pitcoin infusion Turn mother to *left* side O2: 8-10 L O2 via non re-breather mask Push IV fluids (usually LR) -continue to monitor FHR -continue to monitor mother VS, reassure mother -notify HCP and prep for C-section LIONS Left side IV fluids O2 Notify HCP Stop labor inducing meds

Cardiogenic shock

decreased CO lead to inadequate tissue perfusion. Cause: MI, endstage HF, PE, dysrhythmias s/s: low Bp, cerbral hypoxia, rapid/weak pulse, decreased urinary output, dysrhythmias, tachypnea NSG INTV; insert IV and admin med -Monitor s/s of shock and meds TX (med): Diuretic -Vasodilator -Dopamine -Vasopressors

Aplastic Anemia

decreased or damage to marrow stem cell, replacement of marrow with fat. Caused by T cells attacking bone marrow (can be idiopatic, acquired, congenital) DX: bone marrow biopsy, decreased in all CBC elements TX: bone marrow transplant or immunosuppressants PT ARE AT RISK FOR INFECTION AND BLEEDING (bruising, hemorrhage)

Multiple Sclerosis (MS)

destruction of the myelin sheath on neurons in the CNS and its replacement by plaques of sclerotic (hard) tissue *period of remission and exacerbation s/s: Early: slurred speech and diplopia Demyelinations D iplopia / Depression E ye movement painful (Optic neuritis) M otor: Weakness; spasticity n Y stagmus E levation in temperature (Uhthoff's phenomenon) L hermitte's sign I ntention tremor N europathic pain A taxia T alking is slurred; dysarthria I continence (bladder/bowel) -constipation O veractive bladder (urinary urgency) N umbness (sensory defect) S leepy (fatigue) DX: MRI (primary) TX/ NSG INTV: -beta interferon (decrease disease progression and prevent relapse) -antiinflammatory (solumedrol) -tx ataxia with beta-blocker, gabapentin, benzo -tx spasticity (baclofen, benzo) -catherization PRN -bowel/bladder training -Ascorbic acid and ABT r/t UTI -safety r/t fall risk -monitor VS/LOC/ sensory -rest and physical mobility (ROM) -avoid high temps -verbal communication can become impaired to make important points first Can have periods of exacerbation and remission *exacerbation (trigger) can be caused by infection, immunization, pregnancy, stress, fatigue, and heat, trauma, increase physical activity, surgery*

Indirect Coombs test

detects circulating antibodies against red blood cells (RBCs) and is the "screening" component of the prescription to "type and screen" a client's blood.

EKG or ECG

determine cardiac rhythm, rate, and detect dysrhythmias (dx: MI, injury or infarction) Normal Sinus: 60-100 bpm PQRST noted. PR: 0.12-0.20 QRS: 0.04-0.10

Postpartum Depression

develops 2-4 weeks after delivery Monitor mother for any changes and any verbal messages TX: ECT, antidepressants, psychotherapy SUICIDE RISK *PRIORITY: SAFETY OF WOMEN AND CHILDREN*

Osteomalacia

disease marked by softening of the bone caused by calcium and vitamin D deficiency DX; low CA and phosphate NSG INTV: Monitor site Admin Ca and Vitamin D supplements Provide an high Ca and Vitamin D diet Sunlight exposure Monitor for abnormalities Use of brace and surgery

Dislocation

displacement of a bone from its joint s/s: pain to site Deformity/change of joint Change in length of extremity decreased ROM DX: X-ray TX/NSG INTV: Assess pulse Reduction by MD Monitor for pain Provide comfort *Evaluate neurovascular status q 15 min until stable Protect joint during healing (immobilize) Patient education- immobilization device and injury prevention *Avoid pulling on affected area when mobilizing patient. Passive ROM

Baby with umbilical cord

do not immerse baby in bath until cord is removed from belly button. Diaper the baby below the cord to prevent nercrotic

Kaposi Sarcoma

dx: Punch biopsy of the cutaneous lesions *Common in AIDS pt*

Ketones present in urine

dx: urine test Encourage pt to increase fluid intake to excrete

Circumference burn on legs

elevate above the level of the heart Monitor peripheral pulses CMS check Assess skin Monitor VS

Compartment Syndrome

elevate limb and apply ice ONLY 4-6 hrs to keep the leg or risk amputation. May occur immediately or days Cause: trauma, cast/splints Risk: complication of cast/splints s/s: edema diminished pulse delayed cap refill decrease mobility Cold, pallor skin TX: Fasciotomy may be performed or amputation (severe cases) NSG INTV: EARLY DETECTION TO PREVENTION (prevention of ischemia) CHECK CMS AND 6 P's frequently (neurovascular assessment) Assess pain and location of pain site *NO ELEVATION OF AFFECTED LIMB* REMOVE ANY RESTRICTIVE DEVICES (CAST or bandage) Monitor for s/s of infection Monitor urinary output (r/t muscle damage cause myoglobin to be released and damage to renal tubules) tx: Escarotomy/fasciotomy to relieve pressure with return on pulse.

Endometriosis

endometrial tissue located outside the uterus s/s: pelvic pain abnormal uterine bleeding infertility dyspareuria DX: lap TX: NSAIDS or pain med PO contraceptives Surgery- to remove endometrial tissue

2 lbs of fluid overload (common in CHF pt)

equals 1 liter of fluid *Monitor lung sounds for crackles and monitor for edema in extremities Monitor weight daily at the same time *NEVER give pt IV solution with SALINE NOTIFY MD

Time out SURGERY

everyone verify the correct pt, procedure, purpose, allergies, etc NSG INTV: (on floor) *if amputation: mark extremity and have pt/pt family clarify correct extremity and why

CONNECTION

ex: IF A PT HAS A HEART PROBLEM THEY WILL MOST LIKELY HAVE ANOTHER PROBLEM THAT INVOLVES THE HEART.

Hyperthyroidism (Gave's disease)

excessive amount of thyroid hormone *usually affect women more than men s/s: dry skin, puritis bulging eyes palpitations, rapid pulse hyperactivity, dysrhythmias increased appretite weight loss insomnia heat intolerant NSG INTV: provide post op care Assess VS and LOC Small frequent meals Avoid stimulants (tea, coffee), alcohol Monitor weight tx: thyroidectomy or antithyroid med (if cardiac s/s: beta-blocker)

GOUT

excessive uric acid in the blood and deposit around the joints. It can be acute or chronic Occurs commonly in MALES Cause: hereditary and diet high in purines (ex: steak, shell fish, caviar, and organ meats) dehydration Medication (aspirin, diuretic) Kidney disease (r/t inability to excrete uric acid) S/S: (common in BIG TOE) Redness Swelling at joint site elevated temp sudden onset of pain *may only affect one joint DX: family hx LABS (high uric acid levels) TX/NSG INTV RX: allopurinol (for pt at risk of renal insufficiency) , colchicine, corticosteroids, NSAIDS (acute attacks) Rest inflamed joints Monitor VS/LOC Monitor for Increased uric acid levels. (normal: < 7) Provide a low purine (or preservative) diet (avoid or limit red meats and shellfish) Increase fluid intake to prevent stone formation (kidney stones) Monitor renal function Assess for tophi: Deposits of uric acid on ear cartilage (seen as bumps on lobes)

External fixator

external metal frame attached to open bone fragments to stabilize them. NSG INTV: Monitor VS/LOC Monitor pin sites for s/s of infection Elevation to reduce edema CMS, pin site (drainage COCA) Pin care as prescribed by MD Encourage exercise (isometrics) Pt education, procedure, self-care PT/OT Do not hold extremity by fixator

claustrophobia

extreme or irrational fear of confined places. (common in pt who have to perform a MRI) Sedative may be given

obesity

having an excess amount of body fat Can lead to respiratory issues (sleep apnea, resp. failure, CAD, DM) INTV: lifesyle modification, healthy diet (avoid process food, transfat, sugar) Surgical -bariatric surgery for severe obesity -assess pt pre and post op -complications: hemorrage, bile reflux, dumping syndrome, bowel obstruction, dysphagia

Heat Stroke

failure of heat regulating mechanism of the body s/s: N/V confusion and dizziness extremly high temperature dry and red skin tachycardia tachypnea hypotension TX: REDUCE HIGH TEMP ASAP -ABC and reduce temp within 1hr to 102 -cooling: cool sheets, towel, blanket sponge bath -ice to neck, groin, chest, armpit -immerse in cold water bath NSG INTV: -stabalize VS *avoid hypothermia CPR Check core temp via rectum EKG monitor Assess LOC Assess urinary output Monitor for seizure Lie *flat* with *legs elevated* due to the drop in BP and once flat the BP will increase. COMMON AGES: older pt, young pt, pt on some medication, debilitated pt

