saunder's comprehensive NCLEX review- RN

what should be done for a client receiving PN if the bag of IV solution is empty and the nurse is waiting for the delivery of a new bag of solution from the pharmacy?

a 10% dextrose in water solutions should be infused at prescribed rate to prevent hypoglycemia; the prescribed solution should be obtained ASAP

for peripheral fat emulsion infusions, what size gauge is used?

a 20-21 gauge lumen or cannula is used

precautions with IV administered potassium: #2

a dilution of no more than 1 mEq/ 10 mL of solution is recommended

trachea-innominate artery fistula

a malpositioned tube causes its distal tip to push against the lateral wall of the trachea. Continued pressure causes necrosis and erosion of the innominate artery. this is a medical emergency

a client with a calcium imbalance is at risk for...

a pathological fracture. Move the client carefully and slowly; assist client with ambulation

what is purine

a precursor for uric acid, which forms stones and crystals

positions to ensure safety and comfort: cerebral aneurysm

bed rest is maintained with the head of bed elevated 30 to 45 degrees to prevent pressure on the aneurysm site

precautions with IV administered potassium: #3

before administering and frequently during infusion, rotate and invert the bag to ensure that the potassium is distributed evenly throughout the IV solution

normal BP

below 120/80

catheter bag should be kept

below the level of the bladder

corticosteroids: glucocorticoids

betamethasone cortisone acetate dexamethasone hydrocortisone methlprednisolone prednisolone prednisone triamcinolone

in acid-base balance, the metabolic function indicator is...

bicarbonate ion (HCO3-)

bruit

blowing, swooshing sound heard through the stethoscope over an area of abnormal blood flow

food sources of iron

breads cereals dark green vegetables dried fruits egg yolk legumes liver meats organ meats

a decrease in the serum phosphorus level is accompanied by...

an increase in the serum calcium level (and vise versa)

thrombophlebitis

an inflammation of a vein, often accompanied by clot formation (leg veins are most commonly affected)

how does diabetes and DK lead to metabolic acidosis

an insufficient supply of insulin causes increased fat metabolism, leading to an excess accumulation of ketones or other acids; the bicarbonate then ends up being depleted

positions to ensure safety and comfort: peripheral arterial disease

because swelling can prevent arterial blood flow, clients may be advised to elevate their feet at rest, but they should not raise their feet above the level of the heart because extreme elevation slows arterial blood flow

meds for inflammatory bowel disease: corticosteroids

budesonide prednisone hydrocortisone

how will a head injury or increased intracranial pressure affect respiration?

by depressing the respiratory center in the brain, resulting in shallow respiration or slowed breathing

meds to treat hypercalcemia

cinacalcet hydrochloride doxercaliferol calcitonin paricalcitol

meds for inflammatory bowel disease antimicrobials

ciprofloxacin metronidazole rifaximin clarithomycin

African Americans: description

citizens or residents of the united states who may have origins in any of the black populations in Africa.

why is hypocalcemia a risk with blood transfusion?

citrate in transfused blood binds with calcium and is excreted

why does blood transfusion put clients at risk for citrate toxicity

citrate is the anticoagulant used in blood products. It is metabolized by the liver. it binds with calcium and magnesium causing hypocalcemia and hypomagnesemia. This results in citrate toxicity.

food sources of vitamin C (ascorbic acid)

citrus fruits tomatoes broccoli cabbage

how is the effectiveness of fresh frozen plasma transfusion evaluated?

coagulation studies (particularly prothrombin and partial thromboplastin time) and resolution of hypovolemia

in a metabolic imbalance, there is a _______________ relationship between the pH and the HCO3-

corresponding *metabolic acidosis: pH is decreased; HCO3- is decreased *metabolic alkalosis: pH is elevated; HCO3- is elevated

what are some causes of decreased sodium excretion?

corticosteroids cushing's syndrome renal failure hyperaldosteronism

signs of circulatory overload

cough dyspnea chest pain wheezing headache hypertension tachycardia and bounding pulse distended neck veins

adventitious breath sounds

crackles -fine crackles -medium crackles -course crackles wheeze rhonchi pleural friction rub

when the BP is low, the heart rate is usually...

increased

how does hyperaldosteronism cause metabolic alkalosis?

increased renal tubular reabsorption of sodium occurs, with the resultant loss of hydrogen ions.

hyponatremia: renal assessment findings

increased urinary output

how kidney problems cause metabolic acidosis?

increased waste products of protein metabolism are retained; acids increase, and bicarbonate is unable to maintain acid-base balance

how does an increased level of CO2 or a lower level of O2 affect the respiratory rate?

increases respiratory rate

hypercalcemia: respiratory assessment findings

ineffective respiratory movement as a result of profound skeletal muscle weakness

what is the usual infusion time for PBRCs?

infusion time for 1 unit is usually between 2 and 4 hours

infant play: 4-6 months

initiation of actions and recognition of new experiences

intervention for hyponatremia caused by insufficient intake

instruct client to increase oral sodium intake and inform client about foods to include in their diet

how does severe diarrhea cause metabolic acidosis?

intestinal and pancreatic secretions are normally alkaline; therefore, excessive loss of base leads to acidosis

tracheoesophageal fistula (TEF)

excessive cuff pressure causes erosion of the posterior wall of the trachea. A hole is created between the trachea and the anterior esophagus. the client at highest risk also has a nasogastric tube present

atelectasis

excessive mucus collection, with the collapse of alveolar sacs caused by mucous plugs, infectious drainage, or anesthetic medications, results in ineffective gas exchange

percentage solutions

express the number of grams of the medication per 100 mL of solution. for example, calcium gluconate 10% is 10 g of pure medication per 100 mL of solution

ratio solutions

express the number of grams of the medication per total milliliters of solution (epinephrine 1:1000 is 1 g of pure medication per 1000 mL of solution)

hypernatremia: GI assessment findings

extreme thirst

why shouldn't fat emulsions (lipids) be given to clients with egg allergies

fat emulsions (lipids) contain egg yolk phospholipids

vaccines administered sub Q are given where?

fatty areas in the lateral upper arms and anterior thighs

most client receiving dialysis need to restrict ______________

fluids

lacto-ovo vegetarian diet

follow a food pattern that allows for the consumption of dairy products and eggs

if major surgical procedure was performed, avoid lifting

for 6 weeks nothing over 10 pounds avoid activities with pushing or pulling

what is the expected increase in platelets for each unit of platelets administered?

for each unit of platelets admnistered, an increase of 5000-10000 mm^3 (5-10 x10^9/L) is expected

food sources of vitamin D

fortified milk fish oils cereals

cryoprecipitates are prepared from

fresh frozen plasma

high fiber foods

fruits vegetables whole grain products

foods included in dash diet

fruits vegetables whole grains low-fat dair meat fish poultry nuts beans

long duration

glargine detemir

order for removing PPE

gloves goggles/face shield gown mask/respirator

indications for a low-purine diet

gout kidney stones elevated uric acid levels

order for donning PPE

gown mask or respirator goggles/face shield gloves

food sources of vitamin K

green leafy vegetables cauliflower cabbage

signs of thrombophlebitis

hard and cordlike vein heat, redness, tenderness at site IV infusion sluggish

what does aPTT evaluate?

how well the coagulation sequence is functioning, usually used to monitor effectiveness of heparin therapy, and to screen for coagulation disorders

indications for a low potassium diet

hyperkalemia hypoaldosteronism addison's disease ACE inhibitors immunosuppressive meds potassium retaining diuretics

indications for a high potassium diet

hypokalemia renal tubular acidosis GI losses intracellular shifts potassium losing diuretics antibiotics mineralocorticoid or glucocorticoid excess (resulting from aldosteronism, cushing's syndrome, exogenous corticosteroid use)

it's important to monitor the temp of a post op client because

hypothermia may result from anesthesia, a cool operating room, or exposure of the skin and internal organs during surgery

positions to ensure safety and comfort: sengstaken-blakemore and minnesota tubes

if prescribed (rarely occurs), maintain elevation of the head of the bed to enhance lung expansion and reduce portal blood flow, permitting effective esophagogastric balloon tamponade

positions to ensure safety and comfort: retinal detachment

if the detachment is large, bed rest and bilateral eye patching may be prescribed to minimize eye movement and prevent edema *restrictions in activity and positioning following repair of the detachment depends on the HCP's preference and the surgical procedure performed

how does malnutrition cause metabolic acidosis?

improper metabolism of nutrients causes fat catabolism, leading to an excess buildup of ketones and acids

post op clients can usually return to work

in 6-8 weeks (depending on procedure)

positions to ensure safety and comfort: COPD

in advanced disease, place the client in a sitting position, leaning forward, with the client's arms over several pillows or an overbed table

when is acetaminophen contraindicated?

in clients with hepatic or renal disease, alcoholism hypersensitivity

substances that can affect the client in surgery: antidysrhythmics

reduce cardiac contractility and impair cardiac conduction during anesthesia

can insulins be mixed?

regular and NPH can be mixed draw regular first then NPH (use RN to remember)

short duration: slower acting

regular insulin

what is hematocrit?

represents red blood cell mass and is in important measurement in the presence of anemia or polycythemia

hypermagnesemia: respiratory assessment findings

respiratory insufficiency when the skeletal muscles of respiration are involved

symptoms of hemorrhage and/or shock

restlessness weak and rapid pulse hypotension tachypnea cool, clammy skin reduced urine output

symptoms of hypoxemia

restlessness dyspnea diaphoresis tachycardia hypertension cyanosis low pulse oximetry readings

positions to ensure safety and comfort: gastroesophageal reflux disease

reverse trendelenburg- promotes gastric emptying and prevents esophageal reflux

food sources of chloride

salt

hyperphosphatemia: assessment findings

same as assessment for hypocalcemia

angiotensin II receptor blockers end in

sartan

during transfusion, what should you do if signs of hypocalcemia or hyperkalemia occur?

slow the transfusion and notify the HCP

intervention for citrate toxicity

slowing or stopping infusion to allow citrate metabolism. hypomagnesemia and hypocalcemia are also treated

growth hormones

somatropin norditropin mecasermin

interventions for aspiration

suction as needed assess respiratory rate auscultate lung sounds monitor temp for aspiration pneumonia prepare to obtain a chest radiograph

symptoms of pulmonary embolism

sudden dyspnea sudden sharp chest or upper abdominal pain cyanosis tachycardia drop in BP

foods limited in the dash diet

sugar sweetened foods and beverages red meat added fats

signs of air embolism as complication of IV therapy

tachycardia chest pain dyspnea hypotension cyanosis decreased LOC

in a WBC count, what does a "shift to the left" mean?

that an increased number of immature neutrophils is present in the blood

in a WBC count, what does a "shift to the right" mean?

that cells have more than the usual number of nuclear segments; found in liver disease, down syndrome, and megaloblastic and pernicious anemia

in a wet system, gentle bubbling in the suction control chamber indicates

that there is suction and does not indicate that air is escaping from the pleural space

how does massive transfusion of whole blood cause metabolic alkalosis?

the citrate anticoagulant used for the storage of blood is metabolized to bicarbonate

why should clients receiving multiple units of platelets only be given platelets that match their specific human leukocyte antigen (HLA)?

these clients are at risk for becoming alloimmunized to different platelet antigens

how do high altitudes, chronic cold weather, and exercise affect platelet count?

these situations increase platelet count

how do oral contraceptives affect lipid levels?

they may increase the lipid level

indications for platelet transfusion

thrombocytopenia platelet dysfunctions

how does metabolic alkalosis effect respiration?

to compensate, respiratory rate and depth decrease to conserve CO2

purpose of lavage tubes

to remove toxic substances from the stomach

formula for number of milliliters per hour

total volume in milliliters ÷ number of hours = number of milliliters per hour

formula for infusion time

total volume to infuse ÷ milliliters per hour being infused = infusion time

formula for flow rate

total volume x drop factor ÷ time in min = drops/min

management of tracheal stenosis

tracheal dilation or surgical intervention is used

treatment for somogyi effect

treatment includes a decrease in the client's insulin dose and increase in the bedtime snack, or both

treatment for the dawn phenomenon

treatment requires an increase in the client's insulin dose or a change in the time of insulin administration

what position should the client be in for central line insertion, tubing change, and line removal? what additional instruction should be given in these situations?

trendelenburg or supine instruct client to perform the valsalva maneuver

to avoid aspiration in a vomiting post op client

turn the client to a side lying position; have suctioning equipment available and ready to use

how often should the blood administration set be changed?

with each unit of blood

if the client does not have a urinary catheter, the client is expected to void ...

within 6-8 hours post op (depending on anesthesia) should be at least 200 mL

food sources of vitamin B6 (pyridoxine)

yeast corn meat poultry fish

is crossmatching required for PBRC administration?

yes

does a lipid test require fasting?

yes. instruct client to abstain from food and fluids (except water) for 12-14 hours before test, and to abstain from alcohol for 24 hours before the test.

is crossmatching required for fresh frozen plasma?

yes; Rh compatibility and ABO compatibility are required for the transfusion of plasma products

before surgery, should food be withheld?

yes; withhold solid food and liquids as prescribed to avoid aspiration - usually for 6-8 hours before general anesthesia - approximately 3 hours before surgery with local anesthesia

monitor drainage in the chest tube collection chamber, notify HCP if drainage

is more than 70-100 mL/hour or if drainage becomes bright red or increases suddenly

types of lavage tubes

lavacuator ewald tube

how does excessive vomiting or GI suctioning cause metabolic alkalosis?

leads to an excessive loss of hydrochloric acid

positions to ensure safety and comfort: varicose veins

leg elevation above heart level usually is prescribed; the client also is advised to minimize prolonged sitting or standing during daily activities

positions to ensure safety and comfort: venous insufficiency and leg ulcers

leg elevation usually is prescribed

brain natriuretic peptides

less than 100 pg/mL

total cholesterol

less than 200 mg/dL (<5.2 mmol/L)

autologous blood donation is not an option for clients with....

leukemia or bacteremia

thyroid hormones

levothyroxine sodium liothyronine sodium liotrix thyroid, dessicated

short duration: rapid acting insulins

lispro aspart glulisine

food sources of vitamin A

liver egg yolk whole milk green or orange vegetables fruits

beta blockers end in

lol

substances that can affect the client in surgery: anticonvulsants

long term use of certain anticonvulsants can alter the metabolism of anesthetic agents

unless contraindicated, place post-op clients in what position?

low fowlers; to increase the size of the thorax for lung expansion

function of sodium

maintains osmotic pressure and acid-base balance, and assists in the transmission of nerve impulses

RBCs

male 4.5-6.2 million female 4-5.5 million

iron

male 65-175 female 50-170

hemoglobin

male: 14-18 g/dL (140-180 mmol/L) female: 12-16 g/dL (120-160 mmol/L)

uric acid

male: 4.5-8 mg/dL female: 2.5-6.2 mg/dL gout kidney stones

hematocrit

male: 42%-52% female: 37%-47%

high density lipoproteins (HDL)

male: > 40 mg/dL (>1.04 mmol/L) female: > 50 mg/dL (1.3 mmol/L

indication for fresh frozen plasma

may be used to provide clotting factors or volume expansion

substances that can affect the client in surgery: antidepressants

may lower the blood pressure during anesthesia

airborne precautions: diseases.

measles chicken pox (varicella) disseminated varicella zoster pulmonary or laryngeal tuberculosis.

food sources of vitamin B12 (cobalamin)

meat liver

food sources of niacin

meats poultry fish beans peanuts grains

substances that can affect the client in surgery: anticholinergics

medications with anticholinergic effects increase the potential for confusion, tachycardia, and intestinal hypotonicity and hypomotility

what causes metabolic alkalosis?

metabolic alakalosis results from a dysfunction of metabolism that causes an increased amount of available base solution in the blood or a decrease in available acids in the blood

antithyroid meds

methimazole propylthiouracil potassium iodide strong iodine solution

food sources of vitamin B2 (riboflavin)

milk lean meats fish grains

when caring for a client with a sodium imbalance, monitor...

monitor cardiovascular, respiratory, neuromuscular, cerebral, renal, and gastrointestinal status

management of tracheomalacia

monitor client; no special management is needed unless bleeding or airway problems occur

how does the body tolerate hyperphosphatemia?

most body systems tolerate elevated serum phosphorus levels well

manifestations of metabolic acidosis: neuromuscular

no significant findings

manifestations of respiratory acidosis: GI

no significant findings

in general, should medications be taken with an antactid?