Vertex presentation

favorable position

Pulmonary Edema

fluid in the air sacs and bronchioles s/s: dyspnea JVD *pink frothy sputum* coughing chest pain increased RR fatigue sweating increase HR "air hunger" low BP TX: MAD DOG Morphine - causes vasodilation resulting in decreased BP Aminophylline - relaxes airways to make breathing easier Digitalis - improve heart function in pulmonary edema Diuretics (Lasix) - pull excess fluid off Oxygen - improve oxygenation Gases (Blood Gases/ABGs) - assesses respiratory status Nitrates NSG INTV: Elevate HOB to high fowlers Admin O2 Assess lung sounds Monitor respiratory status Admin medication (morphine, diuretic, etc)

Respiratory Alkalosis

pH greater than 7.45 and PaCO2 less than 35 r/t hyperventilation Causes: Anxiety; fear, Pain Fever, sepsis, pregnancy, *thyrotoxicosis (accelerates functions in body) Meds: respiratory stimulants CNS lesions Tx: underlying issue

QID AC HS TID BID

four times a day before meals At bedtime three times a day two times a day

FLAIL CHEST

fracture of 3 or more ribs r/t blunt chest trauma *chest wall lose stability causing resp. distress and impairment s/s: -uneven chest movement during breathing -shallow RR -chest pain DX: CXR TX: MILD: TCDB, Suction, control pain (improve RR) via nerve block *avoid or careful with opioid r/t resp. depression* SEVERE: MECH. VENTILATION,Surgery NSG INTV: Monitor RR Semi-fowler position Provide O2 Monitor ABG *observe for s/s of pulmonary contusion *AVOID ABD. BINDER r/t worsen oxygen/ABG and increase pt pain*

Dry mouth (Xeostomia)

frequent oral care Provide fluids Hard candy Gum *unless contraindicated Saliva substitues

MMR vaccine

given SQ outer aspect of upper arm. Ages 7-18

Rubella vaccine

given at 15 weeks to newborns in the vast's lateralis. But if mother is not immune it is given to her postpartum prior to discharge

Iodine

given post thyroidectomy to: decreased vascularity and thyroid size. Help decrease hemorrhage risk post op thyroidectomy -hyperthyroid pt: iodine kills overactive thyroid cells. *if too much iodine is given it kills thyroid cells and cause pt to become hypothyroidism (tx. levothyroxine)*

erythromycin

given to an neonate after birth as a prophylactic treatment for gonorrhea and chlamydia infection

Vitamin K *shot for babies

given to babies after birth to help with the clotting factor. (prevent hemmorage) Due to the babies lack of intestinal flora (bacteria)

Lactulose

given to pt with hepatic encephalopathy (avoid steak) to help eliminate ammonia in the colon and bacterial growth. (given for elevated ammonia levels. NORMAL: 10-50 mcg so levels >50mcg ) *usually common in liver diseases

Somogyi effect

glucose levels normal or elevated at bedtime then hypoglycemia at 2-3am. Cause: usually by hormone secretions: glucagon, cortisol, and epinephrine -over tx of PM insulin or excessive amount of exercise DX; set 3am alarm and check BS then later in AM for 1-2 weeks. TX: Decrease insulin before bed Snack prior to bedtime (protein)

Chronic Renal Failure

gradual and progressive loss of kidney function, decrease GFR noted over 3 months. *if left untreated can lead to end stage renal disease RISK: DM AKI Drugs (certain ABT, etc) HTN Chronic glomerulonephritis Pyelonephritis s/s: weakness and fatigue seizures bone pain anemia (SOB, fatigue, angina) HTN uremia- an build up of urea (s/s: puritis, mental confusion, headache, lethargic, HTN) N/V DX: decreased GFR, BUN/Creatinine levels increased, creatinine clearance decreased Complication: Hyperkalemia (life-threatening) EKG changes (tall T wave) TX: maintain homeostasis and kidney function Antihypertensives Diuretic Dialysis antiseizure meds Erythropoietin (Epogen) Met. acidosis (tx: Na bicarb) Nutrition: fluid, sodium, potassium, phosphate and protein restriction NSG INTV: -*Daily weight/I and O* -Assess for edema (extremities, JVD, skin turgor) -Assess RR status -Monitor VS -Monitor labs (BUN/Creatinine, electrolytes) -*Monitor EKG r/t potassium levels* -Bed rest

Sinus Tachycardia

greater than 100 (100-150) normal sinus rhythm Cause: stress, shock, blood loss, hyper/hypovolemia, HF, exercise, stimulants,meds. TX: Tx underlying issue Beta-blockers/CCB Catheter ablation

nephrosclerosis

hardening of the kidney arteries r/t chronic HTN s/s: -elevated BUN and CRE -Anemia -Metabolid acidosis r/t kidney unable to excrete acid or reabsord HCO3 -Low (Ca and Na) -High (phosphorus, K+, Mg) -fluid retention (CHF and edema) -HF -uncontrolled BP NSG INTV: Monitor BP and P closely/ VS Monitor kidney function Monitor urinary output Monitor I&O Admin HTN meds

Folic Acid

helps with the prevention of neural tube defection Food that contain folic acid: -organ meats -spinach -broccoli -asparagus -milk -OJ (orange juice)

2 Month old infants

immunizations are given. Except the Hep B which is given 12 hrs after birth

Hypoparathyroidism

inadequate secretion of PTH=hypocalcemia Caused: decrease blood supply and removal of parathyroid gland s/s: PTH Parathesia, positive Trousseu or Chvosteck sign TETANY (muscle weakness, muscle cramps in extremities, bronchospasm, EKG changes) Hypo Ca and High P DX: Trousseau and Chvostek sign, Ca level TX: IV Ca gluconate PO Ca with Vit D Phosphate binders *take after meals Diet: High Ca and low phosphorus NSG INTV: post op care *parathyroidectomy *(MUST HAVE O2, Trach kit, suction at bedside, semi-fowler position)* *Monitor airway and RR* *EKG* Monitor Labs (Ca, P) and dig level Monitor VS and LOC Seizure precaution Encourage food high in Ca

Chronic Venous Insufficiency (CVI)

inadequate venous return over a long period can be r/t DVT* s/s: edema, pain, pigmentation changes (brown) Complication: Venous ulcers, cellulitis, dermatitis TX: -Elevate legs -Avoid prolong sitting or standing -no constrict garments -compression stocking -keep skin clean, dry, and soft

s/s of bleeding (in throat or nose post op)

increase P and RR restlessness frequent swallowing Elevated HOB Provide O2 vomiting bright red blood Monitor VS

DM

increased BS in blood r/t defection in insulin secretion or action RISK FACTORS: *USUALLY TYPE 2 -genetic: TYPE 1 -family hx -obesity -race/ethnicity (blacks/hispanic) -Age over 45 -impaired glucose tolerance -HTN -low HDL -gest. DM or 9lb baby

Anxiety disorder

increased HR, restlessness, and tightness in chest at times tx: drugs: effexor and ativan nsg dx: ineffective coping

Hypervolemia is r/t

increased fluid intake without proper output of fluid Cause: increase Na intake, SIADH, HF, renal failure, initial diuretic use (r/t electrolye loss) S/S: Edema JVD Lung sounds (crackles/rhonchi/wheezing) increase HR shiny skin weight gain SOB cough altered LOC altered urinary output (can be high or low) hypertension increase CVP and pulse pressure DX: specific gravity, electrolyte levels, decrease BUN and H&H Increased aldosterone levels TX: diuretic (loop, thiazide, potassium sparing) low Na diet hypertonic solution (3%) distilled water dialysis increase protein intake NSG INTV: I&O Bed rest Daily weights Monitor electrolyte levels Montior VS/LOC Semi-fowler position TQ2H Low fluid intake and Na diet Assess lungs for crackles Assess extremities for edema (Common in HR and kidney failure pt) *avoid lasix and insulin together r/t risk of cardiac arrest*

Mastitis

infection of the breast Tx: antibiotics, mild analgesics. Breastfeed on unaffected side. Pump and discard on affected side to prevent engorgement. Apply heat Message the area of inflammation to improve milk flow and reduce stasis. Encourage fluids intake Wear a supportive bra Teach proper breast cleaning.

Croup (laryngotracheobronchitis)

infection of the upper airways in children S/S: loud, barking cough resp distress (tachypnea, increase use of muscles, labored breathing) fever hoarse voice irritability and restless diaphoretic TX: ABT, steroids, cough med, pain med RESPIRATORY ISOLATION PRECAUTION INTV: monitor and maintain patent airway RR assessment bed rest and elevated HOB Humidified O2 Encourage fluids as tolerated (IV/PO) *Have resuscitation equipment available and at bedside*

Tuberculosis (TB)

infectious disease caused by Mycobacterium tuberculosis; mainly affects lungs but can affect other organs Risk: TB Risk *T*ight living space (LTC facilities, prison, group homes) *B*elow or at the poverty line *R*efugee (immigrant) *I*mmune system (weak) *S*ubstance abuser (IV) *K*ids under 5 years old due to weak immune system s/s: *may be asymptomatic until active phase fatigue lethargy productive persistant cough (mucopurulent sputum *can be blood streaked) night sweats/chills low-grade fever weight loss/anorexia plueritic chest pain DX: PPD CXR sputum cultures QuantiFERON-TB Gold test *PPD* A TB skin test, read within 48-72 hrs. Done with a TB syringe usually 1ml at a 15 degree angle with needle bevel up. (usually lower forearm) Measure in duration not redness *Positive* -15 mm FOR EVERYONE -10 mm or larger for peds (<4yrs), immigrants, IV drug users, LTC facilities -5 mm for HIV, immunocompromised, transplant, steriod use, older, contact with person with TB, chemo use pt *BCG vaccine can cause a false positive PPD* CXR may be done if PPD is positive. TX: TB drugs for 6 months to a year *review common TB drugs (5) and interventions for each A multidrug therapy NSG INTV: -Initiate airborne precautions (N95, gown, gloves) -Negative pressure room -Isolation for 3 weeks after initiation of drug tx (at home isolation, no visitors, dispose tissue with cough or mucus) -STRICT hand washing -Educate pt to follow med. regimen, cover mouth or nose if cough or sneeze. -Sputum culture every 2-4 weeks after med. treatment -After 3 negative sputum cultures pt is no longer infectious and can return to normal life (work, gym, etc)

epididymitis

inflammation of the epididymis that is frequently caused by the spread of infection from the urethra or the bladder S/S: N/V fever painful scrotum edema NSG INTV: bed rest elevation of the scrotum ice packs, sitz baths analgesics ABT

Osteomyelitis

inflammation of bone, bone marrow, and surrounding soft tissue (can be local or systemic) Cause: -bone biopsy -pressure ulcer or incision -S. Aureus -Direct bone contamination ----surgery, open fracture, traumatic injury (gunshot wound) RISK FACTORS: Poorly malnourished Elderly Obese Children immunocompromise pt chronic disease (DM, RA) corticosteroid use s/s: warmth to area Severe pain in the affected area *bone pain Swelling and redness Fever 103°-104° (may have chills, nausea, and night sweats) General malaise Chronic ulceration of the skin Increased in ESR and WBC (DX) *ESR levels can remain elevated for 3 weeks even after IV ABT tx* TX/NSG INTV: Surgery (implant IV ABT beads then remove) Hyperbaric oxygen system (allow 100% O2 to increase circulation) Bed rest Immobilization IV antibiotics for about 3 to 6 weeks even months *blood culture prior (bone biopsies may be done prior too) Drain in place to drain abcess Assess pain (PRN pain medication) Maintain good alignment Monitor/assess drainage (COCA-color, odor, consistency, amount) monitor kidney and liver function maintain proper nutrition

Infective Endocarditis

inflammation of endothelium that lines heart and cardiac valves. most commonly damages mitral valve, then aortic and tricuspid valves usually caused by bacteria. S/S: PATHOGENS Petechiae Anorexia (flu-like s/s) Tired and weak High fever and HF Osler's nodes: tender, red lesions to hand or feets finGernails changes Embolic events (DVT) Night sweats and new cardiac heart murmur Splenomegaly DX: blood cultures, TEE, EKG, echo TX: IV ABT or antifungal NSG INTV: monitor VS (T) monitor for s/s of embolic events (stroke, PE, MI) monitor for s/s of HF and VS Encourage pt to take full course of ABT or antifungal Educate pt about proper oral care (brush teeth 2-3x daily, dental care q3-6months) Report any fever to HCP ABT prophylaxis prior to any invasive procedures (dental procedures, resp surgery, any oral surgery)

Appendicitis

inflammation of the appendix s/s: RLQ pain -low grade fever -N/V -rebound tenderness -constipation (if suspected NO LAXATIVE or enema r/t perforation risk) -decreased appetite MAIN RISK *PERFORATION= peritonitis (s/s: tachycardia, abd. distention, fever, rapid respiration) DX: CBC (elevated WBC) ABD X-ray U/S CT scan Laparoscopy pregnancy test to r/o ectopic preg. *an sudden absence of pain= appendix rupture* TX: Laparoscopic surgery IV Fluids and ABT therapy NSG INTV: *avoid any warm compress on abdomen or enemas* Elevate HOB Admin pain med Monitor incision sites Monitor VS Encourage ambulation Encourage use of incentive spirometer NG tube to decompress Abd. assessment TEACH pt: -no heavy lifting -follow up apt -incision care per MD order

Osteoarthritis

inflammation of the bone and joint Cause: adv. age, obesity (most common, female, past injury s/s: Pain and swelling of joints after exercise; relieved by rest. Stiffness, inability to flex the joint in the mornings Limitation of joint movement Heberden nodes: nodules on knuckles and fingers Morning stiffness MNEUMONIC (OSTEO) s/s Outgrowths (bony) nodules on knuckles and fingers Sunrise stiffness <30 min Tenderness upon palpation Experience crepitus (joint pain) Only affects joints (weight bearing joints) DX: x-ray, s/s TX/NSG INTV Last resort: arthroplasty Antiinflammatory agents (NSAIDS) Splint joint Rest joint in morning r/t stiffness Monitor VS/LOC Assess joint (movement, function) Provide rest periods Proper nutrition Assess pain and admin pain PRN ROM Teach pt to avoid twisting or wringing motion of hands

Endometritis

inflammation of the inner (lining) of the uterus (endometrium) Risk: prolonged premature ROM C-section Prolonged labor HX of decrease immunity (HIV) TX: Broad specturm ABT NSG INTV: report any s/s of infection TOWREEDA

Gastritis

inflammation of the lining of the stomach cause: H.pylori (common), NSAIDS, alcohol s/s: acute and chronic ACUTE: abd. discomfort -headache -n/v -anorexia -hematemesis, melena *if errosion CHRONIC: abd. discomfort -headache -n/v -belching -anorexia -heartburn -malabsorption of b12 NSG INTV: -ABT tx -Monitor I&O and electrolytes -have small frequent meals -avoid irritants (alcohol, spicy food, smoking) -monitor VS -assess of hemorrage

Meningitis

inflammation of the meninges of the brain and spinal cord s/s: fever initially headache decrease LOC (lethargy) no appeitie stiff neck (nuchal rigidity) Photophobia seizures Rash Positive Brudzinski (flex head and pt flex hip and knee) Positive Kernig (hip flex at 90 degrees) PREVENTION: menigoccocal vaccine, s.pneumoniae vaccine, prophylaxis ABT if exposure to meningitis dx: LP (lumbar puncture) with high protein and low glucose. Cloudy appearance of CSF TX/NSG INTV: Droplet-respiratory isolation/precaution IV Antibiotics- Vancomycin, cephalosporins Dexamethasone (Decadron) Fluid volume expanders- for dehydration & shock Phenytoin (control seizures) Assess/treat increased ICP Assess neuro status, VS, O2 sat. ABG's Mechanical ventilation, maintain airway IV fluids Monitor daily weight, electrolytes, I&O Reduce fever with antipyretics Prevent complications from immobility (PE/DVT, pneumonia) Infection control precautions until 24 H. after ABT tx PLACE PT ON Seizure precaution and fall precaution Have intubation at bedside

Guillain barre syndrome

inflammation of the myelin sheath of peripheral nerves, characterized by rapidly worsening muscle weakness that may lead to temporary paralysis s/s: Ascending muscle weakness and tingling in the feet and legs that spread to the upper body. Paralysis can occur. Increase BP and HR. dysphagia/impaired speech cardiac issues facial muscle weakness SOB slow reflexes bowel and bladder incontinence Fatigue *recovery can take months or years DX: LP to assess CSF fluid TX/NSG INTV: Incentive spirometer to max.resp function and vital capacity Ventilation assistance IV fluids TX: tachycardia and HTN (alpha adrenergic blocking agents -zosin) ASSESS respiratory status ASSESS for DVT/PE (provide prophylaxis ex:lovenox) TQ2H Reduce pt anxiety/EDUCATE PT MONITOR VS/LOC APPLY SCD PASSIVE ROM/AMBULATION TX: mechanical ventilation (controlled ventilation), intubation tray, ECG monitor, and supportive therapy, passive ROM,