no, because the antacid will affect the aborption of the medication

growth hormone receptor antagonists

octreotide acetate lanreotide pegvisomant

in a respiratory imbalance, you find an _______________ relationship between the pH and the paCO2

opposite *in respiratory acidosis the pH is decreased and the paCO2 is elevated *in respiratory alkalosis the pH is elevated and the paCO2 is decreased

types of endotracheal tubes

orotracheal nasotracheal

intervention for hyponatremia accompanied by fluid volume excess

osmotic diuretics are administered to promote the excretion of water rather than sodium

usual lab value changes: partially compensated respiratory acidosis

pH: decreased HCO3-: increased paO2: usually decreased paCO2: increased potassium: increased

usual lab value changes: uncompensated respiratory acidosis

pH: decreased HCO3-: normal paO2: usually decreased paCO2: increased potassium: increased

usual lab value changes: partially compensated metabolic acidosis

pH: decreased HCO3-:decreased paO2: usually normal (depends on co-conditions) paCO2: decreased potassium: increased

usual lab value changes: uncompensated metabolic acidosis

pH: decreased HCO3-:decreased paO2: usually normal (depends on co-conditions) paCO2: normal potassium: increased

usual lab value changes: partially compensated respiratory alkalosis

pH: increased HCO3-: decreased paO2: usually normal (depends on co-condition) paCO2: decreased potassium: decreased

usual lab value changes: uncompensated metabolic alkalosis

pH: increased HCO3-: increased paO2: usually normal (depends on co-conditions) paCO2: normal potassium: decreased

usual lab value changes: uncompensated respiratory alkalosis

pH: increased HCO3-: normal paO2: usually normal (depends on co-condition) paCO2: decreased potassium: decreased

usual lab value changes: partially compensated metabolic alkalosis

pH: increased HCO3-:increased paO2: usually normal (depends on co-conditions) paCO2: increased potassium: decreased

usual lab value changes: compensated respiratory alkalosis

pH: normal HCO3-: decreased paO2: usually normal (depends on co-conditions) paCO2: decreased potassium: decreased

usual lab value changes: compensated metabolic acidosis

pH: normal HCO3-: decreased paO2: usually normal (depends on co-conditions) paCO2: decreased potassium: increased

usual lab value changes: compensated respiratory acidosis

pH: normal HCO3-: increased paO2: usually decreased paCO2: increased potassium: increased

usual lab value changes: compensated metabolic alkalosis

pH: normal HCO3-:increased paO2: usually normal (depends on co-conditions) paCO2: increased potassium: decreased

postoperative complications 9-12

paralytic ileus wound infection wound dehiscence wound evisceration

in a postoperative client, stridor, wheezing, or a crowing sound may indicate

partial obstruction bronchospasm laryngospasm

what should the nurse do if the chest tube is pulled out of the chest accidentally?

pinch the skin opening together, apply an occlusive sterile dressing, cover the dressing with overlapping pieces of 2 inch tape, and call the HCP immediately

positions to ensure safety and comfort: laryngectomy (radical neck dissection)

place the client in a semi-fowler's or fowler's position to maintain patent airway and minimize edema

positions to ensure safety and comfort: rectal enema and irrigations

place the client in the left sim's position to allow the solution to flow by gravity in the natural direction of the colon

positions to ensure safety and comfort: perineal and vaginal procedures

place the client in the lithotomy position

if client in shock had spinal anesthesia, don't elevate legs higher than

placing them on a pillow; otherwise, the diaphragm muscles could be impaired

how quickly should platelets be administered?

platelets are administered immediately upon receipt from the blood bank and are given rapidly, usually over 15 to 30 minutes

conditions common to crackles

pneumonia heart failure asthma restrictive pulmonary diseases pulmonary edema pulmonary fibrosis

postoperative complications 1-4

pneumonia and atelectasis hypoxemia pulmonary embolism hemorrhage

food sources of vitamin B1 (thiamine)

pork nuts whole-grain cereals legumes

positions to ensure safety and comfort: heart failure and pulmonary edema

position the client upright, preferably with the legs dangling over the side of the bed, to decrease venous return and lung congestion

positions to ensure safety and comfort: mastectomy

position the client with head of the bed elevated at least 30 degrees (semi-fowler's), with the affected arm elevated on a pillow to promote lymphatic fluid return after the removal of axillary lymph nodes

kernig's sign

positive when flexes leg at hip and knee and complains of pain along vertebral column when leg is extended= meningeal irritation

positions to ensure safety and comfort: cataract surgery

postoperatively, elevate the head of the bed (semi-fowler to fowler) and position client on the back or the nonoperative side to prevent edema at the operative site

precautions with IV administered potassium: #7

potassium infusion can cause phlebitis; therefore the nurse should assess the IV site frequently for signs of phlebitis or infiltration. If either occurs, stop infusion immediately

how does nasogastric suctioning put clients at risk for hypokalemia?

potassium rich fluids are lost through GI suctioning

proton pump inhibitors end in

prazole

ace inhibitors end in

pril

how does the menstrual cycle affect body temp?

temp decreases slightly just before ovulation but may increase to 1 degree F above normal during ovulation

preschooler: vital signs

temp: Axillary 97.5 - 98.6 F (36.4 - 37 C) HR: 70-110 beats/min Resp: 16-22 breaths/min BP:average, 95/57 mm Hg

newborn vitals

temp: axillary, 96.8-99 F (36-37.2 C) HR: 120-160 bpm Resp: 30-60 breaths/min BP: 80-90/40-50 mm Hg

1 year old vitals

temp: axillary, 97-99 F (36.1-37.2 C) HR: 90-130 bpm Resp: 20-40 breaths/min BP: 90/56 mm Hg

toddler vital signs

temp: axillary, 97.5-98.6 F (36.4-37 C) HR: 80-120 BPM Resp: 20-30 breaths/min BP: average, 92/55 mm Hg

adolescent's vital signs

temp: oral, 97.5 - 98.6 F (36.4 - 37 C) HR: 55-90 beats/min Resp: 12-20 breaths/min BP: average, 121/70 mm Hg

school-age child vital signs

temp: oral, 97.5 - 98.6 F (36.4 - 37 C) HR: 60-100 beats/min Resp: 18-20 breaths/min BP: average, 107/64 mm Hg

causes of increased sodium excretion

-excessive diaphoresis -diuretics -vomiting -diarrhea -wound drainage -renal disease -decreased secretion of aldosterone

causes of serum sodium dilution

-excessive ingestion/irrigation of/with hypotonic solutions -kidney disease/renal failure -freshwater drowning -syndrome of inappropriate antidiuretic hormone secretion

nursing considerations for ureteral and nephrostomy tubes

1. never clamp the tube 2. maintain patency 3. irrigate only if prescribed by the HCP, using strict aseptic technique; a maximum of 5 mL of sterile NS is instilled slowly and gently 4. if patency cannot be established with prescribed irrigation, notify HCP immediately 5. monitor output closely, < 30 mL/hour or lack of output for more than 15 minutes should be reported immediately

thyroxine, free (FT4)

.8-2.4 ng/dL

types of isotonic solutions

.9% normal saline ringer's lactate solution

aspartate aminotransferase (AST)

0-35 units/L used to evaluated hepatocellular disesase

thyroid-stimulating hormone (thyrotropin)

0.2-5.4 microunits/mL

types of hypotonic solutions

0.45% sodium chloride (normal saline) 0.225 normal saline (1/4 NS) 0.33% NS (1/3 NS)

serum creatinine

0.6-1.3 mg/dL (53-115 micromol/L) renal: elevated levels indicate a slowing of GFR

grading pulses

0: absent 1: weak and diminished (barely palpable) 2: normal (easily palpable) 3: full 4: strong and bounding

strict sodium restricted diet

1 g of sodium per day

each unit of PRBCs increases the hemoglobin level by

1 g/dL

platelet counts are normally evaluated .....

1 hour and 18-24 hours after administration

each kilogram (2.2 lb) of weight gained or lost is equal to

1 liter of fluid retained or lost

the nurse should not administer more than ____________ of medication per subcutaneous injection site

1 mL per subcutaneous injection

once thawed, how quickly are cryoprecipitates administered?

1 unit is administered over 15 to 30 minutes

cryoprecipitates can be stored for

1 year

priority nursing actions for wound evisceration

1. call for help (surgeon and supplies) 2. stay with client (surgeon/supplies come to you) 3. while waiting for help, place in low fowler's with knees bent to prevent abdominal tension on suture 4.instruct client to remain quiet and not cough 5.cover wound with sterile normal saline dressing and keep dressing moist 6. take vitals and monitor for shock 7. prepare for surgery as necessary 8. document

precautions for NG feeding 1-4

1. change the feeding container and tubing every 24 hours or per agency policy 2. do not hang more solution than is required for a four hour period; this prevents bacterial growth 3. check expiration date before administering 4. shake formula well before administering

interventions for esophageal and gastric tubes 1-4

1. check patency and integrity of all balloons before insertion 2. label each lumen 3. place the client in the upright or fowler's position for insertion 4. immediately after insertion, prepare for radiography to verify placement

infant: physical development 1-4

1. height increases by 1 inch per month in the first 6 months, and by 1 year the length has increased by 50% 2. weight is doubled at 5 to 6 months and tripled at 12 months 3. at birth, head circumference is 33 to 35 cm, approximately 2 to 3 cm more than chest circumference 4. by 1-2 years of age, head circumference and chest circumference are equal

extubation steps 1-3

1. hyperoxygenate the client and suction the endotracheal tube and the oral cavity 2. place client in semi-fowler's 3. deflate the cuff; have client inhale and, at peak inspiration, remove the tube, suctioning the airway through the tube while pulling it out

moderate sodium restricted diet

2-3 g of sodium per day

blood must be administered within ___________ to ____________ minutes after being received from the blood bank

20 - 30 minutes

normal bicarbonate value (HCO3-)

21-28 mm Hg

for standard IV fluid and clear liquid IV medications, what gauge is used

22-24 gauge lumen or cannula

atrial natriuretic peptides (ANP)

22-27 pg/mL

nursing considerations for NSAIDs and acetylsalicylic acid 4-6

*NSAIDs can amplify the effects of anticoagulants *hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral hypoglycemic agent *a high risk for toxicity exists if the client is taking ibuprofen concurrently with a calcium channel blocker

possible causes of hypoglycemia as PN complication

*PN abruptly discontinued *too much insulin being administered

additional nursing considerations for PN administration: safety consideration

*PN solutions should be stored under refrigeration and administered within 24 hours from the time they are prepared *remove from fridge .5 to 1 hour before use *solutions that are cloudy or darkened should not be used and should be returned to the pharmacy *additions of substances such as nutrients to PN solutions should be done in the pharmacy and not on the nursing unit *consult with nutritionist frequently

How does yin and yang guide food choices during illness?

*Yin foods are cold *yang foods are hot *eat cold foods with a hot illness and vice versa

End of Life Care: Buddhism

*a Buddha shrine may be placed in room *time for meditation at the shrine is important *may refuse medications that alter their awareness (e.g., opioids) *after death, a monk may recite prayers for 1 hour (need not be done in presence of the body) *organ donation is encouraged as an act of mercy

End of Life Care: Judaism

*a client placed on life support should remain so until death *a dying person should not be left alone (a rabbi's presence is desired) *autopsy and cremation are usually not allowed *people in the Jewish faith generally oppose prolonging life after irreversible brain damage

when checking BP why is it important to select the appropriate cuff size?

*a cuff that is too small will yield a falsely high reading *a cuff that is too large will yield a falsely low reading

INR

*a frequently used test to measure the effects of some anticoagulants *2-3 for standard warfarin therapy *3-4.5 for high dose warfarin therapy

nursing considerations for a high fiber diet

*a high fiber diet provides 20-35 g of dietary fiber daily *volume and weight are added to the stool, speeding the movement of undigested materials through the intestine *increased fiber gradually and provide adequate fluids to reduce side effects: cramps, bloating, diarrhea, dehydration *gas forming foods should be limited

commonly used herbs and health products: Melatonin

*a hormone that regulates sleep *used for insomnia

what does a pulse deficit indicate?

*a lack of peripheral perfusion, because cardiac contractions are ineffective *may indicate cardiac dysrhythmias

End of Life Care: catholic and orthodox

*a priest anoints the sick *sacraments are given before death *some eastern orthodox oppose autopsy and/or cremation

End of Life Care: church of jesus christ of latter day saints (mormons)

*a sacrament may be administered at client's request *may prohibit cremation

indications for a fat-restricted diet

*abdominal pain *steatorrhea *flatulence *diarrhea associated with high intakes of dietary fat *to decrease nutrient losses caused by ingestion of dietary fat in individuals with malabsorption disorders *malabsorption disorders *pancreatitis *gallbladder disease *GI reflux

additional nursing considerations for PN administration: renal/liver studies

*abnormal liver function studies may indicate intolerance to or an excess of fat emulsion or problems with metabolism with glucose and protein *abnormal renal function tests may indicate an excess of amino acids

causes of hypokalemia

*actual total body potassium loss *inadequate intake *movement of potassium from from ECF to ICF *dilution of serum potassium

indications for a renal diet

*acute kidney injury *chronic kidney disease *hemodialysis *peritoneal dialysis

hypophosphatemia interventions 5-8

*administer IV phosphorus slowly because of the risks associated with hyperphosphatemia *assess the renal system before administering phosphorus *move client carefully, and monitor for signs of a pathological fracture *instruct the client to increase dietary intake of phosphorus, while decreasing the intake of calcium

prevention of NG complications: vomiting

*administer feedings slowly and, for bolus feedings, make feeding last for at least 30 minutes *measure abdominal girth *do not allow the feeding bag to empty *do not allow air to enter the tubing *administer the feeding at room temp *elevate HOB *administer anitemetics as prescribed

hypocalcemia interventions 4-6

*administer meds that increase calcium absorption *provide a quiet environment to reduce stimuli *initiate seizure precautions

End of Life Care: Islam 3

*after death, only a same-sex muslim should touch the body, if not possible, non-muslims should wear gloves *some oppose autopsy and/or cremation *organ transplant is permitted for the purpose of saving human life

positions to ensure safety and comfort: abdominal aneurysm resection

*after surgery, limit elevation of the head of bed to 45 degrees to avoid flexion of the graft *the client may be turned from side to side

Native Americans: health risks 1

*alcohol abuse *obesity *heart disease *diabetes mellitus

Seventh-Day Adventist (Church of God)

*alcohol and caffeinated beverages are usually prohibited *many are lacto-ovo vegetarians *those who eat meat avoid pork *overeating is prohibited; 5 to 6 hours between meal without snacking is practiced

dietary preferences: Buddhism

*alcohol is usually prohibited *many are lacto-ovo vegetarians *some eat only fish *some avoid only beef

Pentecostal (Assembly of God) dietary preferences

*alcohol is usually prohibited *no food to which blood has been added *some avoid pork

dietary preferences: Church of Jesus Christ of Latter-day Saints (Mormon)

*alcohol, coffee, and tea are usually prohibited *consumption of meat is limited *the first Sunday of every month is optional for fasting

foods permitted on a soft diet

*all foods and seasonings are permitted; however, liquid, chopped, or pureed foods or regular foods with a soft consistency are tolerated best

general tasks that can be delegated to LPN or LVN

*all tasks a UAP can perform *dressing changes *suctioning *urinary catheterization *medication administration (oral, subQ, IM, and selected piggyback meds) *review of teaching initially taught by RN

Hispanic and Latino Americans: cultural interventions

*allow time for client to discuss treatment options with family members *protect privacy *offer to call clergy *ask permission before touching a child when planning to examine or care for him or her *be flexible regarding time of arrival for appointments and avoid rigidity in scheduling care

colloid solutions

*also called plasma expanders *pull fluid from the interstitial compartment into the vascular compartment *used to increase the vascular volume rapidly, such as in hemorrhage or severe hypovolemia

hypernatremia: CNS assessment findings

*altered cerebral function (most common symptom) *normovolemia/ hypovolemia: agitation, confusion and seizures *hypervolemia: lethargy, stupor, coma

fluid volume excess: neuromuscular assessment findings

*altered level of consciousness *headache *visual disturbances *skeletal muscle weakness *parethesias

medications that increase calcium absorption

*aluminum hydroxide- reduces phosphorus levels, causing the countereffect of increasing calcium levels *vitamin D- aids in the absorption of calcium from the intestinal tract

how is calcium related to hyperphosphatemia?