Pericarditis

inflammation of the pericardium Cause: MI, cardiac surgery, SLE s/s: *sharp chest pain *worsen during inspiration or lying down* scratchy friction rub fever dyspnea tachycardia DX: TEE to assess for clots EKG/ECHO *EKG shows ST elevation or T wave inversion CT/MRI TX: Bed rest with HOB elevated 45 degrees NSAIDS Steroids Pericarditis ABT *if caused by bacterial NSG INTV: Provide O2 and bed rest *monitor for s/s of cardiac tamponade* and notify HCP monitor EKG/VS Auscultate heart sounds

Tonsillitis

inflammation of the tonsils Cause: viral or bacterial s/s: sore throat dyspnea dysphagia mouth breathing DX: throat culture *most common cause is STREP (if cause is strep monitor the pt for the development of acute glomerulonephritits and RF) TX: ABT (for full course of tx) surgery (tonsillectomy) *if viral treat s/s NSG INTV: soft to liquid diet cool mist vapor warm salt water gargles lozengers

Any adjustment to a benzodiazepine (ex: -zam/pam/lam)

initiate seizure precaution

Insulin administration

injection areas: abdomen, thigh, and hips, upper arm Rotate injection sites and 1.5 inches apart to prevent lipodysatrophy Teach pt not use same site more than once in 2-3 weeks Don't rub site 45-90 degree angle and leave for 5 sec

Subcutaneous injection

injection to the subcutaneous tissue under the skin Assess skin prior to administration 1-3 ml syringe with 23-25 gauge needle CHECK PREVIOUS ROTATION SITE (CHANGE SITES FROM PREVIOUS TO PREVENT LIPOATROPHY) Pinch the skin and insert needle at a 45-90 degree angle (based on body size) Inject med slowly DON'T MASSAGE SITE DOCUMENT

Intradermal

injection under the skin (dermis) 1 ml syringe with 26-27 guage needle Assess skin prior to admin Insert needle with bevel up at a 15 degree angle Give slowly to form a small bleb Withdraw needle and pat site gently (band aid may be used or circle site with marker) DO NOT MASSAGE SITE DOCUMENT

Food introduction of infant

introduce rice cereal due at 6 months

Chemical eye injury

irrigate eye with sterile solution for at least 10 min. THEN assess visual acuity of pt.

Child with infantile eczema

is at risk for developing asthma TX/NSG INTV: use oatmeal and backing soda as bath additives and add bath oil to bath water after the child has soaked.

Vancomycin -mycin

lab test: peaks and troughs (most hospitals just do troughs) Troughs are done 30 min or immediately before the administration of the next dose to be given Causes: nephrotoxicity and ototoxicity PERFORM A HEARING TEST

An hx of cryptorchidism

later in life may develop a testicular torsion

Sinus Bradycardia

less than 60 bpm normal sinus rhythm Cause: athletic person, sleep, vagus nerve, MI, hyperkalemia, thrombus, meds TX: Assess pt, pt may be asymptomatic: monitor VS close and prior trends. *if pt is symptomatic (SOB, chest pain, fatigue, fainting) notify MD med: atropine or external pacemaker if unresolved with meds.

Focal seizure

localized seizure often affecting one limb or finger -s/s: mouth jerk -unintelligibly speech -dizzy, unusual sound, sight, taste NO LOC

"Ineffective response" NCLEX QUESTIONS

look for the abnormal or negative Nothing is absolute: all, never, only, always Never ask 'why'

Hypothyroidism

low level of thyroid hormone Cause: Atrophy of thyroid gland, thyroidectomy, radiation, excess/deficient iodine, lithium. s/s: extreme fatigue hair loss, dry skin hoarseness constipation goiter formation (avoid foods: Brussel sprouts, kohlrabi, turnips, rutabaga, radishes, cabbage, kale, and cauliflower r/t increase growth of goiter and impair thyroid function) menstrual disturbance weight gain intolerant to cold NSG INTV: tx: synthroid Assess cardiac dysfunction Monitor VS and LOC Provide rest period r/t fatigue

Immune system Organs

lymph nodes/vessels* spleen* thymus bone marrow liver* tonsils adenoids skin

Purpose of renal system

maintain body's homeostasis -regular fluids and electrolytes -remove waste -urine formation -control BP -Regulate RBC production *via erythropoietin -Acid-base balance *kidney reabsorb or produce HCO3 to maintain body pH.

Larynx/Bladder Cancer risk

males who smoke and drink -Bladder cancer pt may experience hematuria or bloody urine.

Pain in flank area

may Indication of an kidney infection

Prolactin Oxytocin

milk production milk ejection from the breast (IV or nipple stimulation)

transsphenoidal hypophysectomy

minimally invasive endoscopic surgery that removes pituitary tumors through the nasal cavity via the sphenoid sinus (transsphenoidal) without affecting brain No teeth brushing for 1-2 weeks to heal incision Pt can floss and use mouthwash *small amount of serosanguineous drainagesurrounded by clear fluid on the nasal dressing-NOTIFY HCP*

Postterm baby (over the 40 week)

monitor blood glucose levels r/t macrosomic. Increased risk of hypoglycemia

ICP in newborn

monitor for bulging anterior fontanelle Poor shrill cry Notify RN of s/s.

Iron deficiency anemia

most common type of anemia Cause: Ulcers, gastritis, IBS, GI tumors, menorrhea, chronic alcoholism (all cause blood loss) s/s: fatigue palpitation brittle and ridged nails pica smooth/sore tongue S/S: LOW IRON Lethargic Overexerted easily (SOB) Weird food craving (PICA) Inflammation of tongue (smooth/sore) Reduced hemoglobin levels Observe RBC changes Neuro changes, nail changes (brittle/ridged) TX: consume foods rich in Iron (Organ meats, beans, leafy green veggies, raisins, molasses, chickpeas, peas, lentils) IV infusion Dextran Take Iron PO with citrus fruit/juice or Vit. C, on empty stomach (1 hr before meals or 2 hrs after meals; stools will be dark r/t iron tab.). Dairy products, antacids, food r/t decrease iron absorption. Liquid iron mix with juice and drink through straw r/t stain teeth

DAILY WEIGHTS

most useful and effective method for determining fluid balance

arterial circulation

movement of blood through the arteries sensory issues can develop NEVER ELEVATE

Stool with ova/paracite

must be sent to the lab ASAP because the the ova/paracites will die

Fracture nsg care

neurovascular check *assess every hour for 1st 24hr then frequently 1. pain 2. pulses (distal pulses or use doppler) 3. movement (sensation) 4. color 5. edema Teach pt isometric exercises (ex: straight leg raises and quad setting) s/s of circulatory impairment: numbness, tingling, coolness, decreased CMS, diminished pulses, edema, pallor. *NOTIFY charge nurse or HCP*

Abnormalities on a cardiac monitor

nurse needs to check all telemetry leads to confirm the rhythm (#1), check the clients BP and level of consciousness, and then obtain a stat ECG

Informed consent

obtained for any invasive procedure avoid any form of sedation or drank alcohol prior to sign of consent Patient must have full knowledge of specific procedure by the MD and consent *obtained by MD* Nurse witness signature Nurse make sure pt is signing voluntary and competent to sign CONSENT NOT NEEDED: AN EMERGENCY OR DELAYED PROCEDURE

Check blood glucose in infants

on heel on side not MIDDLE r/t the nerve endings. Normal Level: 40-60 mg *hypoglycemia if BS <40

Glasgow Coma scale (0-15)

only for pt with a head injury *ANY KIND OF HEAD INJURY *ANY HEAD INJURY IMMOBILIZE HEAD AND NECK Highest is a 15 score. Score <8 requires intervention <3= deep coma Assess eye open response Assess motor response Assess verbal response

Normal wound vac or neg pressure dsg

output 300 ml per shift Used for pt with a knee replacement

hyperparathyroidism

over secretion of PTH via gland Cause: high Ca and low P levels, tumor. s/s: apathy bone fx polyuria muscle weakness cardiac dysrhythmias HTN constipation stone formation (in kidney) DX: PTH and Ca level TX: Calcitonin, Lasix, IV fluids, parathyroidectomy (MUST have trach kit, O2, and suction at bedside) Dialysis NSG INTV: Monitor Ca and P level I/O Increase PO or IV fluids (1-2L) r/t risk of calculi formation and flush Ca. (strain urine) Encourage ambulation Safety precaution pt injury risk r/t bone density loss EKG Diet: low Ca and high phosphorus

Respiratory Acidosis

pH is less than 7.35 and PaCO2 is greater than 45 r/t hypoventilation Cause: CNS depression: Medications (ex: opioids) , head injury, spinal cord injury, neuromuscular disease Pulmonary disorders: Atelectasis, pneumonia, pneumothorax, PE TX: O2 and increase ventilation (bag mask) *Tx: underline issue

Metabolic Acidodis

pH is less than 7.35 and bicarb is less than 22. Causes: *Deficit of base*: diarrhea and intestinal fistulas *Excess acid*: renal failure, DKA, anaerobic metabolism, starvation, salicylate intoxication Tx: Medication: Sodium Bicarb Pt underlying condition that cause metabolic acidosis must be tx or corrected.

Metabolic Alkalosis

pH is more than 7.45 and bicarb is greater than 26. *Excess of base*: Ingestion of antacids, excess use of bicarbonate, use of lactate in dialysis *Loss of acid*: Vomiting, gastric suction, excess use of diuretic TX: Acetazolamide (Diamox) and IV admin of acids *Tx underline issue

Fibromyalgia

pain in the fibrous tissues and muscles s/s: pain and muscle ache Cause: stress, trauma, viral infection causes: STIR MAD IF sleep apnea TMJ syndrome IBS Restless leg Memory loss Anxiety Insomnia Fatigue TX/NSG INTV AAA Analgesic (NSAIDS) Antidepressants anticonsulsants (lyrics) listen to pt provide emotional support encourage exercise program (swimming)

Impending death s/s

physical: decreased urine output and more concentrated, edema of the extremities or over sacrum, incontinence, pulse increases and becomes weak or thready, decreased BP, Cheyne-stokes respirations and secretions begins to pool in lungs. *HEARING IS THE LAST TO GO.* Psychosocial: closure with people in saying goodbye. Help pt to find comfort and support. nsg intv: provide pain management, bowel movement, allow family to see pt

Cataract Surgery

place a mydriatic eye drops Wear eye shield at night and eye glass during the day

Prevent SIDS

place infant on side-lying or supine position Common in premature babies

Chest injuries

place pt in fowlers positon provide Oxygen Obtain an ECG to monitor cardiac function. Provide O2 (#1)

W/C for pt with hemiparlesis

place w/c on unaffected side

s/s of rheumatic fever

poly arthritis skin eruptions choria inflammation of the heart (carditis) TX: penicillin

Hypokalemia

potassium level <3.5 Cause: prolonged diuretic, steroid, and ABT use not eating for prolonged period s/s: 7 L's Lethargy Leg cramps Limp leg Lots of urine (polyuria) Lethal dysrhythmias, no chest pain (U waves) Low shallow respiration Low BP and HR *paralytic ileus *if prolonged it impaired ADH and insulin resistance causing osmotic diuresis r/t high BS levels DX: EKG changes (elevated U wave, flat T wave) 24hr urine ABG tx: PO/IV fluids PO/IV potassium Increase K food intake (raisins, bananas, apricots, oranges, beans, potatoes, carrots, organ meat) Cardiac changes: peak p waves, flat T waves, depressed ST segment, and *U waves* NSG INTV: Monitor RR *Must monitor urinary output and renal function prior and during IV K* NO PEE NO K PO K take with food to decrease GI upset *MUST HAVE EKG MONITOR (IV K)* *Never give potassium IV push* Monitor potassium levels Monitor VS/LOC *if Mg levels are low, Mg must be corrected prior to correct K levels* Monitor dig levels for pt on dig (r/t toxicity risk)

cardiac tamponade

pressure on the heart caused by fluid in the pericardial space Cause: blunt or pentrating trauma, pacemaker insertion, cardiac cath s/s: TRIAD -hypotension *narrow pulse pressure -JVD -*distant, muffled heart sounds* chest pain dyspnea tachycardia DX: CXR TX: Pericardiocentesis NSG INTV: ascultate heart sounds Monitor VS Monitor insertion site for infection or bleeding

Mammogram

prior instruct the pt not to put on deoderant or perfume r/t distort imaging.

Vomiting and Diarrhea

priority is replacing fluids and electrolyte that is missing IV fluids Assess for s/s of dehydration (sunken eyes, skin turgor, mucous membranes) Monitor VS/LOC

Pyloric Stenosis

projectile vomiting common in newborns Risk of fluid and electrolyte imbalance

Hypovolemia

prolonged period of inadequate fluid intake Cause: DI, Addison's disease, vomiting, diarrhea, GI suctioning, burn, hemorrhage S/S: acute wt loss sluggish skin turgor oliguria concentrated urine weak, fast plse flat JV increase temp orthostatic hypotension increase RR cool, clammy, pale skin anorexia nausea cramps muscle weakness sunken eyes DX: BUN, H&H, electrolytes, urine specific gravity TX: IV albumin *assess for reaction IV fluids (isotonic and hypotonic)*monitor for fluid overload Blood products NSG INTV: Breath sounds Provide oral care (lip balm, avoid alcohol mouthwash, salt water rinse) Assess labs (H&H, BUN, creatinine), UA Daily wt Monitor VS/LOC I&O (especially urine output) Monitor mucous membrane, skin turgor Encourage PO IV hydration: isotonic (0.9%/LR) to hydrate bloodstream then hypotonic (0.45%) to hydrate cells. (warm)

Baby Postpartum/Immediately after birth

promote skin to skin. provide a quiet environment with no lights. Dry, suction, provide warmth Monitor mother for s/s of infection (usually temp. over 100.4)

Cocaine withdrawal

prone to depression. Monitor the patient for suicidal indications. Suicidal pt have difficult expressing anger to others. Monitor stress. Denial is common.

Hiatal Hernia

protrusion of a part of the stomach upward through the opening in the diaphragm s/s: heartburn, regurgitation, dysphagia, chest pain after eating, belching, reflux, feel full. NSG INTV: -low fat diet -avoid eating 2 hr before bed -avoid tight clothes -elevated HOB -avoid caffeine, alcohol, tobacco -maintain body weight

Wound Eviseration

protrusion of internal organ at incision tx: notify RN or HCP Low fowlers with knee bent Cover with NS gauze Splint incision when coughing Monitor VS

Baker Act

provides individuals who have a mental illness, or who may harm or neglect themselves or others, with an emergency service and temporary detention for psychiatric evaluation and voluntary or involuntary short-term community inpatient treatment. *nursing consideration* -pt must have a 1:1 sitter at bedside - within or post 24hr post baker act pt must be seen by psych.

Breastfeed

q2-3 hr. Stay on breast for 5 min because that is when most of the sucking occurs in the baby. Promote nipple stimulation which will promote breast milk and uterine contraction. Dont take meds prior to breastfeeding ONLY AFTER. Change breast with each feeding. Mother increase intake of 500 kcal. FORMULA FEEDING- 3-4 hrs. Colosterom: kicks in the first 3 days of birth

Protein (contradicted in diet for renal failure pt)

r/t protein breakdown caused the release of cellular potassium into the blood stream but due to kidney failure potassium is unable to be excreted which leads to hyperkalemia. *Hyperkalemia causes dysrhythmias to occur*

Atrial fibrillation

rapid, random, ineffective contractions of the atrium Ventricular rate 120-200 complication: *STROKE, HF*, and low BP Cause: adv. age, CAD, HTN, HF, nicotine s/s: SOB, fatigue, palpitation, AMS (LOC), chest pain or discomfort, hypotension, pulse deficit, weakness, dizziness, syncope, JVD TX: based on cause Unstable pt: electrical cardioversion Acute: IV adenosine *if unresponsive to meds: electrocardioversion, pacemaker, catheter ablation *PT MUST BE ON AN ANTICOAGULANT* TX: ABCD CPR Oxygen Anticoagulants (heparin) Beta-blocker (metroprolol) Cardiovert Digoxin DIET: low sodium and potassium diet

Acute Kidney Injury

rapid-onset disease of the kidneys resulting in a failure to produce urine s/s: oliguria, nonoliguia or anuria lethargic and ill dry skin and mucous membranes headache muscle twitching seizures DX: increased BUN/Creatinine, specific gravity (indicator of fluid volume), EKG changes (r/t hyperkalemia), CT or MRI, renal US Stages: 1. pre-renal: *common* caused by impaired blood flow 2. intra-renal: damage to kidney tubules 3. post renal: caused by obstruction in kidneys DX: BUN/ Creatinine Electrolytes Urine output Phases: 1. initiation 2. oliguria: elevated specific gravity, urinary output <400ml/day, hyperkalemia develops 3. Diuresis: increased urinary output, monitor for s/s of dehydration 4. Recovery: means improved kidney function, labs normalize, increased alertness and no seizures TX: antihypertensives, diuretic, digoxin Nutrition: restrict foods high in potassium (sweet potato, yogurt, juice, bannanas) NSG INTV: monitor F&E levels and tx Monitor EKG/VS Daily weight and I/O Assess for edema (extremities, VS, JVD, I/O) TCDB/TQ2H Prep for dialysis Prevent infection (avoid foley cath) *If hyperkalemia occurs: TX: kayexelate, IV D50 with 10U of reg. insulin, IV Ca gluconate to protect heart

PPD

read within 48-72 hrs. Done with a TB syringe usually 1ml at a 15 degree angle with needle bevel up. (usually lower forearm) Measure in duration not redness *Positive* -15 mm FOR EVERYONE -10 mm or larger for peds (<4yrs), immigrants, IV drug users, LTC facilities -5 mm for HIV, immunocompromised, transplant, steriod use, older, contact with person with TB, chemo use pt *BCG vaccine can cause a false positive CXR may be done if PPD is positive.