*an increase in phosphorus is accompanied by a decrease in calcium *the problems that occur in hyperphosphatemia center on the hypocalcemia that results when serum phosphorus levels increase.

manifestations of tracheomalacia

*an increased amount of air is required in the cuff to maintain the seal *a larger tracheostomy tube is required to prevent an air leak at the stoma *food particles are seen in tracheal secretions *the client does not receive the set tidal volume on the ventilator

interventions for chest tube drainage system

*an occlusive sterile dressing is maintained at the insertion site *keep drainage system below the level of the chest *do not strip or milk tube unless specified by HCP *keep a clamp and sterile occlusive dressing at bedside at all times *never clamp chest tube without written RX from HCP *if drainage system cracks or breaks, insert chest tube into a bottle of sterile water, remove the cracked or broken system, and replace it with a new system

manifestations of metabolic alkalosis: GI

*anorexia *nausea *vomiting

commonly used herbs and health products: saw palmetto

*anti-estrogen activity *used for UTIs and benign prostatic hypertrophy

commonly used herbs and health products: aloe

*anti-inflammatory and antimicrobial effect *accelerates wound healing

commonly used herbs and health products: st. johns wart

*antibacterial *antiviral *antidepressant

commonly used herbs and health products: Ginger

*antiemetic; used for nausea and vomiting

commonly used herbs and health products: Garlic

*antioxidant *lowers cholesterol levels

commonly used herbs and health products: milk thistle

*antioxidant *stimulates production of new liver cells *reduces liver inflammation *used for liver and gallbladder disease

commonly used herbs and health products: Ginkgo biloba

*antioxidant *used to improve memory

commonly used herbs and health products: peppermint oil

*antispasmodic *used for irritable bowel syndrome

commonly used herbs and health products: chamomile

*antispasmodic effect *anti-inflammatory effect *mild sedative effect

signs or symptoms of hypoglycemia as PN complication

*anxiety *diaphoresis *hunger *low blood glucose < 70 mg/dL *shakiness *weakness

hypokalemia: neuromuscular assessment findings

*anxiety, lethargy, confusion coma *skeletal muscle weakness, leg cramps *loss of tactile discrimination *paresthesias *deep tendon hyporeflexia

collection of an ABG specimen: steps 7-9

*apply pressure immediately to the puncture site following the blood draw; maintain pressure for 5 minutes (10 minutes if client takes anticoagulants) *appropriately label the specimen and transport it on ice to the laboratory *on the laboratory form, record the client's temp and the type of supplemental O2 that the client is receiving

sings and symptoms of an air embolism as PN complication

*apprehension *chest pain *dyspnea *hypotension *loud churning sound heard over pericardium on auscultation *rapid and weak pulse *respiratory distress

hypotonic solutions

*are more dilute and have a lower osmolality than body fluids *causes water to move into cells by osmosis *should be administered slowly to prevent cellular edema

precautions with IV administered potassium: #8

*asses renal function before administering potassium *monitor intake and output during administration

prevention of hypervolemia as PN complication

*assess client history for risk of hypervolemia *administer PN solution via an electronic infusion device and ensure proper function of the device *never increase the rate of infusion of the device to "catch up" if the infusion gets behind *monitor intake and output *monitor weight daily (ideal weight gain is 1-2 lb per week)

collection of an ABG specimen: steps 4-6

*assess factors that may affect the accuracy of the results, such as changes in O2 settings, suctioning in the last 20 minutes, and client's activities *provide emotional support to the client *assist with the specimen draw; prepare a heparinized syringe (if not already prepackaged)

prevention of hyperglycemia as PN complication

*assess for history of glucose intolerance *assess med history (corticosteroids increase blood glucose) *begin infusion as a slow rate as prescribed (usually 40-60 ml/h) *monitor blood glucose levels *administer regular insulin as prescribed *use strict aseptic technique to prevent infection

prevention of NG complications: diarrhea

*assess for lactose intolerance *use fiber containing feedings *administer feedings slowly and at room temp

African Americans: cultural interventions

*assess the meaning of verbal and nonverbal behavior *be flexible and avoid rigidity in scheduling care *encourage family involvement *alternative modes of healing include herbs, prayer, and laying on of hands practices

prevention of tracheostomy tube obstruction

*assist the client to cough and deep breath *provide humidification and suctioning *clean the inner cannula regularly

examples of conditions causing respiratory acidosis

*asthma *atelectasis *brain trauma *bronchiectasis *bronchitis *CNS depressants *emphysema and COPD *administering high oxygen levels per nasal cannula to clients are CO2 retainers (COPD, emphysema) *hypoventilation *pneumonia *pulmonary edema *pulmonary emboli

special instructions for serum creatinine test

*avoid excessive exercise for 8 hours before test *avoid excessive red meat intake for 24 hours before test

positions to ensure safety and comfort: total hip replacement

*avoid extreme internal and external rotation *avoid adduction; in most cases side-lying is permitted as long as an abduction pillow is in place *maintain abduction when the client is in a supine position or positioned on the nonoperative side *place a wedge (abduction) pillow between the client's legs to maintain abduction; instruct client not to cross legs

Roman Catholic dietary preferences

*avoid meat on ash Wednesday and Fridays on lent *optional fasting during lent season *children, pregnant women, and ill individuals are exempt from fasting

prevention/intervention for hematoma as complication of IV therapy

*avoid piercing posterior wall of vein *do not apply tourniquet to extremity immediately after unsuccessful venipuncture *when discontinuing IV, apply pressure to site for 2-3 minutes and elevate the extremity *if hematoma develops: -elevate extremity -apply pressure and ice as prescribed

what IV gauge is used on small veins

24-25 gauge lumen or cannula

amylase

25-151 units/L level is greatly elevated in pancreatitis

Asian Americans: cultural interventions

*be aware of and respect personal boundaries, and request permission to touch *limit eye contact *avoid gesturing with hands *female clients usually prefer female health care providers (HCP) *clarify responses to questions and expectations of the HCP *be flexible and avoid rigidity in scheduling care *encourage family involvement

endotracheal tubes: interventions

*correct placement is 1-2 cm above the carina and is confirmed via x-ray *assess placement by auscultating both sides of chest while manually ventilating with a resuscitation (Ambu) bag *prevent dislodgment and pulling/tugging; suction, coughing, and speaking place extra stress on the tube and can cause dislodgment *monitor cuff pressures at least every 8 hours -should not exceed 20 mm Hg *minimal leak and occlusive techniques are used for cuff inflation and to check cuff pressure *an Ambu bag must be kept by the bedside at all times

infant skills: 6-7 months

*creeps *sits with support *imitates *exhibits fear of strangers *holds arms out *frequent mood swings *waves "bye-bye"

interventions for circulatory overload as complication of IV therapy

*decrease the flow rate to a minimum (keep the vein open) rate *elevate head of bed *keep client warm *assess lung sounds *assess for edema *notify HCP

manifestations of metabolic acidosis: cardiovascular

*decreased BP *dysrhythmias *warm, flushed skin

manifestations of respiratory acidosis: cardiovascular

*decreased BP *dysrhythmias (related to hypoerkalemia caused by compensation *warm, flush skin

hypocalcemia: cardiovascular assessment findings

*decreased HR *hypotension *diminished peripheral pulses

hypophosphatemia assessment findings: cardiovascular

*decreased contractility and cardiac output *slowed peripheral pulses

hypercalcemia: GI assessment findings

*decreased motility and hypoactive bowel sounds *anorexia *nausea *abdominal distention *constipation

hypokalemia: GI assessment findings

*decreased motility, hypoactive to absent bowel sounds *nausea, vomiting, constipation, abdominal distension *paralytic ileus

hypophosphatemia assessment findings: hematological

*decreased platelet aggregation and increased bleeding *immunosuppression

causes of hyperphosphatemia

*decreased renal excretion resulting from renal insufficiency *tumor lysis syndrome *increased intake of phosphorus, including dietary intake or overuse of phosphate-containing laxatives or enemas *hypoparathyroidism

fluid volume excess: laboratory findings

*decreased serum osmolality *decreased hematocrit *decreased BUN level *decreased serum sodium level *decreased urine specific gravity

causes of hypernatremia

*decreased sodium excretion *increased sodium intake *decreased water intake *increased water loss

manifestations of metabolic acidosis: respiratory

*deep, rapid respirations (kussmaul's respirations)

interventions for iron overload

*deferoxamine, administered IV or subQ, removes accumulated iron via the kidneys -urine turns red as iron is secreted

nursing considerations for a mechanical soft diet

*degree of texture modification depends on individual need, including pureed, mashed, ground, or chopped *foods to avoid: -nuts -dried fruits -raw fruits and vegetables -fried foods -tough, smoked, or salted meats -foods with coarse textures

causes of hemoconcentration

*dehydration *use of lithium *adrenal insufficiency

Hispanic and Latino Americans: social roles 2

*depending on acculturation factors, men are usually wage earners and decision makers, and women are homemakers and caretakers *religion is usually catholicism, but may vary *usually have strong church affiliations *social organizations are strong within the community

analyzing ABG results: step 2

*determine if paCO2 is elevated or decreased -if paCO2 reflects an opposite relationship to the pH, the imbalance is respiratory -if the relationship is not opposite, go to step 3

analyzing ABG results: step 3

*determine if the HCO3- reflects a corresponding relationship with the pH. If so, the imbalance is metabolic

analyzing ABG results: step 1

*determine if the pH is elevated or decreased -elevation reflects alkalosis -decrease reflects acidosis

analyzing ABG results: step 4

*determine level of compensation -normal pH indicates full compensation -for respiratory imbalances, look at HCO3- to determine state of compensation -for metabolic imbalances, look at paCO2 to determine state of compensation

Asian Americans: social roles

*devoted to tradition *large extended families are common *loyalty to family and honor are valued *the family unit is structured an hierarchical *men have the power and authority and men are expected to be obedient *education is viewed as important *religions include Taoism, Buddhism, Confucianism, Shintoism, Hinduism, islam, and Christianity *social organizations are strong within the community

causes of metabolic acidosis

*diabetes or diabetic ketoacidosis *excessive ingestion of acetylsalicylic acid *high fat diet *insufficient metabolism of carbs *malnutrition *renal insufficiency, acute kidney injury, chronic kidney disease *severe diarrhea

metabolic acidosis: interventions in kidney disease

*dialysis may be used to remove protein and waste products, thereby lessening the acidotic state *a diet low in protein and high in calories decreases the amount of protein waste products, which in turn lessens the acidosis

nursing considerations for a high iron diet

*diet includes organ meats, meat, egg yolks, whole wheat products, dark green leafy vegetables, dried fruit, and legumes *concurrent intake of vitamin C with iron foods enhances absorption of iron

manifestations of tracheostomy tube obstruction

*difficulty breathing *noisy respiration *difficulty inserting the suction catheter *thick, dry secretions *unexplained peak pressures if client is on a mechanical ventilator

manifestations of dislodged tracheostomy tube

*difficulty breathing *noisy respiration *restlessness *excessive coughing *audible wheeze or stridor

indications for a soft diet

*difficulty chewing or swallowing *ulcerations of the mouth or gums *oral surgery *broken jaw *plastic surgery of the head or neck *dysphagia *stroke

hypermagnesemia: neuromuscular assessment findings

*diminished or absent deep tendon reflexes *skeletal muscle weakness

End of Life Care: Islam 2

*discussions about death are not usually welcome *stopping medical treatment is against the will of Allah *grief may be expressed by slapping or hitting the body

side and adverse effects of NSAIDs 5-7

*dizziness *tinnitus *pruritis

interventions for thrombophlebitis

*do not irrigate the IV catheter *remove IV device immediately *notify HCP *restart in opposite extremity

positions to ensure safety and comfort: craniotomy

*do not position on site that was operated on because brain has no bony covering at the site *elevate HOB 30-45 degrees *maintain head in midline, neutral position (facilitates venous return from head)

salem sump tube

*double lumen nasogastric tube with an air vent *used for decompression with intermittent continuous suction

manifestations of metabolic acidosis: neurological

*drowsiness *confusion *headache *coma

manifestations of respiratory acidosis: neurological

*drowsiness *disorientation *dizziness *headache *coma

manifestations of metabolic alkalosis: neurological

*drowsiness *dizziness *nervousness *confusion

side and adverse effects of acetylsalicylic acid (aspirin) 4-6

*drowsiness *headaches *vision changes

hypernatremia: integumentary assessment findings

*dry and flushed skin *dry and sticky tongue and mucous membranes *presence or absence of edema, depending on fluid volume changes

dietary preferences: Eastern Orthodox

*during lent, all animal products, including dairy, are forbidden *fasting occurs during Advent *exceptions from fasting: -illness -pregnancy -children may be exempt

positions to ensure safety and comfort: lumbar puncture

*during procedure: lateral position, with the back bowed at the edge of the examining table, knees flexed up to the abdomen, neck flexed so that the chin is resting on the chest *after procedure: supine position for 4-12 hours, as prescribed

nursing considerations for a fat-restricted diet

*clients with malabsorption may also have difficulty tolerating fiber and lactose *vitamin and mineral deficiencies may occur in clients with diarrhea or steatorrhea *a fecal fat test may be prescribed and inidates fat malabsorption with excretion of more than 6 to 8 g of fat per day during the 3 days of specimen collection

nursing considerations for a soft diet

*clients with mouths sores should be served foods at cooler temps *provide plenty of fluids with meals to ease chewing and swallowing *drinking fluids through a straw may be easier (may be contraindicated with dysphagia)

non-urgent conditions

*closed fracture *minor lacerations *sprains *strains *contusions

Hispanic and Latino Americans: personal space preferences

*comfortable in close proximity with family, friends, and acquaintances *very tactile, use embraces and handshakes *value the physical presence of others *politeness and modesty are important

intermittent or cyclic PN

*commonly administered over-night *allows clients requiring PN on a long-term basis to participate in activities of daily living during the day without the inconvenience of an IV bag and pump set *monitor glucose levels closely because of the risk for hypoglycemia due to lack of glucose during non-infusion times

causes of hypertonic dehydration

*conditions that increase fluid loss -excessive perspiration -hyperventilation -ketoacidosis -prolonged fever -diarrhea -early-stage kidney disease -diabetes insipidus

indications for a high fiber (high residue) diet

*constipation *irritable bowel syndrome with the primary symptom is alternating constipation and diarrhea *asymptomatic diverticular disease

Hispanic and Latino Americans: alternative modes of healing

*consultation with lay healers *restoration of balance with hot or cold foods *prayer *religious medals

the nurse must wait 15 - 30 minutes to take an oral temp when the client has recently...

*consumed hot or cold foods or liquids *smoked *chewed gum

types of PN administration

*continuous *intermittent or cyclic

commonly used herbs and health products: dehyroepiandrosterone (DHEA)

*converts to androgens and estrogen *slows effects of aging *used for erectile dysfunction

Native Americans: food preferences

*cornmeal *fish *game *fruits *berries

positions to ensure safety and comfort: liver biopsy

*during procedure: position the client supine, with the right side of the upper abdomen exposed; the client's right arm is raised and extended behind the head and over the left shoulder *after the procedure, assist client into a right lateral position and place a small pillow or folded towel under the puncture site for at least 3 hours or as prescribed

positions to ensure safety and comfort: thoracentesis

*during procedure: to facilitate removal of fluid from the pleural space, position the client sitting on the edge of the bed and leaning over the bedside table with the feet supported on a stool, or lying in bed on the unaffected side with the client in fowler's position *after procedure: position of comfort

positions to ensure safety and comfort: amputation of lower extremity

*during the first 24 hours, elevate the foot of the bed to reduce edema (the residual limb is supported with pillows but not elevated because of the risk of flexion contractures). *if prescribed, position the client in a prone position twice a day for 20-30 minutes to stretch muscles and prevent flexion conractures of the hip

causes of hypotonic overhydration

*early kidney disease *heart failure *syndrome of inappropriate antidiuretic hormone secretion *inadequately controlled IV therapy *replacement of isotonic fluid loss with hypotonic fluids *irrigation of wounds and body cavities with hypotonic fluids

hypernatremia: neuromuscular assessment findings

*early: spontaneous muscle twitches; irregular muscle contractions *late: skeletal muscle weakness; deep tendon reflexes diminished or absent

positions to ensure safety and comfort: increased intracranial pressure

*elevate HOB 30-45 degrees *maintain head in midline, neutral position *avoid extreme hip and neck flexion

interventions for respiratory acidosis 5-8

*encourage hydration to thin secretions *reduce restlessness by improving ventilation rather than by administering meds which further depress respirations *prepare to administer respiratory treatments as prescribed *suction airway as necessary

nursing considerations for a high calorie high protein diet

*encourage nutrient dense, high calorie foods such as whole milk and milk products, peanut butter, nuts and seeds, beef, chicken, pork, and eggs *encourage snacks between meals such as milkshakes, instant breakfasts, and nutritional supplements

how do you assist client experiencing respiratory alkalosis with prescribed breathing techniques and aids

*encourage voluntary holding of the breath if appropriate *provide use of a rebreathing mask as prescribed *provide CO2 breaths as prescribed (rebreathing into a paper bag)

discontinuing PN therapy

*evaluation by nutritionist or pharmacist must be done before PN is discontinued *gradually decrease the flow rate for 1 to 2 hours while increasing oral intake (helps prevent hypoglycemia) *after removal, change dressing daily until insertion site is healed *encourage oral intake *record oral intake, body weight, and lab results of serum electrolyte and glucose levels

possible causes of hypervolemia as PN complication

*excessive fluid administration or administration that is too rapid *renal dysfunction *heart failure *hepatic failure

causes of increased calcium absorption

*excessive oral intake of calcium *excessive oral intake of vitamin D

causes of hyperkalemia

*excessive potassium intake *decreased potassium excretion *movement of potassium from the ICF to the ECF

causes of hypertonic overhydration

*excessive sodium ingestion *rapid infusion of hypertonic saline *excessive sodium bicarbonate therapy

what are some causes of actual total body potassium loss

*excessive use of meds such as diuretics or corticosteroids *increased secretion of aldosterone *vomiting and diarrhea *wound drainage, particularly GI wounds *prolonged nasogastric suction *excessive diaphoresis *renal disease impairing reabsorption of potassium

End of Life Care: Native Americans

*family meetings may be held to make decisions about end-of-life care and the type of treatments that should be pursued *some groups avoid contact with the dying (may prefer to die in the hospital)

End of Life Care: Asian Americans

*family members may make decisions about care and often do not tell the client the diagnosis or prognosis *dying at home may be considered bad luck *organ donations may not be allowed in some groups

examples of conditions that cause respiratory alkalosis

*fever *hyperventilation *hypoxia *hysteria *overventilation by mechanical ventilators *pain

water soluble vitamins

*folic acid *niacin *vitamin b1 (thiamine) *vitamin b2 (riboflavin) *vitamin b6 (pyridoxine) *vitamin b12 (cobalamin) *vitamin C (ascorbic acid)

manifestations of TEF

*food particles are seen in tracheal secretions *increased air in cuff is needed to achieve a seal *increased coughing and choking while eating *client does not receive set tidal volume on the ventilator

foods to be avoided on a soft diet

*foods that contain nuts or seeds *foods that can become easily trapped in the mouth *raw fruits and vegetables *fried foods *whole grains

Asian Americans: personal space preferences

*formal personal space is preferred, except with family and close friends *usually do not touch each other during conversation *for some cultures, touch is unacceptable between members of the opposite sex *the head is considered sacred in some cultures, so it may be disrespectful to touch the head

African Americans: food preferences

*fried foods *chicken *pork *greens such as collard greens *rice *some pregnant women suffer from pica

how does the plasma protein system buffer the ECF?