Car seat

rear facing until 2 years old or 35-40 lbs

Raynaud's disease

recurrent episodes of pallor and cyanosis primarily in fingers and toes Pt should wear loose, warm clothing to avoid cold temperatures Some pt may move to warmer climates (ex:Florida) but it MAY not be beneficial

Presbycusis

refers to the age-related, irreversible, degenerative changes of the inner ear that lead to decreased hearing acuity. Low-pitched tones of voice are more easily heard and interpreted by the older client

Parathyroid gland (hormones)

regulate Ca and phosphate levels NORMAL LEVELS: Ca: 8.6-10.6 P: 2.5-4.5 if Ca levels low-PTH pulls Ca from small intestine and bones to bloodstream. If Ca levels high- calcitonin pulls Ca from bloodstream to bones

CXR

remove all jewelry and metal objects. Should be preformed after admin of O2 (PRN) and first dose of anitbiotics (if applicable)

Kidney stone

renal calculi Cause: MNEUMONIC: CRYSTAL Consuming food with oxalates, purine, salt, med with Ca Recurrent UTI hYpercalcemia, hYperparathyroidism, hYpercitraturia Structural blockage, stasis of urine Too much acid (gout, dehydration) Acquired Low activity (immobility) s/s: renal/flank pain, hematuria dx: KUB, US, 24hr urine TX: surgery or non surgery *nonsurgery:* Increased PO intake -pain management (ASSESS PAIN (PQRST) and give pain med. -strain urine *ask MD if want to collect kidney stone for examination* *surgery* ex: lithotripsy -use shock wave to shatter stone -INCREASE PO FLUID TO FLUSH OUT FRAGMENT AND PREVENT OBSTRUCTION (1-3L) *strain urine (Ask MD if want stone to lab for analysis)

Hematopiesis

replacement of cells Primary site is bone marrow (pelvis, ribs, stermun)

Opiate side effects

respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, *constipation*, and urinary retention. Antidote: Narcan

ARDS (acute respiratory distress syndrome)

respiratory failure in an adult cause: aspiration, drug overdose, DIC, burn *high mortality s/s: agitation, combativeness productive cough with pinky frothy sputum (pulmonary edema) intercostal retractions/crackles cyanosis refractory hypoxemia r/t atelectasis dyspnea tachycardia, heart palpitations DX: BNP *low* CXR- shows infiltration BD EKG PFT TX: mechanical vent with PEEP Oxygen Frequent ABG NSG INTV: VS/LOC TQ2H ascultate lung sounds Prone position improve oxygenation Eye drop Sedation to decrease O2 use Assess frequenctly

Ménière's disease

results in a degeneration of inner ear structures S/S: hearing loss tinnitus *vertigo* increase in pressure within the inner ear NSG INTV: Have pt change position slowly and get up/turn slowly r/t vertigo PLACE PT ON FALL PRECAUTION Monitor VS/LOC Assess diet pt should be on a low Na diet

TIA

transient ischemic attack (mini stroke) no dead tissue and usually resolve in 24 hours TIME IS ESSENTIAL NSG INTV: Similar to stoke -Monitor VS and neuro status frequently -SAFETY -FALL PRECAUTIONS -Monitor r/t risk of more TIA strokes to occur or an STROKE

Osteoporosis

s/s: *Kyphosis, loss in height *Vertebral collapse *Fractures (hip, wrist) Pathological fractures Chronic pain Constipation, abdominal distention Impairment of balance and respiratory function MNEUMONIC (FRAIL) s/s Fracture (hip, wrist, spine compression) Respiratory issues, rounding of upper back Asymptomatic until fx occurs Inches of height lost (2-3in) kyphosis Lower back, neck, hip pain (chronic) DX: bone scan, labs (Ca/phosphorus) pain that increase with activity and decrease with pain Common in women post menopause r/t decrease estrogen Common in white women TX: Prevent fx weight bearing exercises (climbing stares, jogging, hiking) Ca/Vitamin D supplements Hormone replacement (estrogen, calcitonin) RX: FOSMAX: Remain upright for 30min after medication. Drink a full glass of water with medication Take on empty stomach NO food or drink 30 min after med. NSG INTV: Monitor respiration (TCDB, TQ2H, Incentive spirometer) Safety interventions FALL PRECAUTIONS Handle pt gently Assess pain and admin pain per order PRN Bowel function management

Autonomic Dysreflexia/Hyperreflexia (late phase)

s/s: *Pounding headache* (indication to check BP) profuse sweating nasal congestion flushed skin bradycardia *Peripheral HTN* blurred vision CAUSE: 3 B's *Bladder issue* (UTI, full bladder, kinked foley cath) Bowel (fecal impaction, constipation) Breakdown of skin (pressure, cut, bruise) *others: menstruation, sex, labor NSG INTV -Place client in *Sitting position (or elevate HOB at *90* degrees) first before any other implementation to reduce BP* -Loosen constrictive clothing (socks, scd, etc) -Assess for bladder distention and bowel impaction -Administer antihypertensive meds (may cause stroke MI, seizure) ex:* Hydralazine* Intermittent catherization (bowel and bladder training) Teach pt how to prevent via regular bowel/bladder training, high fiber diet *HAVE CATHETER AND LUBE AT BEDSIDE (to relieve bladder and assess rectum for stool)*

Lower back pain

s/s: Acute or Chronic Radiculopathy/Sciatica abnormal Gait Decreased Spinal Mobility decrease Reflexes (DTR) Motor strength Abnormal Sensation- tingling, numbness Posture Muscle Spasms TX/NSG INTV: surgery is needed based on dx Rest Stress reduction Relaxation Analgesics Heat/cold application per MD order Semi-fowlers with knees flexed Traction/bed rest Back exercises Corsets/braces Teach proper body mechanics

Fractures

s/s: BROKEN Bruising with pain and swelling Reduced movement Odd apperance Krackling sound of bones rubbing together Edema and erythema at site Neurovascular impairment (6P/5P) NSG INTV: Elevate to Decreased edema Comfort measures/pain management Encourage ROM PT Assistive devices D/C planning Follow up with MD Teach pt isometric exercises to improve muscle strength (ex: straight leg raises and quad setting)

SHOCK patient

s/s: Bleeding and Drainage s/s: low BP, increase HR, and pale/diaphoretic skin, restlessness, increased RR, cold and clammy skin, dysrhythmias (may be present) NSG INTV: O2 (2L via NC) Monitor VS/LOC Knees straight *Head slightly elevated with all 4 extremities elevated on pillow to help venous return (modified Trendelenburg)*

Hiatal Hernia in a neonate

s/s: Coughing, wheezing, and short periods of apnea

Thalassemia major (Cooley's anemia)

s/s: Hepatomegaly, protruding teeth, pathological fractures, jaundice, renal failure

Neuroleptic malignant syndrome (NMS) is like S&M

s/s: Hot (hyperpyrexia) Stiff (increased muscle tone) Sweaty (diaphoresis) B/P, pulse, and respirations go up and they start to Drool

Treating a strain/sprain/or swelling of limbs. *recent arm/leg (extremities) cast due to impaired circulation.

s/s: PET Painful ROM Edema Tenderness to joint NSG INTV: IMMOBILIZE RICE R- Rest to promote healing I - Ice cause vasoconstriction which reduce edema C - Compression to help reduce edema to decrease bleeding and edema and provide support E- Elevation to decrease edema CMS assessment Monitor VS/LOC Strain is pulled muscle Sprain is injury to ligament

Folate deficiency anemia

s/s: Smooth/sored/red mouth & tongue pale mucous membranes pallor fatigue headache NO NEURO S/S TX: PO folic acid 1 mg Increase folic acid intake diet

Wernicke encephalopathy

s/s: confabulation ataxia delirium decreased LOC

Child abuse

s/s: conflicting stories about injury from mother and child. Bruises in various stages of healing Poison indigestion/ingestion of unknown chemicals: FIRST thing is to call POISON CONTROL. NURSE OR HCP MUST REPORT ANY S/S of ABUSE