*functions along with the liver to vary the amount of hydrogen ions in the chemical structure of plasma proteins, which have the ability to attract or release hydrogen ions.

side and adverse effects of acetylsalicylic acid (aspirin) 1-3

*gastric irritation *flushing *tinnitus

side and adverse effects of NSAIDs 1-4

*gastric irritation *hypotension *sodium and water retention *blood dyscrasias

hyponatremia: neuromuscular assessment findings

*generalized skeletal muscle weakness that is worse in the extremities *diminished deep tendon reflexes

metabolic acidosis: interventions in diabetes and DK

*give insulin as prescribed to hasten the movement of glucose into the cells, thereby decreasing the concurrent ketosis *when glucose is being properly metabolized, the body will stop converting fats to glucose *monitor for circulatory collapse caused by polyuria, which may result from the hyperglycemic state; osmotic diuresis may lead to extracellular volume deficit.

prevention of hypoglycemia s PN complication

*gradually decrease PN solution when discontinued *infuse 10% dextrose at same rate as the PN to prevent hypoglycemia for 1-2 hours after the PN solution is discontinued *monitor glucose levels and check the level 1 hour after discontinuing the PN

infant skills: 4-5 months

*grasps objects *switches objects from hands *rolls over for the first time *enjoys social interaction *begins to show memory *aware of unfamiliar surroundings

food sources of folic acid

*green leafy vegetables *liver *beef *fish *legumes *grapefruit *oranges

preschooler: physical development

*grows 2.5-3 inches per year *average height is 37 inches at age 3, 40.5 inches at age 4, and 43 inches at age 5 *gains approximately 5 pounds per year, weighs 40 lbs at age 5 *requires 12 hours of sleep each day *eruption of deciduous teeth is complete

toddler: physical development 4-6

*growth of about 3 inches per year; height of toddler is 34 inches at age 2 *lordosis is noted *typically sleeps through the night and has 1 daytime nap; the daytime nap is normally discontinued at about age 3

Isotonic solutions

*have same osmolality as body fluids *increase extracellular fluid volume *do not enter cells because no osmotic force exists to shift the fluids

Native Americans: health and illness

*health is usually considered a state of harmony between the individual, family, and environment *some believe that illness is caused by supernatural forces and disequilibrium between the person and environment *traditional health and illness beliefs may continue to be observed, including natural and religious folk medicine traditions

Hispanic and Latino Americans: health and illness

*health may be viewed as a reward from God or a result of good luck *some believe that health results from a state of physical and emotional balance *illness may be viewed as a punishment from God *some may adhere to nontraditional health measures such as folk medicine

Asian Americans: health and illness

*health/illness is due to balance/imbalance between yin and yang (positive and neg energy forces) *healthy body viewed as gift from god *illness may also be attributed to prolonged sitting or lying or to overexertion *food preferences include raw fish, rice, and vegetables

toddler: physical development 1-3

*height and weight increase in phases, reflecting growth spurts and lags *head circumference increases about 1 inch between ages 1 and 2; thereafter increase is about 1/2 inch per year until age 5 *weight gain is slower than in infancy; by age 2, the average weight is 22 to 27 pounds (10-12 kg)

primary buffer systems in ECF

*hemoglobin system *plasma protein system *carbonic acid-bicarbonate system *phosphate buffer system

positions to ensure safety and comfort: stroke

*hemorrhagic strokes- elevate HOB 30 degrees *ischemic strokes- HOB is flat *maintain head in midline, neutral position (facilitates venous return from head) *avoid extreme hip and neck flexion

Asian Americans: alternative modes of healing

*herbs *acupuncture *restoration of balance with food *massage *prayers and incense

Native Americans: alternative modes of healing

*herbs *restoration of balance between the person and the universe *consultation with traditional healers

possible causes of hyperglycemia as PN complication

*high concentration of dextrose in PN solution *client receiving solution too quickly *not enough insulin *infection

characteristics of wheezes

*high-pitched, musical, squeaking sound *usually heard during expiration, but may also be heard during inspiration *occurs in small airways

indications for washed red blood cells

*history of allergic transfusion reactions *hematopoietic stem cell transplant

causes of intracellular movement of magnesium

*hyperglycemia *insulin administration *sepsis

causes of intracellular phosphorus shift

*hyperglycemia *respiratory alkalosis

causes of increased bone resorption of calcium

*hyperparathyroidism *hyperthyroidism *malignancy (bone destruction from metastatic tumors) *immobility *use of glucocorticoids

causes of increased phosphorus excretion

*hyperparathyroidism *malignancy *use of magnesium-based or aluminum hydroxide-based antacids

what conditions decrease the ionized fraction of calcium?

*hyperproteinemia *alkalosis *meds such as calcium chelators or binders *acute pancreatitis *hyperphosphatemia *immobility *removal or destruction of the parathyroid gland

Asian Americans: health risks

*hypertension *heart disease *cancer *lactose intolerance *thalassemia

Hispanic and Latino Americans: health risks

*hypertension *heart disease *diabetes mellitus *obesity *lactose intolerance *parasites

indication for sodium restricted diet

*hypertension *heart failure *renal disease *cardiac disease *liver disase

manifestations of respiratory alkalosis: respiratory

*hyperventilation (lungs are unable to compensate when there is a respiratory problem)

manifestations of metabolic alkalosis: respiratory

*hypoventilation (compensatory action by the lungs)

manifestations of respiratory acidosis: respiratory

*hypoventilation with hypoxia

interventions for hypernatremia

*if cause is fluid loss, prepare to administer IV infusions *if cause is inadequate renal secretion of sodium, prepare to administer diuretics that promote sodium loss *restrict sodium and fluid intake as prescribed

positions to ensure safety and comfort: deep vein thrombosis

*if the extremity is red, edematous, and painful, traditional heparin sodium therapy may be initiated. bed rest with leg elevation may also be prescribed *clients receiving low-molecular-weight heparin can usually be out of bed after 24 hours if pain level permits

positions to ensure safety and comfort: cardiac catheterization

*if the femoral vessel was accessed for the procedure, the client is maintained on bed rest for 4-6 hours, the client may turn from side to side *the affected extremity is kept straight and the head is elevated no more than 30 degrees until hemostasis is adequately achieved

positions to ensure safety and comfort: spinal cord injury

*immobilize the client on a spinal back-board, with the head in a neutral position *prevent head flexion, rotation, or extension; immobilize head with a firm, padded cervical collar *logroll the client; no part of the body should be twisted or turned, nor should the client be allowed to assume a sitting position

when should a rectal temp be avoided?

*in cardiac clients *the client who has undergone rectal surgery *the client with diarrhea *fecal impaction *rectal bleeding *clients at risk for bleeding

Amish: health risks

*in general, they have fewer risks for disease because of their lifestyle (manual labor, diet, rare use of tobacco/alcohol) *genetic disorders are a risk because of intermarriage *nonimmunization *sexual abuse of women

vaccines given at 2 months

*inactivated poliovirus vaccine (IPV) *diphtheria, tetanus, acellular pertussis (DTap) vaccine *Haemophilus influenzae type b conjugate vaccine (Hib) *pneumococcal conjugate vaccine (PCV) *rotavirus (RV)

causes of isotonic dehydration

*inadequate intake of fluids and solutes *fluid shifts between compartments *excessive losses of isotonic body fluids

what are some causes of inhibition of calcium absorption from the GI tract?

*inadequate oral intake of calcium *lactose intolerance *malabsorption syndromes such as celiac sprue or Crohn's disease *inadequate intake of vitamin D *end-stage renal disease

causes of isotonic overhydration

*inadequately controlled IV therapy *kidney disease *long term cortosteroid therapy

Amish: cultural interventions

*include husband or father in health care decisions for female members *health care instructions must be given in simple, clear language *teaching should be focused on health implications associated with nonimmunization, intermarriage, and sexual abuse issues

what can clients on a full liquid consume?

*includes clear and opaque liquid foods and those that are liquid at body temp -all clear liquids -plain ice cream -sherbet -breakfast drinks -milk -pudding and custard -soups that are strained -refined cooked cereals -fruit juices -strained vegetable juices

hypercalcemia: cardiovascular assessment findings

*increased HR in early phase *bradycardia that can lead to arrest in late phase *increasing BP *bounding, full peripheral pulses

causes of hypercalcemia

*increased calcium absorption *decreased calcium excretion *increased bone resorption of calcium *hemoconcentration

hypocalcemia: GI assessment findings

*increased gastric motility; hyperactive bowel sounds *cramping, diarrhea

causes of hypermagnesemia

*increased magnesium intake *decreased renal excretion of magnesium as a result of renal insufficiency

hyponatremia: GI assessment findings

*increased motility and hyperactive bowel sounds *nausea *abdominal cramping and diarrhea

fluid volume excess: GI assessment findings

*increased motility in the GI tract *diarrhea *increased body weight *liver enlargement *ascites

hyperkalemia: GI assessment findings

*increased motility, hyperactive bowel sounds *diarrhea

what are some causes of increased water loss?

*increased rate of metabolism, *fever, *hyperventilation, *infection, *excessive diaphoresis, *watery diarrhea, *diabetes insipidus

fluid volume excess: respiratory assessment findings

*increased respiratory rate & shallow respirations *dyspnea *moist crackles

fluid volume deficit: laboratory findings

*increased serum osmolality *increased hematocrit *increased blood urea nitrogen(BUN) level * increased serum sodium level *increased urinary specific gravity

fluid volume excess: renal assessment findings

*increased urine output if kidneys can compensate; decreased output if kidney damage is the cause

commonly used herbs and health products: Ginseng

*increases physical endurance and stamina *used for stress and fatigue

possible causes of pneumothorax as PN complication

*inexact catheter placement resulting in puncture of the pleural space

how quickly should fresh frozen plasma be administered?

*infuse within 2 hours of thawing, while clotting factors are still viable *infuse over a period of 15-30 minutes

continuous PN

*infused continuously over 24 hours *most commonly used in a hospital setting

sources of fluid intake

*ingested water = 1200-1500 mL *ingested food = 800-1100 mL *metabolic oxidation = 300 mL total daily intake = 2300-2900 mL

causes of hypocalcemia

*inhibition of calcium absorption from the GI tract *increased calcium excretion *conditions that decrease the ionized fraction of calcium

respiratory alkalosis: initial assessment findings

*initially, the hyperventilation and respiratory stimulation cause abnormal rapid respiration *in an attempt to compensate, the kidneys excrete excess circulating bicarbonate into the urine

hypomagnesemia interventions 4-7

*initiate seizure precautions *during magnesium administration, monitor for diminished deep tendon reflexes, suggesting hypermagnesemia *oral preparations of magnesium may cause diarrhea and increase magnesium loss *instruct client to increase foods containing magnesium

nasotracheal tubes

*inserted through a nostril; this smaller tube increases resistance and the client's work of breathing *its use is avoided in clients with bleeding disorders *it is more comfortable for the client and the client is unable to manipulate the tube with the tongue

orotracheal tubes

*inserted through the mouth, allows use of a larger diameter tube and reduces the work of breathing *indicated when the client has a nasal obstruction or a predisposition to epitaxis *uncomfortable and can be manipulated by the tongue, causing airway obstruction; an oral airway may be needed to keep the client from biting the tube

causes of hypophosphatemia

*insufficeient phosphorus intake *increased phosphorus excetion *intracellular shift

causes of hypomagnesemia

*insufficient magnesium intake *increased magnesium excretion *intracellular movement of magnesium

nursing considerations for a clear liquid diet

*intended for short term use *by limiting caffeine intake, an upset stomach and sleeplessness may be prevented *the client may consume sugar and salt *dairy products and fruit juices with pulp are not clear liquids

hyperphospatemia interventions

*interventions entail the management of hypocalcemia *administer phosphate-binding meds that increase fecal excretion of phosphorus by binding phosphorus from food in the GI tract *instruct client to avoid phosphate-containing meds, including laxatives and enemas *instruct client to decrease the intake of food that is high in phosphorus *instruct client in medication administration: -take phosphate binding meds -emphasize that they should be taken with or immediately following meals.

when checking BP, avoid applying a cuff to an extremity...

*into which IV fluids are infusing *where an arteriovenous shunt or fistula is present *on the side on which breast or axillary surgery has been performed *that has been traumatized or is diseased

adequate needle length and gauge are as follows:

*intramuscular- 1 inch, 23-25 gauge *sub Q- 5/8 inch, 25 gauge

hypomagnesemia: CNS assessment findings

*irritability *confusion

hypophosphatemia assessment findings: CNS

*irritability *confusion *seizures

hypocalcemia: neuromuscular assessment findings

*irritable skeletal muscles: twitches, cramps, tetany, seizures *painful muscle spasms in the calf or foot during periods of inactivity *paresthesias followed by numbness that may affect the lips, nose, and ears in addition to the limbs *positive Trousseau's and Chvostek's signs *hyperactive deep tendon reflexes *anxiety, irritability

signs of readiness for toilet training

*is able to stay dry for 2 hours *is waking up dry from a nap *is able to sit, squat, and walk *is able to remove clothing *recognizes the urge to defecate or urinate *expresses willingness to please a parent *is able to sit on the toilet for 5-10 minutes without fussing or getting off

what causes respiratory acidosis?

*it is caused by primary defects in the function of the lungs or changes in normal respiratory patterns *any condition that causes an obstruction of the airway or depresses the respiratory system

liquid potassium chloride should be taken with what? why is this?

*juice or another liquid *to mask the unpleasant taste

causes of decreased calcium excretion

*kidney disease/renal failure *use of thiazide diuretics

Amish: Description

*known for simple living, plain dress, and reluctance to adopt modern convenience *Christian religious denominations (Mennonite churches) *cultural beliefs and preferences vary depending on specific amish community

Hispanic and Latino Americans: communication

*languages are primarily English and Spanish *members ted to be verbally expressive, yet confidentiality is important *avoiding eye contact with a person in authority may indicate respect and attentiveness *direct confrontation is usually disrespectful and the expression of negative feelings may be impolite *dramatic body language, such as gestures or facial expressions may be used to express emotion or pain

Asian Americans: communication

*languages include Chinese, Japanese, Korean, Filipino, Vietnamese, and English *silence is valued *eye contact may be considered inappropriate or disrespectful (some cultures see it as a sexual invite) *criticism or disagreement is not expressed verbally *head nodding doesn't always mean agreement *the word "no" may be interpreted as disrespect for others

African Americans: social roles

*large extended family networks are important; older adults are respected *many households are headed by a single female parent *religion and church are sources of strength

manifestations of respiratory alkalosis: neurological

*lethargy *lightheadedness *confusion

preschooler: play 7-9

*likes dress-up clothes, paints, paper, and crayons for creative expression *swimming and sports aid in growth development *puzzles and toys aid with fine motor development

positions to ensure safety and comfort: laminectomy and other vertebral surgery

*logroll the client *when out of bed, the client's back is kept straight (use straight back chair) with feet resting comfortably on the floor

postural abnormalities

*lordosis (swayback): increased lumbar curvature *kyphosis (hunchback): exaggeration of the posterior curvature of the thoracic spine *scoliosis: lateral spine curvature

characteristics of coarse crackles

*low-pitched, bubbling or gurgling sounds *start early in inspiration and extend into the first part of expiration *not cleared by cough

characteristics of rhonchi

*low-pitched, coarse, loud, low snoring sound *usually heard during expiration, but may also be heard during inspiration *coughing may clear

what other regulatory systems exist for hydrogen ion concentration in the blood?

*lungs *kidneys *potassium

hypermagesemia: lab findings

*magnesium level exceeding 2.1 mg/dL ECG changes: -prolonged PR interval -widened QRS complexes

hypomagnesemia: lab findings

*magnesium level less than 1.3 mg/dL *electrocardiographic changes: -tall T waves -depressed ST segments

what are some causes of increased magnesium intake

*magnesium-containing antacids and laxatives *excessive administration of magnesium IV

prevention of TEF

*maintain cuff pressure *monitor the amount of air needed for inflation to detect changes *progress to a deflated or cuffless tube as soon as possible

how does the carbonic acid-birbaronate system buffer the ECF?

*maintains a ratio of 20 parts bicarb to 1 part carbonic acid *carbonic acid concentration is controlled by CO2 excretion by the lungs *kidneys control the bicarb concentration and selectively retain or excrete bicarb in response to body needs

how does hemoglobin system buffer the ECF

*maintains acid-base balance through a chloride shift: for each chloride ion that leaves a red blood cell, a bicarbonate ion enters, and vise versa

prevention of an air embolism as PN complication

*make sure all catheter connections are secured *clamp the catheter when not in use and when changing caps *instruct the client in the valsava maneuver for tubing and cap changes *for tubing and cap changes, place the client in the trendelenburg position (if not contraindicated) with the head turned in the opposite direction of the insertion site; client should hold breath and bear down

causes of insufficient phosphorus intake

*malnutrition and starvation

causes of insufficient magnesium intake

*malnutrition and starvation *vomiting and diarrhea *malabsorption syndrome *celiac disease *crohn's disease

dietary preferences: hinduism

*many are vegetarians *those who eat meat avoid beef and pork *fasting rituals vary *children are not allowed to fast

esophageal and gastric tubes

*may be used to apply pressure against bleeding esophageal veins to control the bleeding when other interventions are not effective or they are contraindicated *not used if the client has ulceration or necrosis of the esophagus or has had previous esophageal surgery because of the risk of rupture

Dietary Kosher laws

*meats allowed include animals that vegetable eaters, cloven-hoofed animals (deer, cattle, goats, sheep), and animals that are ritually slaughtered. *fish that have scales and fins are allowed *meat (including fish) cannot be eaten with dairy

causes of increased magnesium excretion

*medications such as diuretics *chronic alcoholism

common low risk therapies

*meditation *relaxation techniques *imagery *music therapy *massage *touch *laughter and humor *spiritual measures, such as prayer

characteristics of medium crackles

*medium pitched, moist sound *heard halfway through inspiration *not cleared by cough

Native American: social roles

*members are family orientated *basic family unit is the extended family, which often includes persons from several households *grandparents may be viewed as family leaders *elders are honored *children are taught to respect traditions *father usually works outside of home, mother assumes domestic duties

End of Life Care: African Americans

*members discuss issues with spouse or older family members *family is highly valued and is central to care of terminally ill members *open displays of affection are common and expected *prefer to die at home

teaching points for herbs

*moisture sunlight and heat may alter the components of herbal preparations *if surgery is planned, herbs may need to be discontinued 2-3 weeks before surgery

hypomagnesemia interventions 1-3

*monitor cardio, resp, GI, neuromus, and CNS status; place on cardiac monitor *assess for and treat hypocalcemia, which usually accompanies hypomagnesemia *adminster magnesium sulfate by the IV route in sever cases (intramuscual injections cause pain and tissue damage); monitor magnesium levels frequently

interventions for hypokalemia

*monitor cardio, resp, neuro-mus, GI, and renal status *place on cardiac monitor *monitor electrolyte values *administer potassium supplements orally or IV as prescribed *institute safety measures for the client experiencing muscle weakness *potassium-losing diuretic will be replaced for potassium sparing diuretic *teach about foods high in potassium

hypocalcemia interventions: 1-3

*monitor cardio, resp, neuro-mus, and GI status; place on cardiac monitor *administer calcium orally or IV as prescribed *when administering calcium IV, -warm the injection to body temp before administering -administer slowly -monitor for ECG changes -observe for infiltration -monitor for hypercalcemia

hyperkalemia interventions 1-3

*monitor cardio, resp, neuro-musc, renal, and GI status. place on cardiac monitor *discontinue/hold supplements (oral and IV) *initiate K restricted diet

hypophosphatemia interventions 1-4

*monitor cardio, resp, neuromus, CNS, and hematological status *discontinue meds that contribute to the imbalance *administer phosphorus orally along with a vitamin D supplement *prepare to administer phosphorus IV when phosphorus levels fall below 1 mg/dL and when the client experiences critical clinical manifestations

interventions for hypermagnesemia

*monitor cardio, resp, neuromus, and CNS status; place on cardiac monitor *diuretics are prescribed to increase renal excretion of magnesium *IV administered calcium chloride or calcium gluconate may be prescribed to reverse the effects of magnesium on cardiac muscle *instruct to restrict dietary intake of magnesium *instruct to avoid laxatives and antacids containing magnesium

hypercalcemia interventions 1-4

*monitor cardio, resp, neuromus, renal, and GI status; place on cardiac monitor *discontinue IV infusions and oral administration of products containing calcium and/or vitamin D *discontinue thiazide diuretics and replace with diuretics that enhance calcium secretion *administer meds that inhibit calcium resorption from the bone

interventions for respiratory acidosis 9-11

*monitor electrolyte values, particularly the potassium and ABG levels *administer antibiotics for respiratory infection or other meds as prescribed *prepare for endotracheal intubation and mechanical ventilation of CO2 levels rise above 50 mm Hg and if signs of acute respiratory distress are present

additional nursing considerations for PN: labs and blood studies

*monitor electrolyte, albumin, renal and liver function *blood studies for blood chemistry are normally done every other day or 3 times per week *results of blood study are basis for the HCP continuing or changing the PN solution or rate

prevention of pneumothorax as PN complication

*monitor for signs of pneumothorax *obtain a chest x-ray after insertion of the catheter to ensure proper catheter placement *PN is not initiated until correct catheter placement is verified an the absence of pneumothorax is confirmed

interventions for respiratory acidosis 1-4

*monitor for signs of respiratory distress *administer O2 as prescribed *place in semi-fowler's *encourage and assist to turn, cough, and deep-breathe

general interventions for metabolic acidosis 1-3

*monitor for signs of respiratory distress *assess level of consciousness for CNS system depression *monitor intake and output and assist with fluid and electrolyte replacement as prescribed

metabolic alkalosis: interventions 1-3

*monitor for signs of respiratory distress *monitor ABGs and potassium and calcium levels *institute safety precautions

interventions for respiratory alkalosis 1-4

*monitor for signs of respiratory distress *provide emotional support and reassurance *encourage appropriate breathing patterns *assist with breathing techniques and breathing aids as prescribed

interventions for thrombophlebitis

*monitor legs for swelling, inflammation, pain, tenderness, venous distension and cyanosis; notify surgeon if any of these signs are present *elevate the extremity 30 degrees without allowing any pressure on the popliteal area *encourage antiembolism stocking (remove twice a day to wash and inspect legs) *use a sequential compression device as prescribed *encourage early ambulation *do not dangle legs *do not sit in 1 position for extended period of time *administer anticoagulants (heparin, enoxaparin) as prescribed

hypertonic solutions

*more concentrated solutions and have a higher osmolality than body fluids *pulls water from cells into ECF by osmosis

Amish: health and illness

*most will need church (bishop and community) permission to be hospitalized as the community will come together to pay the costs *most likely will not have health insurance *barriers to modern health care include distance, lack of transportation, cost, and language (scientific jargon is not often understood)

hypocalcemia interventions 7-9

*move client carefully, and monitor for signs of a pathological fracture *keep 10% calcium gluconate available for treatment of acute calcium deficit *teach client to identify and consume foods high in calcium

hyperkalemia: neuromuscular assessment findings: early

*muscle twitches *cramps *paresthesias: tingling and burning, followed by numbness in the hands and feet and around the mouth.

dietary preferences: Judaism

*must adhere to dietary kosher laws *24 hour fasting observed during Yom Kippur *pregnant women, children and ill people are exempt from fasting. *during passover, only unleavened bread is eaten

manifestations of metabolic acidosis: GI

*nausea *vomiting *diarrhea *abdominal pain

manifestations of respiratory alkalosis: GI

*nausea *vomiting *epigastric pain

End of Life Care: protestant

*no last rites are provided *prayers are given to offer comfort and support

general tasks that can be delegated to UAP

*noninvasive interventions: -skin care -range of motion exercises -ambulation -grooming -hygiene measures

somogyi effect

*normal or elevated blood glucose levels are present at bedtime; hypoglycemia occurs at about 2 to 3 am, which causes an increase in counterregulatory hormones *by about 7am, in response to the counterregulatory hormones, the blood glucose rebounds significantly to the hyperglycemic range

End of Life Care: Jehovah's Witnesses

*not allowed to receive blood transfusions *believe the soul cannot live after the body has died

hypocalcemia: respiratory assessment findings

*not directly affected; however, respiratory failure or arrest can result from decreased respiratory movement because of muscle tetany or seizures

interventions for septicemia

*notify HCP *obtain blood cultures and cultures of the blood bag *administer oxygen, IV fluids, anitbiotics, vasopressors, and corticosteroids as prescribed

interventions for pneumothorax as PN complication

*notify HCP *prepare to obtain a chest x-ray *small pneumothorax may resolve *larger pneumothorax may require chest tube

interventions for infection as PN complication

*notify HCP *remove catheter *send catheter tip to the laboratory for culture *prepare to obtain blood culture *prepare for antibiotic administration

interventions for pulmonary embolism

*notify surgeon immediately *monitor vital signs *administer oxygen and meds as prescribed

interventions for hypoglycemia as PN complication

*notify the HCP *administer IV dextrose *monitor blood glucose level

interventions for hyperglycemia as PN complication

*notify the HCP *the infusion rate may need to be slowed *monitor blood glucose levels *administer regular insulin as prescribed

Hispanic and Latino Americans: social roles 1

*nuclear family is basic unit; and large extended families are common *extended family is highly regarded *needs of the family take precedence over the needs of the individual

Native Americans: cultural interventions 2

*obtain input from extended family *encourage client to personalize space *in the home, assess for the availability of running water, and modify infection control and hygiene practices as necessary

collection of an ABG specimen: steps 1-3

*obtain vital signs *determine whether the client has an arterial line in place (allows for arterial blood sample w/out further puncture to client) *perform Allen's test to determine the presence of collateral circulation

conditions considered urgent

*open fracture with a distal pulse *large wounds

when administering oral potassium supplements, remember that...

*oral potassium supplements may cause nausea and vomiting *they should not be taken on an empty stomach *abdominal pain, distension, nausea, vomiting, diarrhea, or GI bleeding may indicate need to discontinue

brudzinski's sign

*passive flexion of hip and knee when neck is flexed *indicates meningeal irritation

End of Life Care: Amish

*permit organ donation with the exception of heart transplants (heart is soul of body) *funerals conducted in home: no eulogy, plain casket with no flowers or other displays *women are usually buried in wedding dress *soul moves on to heaven or hell

Native American: personal space preference

*personal space is important *members may lightly touch another person's hand during greeting *massage may be used for the newborn to promote bonding between the infant and mother *some groups may prohibit touching of a dead body

medications that inhibit calcium resorption from the bone

*phosphorus *calcitonin (Calcimar) *bisphosphonates *prostaglandin synthesis inhibitors (acetylaslicylic acid, nonsteroidal antiinflammatory meds)

fluid volume excess: integumentary assessment findings

*pitting edema in dependent areas *pale, cool skin

positions to ensure safety and comfort: thyroidectomy

*place in semi-fowler's to fowler's position to reduce swelling and edema in neck area *support head/neck with sandbags, pillows, or other stabilization devices *avoid neck extension to decrease tension on the suture line

preschooler: play 1-3

*play is cooperative *has imaginary playmates *likes to build and create things, play is simple and imaginative

possible causes of infection as PN complication

*poor aseptic technique *catheter contamination *contamination of solution

dietary preferences: Islam

*pork is forbidden *birds of prey are forbidden *meat must be ritually slaughtered *during month of Ramadan, fasting occurs during the day (pregnant women are excluded)

most salt substitutes contain _______________ and should not be used by clients with _________________ __________________.

*potassium *renal disease

precautions with IV administered potassium: #1

*potassium is never administered by IV push, intramuscular, or subcutaneous routes. *IV potassium is always diluted and administered using an infusion device

hyperkalemia: lab findings

*potassium level exceeding 5.0 *electrocardiographic changes: -tall peaked T waves -flat P waves -widened QRS complex -prolonged PR interval

what are some causes of decreased potassium excretion?

*potassium sparing diuretics *kidney disease/renal failure *adrenal insufficiency (addison's disease)

End of Life Care: Hinduism

*pre-death rituals include -tying a thread around the neck or wrist of dying person -sprinkling person with special water -placing a basil leaf on person's tongue *after death, the sacred threads are not removed and the body is not washed *cremations is usually preferred; ashes are cast into a holy river

hyperkalemia interventions 8-11

*prepare for IV administration of hypertonic glucose with regular insulin to move excess potassium into the cells *when blood transfusions are needed, give fresh blood (stored blood may elevate K level because breakdown of older blood releases K) *teach clients to identify and avoid foods high in potassium *avoid salt substitutes or other potassium containing substances

hypercalcemia interventions 5-8

*prepare the client with severe hypercalcemia for dialysis if medications fail to reduce the calcium level *move the client carefully, and observe for signs of a pathological fracture *monitor for flank or abdominal pain, and strain the urine to check for the presence of urinary stones *instruct the client to avoid foods high in calcium

hyperkalemia interventions 4-7

*prepare to administer K-excreting diuretics if renal function is not impaired *prepare to administer sodium polystyrene sulfonate (Kayexalate) if kidney function is impaired *prepare for dialysis if levels are critically high *prepare for IV administration of calcium if hyperkalemia is sever, to avert myocardial excitability

metabolic alkalosis: interventions 4-6

*prepare to administer medications and IV fluids as prescribed to promote the kidney excretion of bicarbonate *prepare to replace potassium as prescribed *treat the underlying cause of the alkalosis

general interventions for metabolic acidosis 4-6

*prepare to administer solutions intravenously as prescribed to increase the buffer base *initiate safety and seizure precautions *monitor the ABG levels and the potassium level closely; as metabolic acidosis resolves, potassium moves back into the cells and the potassium level decreases

prevention of tracheal stenosis

*prevent pulling of and traction on the tracheostomy tube *properly secure the tube in the midline posision *maintain cuff pressure *minimize oronasal intubation time

prevention/interventions for air embolism as complication of IV therapy

*prime tubing with fluid before use, and monitor for air bubbles *secure all connections *replace IV fluid before bottle/bag is empty *monitor for signs of air embolism; if suspected: -clamp tubing -turn client on left side with head of bed lowered (trendelnburg) to trap air in the right atrium -notify HCP

droplet precautions: barrier protection.

*private room or cohort client *use a surgical mask when within 3 ft of client *surgical mask on client when out of room.

contact precautions: barrier protection.

*private room or cohort client *use of gloves and a gown whenever entering a client's room *standard precautions as necessary

commonly used herbs and health products: black cohosh

*produces estrogen-like effects

hypercalcemia: neuromuscular assessment findings

*profound muscle weakness *diminished or absent deep tendon reflexes *disorientation, lethargy, coma

hyperkalemia: neuromuscular assessment findings: late

*profound weakness *ascending flaccid paralysis in the arms and legs (trunk, head, and respiratory muscles become affected when K levels are lethal)

hyperkalemia: respiratory assessment findings

*profound weakness of the skeletal muscles leading to respiratory failure

wound evisceration

*protrusion of the internal organs through an incision *usually occurs 6-8 days after surgery

nursing considerations for a protein restricted diet

*provide approximately 40-60 g of protein/day *the less protein allowed, the more important it is that all protein in the diet be of high biological value *foods are limited to the milk, meat, bread, and starch groups

interventions for respiratory alkalosis 5-7

*provide cautious care with ventilator clients so that they are not forced to take breaths too deeply or rapidly *monitor electrolyte values (especially potassium and calcium) and ABG levels *prepare to administer calcium gluconate for tetany as prescribed

indications for a clear liquid diet 1-3

*provides fluid and some electrolytes to prevent dehydration *used as an initial feeding after complete bowel rest *used initially to feed a malnourished person or a person who has not had any oral intake for some time

indications for a mechanical soft diet

*provides foods that have been mechanically altered in texture to require minimal chewing *clients who have difficulty chewing but can tolerate more variety in texture than a liquid diet offers *dental problems *surgery of head or neck *dysphagia

toddler play: toys

*push-pull toys *blocks *sand *finger paints and bubbles *large balls *crayons *trucks and dolls *containers *play-doh *toy telephones *cloth books *wooden puzzles

foods to avoid in a low fiber diet

*raw fruits (except bananas) and vegetables *nuts and seeds *plant fiber *whole grains *limit dairy to 2 servings a day

low-density lipoproteins (LDLs)

*recommended: <100 mg/dL (<2.6 mmol/L) *near optimal: 100-129 mg/dL (2.6-3.4 mmol/L) *moderate risk for CAD: 130-159 (3.37-4.12 mmol/L) *high risk for CAD: >160 mg/dL (>4.14 mmol/L)

why would insulin be added to PN solution?

*regular insulin may be added to control the blood glucose level because of the high concentration of glucose in the PN solution

function of potassium

*regulates water balance, electrical conduction in muscle cells, and acid-base balance

interventions for phlebitis

*remove IV device immediately *restart IV in opposite extremity *notify HCP *apply warm, moist compresses as prescribed

interventions for poisoning

*remove any obvious materials from the mouth, eyes or body area immediately *identify the type and amount of substance ingested *call poison control before attempting an intervention *if vomiting occurs or is required, save vomitus and bring to poison control center *if poison control recommends hospitalization, call for an ambulance *never induce vomiting following ingestion of lye, household cleaners, grease, or petroleum products *never induce vomiting in an unconscious patient

prevention/interventions for catheter embolism

*remove catheter carefully *inspect catheter when removed *if catheter tip has broken off: -place a tourniquet as proximally as possible to IV site on affected limb -notify HCP immediately -prepare to obtain a radiograph -prepare client for surgery to remove catheter piece if necessary

interventions for infiltration

*remove the IV device immediately *elevate extremity *apply compress to affected area (hot or cold depending on IV solution that was infusing and HCP prescription) *do not rub infiltrated area

management of trachea-innominate artery fistula

*remove the tracheostomy tube immediately *apply direct pressure to the innominate artery at the stoma site *prepare the client for immediate repair surgery

indication for a protein restricted diet

*renal disease *end stage liver disease

what are some causes of increased calcium excretion?

*renal failure, polyuric phase *diarrhea *steatorrhea *wound drainage, especially GI

what causes respiratory alkalosis?

*respiratory alkalosis results from conditions which overstimulate the respiratory system

signs and symptoms of hyperglycemia as PN complication

*restlessness *confusion *weakness *diaphoresis *elevated blood glucose > 200 mg/dL *excessive thirst *fatigue *kussmaul respirations *coma (when severe)

nursing considerations for a cardiac diet

*restrict total fat, cholesterol, and sodium *teach about dash diet or other prescribed diet

chest tube drainage system

*returns negative pressure to the intrapleural space *used to remove abnormal accumulations of air and fluid from the pleural space

rounding rules for medication calculation

*round standard injection doses to tenths and measure in a 3 mL syringe *round small, critical amounts, or children's doses to hundredths and measure in a 1 mL tuberculin syringe

Native Americans: religion/spirituality

*sacred myths and legends provide spiritual guidance for some *most adhere to some form of christianity with healing practices integrated *community and social organizations are important

End of Life Care: Islam 1

*second degree male relatives (cousins or uncles) should be contact people and they will determine if client/family should be informed *may choose to face mecca (west or southwest) *head should be elevated above body

prevention of dislodged tracheostomy tube

*secure the tube in place *minimize manipulation of and traction on the tube *ensure client does not pull on the tube *ensure that a tracheostomy tube of the same type and size is at the client's bedside

wound dehiscence

*separation of the wound edges at the suture line *usually occurs 6-8 days after surgery

hypokalemia: lab findings

*serum potassium level lower than 3.5 *electrocardiogram changes: - ST depression - shallow, flat, or inverted T waves - prominent U waves

hyponatremia: lab findings

*serum sodium level less than 135 *decreased urinary specific gravity

hypernatremia: lab findings

*serum sodium level that exceeds 145 *increased urinary specific gravity

hypokalemia: respiratory assessment findings

*shallow, ineffective respirations that result from profound weakness of the skeletal muscles of respiration *diminished breath sounds

African Americans: health risks

*sickle cell anemia *hypertension *heart disease *cancer *lactose intolerance *diabetes mellitus *obesity

Native American: communication

*silence indicates respect for the speaker *may speak in low tone of voice and expect others to be attentive *eye contact may be viewed as a sign of disrespect *body language is important

levin tube

*single lumen nasogastric tube *used to remove gastric contents via intermittent suction or to provide tube feedings

airborne precautions: barrier protection.