Heart Failure (LEFT SIDE)

s/s: dyspnea, crackles on lung auscultation (wheezing present as well), and a hacking cough, tachycardia, orthopnea, confusion, restlessness, cyanosis, fatigue MNEUMONIC DROWNING Dyspnea Rales (crackles) Orthopnea Weakness Nocturnal dyspnea Increased HR Nagging cough Gaining weight Dx: ECHO, CXR, EKG, *BNP*, BUN, electrolytes, TSH, CBC, U/A, creatinine, cardiac stress test, cardiac catherization. *BNP level >100 indicate HF* TX: based on severity -Medication -decrease NA intake -Limit fluids intake -Daily weight -O2 -Lung sounds *nursing consideration* Auscultate lung sounds Monitor ECG Observe for SE of medications Obtain daily weight monitor lung sounds Monitor serum drug levels (ex. digoxin) Monitor electrolyte levels (especially potassium)

neuroleptic malignant syndrome

s/s: fever, HTN, severe extrapyramidal symptoms, and alteration in consciousness

PTSD

usually occurs with traumatic events from childhood or adult

Carbon Monoxide Poisoning

s/s: flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; N/V, dizziness, tinnitus, vertigo, confusion, drowsiness, *pale to reddish-purple skin*, and tachycardia; seizure and coma; and death assess for cherry-red color to mucous membranes Transport the pt to open air. *Normal carboxyhemoglobin is less than 5%*.

Low plt count

s/s: glum bleed, brusing, petechiae Normal Range: 150-200,000

Body defense Mechanism (IMMUNE)

s/s: heat, swelling, pain Phagocytic immune response - involves WBC (granulocytes and macrophages) which ingest foreign particles and destroy invading agents. Also remove body's own dying or dead cells. Antibody response - B lymphocytes turn into plasma cells to manufacture antibodies. These antibodies are highly specific proteins in blood that attempt to disable invaders. Cellular immune response - T lymphocytes turn into cytotoxic (killer) T cells and attack pathogens.

tonic-clonic seizure (grand mal seizure)

s/s: jerky movement with intense rigidity Epileptic cry tongue injured Incontinent of stool or urine blood on pillow for infant Usually tx with a -pam *see seizure precation

Herniated disk

s/s: lower back pain, Weakness whenraising the big toe and ankle, Numbness and pain in the foot, and Pain radiating down the posterior hip and thigh

Infants with MENINGITIS

s/s: poor or shrill cry (infants) decrease LOC (lethargy) no appeitie fever n/v DX: LP NSG INTV: *Meningitis at 6 months (newborn) may have cerebral palsy IV ABT tx after LP culture sent to lab HOB elevated monitor for s/s of increased ICP Initiate seizure precaution. PREVENTION Recommendation: pneumococcal vaccine at 2 months

Smoke inhalation injury

s/s: resp. distress Tachypnea Tachycardia NSG INTV: Monitor airway and sputum (usually soot). Respiratory assessment of patient. Provide 100% humidified O2 via face-mask

Absence seizure

seizure involving a brief loss of consciousness without motor involvement; previously termed petit mal (little bad) seizure s/s: momentary loss in LOC blank stare NSG INTV: Monitor LOC Document characteristic of seizure Notify MD

BNP

serves as a marker for HF; the higher the level the more sever HF Less than 100 pg/mL

Coitus

sex

STAGES OF GRIEF

shock denial anger bargaining depression acceptance.

Tricyclic antidepressants

side effects are orthostatic hypotention and urinary retention, drynes of mouth, nose, and throat, constipation, blurred vision drug choice: based on age and gender

Depression medication

usually take effect a week after beginning therapy

Boggy uterus

soft uterus= possible hemmorage Message the uterus until firm Monitor mother VS *if message is ineffective notify HCP

GERD (gastroesophageal reflux disease)

solids and fluids return to the mouth from the stomach RISK FACTORS: (sleep apnea, obesity, older age, NG tube) -NSAID use -stress -overeating -excessive fatty food, spicy, citrus, alcohol -med that relax LES S/S: HERD LPN Heartburn Epigastric pain Regurgitation Dry cough *worsen at night Lung/ear infection Problem swallowing (dysphagia) Nausea *pt at risk of aspiration-place on aspiration precaution NSG INTV Assess pt for s/s Encourage low fat diet, avoid caffeine, tobacco, beer, milk, peppermint Maintain proper weight Avoid eating 2-3 hr prior to bed Elevate HOB Encourage small meals

Hearing/Visual impaired

speak in normal tone Face the pt when talking to them Alert pt when approaching Orient pt to enviornment Visual: organize food in clock position so pt able to locate items

Gastric analysis

study of the stomach content to determine the acid content and to detect disorders NSG INTV: -NPO 12 hr prior -avoid gastric meds -no smoking -position with HOB elevated -aspirate stomach contents every 15min for 1 hr. label and send to lab

Panic Attack

sudden onset of intense panic in which multiple physical symptoms of stress occur, often with feelings that one is dying s/s: decreased peripheral vision, feeling of going crazy, tachycardia, palpitations, diaphoretic.

Urinary Diversion: Ileal Conduit

surgical creation of an alternate route for excretion of urine via stoma through abdominal wall NSG INTV: Monitor I&O Monitor VS Monitor stoma and surrounding skin ENCOURAGE FLUID INTAKE *normal: beefy red stoma=good vascular perfusion *NOT NORMAL: purple, black, pule stoma=vascular is compromised NOTIFY MD* *stoma=edematous= obstruction of blood flow NOTIFY MD*

arthrocentesis

surgical puncture to remove fluid from the joint space NSG INTV: sterile dressing compression dressing Ice per MD order rest joint for 24 hours CMS check and 5P check Pain assessment and admin pain med Weight bearing per MD order

bariatric surgery

surgical reduction of gastric capacity to treat morbid obesity by reducing stomach size thus decrease food intake Surgical -bariatric surgery for severe obesity -assess pt pre and post op -complications: hemorrhage, bile reflux, dumping syndrome, bowel obstruction, dysphagia *NEVER INSERT NG TUBE POST OP r/t risk of rupture* NSG INTV: educate pt on diet, limited mobility, gradual exercise DIET ADVANCEMENT: clear liquid to full liquid to soft solid to solid food

N/V during pregnancy

take a cracker PRIOR to getting out of bed in the morning to help reduce s/s.

Fe (iron) supplements

take with Vit C to help with absorbtion (orange juice or tomato juice) Avoid taking: bran, milk, tea, and antacids which decrease absorption

Corticosteroids

taken in the morning because it mimics the body natural release of cortisol Avoid aspirin and OTC med. Cause hyperglycemia, increase risk for infection, LT use can cause osteoporosis

Bell's Palsy

temporary paralysis of the seventh cranial nerve that causes paralysis (muscle weakness) only on the affected side of the face s/s: facial drooping (1/2 face) Numbness (1/2 face) *NO PAIN* speech difficulties increased lacramation pain in face, ear, eye area reduce ability to blink difficulty eating on affected side TX/NSG INTV: Steroids* - reduces inflammation Maintain muscle tone to prevent atrophy Electrical stimulation Heat application per MD order Facial exercise (whistling, blowing out checks, wrinkling forehead) Assess pain level and admin pain med PRN Provide eye care Apply eye shield on affected eye to prevent corneal abrasion lead to blindness Eye drops per order Pt usually recover in 3-5 weeks

Insensible Water Loss

the amount of fluid lost on a daily basis from the lungs, skin, respiratory tract, and water excreted in the feces Ex: increased RR

Peritoneal Dialysis

the lining of the peritoneal cavity acts as the filter to remove waste from the blood NSG INTV: Turn pt from side to side *BEFORE* checking for kinks in tubing Warm dialystate prior to use of dialysis for pt comfort, dilate vessels, and increase urea clearance Elevate HOB Assess tube for any kinks Check level of tube (should be below pt abd.) Monitor VS Assess for s/s of fluid overload Regular insulin for DM pt r/t high glucose solution Assess color of drainage (should be clear or straw color if cloudy indicate infection: Notify HCP and ABT tx) Complicaiton: 1. Peritonitis s/s: cloudy drainage fluid diffuse abd pain rebound tenderness hypotension/tachycardia *s/s of shock DX: C/S TX: ABT 10-14 days via intraperitoneal 2. Bleeding *common after new insertion of cath but if prolonged ask if pt (female) is menstruating DOCUMENT 3. Hyperglycemia (monitor BS levels especially in DM pt)

gynecoid pelvis

the most favorable pelvis for delivery

Hemodialysis

the process by which waste products are filtered directly from the patient's blood Use: AV fistula *common* -joining an artery to a vein surgically (nsg intv: assess for bleeding, encourage exercise extremity, assess for bruit or thrill) *take 2-3 months until able to use Complications: anemia bone pain fx dialysis equilibruim r/t rapid fluid shift (s/s: N/V, decreased LOC, seizure, restless, *headache*) tx: slow down rate and call HCP *s/s should decrease over time with dialysis tx* NSG INTV: Protect AV access (avoid BP, blood draw on extremity) Assess for bruit or thrill Monitor for s/s of hyperkalemia Hold antihypertensives/meds until dialysis is complete r/t hypotension risk Assess and change dressing PRN Ensure pt adhere to dialysis appointments Monitor for s/s of infection