*single room *neg airflow pressure (minimum of 6-12 air exchanges per hour) *door stays closed *ultraviolet germicide irradiation or HEPA filter in room *health care workers wear respiratory mask (N95 or higher) *client wears surgical mask if out of room.

infant skills: 8-9 months

*sits steadily unsupported *crawls *may stand while holding on *begins to stand without help

interventions for hypervolemia as PN complication

*slow or stop IV infusion *notify the HCP *restrict fluids *administer diuretics *use dialysis (in extreme cases)

hyperkalemia: cardiovascular assessment findings

*slow, weak, irregular HR *decreased BP

infant skills: 2-3 months

*smiles *turns head side to side *cries *follows objects *holds head in midline

when/how should solid foods be introduced to infants?

*solids (strained, pureed, finely mashed) are introduced at 5-6 months of age *introduce solids one at a time usually at intervals of 4-5 days to ID food allergies *sequence of food introduction: iron-fortified rice cereal, fruits, vegetables, then meats *eggs can be given at 12 months

infant play: toys

*solitary play *stuffed animals *crib mobiles with contrasting colors *squeeze toys *rattles *musical toys *water toys during bath *large picture books *push toys after infant begins walking

African Americans: communication

*standard english *head nodding doesn't always mean agreement *prolonged eye contact may be viewed negatively *non-verbal communication may be important *personal questions on initial contact viewed as intrusive

manifestations of tracheal stenosis

*stenosis is usually seen after the cuff is deflated or the tracheostomy tube is removed *the client has increased coughing, inability to expectorate secretions, or difficulty breathing and talking

commonly used herbs and health products: Echinacea

*stimulates the immune system

interventions for vomiting during NG feeding

*stop tube feeding *place in side-lying position *suction as needed

purpose of single lumen urinary catheter

*straight catheterization to empty bladder *obtain sterile urine specimen *check the residual amount of urine after the client voids

management of TEF

*suction; manually administer oxygen by mask to prevent hypoxemia *use a small soft feeding tube instead of a nasogastric tube for tube feedings *a gastrostomy or jejunostomy may be performed *montir client with a nasogastric tube closely; assess for TEF and aspiration

pleural friction rub

*superficial, low-pitched, coarse rubbing or grating sound (like to surfaces rubbing together) *heard throughout inspiration and expiration *loudest over the lower anterolateral surface *not cleared by cough

indications for a low-fiber (low residue) diet

*supplies foods that are least likely to form an obstruction when the intestinal tract is narrowed by inflammation or scarring or when GI motility is slowed *inflammatory bowel disease *partial obstructions of the intestinal tract *gastroenteritis *diarrhea *other GI disorders

hyponatremia: cardiovascular assessment findings

*symptoms vary with changes in vascular volume *normovolemic: rapid pulse; normal BP *hypovolemic: thready, weak, rapid pulse; hypotension; flat neck veins; normal or low central venous pressure *hypervolemic: rapid, bounding pulse; BP & CVP are normal or elevated

how does the phosphate buffer system buffer the ECF?

*system acts like bicarb and neutralizes excess hydrogen ions *located in all cells and body fluid and is especially active in the kidney

manifestations of metabolic alkalosis: cardiovascular

*tachycardia *dysrhythmias (related to hypokalemia from compensation)

manifestations of respiratory alkalosis: cardiovascular

*tachycardia *dysrhythmias (related to hypokalemia from compensation)

hypomagnesemia: cardiovascular assessment findings

*tachycardia *hypertension

triage: non-urgent

*tagged green/ priority 3 *assigned to clients with local injuries, no immediate complications, and who can wait at least 2 hours for treatment *evaluate every 1-2 hours after after initial treatment

triage: emergent

*tagged red/priority 1 *assigned to clients with life threatening conditions needing immediate attention *continuous evaluation *high probability for survival once stabilized

triage: urgent

*tagged yellow/ priority 2 *assigned to clients who require treatment and whose injuries have complications that are not life-threatening, provided that they are treated within 30 minutes to 2 hours *continuous evaluation every 30-60 minutes after initial treatment

manifestations of respiratory alkalosis: neuromuscular

*tetany *numbness *tingling of extremities *hyperreflexia *seizures

management of tracheostomy tube obstruction

*the HCP repositions or replaces the tube if obstruction occurs as a result of cuff prolapse over the end of the tube

nursing consideration for salem sump tube

*the air vent on a salem sump tube is not to be clamped and is to be kept above the level of the stomach *if leakage occurs through the air vent, instill 30 mL of air into the air vent and irrigate the main lumen with normal saline (NS)

what does PT evaluate?

*the amount of time it takes for clot formation *used to monitor response to warfarin sodium therapy

End of Life Care: Hispanic and Latino groups 1

*the family generally makes decisions and may request to withhold the diagnosis or prognosis from the client *extended family members often are involved in end-of-life care (pregnant women are exempt) *several family members may at the dying person's bedside

description of intestinal tubes

*the intestinal tube is passed nasally into the small intestine *the tube enter the small intestine through the pyloric sphincter because of the weight of a small bag containing tungsten at the end

toddler play:

*the major socializing mechanism is parallel play, and therapeutic play can begin at this age *short attention span causes frequent toy changes *the toddler explores body parts of self and others

precautions with IV administered potassium: #5

*the maximum recommended infusion rate is 5 to 10 mEq/hr *infusion rate should never exceed 20 mEq/hr under any circumstances

toddler skills: 1-4

*the toddler begins to walk with 1 hand held by age 12-13 months *runs by age 2 *walks backward and hops on 1 foot by age 3 years *usually cannot alternate feet when climbing stairs

manifestations of trachea-innominate artery fistula

*the tracheostomy tube pulsates in synchrony with the heartbeat *there is heavy bleeding from the stoma *is is a life-threatening complication

nursing considerations for NSAIDs and acetylsalicylic acid 1-3

*these meds are contraindicated in clients experiencing gastric irritation, ulcer disease, or an allergy to the med *bleeding is a concern *instruct client to take oral doses with milk or a snack to reduce gastric irritation

nursing considerations for a full liquid diet

*this diet is nutritionally deficient in energy and many nutrients *use of a complete nutritional liquid supplement is often necessary to meet nutrient needs for clients on this diet for more than 3 days

minimal leak technique

*this is used for cuff inflation and checking cuff pressure for cuffs without pressure relief valves *inflate the cuff until a seal is established; no harsh sound should be heard through a stethoscope placed over the trachea when the client breathes in, but a slight air leak on peak inspiration is present and can be heard *the client cannot make verbal sounds, and no air is felt coming out of the client's mouth

hypokalemia: cardiovascular assessment findings

*thready, weak, irregular pulse *weak peripheral pulses *orthostatic hypotension

African Americans: time orientation and personal space preferences

*time orientation varies and may include past, present, or future orientation *relationships and events may be considered more important than timeliness *comfortable with close personal space when interacting with family and friends

what causes potassium to move from the ICF to the ECF

*tissue damage *acidosis *hyperuricemia *hypercatabolism

albumin

3.4-5 g/dL presence in urine indicates renal dysfunction

normal potassium value

3.5-5 mEq/L

normal PaCO2

35-45 mm Hg

normal temp

36.4-37.5 degrees celsius 97.5-99.5 degrees fahrenheit

purpose of NG tubes

*to decompress the stomach by removing fluids or gas to promote abdominal comfort *to allow surgical anastomoses to heal without distention *to decrease the risk of aspiration *to administer meds to clients unable to swallow *acts as temporary feeding tube *ti irrigate the stomach and remove toxic substances, such as in poisoning

positions to ensure safety and comfort: positions to ensure safety and comfort: arterial vascular grafting of an extremity

*to promote graft patency after the procedure, bed rest is usually maintained for 24 hours and the affected extremity is kept straight *limit movement and avoid flexion of the hip and knee

conditions that are considered emergent

*trauma victims *chest pain *severe respiratory distress *cardiac arrest *limb amputation *acute neurological deficits *chemical splashes to the eye

manifestations of metabolic alkalosis: neuromuscular

*tremors *hypertonic muscles *muscle cramps *tetany *tingling of extremities *seizures

Native Americans: health risks 2

*tuberculosis *arthritis *lactose intolerance *gallbladder disease

hypomagnesemia: neuromuscular assessment findings

*twitches; paresthesias *positive trousseau's and chvostek's signs *hyperreflexia *tetany, seizures

preschooler: play 4-6

*understands sharing and is able to interact with peers *requires regular socialization with mates of similar age *play activities include a large space for running and jumping

hypocalcemia: renal assessment findings

*urinary output varies depending on the cause

hypercalcemia: renal assessment findings

*urinary output varies depending on the cause *formation of renal calculi; flank pain

prevention of tracheomalacia

*use an uncuffed tube as soon as possible *monitor cuff pressure and air volume closely to detect changes

prevention of NG complications: clogged tubes

*use liquid form of meds, if possible *flush the tube with 30-50 mL of water or NS before and after med administration and bolus feeding *flush with water every 4 hours for continuous feeding

prevention of infection as PN complication

*use strict aseptic techniques *monitor temp *assess IV site for signs of infection *change site dressing, solution, and tubing as specified by agency policy *do not disconnect tubing unnecessarily

prevention of trachea-innominate artery fistula

*use the correct tube size and length, and maintain the tube in midline position *prevent pulling or tugging of the tracheostomy tube *immediately notify HCP of a pulsating tube

indications for a full liquid diet

*used as a transition diet after clear liquids following surgery *used for clients who have difficulty chewing, swallowing, or tolerating solid foods

indications for a clear liquid diet 4-5

*used for bowel preparation for surgery or diagnostic tests, as well as post-operatively and in clients with fever, vomiting, or diarrhea *used in gastroenteritis

occlusive technique

*used for cuff inflation and checking cuff pressures for cuffs without pressure relief valves *provides an adequate seal in the trachea at the lowest possible cuff pressure *uses same procedure as minimal leak technique, without an air leak

indications for endotracheal tubes

*used to maintain a patent airway *when the client needs mechanical ventilation *if an artificial airway is needed for more than 10-14 days, a tracheostomy may be created to avoid mucosal and vocal cord damage

purpose of double lumen urinary catheter

*used when an indwelling catheter is needed for continuous bladder drainage; one lumen is for drainage and the other is for balloon inflation

purpose of triple lumen urinary catheter

*used when bladder irrigation and drainage is necessary; 1 lumen is for instilling the bladder irrigant solution, 1 lumen is for continuous bladder drainage, and 1 lumen is for balloon inflation.

Amish: Communication

*usually speak a German dialect (Pennsylvania Dutch) *German used during worship *English learned in school

infant play: birth to 3 months

*verbal *visual *tactile stimuli

prevention of NG complications: aspiration

*verify tube placement *do not administer feeding if residual is more than 100 mL *keep HOB elevated

fat soluble vitamins

*vitamin A *vitamin D *vitamin E *vitamin K

End of Life Care: Hispanic and Latino groups 2

*vocal expressions of grief are expected *may refuse procedures that alter the body (autopsy) *dying at home may be considered bad luck

infant skills: 14-15 months

*walks alone *can crawl up stairs *shows emotions such as anger and affection *will explore away from mother in familiar surroundings

infant skills: 12-13 months

*walks with 1 hand held *can take a few steps without falling *can drink from a cup

what causes dilution of serum potassium?

*water intoxification *IV therapy with potassium poor solution

hypophosphatemia assessment findings: neuromuscular

*weakness *decreased deep tendon reflexes *decreased bone density that can cause fractures and alterations in bone shape *rhabdomyolysis

standard precautions: gown

*wear gowns if soiling of clothing is likely from blood or body fluid.

standard precautions: eye/face protection

*wear masks eye protection or face shields if client care activities may generate splashes or sprays of blood or body fluid

when should a rectal temp be taken?

*when an accurate temp cannot be obtained orally *the client has nasal congestion *has undergone nasal or oral surgery, or had jaw wired *has a nasogastric tube in place *is unable to keep mouth closed *is at risk for seizures

standard precautions: gloves

*when touching blood, body fluids, secretions, excretions, *non-intact skin, mucous membranes, *contaminated items; *remove gloves and wash hands between client care contacts

foods that are low in fiber

*white bread *refined cooked cereals *cooked potatoes without skins *white rice *refined pasta

categories of complementary and alternative medicines (CAM)

*whole medical systems *mind-body medicine *biologically based practices *manipulative and body-based practices *energy medicine

additional nursing considerations for PN administration: refeeding syndrome

*with severely malnourished clients, monitor for refeeding syndrome (a rapid drop in potassium, magnesium, and phosphate serum levels) *this electrolyte shift can cause cardiovascular, respiratory, and neurological problems *monitor for shallow respirations, confusion, weakness, bleeding tendencies, and seizures (inform HCP if symptoms are present)

Amish: social roles

*women are not allowed to hold positions of power in the congregation *roles for women are considered equally important to those of men, but are very unequal in terms of authority *family life has a patriarchal structure *marriage outside of the faith is not usually allowed; unmarried women remain under the authority of their fathers

no added salt diet

4 g of sodium per day

glycosylated hemoglobin (A1c)

4% - 6% *test doesn't require fasting

grading scale for pulses

4+ = strong and bounding 3+ = full pulse, increased 2+ = normal, easily palpable 1+ = weak, barely palpable 0 = absent, not palpable

after completion of PRBC transfusion, the change in lab values (hemoglobin and hematocrit) takes

4-6 hours

alanine aminotransferase (ALT)

4-6 international units/L used to identify and/or monitor hepatocellular disease of the liver

extubation steps 4-7

4. after removal, instruct client to cough and deep-breathe to assist in removing accumulated secretions in the throat 5. apply oxygen therapy, as prescribed 6. monitor for respiratory difficulty; contact HCP if it occurs 7. inform the client that hoarseness or a sore throat is normal and that the client should limit talking if it occurs

interventions for intestinal tubes 4-6

4. assess the abdomen during the procedure by monitoring drainage from the tube and the abdominal girth 5. if the tube becomes blocked, notify the HCP 6. to remove the tube, the tungsten is removed from the balloon portion of the tube with a syringe; the tube is removed gradually (6 inches /15cm every hour) as prescribed

administration of NG feeding 4-6

4. assess tube placement by aspirating gastric contents and measuring the pH (should be 3.5 or lower) 5. aspirate all stomach contents (residual), measure the amount, and return contents to the stomach (unless residual appears abnormal or the amount is greater than 250 mL) 6. warm feeding to room temp to prevent diarrhea and cramps

preschooler skills: 4-6

4. athletic abilities begin to develop 5. demonstrates increased skills in balancing 6. alternates feet when climbing stairs

alkaline phosphatase

4.5-13 king-armstrong units/dL

commonly used dressings for post op clients

4x4 inch gause nonadherent pads abdominal pads gauze rolls split gauze (aka drain sponge)

WBC

5,000-10,000

thyroxine (T4)

5-12 mcg/dL

precautions for NG feeding 5-7

5. always asses bowel sounds; do not administer any feedings if bowel sounds are absent 6. administer the feeding at the prescribed rate or via gravity flow (intermittent bolus feedings) with a 50-60 mL syringe with plunger removed 7. gently flush with 30=50 mL of water or NS using the irrigation syringe after the feeding

infant: physical development 5-8

5. anterior fontanel closes by 12 to 18 months 6. posterior fontanel closes by the end of the second month 7. first primary teeth to erupt are the lower central incisors at approximately 6-10 months 8. in general, by 3 to 4 months, infants sleep 9 to 11 hours

interventions for esophageal and gastric tubes 5-7

5. maintain head elevation once the tube is in place 6. double clamp the balloon ports to prevent air leaks 7. keep scissors at the bedside at all times; monitor for respiratory distress, and if it occurs, cut the tubes to deflate the balloons

tracheostomy interventions 5-8

5. monitor for bleeding, difficulty with breathing, absence of breath sounds, and crepitus, which are indications of pneumothorax or hemorrhage 6. provide respiratory treatments as prescribed 7. suction fluids as needed; hyperoxygenate before suctioning 8. if allowed to eat, sit up for meals and ensure that cuff is inflated for meals and for 1 hour after to prevent aspiration

sever sodium restricted diet

500 mg of sodium per day (rarely prescribed)

blood urea nitrogen (BUN)

6-20 mg/dL (2.1-7.1 mmol/L) renal: elevated levels indicated a slowing of GFR

protein

6-8 g/dL

normal pulse

60-100 bpm

sutures are removed

7-10 days after surgery

staples are removed

7-14 days after surgery skin may become slightly reddened when staples are ready to be removed

preschooler skills: 7-9

7. can tie shoelaces by age 6 8. may talk continuously and ask many "why" questions 9. vocabulary increases to about 900 words by age 3 and to 2100 words by age 5

administration of NG feeding 7-9

7. use an infusion feeding pump for continuous or cyclic feedings 8. for bolus feeding, maintain the client in a high fowler's position for 30 minutes after the feeding. use an infusion pump or allow the feeding to infuse via gravity. Do not plunge the feeding into the stomach 9. for a continuous feeding, keep the client in a semi-fowler's position at all times

normal pH value

7.35-7.45

glucose

70-110

interventions for esophageal and gastric tubes 8-10

8. to prevent ulceration or necrosis of the esophagus, release esophageal pressure at intervals as prescribed and per agency policy 9. monitor for increased bloody drainage which may indicate persistent bleeding and rupture of the varices 10. monitor for signs of esophageal rupture, which include a drop in BP, increased heart rate, and back and upper abdominal pain

normal PaO2

80-100 mm Hg

triiodothyronine (T3)

80-230 ng/dL

normal value for calcium

9-10.5 mg/dL

tracheostomy interventions 9-11

9. monitor cuff pressures as prescribed 10. assess the stoma and secretions for blood or purulent drainage 11. follow the CHP's prescriptions and agency policy for cleaning the stoma and inner cannula; usually, half-strength hydrogen peroxide is used

a pulse oximetry reading below __________ should be reported the the HCP.

90% (except in certain chronic conditions in which this value is the normal state)

chloride

98-107

tryglycerides:

< 150 mg/dL (<1.7 mmol/L)

myoglobin

< 90 mcg/L elevation could indicate MI

in the metric system, to convert smaller to larger

divide by 1000 or move decimal point 3 places to the left

how often should an IV bag or bottle of solution be changed?

do not let an IV bag or bottle of solution hang for more than 24 hours to diminish the potential for bacterial contamination

atelectasis may be the result of airway obstruction caused by

accumulated secretions failure to deep breath after surgery failure to ambulate after surgery

what is the antidote for acetaminophen?

acetylcysteine

proton pump inhibitors treat

active ucer disease erosive esophagitis pathological hypersecretory conditions

meds for inflammatory bowel disease: immunomodulators

adalimumab certolizumab infliximab natalizumab

normal breath sounds

vesicular (lesser bronchi, bronchioles, lobes) bronchovesicular (main bronchi) bronchial (trachea)

signs of iron overload

vomiting diarrhea hypotension altered hematological values

symptoms of paralytic ileus

vomiting postoperatively abdominal distention absence of bowel sounds, bowel movement, or flatus

isotonic dehydration

water and dissolved electrolytes are lost in equal proportions

hypertonic dehydration

water loss exceeds electrolyte loss

signs of transfusion reaction in an unconscious patient

weak pulse fever tachycardia or bradycardia hypotension visible hemoglobinuria oliguria or anuria

how often should IV dressings be changed?

when dressing is wet or contaminated, or as specified by agency protocol

how does insufficient metabolism of carbs cause metabolic acidosis

when the oxygen supply is not suffcient for the metabolism of carbs, lactic acid is produced and lactic acidosis results

what are packed red blood cells (PBRCs) used for?

PBRCs are a blood product used to replace erythrocytes

describe the tonicity of PN solutions

PN solutions are hypertonic due to the higher concentrations of glucose and addition of amino acids

in acid-base balance, the respiratory function indicator is the ...

PaCO2

creatine kinase

*26-174 *enzyme found in muscle and brain tissue that reflects tissue catabolism resulting from cell trauma *test is performed to detects myocardial or skeletal muscle damage, or CNS damage

activated partial thromboplastin time (aPTT)

*28-35 seconds *should be between 1.5 and 2.5 normal when receiving haparin therapy *if value is prolonged (longer than 87.5 seconds), initiate bleeding procautions

Troponin I

*< 0.6 mg/mL *> 1.5 indicated MI

natriuretic peptide most indicative of CHF

*BNP *the higher the BNP level, the more severe the CHF *in the presence of an elevated BNP, dyspnea is due to CHF; if BNP is normal, dyspnea is due to pulmonary problem

characteristics of fine crackles

*High pitched, short, crackling/popping sound *heard on end of inspiration *not cleared by coughing

vaccines given at 11-12 years

*MMR (if not administered at 4-6 years) *diphtheria, tetanus, acellular pertussis adolescent preparation (Tdap) *meningococcal vaccine (MCV4), booster- age 16 *human papilloavirus (HPV) first dose at age 11-12, second dose 2 months after first, third dose 6 months after first

why should an inability to obtain a temp not be ignored?

because it could represent a condition of hypothermia, a life-threatening condition in very young and older clients

toddler nutrition

*2-3 servings of milk daily *trans-fatty acids and saturated fats need to be restricted; otherwise fat restriction is not appropriate for a toddler *iron-fortified cereal and a high iron diet, adequate amounts of calcium and vitamin D, and Vitamin C are essential

the nurse should not administer more than _____________ of medication per intramuscular injection site (____________ for the deltoid)

* 3 mL per intramuscular injection site *2 mL for the deltoid

Troponin T

* <0.1 ng/mL * anything greater indicates MI

Fluid Volume Deficit: Integumentary assessment findings

* Dry skin * poor turgor, tenting * dry mouth

Fluid Volume Deficit: Neuromuscular assessment findings

* decreased central nervous system activity, from lethargy to coma * fever, depending on the amount of fluid loss * skeletal muscle weakness

Fluid volume deficit: GI assessment findings

* decreased motility and diminished bowel sounds *constipation * thirst * decreased body weight

Fluid Volume Deficit: Renal assessment findings

* decreased urine output

positions to ensure safety and comfort: NG irrigation and tube feedings

* elevate head of bed (semi-fowler's to fowler's) to prevent aspiration *maintain head elevation for 30 minutes to 1 hour after an intermittent feeding *the head of bed should remain elevated for continuous feedings

Fluid Volume Deficit: Respiratory assessment findings

* increased rate and depth of respirations * dyspnea

causes of hyponatremia

* increased sodium excretion * inadequate sodium intake * dilution of serum sodium

interventions for fluid volume deficits

* monitor cardiovascular, respiratory, neuromuscular, renal, integumentary, and GI status * prevent further fluid losses and increase fluid compartment volumes to normal ranges *provide oral rehydration therapy if possible and IV fluid replacement if the dehydration is severe; monitor intake and output *generally, isotonic dehydration is treated with isotonic fluid, hypertonic dehydration is treated with hypotonic fluid, and hypotonic dehydration is treated with hypertonic fluid *administer meds as prescribed, such as antidiarrheal, antimicrobial, antiemetic, and antipyretic meds, to correct the cause and treat any symptoms *adminster oxygen as prescribed *monitor electrolyte values and prepare to administer medications to treat an imbalance if one is present

interventions for fluid volume excess

* monitor cardiovascular, respiratory, neuromuscular, renal, integumentary, and GI status * prevent further fluid overload and restore normal fluid balance *administer diuretics: osmotic diuretics typically are prescribed first to prevent severe electrolyte imbalances *restrict fluid and sodium intake as prescribed *monitor intake and output; monitor weight *monitor electrolyte values and prepare to administer medications to treat an imbalance if one is present

Fluid Volume Deficit: Cardiovascular assessment findings

* thready, increased pulse rate * decreased BP and orthostatic hypotension * flat neck and hand veins in dependent positions * diminished peripheral pulses * decreased central venous pressure * dysrhythmias

anasarca

*(generalized edema) excessive accumulation of fluid in the interstitial space throughout the body *occurs as a result of conditions such as cardiac, renal, or liver failure

Lactate dehydrogenase (LDH)

*140-280 units/L *levels rise about 24 hours after a MI

management of dislodged tracheostomy tube

*be familiar with policy regarding replacement of a tracheostomy tube as a nursing procedure *during the first 72 hours following surgical placement, the nurse manually ventilates client with Ambu bag while another nurse calls the rapid response team for help after 72 hours: -extend neck and open the tissues of the stoma to secure the airway - if present, grasp retention sutures to spread opening -use a tracheal dilator to hold the stoma open -prepare to insert a tracheostomy tube; place the obturator into the tube, replace the tube, and remove obturator -maintain ventilation via Ambu bag -assess airflow and bilateral breath sounds -if unable to secure an airway, call the rapid response team and the anesthesiologist

positions to ensure safety and comfort: cerebral angiography

*bed rest as prescribed *the extremity into which the contrast medium was injected is kept straight and immobilized for 6-8 hours

toddler skills: 5-7

*begins to master fine motor skills for building, undressing, and drawing lines *the young toddler often uses "no" even when they mean "yes" to assert independence *begins to use short sentences and has a vocabulary of about 300 words by age 2

standard precautions: hand washing

*between client contacts; *after contact with blood, body fluids, secretions or excretions, nonintact skin, or mucous membranes; *after contact with equipment or contaminated articles; *immediately after removing gloves *use alcohol based rubs when hands are not visibly soiled (doesn't kill C Diff)

additional nursing considerations for PN: blood draws

*blood for testing may be drawn from the central venous access site *a port other than the port used to infuse the PN is used for blood draws after the PN has been stopped for several minutes because the PN solution could alter the results *the client with a central venous access site receiving PN should still have a venipuncture site

signs and symptoms of hypervolemia as PN complication

*bounding pulse *crackles on lung auscultation *headache *increased BP *jugular vein distention *weight gin greater than desired

fluid volume excess: cardiovascular assessment findings

*bounding, increased pulse rate *elevated BP *distended neck and hand veins *elevated central venous pressure *dysrhythmias

hypermagnesemia: cardiovascular assessment findings

*bradycardia *dysrhythmias *hypotension

preschooler: bowel and bladder control

*by age 4, the preschooler has daytime control of bowel and bladder but may experience bed-wetting accidents at night *by age 5, the preschooler achieves bowel and bladder control, although accidents may occur in stressful situations

hypocalcemia: lab findings

*calcium level less than 8.6 mg/dL *electrocardiographic changes -prolonged ST interval -prolonged QT interval

hypercalcemia: lab findings

*calcium level that exceeds 10.5 mg/dL *electrocardiographic changes: -shortened ST segment -widened T wave

calculating infusions prescribed by unit dosage per hour

*calculation is a two step process 1. determine the amount of medication per 1 mL 2. determine the infusion rate or milliliters per hour example: RX: continuous heparin sodium by IV at 1000 units per hour available: IV bag of 500 mL D5W with 20000 units of heparin sodium how many milliliters per hour are required to administer correct dosage? step 1: 20000 units ÷ 500 mL = 40 units / 1 mL step 2: 1000 units ÷ 40 units = 25 mL/hour

infant skills: 10-11 months

*can change from prone to sitting position *walks while holding on to furniture *stands securely *entertains self for periods of time

White Americans: health risks

*cancer *heart disease *diabetes *obesity *hypertension *thalassemia

possible causes of air embolism as PN complication

*catheter system opened or IV tubing disconnected *air entry on IV tubing changes

toddler: bowel and bladder control

*certain signs indicate that a toddler is ready for toilet training *bowel control develops before bladder control *by age 3, the toddler achieves fairly good bowel and bladder control *the toddler may stay dry during the day but may need a diaper at night until about age 4

signs and symptoms of an adverse reaction to lipids

*chest and back pain *chills *cyanosis *diaphoresis *dyspnea *fever *flushing *headache *nausea and vomiting *pressure over the eyes *thrombophlebitis *vertigo

signs and symptoms of pneumothorax as PN complication

*chest or shoulder pain *sudden SOB *cyanosis *tachycardia *absence of breath sounds on affected side

signs and symptoms of infection as PN complication

*chills *fever *elevated WBC count *redness or drainage at insertion site

signs of an immediate transfusion reaction

*chills and diaphoresis *muscle aches, back pain or chest pain *rashes, hives, itching, swelling *rapid, thready pulse *dyspnea, cough, or wheezing *pallor and cyanosis *apprehension *tingling and numbness *headache *nausea, vomiting, abdominal cramps, diarrhea

causes of hypotonic dehydration

*chronic illness *excessive fluid replacement (hypotonic) *kidney disease *chronic malnutrition

interventions for an air embolism as PN complication

*clamp all ports of the IV catheter *place the client in a left side-lying position with the head lower than the feet *notify the HCP *administer oxygen

Native Americans: cultural interventions 1

*clarify communication *understand that a lack of eye contact doesn't mean client isn't listening *be attentive to your own use of body language

what can clients on a clear liquid diet consume?

*clear liquids *foods that are relatively transparent to light, and are liquid at room temp: -water -bouillon -clear broth -carbonated beverages -gelatin -hard candy -lemonade -ice pops -coffee or tea

precautions with IV administered potassium: #6

*client receiving more than 10 mEq/hr should be placed on a cardiac monitor and monitored for cardiac changes *infusion should be controlled by an infusion device

pitting edema scale

1+ a barely perceptible pit (2mm) 2+ a deeper pit, rebounds in a few seconds (4mm) 3+ a deep pit, rebounds in 10-20 seconds (6mm) 4+ a deeper pit, rebounds in > 30 seconds (8mm)

atelectasis usually occurs

1-2 days after surgery

tracheostomy interventions 1-4

1. assess respiration and for bilateral breath sounds 2. monitor ABGs and pulse oximetry 3. encourage coughing and deep breathing 4. maintain a semi-fowler's to high fowler's position

interventions for intestinal tubes 1-3

1. assess the HCP's prescription and agency policy for advancement and removal of the tube and tungsten 2. position the client on the right side to facilitate passage of the weighted bag in the tube through the pylorus of the stomach and into the small intestine 3. do not secure the tube to the face with tape until it has reached final placement (may take several hours) in the intestines

preschooler skills: 1-3

1. has good posture 2. develops fine motor coordination 3. can hop, skip, and run more smoothly

interventions for circulatory overload

1. slow rate of infusion 2. place client in upright position, feet in dependent position 3. notify HCP 4. administer oxygen, diuretics, and morphine sulfate, as prescribed 5. monitor for dysrhythmias 6. phlebotomy may be prescribed in severe cases

interventions for transfusion reaction

1. stop transfusion 2. change IV tubing down to the IV site, and keep line open with normal saline 3. notify HCP and blood bank 4. stay with the client, observing signs and symptoms and monitoring vitals as often as every 5 minutes 5. prepare to administer emergency medications as prescribed 6. obtain a urine specimen for lab studies 7. return blood bag, tubing, attached labels, and transfusion record to the blood bank 8. document occurrence, actions taken, and the client's response

administration of NG feeding 1-3

1. usually, if the residual is less than 100 mL, feeding is administered 2. assess bowel sounds; hold the feeding and notify HCP if bowel sounds are absent 3. position the client in a high fowler's position; if comatose, place in high fowler's and on the right side

specific gravity

1.016-1.022

normal value for magnesium

1.3-2.1 mg/dL

lipase

10-140 units/L elevated levels occur in pancreatic disorders

ammonia

10-80 mcg/dL elevated levels indicated hepatic dysfunction, and may lead to encephalophathy

preschooler skills: 10-12

10. by age 3, usually talks in 3 or 4 word sentences and speaks in short phrases 11. by age 4, speaks 5 or 6 word sentences, and by age 5, speaks in longer sentences that contain all parts of speech 12. can be understood readily by others and can understand clearly what others are saying

in the standard insulin syringe, 100 units is how many mL?

100 units = 1 mL

protrombin time (PT)

11-12.5 seconds should be between 1.5 and 2.5 times normal when receiving anticoagulation therapy *if PT is longer than 32 seconds, and INR is greater than 3, initiate bleeding precautions

opioids should not be given if a client's respiratory rate is less than ___________, or if _______________ develops.

12 breaths per minute, bradycardia (hold med and notify HCP)

normal respiratory rate

12-20 bpm

tracheostomy interventions 12-14

12. administer humidified oxygen as prescribed (normal humidification process is bypassed in clients with tracheostomy) 13. obtain assistance in changing tracheostomy ties: after placing new ties, cut and remove old ties 14. keep a resuscitation (Ambu) bag, obturator, clamps, and spare tracheostomy tube of the same size at the bedside

prehypertension

120/80 - 139/89

normal serum sodium value

135-145 mEq/L

normal sodium value

135-145 mEq/l

stage 1 hypertension

140/90 - 159/99

platelet count

150,000-400,000

stage 2 hypertension

160/100 or greater

when calculating dosages of oral meds, question prescriptions that call for more than _________ tablets

3

autologous blood donations can be made every

3 days (as long as hemoglobin levels remain in a safe range)

each unit of PRBCs increases the hematocrit by

3%

types of hypertonic solutions

3% NS 5% NS 10% dextrose in water (D10W) 5% dextrose in 0.9%NS (D5W/NS) 5% dextrose in 0.45% NS (D5W 1/2 NS) 5% dextrose in lactated ringer (D5LR)

normal phosphorus value

3-4.5 mg/dL

pneumonia may develop ________________ days postoperatively

3-5 days

if an opioid has bee prescribed, after administration, assess the client ...

every 30 minutes for respiratory rate and pain relief

how often should you check residual volume?

every 4 hours before each feeding before giving meds

how often should you irrigate NG tubes?

every 4 hours with 30-50 mL of NS

how often should venipuncture sites be changed?

every 72-96 hours

universal RBC recipient

AB pos

how often should IV tubing be changed?

every 96 hours or with change of venipuncture site

which body systems are affected by a potassium deficit?

every body system is affected, which is why an imbalance is potentially life threatening.

dietary preferences: Jehovah's Witnesses

Any foods to which blood has been added are prohibited. They can eat animal flesh that has been drained.

weber test

Assesses bone conduction w/ vibrating tuning fork in middle of forehead

does fresh frozen plasma contain platelets?

no

how does BP change throughout the day?