Ventricular fibrillation (V-fib)

the rapid, irregular, and useless contractions of the ventricles Rhythm: no P wave, QRS complex noted. HR: greater than 300 BPM Monitor VS Cause: MI, untx V-tach, electric shock S/S: unresponsive, NO PULSE or RESP TX: CPR/ACLS, O2 *DEFIBRILLATION* (SYNCH OFF) NSG INTV: confirm rhythm prior to defib resume CPR

HIV/AIDS

the virus that causes AIDS, spread through bodily fluids (Blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk, transfusion, sexual contact, infected needle) Life cycle: DNA synthesis - the virus with the enzyme reverse transcriptase* carried within the virus and changes its own RNA into a double stranded DNA structure. DNA carries instructions for viral replication. Virus can't live outside a living host. NEEDS A HOST TO LIVE NSG INTV: Monitor VS/LOC Establish daily routine Use clear, simple terms Oral care Encourage rest and activity Energy conservation TQ2H TCDB, postural drainage, precussion Reduce pressure risk Avoid scratching Avoid adhesive tape Provide skin care Assess and promote bowel pattern Avoid raw food, foods high in fiber, spicy, and hot/cold food Monitor daily weight, I&O, daily intake. Admin antidiarrheal and antiemetics Monitor labs Elevate HOB PRECAUTION: place soiled clothing in plastic bag may experience fatigue so teach pt to conserve energy and have rest periods Have frequently used items within reach at bedside Avoid fatty, stimulant foods (vegetable, fruits, spicy, sweet food, alcohol, caffeine) Have small frequent meals Increase fluid intake Teach pt to use protection (avoid lambskin condoms)

arthroscopy

the visual examination of the internal structure of a joint NSG INTV: compression dressing Ice per MD order elevate joint CMS check and 5P check Pain assessment and admin pain med Weight bearing per MD order

TURP

transurethral resection of the inner portion prostate gland RISKS: bleeding urinary incontinence urethral strictures (s/s: dyruia, strain to urinate, weak urine stream, dripple urine) POSTOP NSG INTV: -monitor for bleeding (red-pink then clear pink within 24hr *normal) Monitor VS Monitor I&O Avoid strain and constipation *use aseptic technique if irrigation ordered.

T-tube

tube placed in the bile duct for drainage into a small pouch (bile bag) on the outside of the body normal drainage post op is 500-1000ml then gradually decrease over few days Assess COCA (color, odor, clarity, amount)

Drains

tubes that provide a means for removing blood and/or bodily fluids from a wound Assess pt for s/s of abnormal Monitor VS and LOC ASSESS and DOCUMENT DRAINAGE: COCA Color Odor Clarity Amount (output) *serosanguineous drainage is usually normal *notify any abnormal drainage to HCP/MD (bright red bleeding, purulent, sanguineous) Sengstaken-bakemore tube (used to tx esophageal varices)- IF RESP. DISTRESS IS NOTED CUT BALLOON PORT. (have scissors near by or at BEDSIDE) Mark tube

Air Embolism

turn pt on left side with HOB flat or tendelenburg Provide O2 Monitor VS Avoid by priming IV line prior to administer of IV fluids

Poison ivy

tx: Take a shower immediately, and lather and rinse several times.

acute nephritic syndrome

type of renal failure with glomerular inflammation Post-infection cause: -strep throat -impetigo (common in children) -virus (HIV) -SLE (lupus) s/s: flank pain, hematuria, edema, protienuria, low albumin (confusion in elderly) DX: increased BUN and CRE, hematuria NSG INTV: Assess renal function - daily weights -HIGH CARB DIET and low Na -monitor VS -Monitor I&O

Prolapsed Cord (umbilical cord)

umbilical cord preceed presenting part cause: ROM NSG INTV: Monitor FHR Use glove hand and life newborn head off cord until MD arrives 8-10L O2 via non-rebreather face mask 18G needle (LR) Knee chest position or Trendelenburg or hips elevated NEVER touch CORD Apply saline soaked guaze to cord to prevent from drying Prep for C-Section

Comatose pt

unarousable - eyes closed to any stimulus (verbal, pain, sensory) NSG INTV: Assess LOC and VS Provide safety Use SCD/Ted hose due to risk of clot development TQ2H r/t risk of pressure ulcer Provide eye care to prevent corneal irritation which can lead to blindness Keep eye moist (artificial tears or med. eye drops)

UA

urinalysis Assess color Clarity Odor pH and specific gravity *urine culture done to identify bacteria for ABT therapy

UTI

urinary tract infection which is an infection in the urinary tract *more common in women r/t shorter urethra RISK FACTORS: Failure to empty bladder Obstruct urine flow *if in male could=prostate Baths Pantyhose Sex Foley cath S/S: dyuria urinary urgency and frequency lower back pain low grade fever hematura confusion *common in elderly NSG INTV: encourage PO fluids (1-3L) Pain management Assess VS, LOC, WBC, and blood cultures *Avoid coffee, tea r/t bladder spasm Educate on prevention

Skeletal Traction

use a overhead trapeze to help the pt to move up and maintain alignment NSG INTV: Assess resp. status (r/t risk of pneumonia) Provide high fiber and fluids to prevent constipation use fx pan Weights hang freely Look for signs of infection PERFORM NEUROVASCULAR ASSESSMENT CMS q1 hr/first 24 hrs then frequenly after Assess pin site at least every 8 hrs for infection signs, report, and follow care order Monitor VS/LOC Monitor pain Firm Mattress Ask MD about turning pt ROM exercises Keep good alignment (check if pain) Check ropes and pulley system Never change setting AT ALL only emergency *NEVER D/C traction without MD order* Monitor for DVT manifest. *Provide preventive measures for DVT (meds as ordered, good hydration, ankle/foot pump exercises q 1-2 hrs as possible) *SEROUS drainage is normal if drainage COCA RISK OF COMPARTMENT SYNDROME CHECK NEUROVASCULAR ASSESSMENT

Slight weakness on specific side of body

use a straight-leg cane

Liquid/PO med admin to infant

use oral syringe and place med in side of mouth If vomits DO NOT readmin wait til the next dose and notify the HCP

ECT

used to tx pt with depression. Tx is successful if pt has a grand mal seizure (tx: benzo -lam/pam/zam) SE: confusion

Amoniasalt

used to wake pt when physically "out of it" and place in specipan to help increase urination if difficulties occur. Used in mother-baby ER situations

Fetal Movement

usually felt 14-16 weeks pregnant Braxton Hicks: are NORMAL during pregnancy

Lochia

vaginal discharge post birth. COLORS OF LOCHIA: rubra-red 0-3 days Serosa-pink 4-7 days Alba- white 7-10 days Monitor saturation of pad *if more than 1 pad saturated within 1 hr, monitor mother VS/LOC and notify HCP

Frostbite

white color of the skin, which is insensitive to touch tx: Rapid and continual rewarming of the toes in a warm-water bath until flushing of the skin occurs *If to the whole body: warm the head and torso first

Admission to ER

with GI bleeding and abnormal liver enzymes think a possible substance abuse

Alcohol withdrawal

withdrawal of prolonged alcohol use Early s/s: elevated VS and agitation s/s: visual and auditory hallucination and tonic clonic seizure, insomia, diaphoresis, tachycardia, incrase bilirubin, tremor NSG INTV: *Initiate seizure precaution (pad side rails, bed in lowest position, call bell within reach)* *EKG/VS (Torsades de pointes is commonly seen on EKG and fatal if no tx)* *monitor Magnesium level* *Mg level tends to decrease r/t increased urination caused by alcohol use causing loss of Mg via excretion Have a PRN order for ATIVAN (or any benzo) Suctioning equipment at bedside PT MUST HAVE AN IV Prone to seizure (given IV magnesium sulfate to prevent) *monitor deep tendon reflex with magnesium sulfate tx Denial is common r/t alcohol use

arthography

x-ray of a joint taken after the injection of a contrast medium into the joint NSG INTV: Check for allergies (iodine/shellfish) Assess renal function rest joing for 12 hours compression dressing