BP is typically lowest in the early morning, gradually increases during the day, and peaks in the late afternoon and evening

intervention for hyponatremia caused by inappropriate or excessive secretion of ADH

administer medication that antagonize ADH

standard formula for calculating a medication dosage

D/A x Q = X D (desired) is the dosage that the HCP prescribed A (available) dosage strength stated on med label Q (quantity) volume or form in which the dosage strength is available, such as tablets, capsules, or milliliters

vaccines given at 15-18 months

DTaP

vaccines given at 4-6 years

DTaP IPV MMR varicella vaccine

vaccines given at 6 months

DTap Hib HepB IPV PCV RV

vaccines given at 4 months

DTap Hib IPV PCV RV

rinne test

Done by placing the base of a vibrating tuning fork on the patient's mastoid bone

pregnancy outcomes can be described with the acronym

G- gravidity T- term births P- preterm births A-abortions L- current living children

hypernatremia: cardiovascular assessment findings

HR and BP responds to vascular volume status

vaccine given at 1 month

Hep B

vaccine given at birth

Hep B

disease most commonly transmitted via blood transfusion

Hep C

vaccines given IM

HepB DTaP Hib PCV HepA MCV4 HPV IPV (usually given subcutaneously)

vaccines given at 18-33 months

Hepatitis A, second dose (6-18 months after first)

vaccines given at 12-15 months

Hib PCV measles, mumps, rubella (MMR) vaccine Hepatitis A, first dose (second is given 6-18 months after first dose) varicella vaccine

vaccines given Subcutaneously

IPV (may also be given IM) MMR Varicella

intervention for hyponatremia accompanied by fluid volume deficit

IV sodium chloride infusions to restore sodium and fluid balance

abdominal assessment order

Inspection Auscultation Percussion Palpation

intermediate duration

NPH

can IV meds and/or blood be given through the PN line

No. To prevent infection and solution incompatibility, IV meds and blood are not given through the PN line

are veins in the lower extremities acceptable for a peripheral IV?

No; because of the risk of thrombus formation and the pooling of medications in areas with poor venous return

universal RBC donor

O neg

vaccine given orally

RV

is crossmatching required for platelet transfusions?

no but is usually done anyway

excessive bubbling in the water seal chamber indicates

an air leak in the chest tube system

signs of hematoma as complication of IV therapy

ecchymosis; immediate swelling and leakage of blood at the site, and hard/painful lumps at site

droplet precautions: diseases.

adenovirus diphtheria (pharyngeal) epiglottitis influenza meningitis mumps mycoplasmal or meningococcal pneumonia pneumonia parovirus pertussis rubella scarlet fever sepsis streptococcal pharyngitis.

positions to ensure safety and comfort: autograft

after surgery, the site is immobilized usually for 3-7 days to provide the time needed for the graft to adhere and attach to the wound bed

stridor is an indication of

airway edema, which places client at risk for airway obstruction

bisphosphonates and calcium regulators

alendronate sodium calcitonin salmon etidronate disodium ibandronate pamidronate disodium risedronate sodium tiludronate disodium zoledronic acid

what causes potassium to move from the ECF to the ICF?

alkalosis hyperinsulinism

sodium free spices and flavorings

allspice almond extract bay leaves caraway seeds cinnamon curry powder garlic powder or garlic ginger lemon extract maple extract marjoram mustard powder nutmeg

commonly used herbs and health products: Glucosamine

amino acid that assists in the synthesis of cartilage

foods to restrict in a low-purine diet

anchovies herring mackerel sardines scallops organ meats gravies meat extracts wild game goose sweetbreads

indications for a high iron diet

anemia

manifestations of Hep C

anorexia nausea vomiting dark urine jaundice (symptoms usually occur 4-6 weeks after transfusion)

substances that can affect the client in surgery: antibiotics

antibiotics potentiate the action of anesthetic agent

gas forming foods

apples artichokes barley beans bran broccoli brussels sprouts cabbage celery cherries coconuts eggplant figs honey melons milk molasses nuts onions radishes soybeans wheat yeast

foods low in potassium

applesauce green beans cabbage lettuce peppers grapes blueberries cooked summer squash cooked turnip greens pineapple raspberries

if post op client is shivering

apply warm blankets continue oxygen administer meds as prescribed

a wound that is pulsating bright red blood indicates what type of puncture

arterial puncture

urinary retention occurs...

as a result of loss of muscle tone caused by anesthetics or opioid analgesics, and appears 6-8 hours after surgery

removal of NG tube

ask client to take a deep breath and hold it; remove the tube slowly and evenly over the course of 3-6 seconds (coil tube around the hand while removing it).

evaluation of effectiveness of cryoprecipitates

assessed by monitoring coagulation studies and fibrinogen levels

evaluation of granulocyte transfusion

assessed by monitoring the WBC and differential counts

at what point before surgery should anticoagulants, antiplatelets, and thrombolytics be discontinued?

at least 48 hours before surgery, or as specified by the surgeon; clopidogrel usually has to be discontinued 5 day before surgery

indications for a cardiac diet

atherosclerosis diabetes mellitus hyperlipidemia hypertension myocardial infarction nephrotic syndrome renal failure

common food sources for potassium

avocado bananas cantaloupe carrots fish mushrooms oranges potatoes pork, beef, veal raisins spinach strawberries tomatoes

common food sources for magnesium

avocado canned white tuna cauliflower cooked rolled oats green leafy vegetables (spinach and broccoli) milk oatmeal wheat bran peanut butter almonds peas pork, beef, chicken soybeans potatoes raisins yogurt

infant play: 6-12 months

awareness of self, imitation, repetition of pleasurable actions

meds for inflammatory bowel disease: immunosuppressant

azathioprine cycloporine mercaptopurine tacrolimus

signs of septicemia

rapid onset of chills and high fever vomiting diarrhea hypotension shock

signs of infiltration as complication of IV therapy

edema pain numbness at site coolness at site may or may not have blood return

food sources of zinc

eggs leafy vegetables meats protein-rich foods

Hispanic and Latino Americans: food preferences

beans, fried foods, spicy foods

common food sources of sodium

bacon butter canned food cheese cured pork frankfurters hot dogs ketchup lunch meat milk mustard processed food snack food soy sauce table salt white and whole wheat bread

meds for inflammatory bowel disease: 5- aminosalicylates

balsalazide mesalamine sulfasalazine

why is it important to monitor for hyponatremia in a client taking lithium?

because hyponatremia can cause diminished lithium excretion, resulting in lithium toxicity

how do you evaluate the effectiveness of a PRBC transfusion?

evaluation is based on the resolution of the symptoms of anemia and an increase in the erythrocyte, hemoglobin, and hematocrit count

should you write on plastic IV bags with a pen?

do not write on a plastic IV bag with a marking pen because the ink may be absorbed through the plastic into the solution. Use a label and a ballpoint pen for writing on the label, placing the label onto the bag.

dawn phenomenon

characterized by hyperglycemia upon morning awakening that results from excessive early morning release of GH and cortisol

common food sources for calcium

cheese collard greens leafy greens: kale, spinach milk and soy milk rhubarb sardines tofu yogurt oranges

vitamin D supplements

cholecalciferol ergocalciferol

renal diet

controlled amounts of: protein sodium phosphorus calcium potassium and fluids

what is the antidote for magnesium overdose?

calcium gluconate

substances that can affect the client in surgery: herbal substances

can interact with anesthesia and cause a variety of adverse effects. may need to be discontinued before surgery, so make sure you ask about use in preop interview

substances that can affect the client in surgery: antihypertensives

can interact with anesthetic agents and cause bradycardia, hypotension, and impaired circulation

types of intestinal tubes

cantor tube miller-abbott tube

substances that can affect the client in surgery: corticosteroids

cause adrenal atrophy and reduce the ability of the body to withstand stress; before and during surgery, dosages may be increased temporarily

how does a high-fat diet cause metabolic acidosis?

causes a much too rapid accumulation of the waste products of fat metabolism, leading to a buildup of ketones and acids

how does excessive ingestion of acetylsalicylic acid cause metabolic acidosis?

causes an increase in the hydrogen ion concentration

can blood products be administered rapidly?

components containing few RBCs and platelets may be infused rapidly, but caution should be taken to avoid circulatory overload

tracheomalacia

constant pressure exerted by the cuff causes tracheal dilation and erosion of cartilage

increasing light causes pupils to

constrict

babinski's sign

dorsiflexion of the great toe and fanning of the other toes *abnormal after age 2 and indicates CNS disease

when mixing insulins.....

draw up the shortest acting insulin first

hypermagnesemia: CNS assessment findings

drowsiness and lethargy that progresses to coma

hyponatremia: integumentary assessment findings

dry mucous membranes

formula to convert celsius to fahrenheit

degrees celsius x 9/5 + 32 = degrees fahrenheit

formula to convert fahrenheit to celsius

degrees fahrenheit - 32 x 5/9 = degrees celsius

common food sources of phosphorus

dairy products fish organ meats nuts pork, beef, chicken pumpkin, squash whole grain breads and cereals

purpose of intestinal tubes

decompress the bowel remove accumulated intestinal secretions

signs of catheter embolism

decreased BP pain along the vein weak, rapid pulse cyanosis of the nail bed loss of consciousness

hypernatremia: renal assessment findings

decreased urinary output

types of colloid solutions

dextran albumin

how do green leafy vegetables affect PT?

diets high in green leafy vegetables can increase the absorption of vitamin K, which shortens the PT

decreasing light causes pupils to

dilate

calcium channel blockers end in

dipine

bilirubin

direct (conjugated): 0-0.3 mg/dL indirect (unconjugated): 0.1-1 mg/dL total: lower than 1.5 mg/dL elevated levels indicate jaundice

hypotonic dehydration

electrolyte loss exceeds water loss

positions to ensure safety and comfort: skin graft

elevate and immobilize the graft site to prevent movement and shearing of the graft and disruption of tissue; avoid weight bearing

interventions for shock

elevate legs notify surgeon determine and treat cause of shock administer oxygen as prescribed monitor LOC monitor vitals for increased pulse or decreased BP monitor intake and output assess color, temp, turgor and moisture administer IV fluids, blood, and colloid solutions as prescribed

positions to ensure safety and comfort: circumferential burns of the extremities

elevate the extremities above the level of the heart to prevent or reduce dependent edema

positions to ensure safety and comfort: hypophysectomy (hypophysis is the pituitary gland)

elevate the head of the bed to prevent increased intracranial pressure

positions to ensure safety and comfort: burns of the face and head

elevate the head of the bed to prevent or reduce facial, head, and tracheal edema

potential deficiencies in vegetarian diets

energy protein vitamin B12 zink iron calcium omega-3 fatty acids vitamin D (if sun exposure is limited)

school-age children play:

enjoys drawing collecting items dolls pets guessing games board games listening to the radio TV reading watching videos or DVDs computer games team sports secret clubs group peer activities scout organizations

precautions with IV administered potassium: #4

ensure that the IV bag is properly labled

conditions causing rhonchi

head in disorders causing obstruction of the trachea or bronchus, such as chronic bronchitis

hyponatremia: CNS assessment findings

headache personality changes confusion seizures coma

conditions causing pleural friction rub

heard in individuals with pleurisy (inflammation of the pleural surfaces)

conditions causing wheezing

heard in narrowed airway diseases such as asthma

signs of phlebitis as complication of IV therapy

heat, redness, tenderness at site not swollen or hard IV infusion sluggish

why would heparin be added to PN solution?

heparin may be added to reduce the buildup of a fibrinous clot at the catheter tip

the major concerns with acetaminophen is...

hepatotoxicity

positions to ensure safety and comfort: autonomic dysreflexia

high fowler's position to assist with adequate ventilation and the prevention of hypertensive stroke

positions to ensure safety and comfort: NG tube insertion

high fowler's position with head tilted forward (helps to close trachea and open esophagus) and pillows behind the shoulders

how does ingestion of and/or infusion of excess sodium bicarbonate cause metabolic alkalosis?

it causes an increase in the amount of base in the blood

stimulation of the sympathetic nervous system does what to the heart rate?

it increases it

sources of fluid output

kidneys = 1500 mL insensible loss (skin) = 600-800 mL insensible loss (lungs) = 400-600 mL GI tract = 100 mL total daily output = 2600-3000 mL

lacto-vegetarian diet

lacto-vegetarians eat milk, cheese, and dairy foods, but avoid meat, fish, poultry, and eggs

positions to ensure safety and comfort: hemorrhoidectomy

lateral (side-lying) position to prevent pain and bleeding

contact precautions: diseases.

multidrug-resistant organisms enteric infections (C diff) Resp infections (respiratory syncytial virus RSV) influenza wound infections skin infections eye infections. contact with contaminated objects

in the metric system, to convert larger to smaller

multiply by 1000 or move decimal point 3 places to the right

rhabdomyolysis

muscle tissue breakdown results in the release of the protein myoglobin into the blood. Myoglobin can damage the kidneys

tracheal stenosis

narrowed tracheal lumen is the result of scar formation from irritation of tracheal mucosa by the cuff

piggy back tubing should be connected to the injection site ______________ to the drip chamber.

nearest

substances that can affect the client in surgery: insulin

need for insulin may be reduced because of decreased nutritional intake before surgery, or may be increased due to increased stress response

if ileus occurs, it is treated first....

nonsurgically with bowel decompression by insertion of a nasogastric tube attached to intermittent or constant suction

interventions for hemmorrhage

provide pressure to the site of bleeding notify surgeon administer oxygen as prescribed administer IV fluids and blood as prescribed prepare the client for a surgical procedure, if necessary

in a postoperative client, crackles or rhonchi may indicate

pulmonary edema

hypernatremia: respiratory assessment findings

pulmonary edema if hypervolemia is present

when would a large gauge (18-19 gauge lumen or cannula) IV be used

rapid emergency fluid administration, blood products, anesthetics, preoperative and postoperative clients.

manifestations of respiratory acidosis: neuromuscular

seizures

positions to ensure safety and comfort: paracentesis

semi-Fowler's in bed, or sitting upright on the side of the bed, or in a chair with feet supported (client is assisted into a position of comfort after procedure)

positions to ensure safety and comfort: bronchoscopy postprocedure

semi-fowler's to prevent choking or aspiration from impaired ability to swallow

indications for granulocyte transfusion

sepsis neutropenic clients with infection that is unresponsive to antibiotics

indications for a high calorie, high protein diet

severe stress burns wound healing cancer HIV AIDS COPD respiratory failure any other debilitating disease

hypomagnesemia: respiratory assessment findings

shallow respirations

hypophosphatemia assessment findings: respiratory

shallow respirations

hyponatremia: respiratory assessment findings

shallow, ineffective respiratory movement as a late manifestation related to skeletal muscle weakness

postoperative complications 5-8

shock thrombophlebitis urinary retention constipation

NPH can be mixed with

short duration insulins: regular lispro aspart glulisine

postoperative respiratory rate

should be greater than 10 and less than 30 breaths per minute

timeline for autologous blood donation

should begin within 5 weeks of transfusion date and end at least 3 days before the date of transfusion

preschooler: nutrition

similar to those required for the toddler although the daily amounts of minerals, vitamins, and protein may increase with age

sims position

sims position: the client is lying on the side with the body turned prone at 45 degrees. The lower leg is extended, with the upper leg flexed at the hip and knee to a 45-90 degree angle

types of urinary catheters

single lumen double lumen triple lumen

why is hyperkalemia a risk with blood transfusion?

stored blood liberates potassium through hemolysis; the older the blood, the higher the risk of hyperkalemia (this is why patients with renal failure or insufficiency should always receive fresh blood)

school-age child: physical development

the first permanent teeth erupt around age 6, and deciduous teeth are lost gradually

how do diuretics cause metabolic alkalosis?

the loss of hydrogen ions and chloride from diuresis causes a compensatory increase in the amount of bicarbonate in the blood

positions to ensure safety and comfort: postural drainage

the lung segment to be drained should be in the uppermost position; trendelenburg's position may be used

what is hemoglobin?

the main component of erythrocytes and serves as a vehicle for transporting oxygen and CO2

substances that can affect the client in surgery: anticoagulants, antiplatelets, and thrombolytics

the meds alter normal clotting factors and should be discontinued 48 hours before surgery (clopidogrel should be discontinued 5 days before surgery)

how often should the nurse assess vitals in patients receiving blood product transfusions?

the nurse should measure vitals and assess lung sounds before the transfusion and again after the first 15 minutes, and then every 30 - 60 minutes until an hour after administration is complete

ovo-vegetarian diet

the only animal foods consumed are eggs

when full compensation has occurred, you will know because...

the pH is within normal limits

what is a pulse deficit?

the peripheral pulse rate (radial) is less than the ventricular contraction rate (apical)

how does physical exercise affect body temp?

use of the large muscles creates heat, causing an increase in body temp

when is vented tubing necessary?

use vented tubing for glass or rigid plastic containers to allow air to enter and displace the fluid as it leaves; fluid will not flow from a rigid IV container unless it is vented.

mineralcorticoids treat what?

used for replacement therapy in primary and secondary adrenal insufficiency in addison's disease

indication for cryoprecipitates

used to replace clotting factors,especially factor VIII and fibrinogen

commonly used herbs and health products: Valerian

used to treat nervous disorders such as anxiety, restlessness, and insomnia

how often should you check blood sugar for PN patients?

usually every 4 hours because of the risk for hyperglycemia

common drug resistant infections

vancomycin resistant enterococci methicillin resistant staphylococcus aureus multidrug resistant tuberculosis carbepanem resistant enterobacteriaceae

vaccines administered intramuscularly are given where?

vastus lateralis muscle (best site) ventrogluteal muscle deltoid can be used for children 36 months or older

vegan diet

vegans follow a strict vegetarian diet and consume no animal foods

food sources of vitamin E

vegetable oils green leafy vegetables cereals apricots apples peaches

symptoms of thrombophlebitis

vein inflammation aching or cramping pain vein feels hard and cordlike and is tender to touch elevated temp

which sites are acceptable for peripheral IV?

veins in the hand, forearm, and antecubital fossa