NCLEX

intimate partner violence (IPV)

-abusive partner often demonstrates jealousy/possessiveness -victims may not leave due to financial concerns or fear of harm by abuser -violence against females often increase during pregnancy -occurs in all religious, socioeconomic, racial, hetero/homo groups equally think IPV is EQUALITY *is NOT most common in one specific group

Lobes of the brain and functions

Parietal: sensory input think "pain, paresthesias" frontal: behaviors/actions--controls personality think "I shouldve had a V8" *broca's (expressive) aphasia= cant speak occipital: visual images temporal: auditory input/visual *deficit here means can't understand verbal/written language *wernikes (receptive aphasia)

PE vs brain embolism--priority?

afib--embolism can cause stroke DVT-- embolism can cause PE *this pt is higher risk cause PE goes to resp!

Meds contraindicated in glaucoma

atropine!! cyclopenolate -->any mydriatics (cause pupil dilation) levodopa diphenhydramine, ephedrine (allergy meds) anti-cholinergics! anti-emetics (have anti-cholinergic effects) tricyclic anti-depressants/SSRIs scopolamine (transdermal patch) for motion sickness= anti-cholinergic effects

Ziprasidone

atypical antipsychotic (think "rispiradone) rx= acute bipolar mania, acute psychosis, agitation risk= QT PROLONGATION-->TORSADES DE POINTES -take baseline EKG and K+ -place on cardiac monitor -monitor for hypotension and seizures -increased AEs with alcohol

Sjogren's syndrome

autoimmune destruction of minor salivary glands and lacrimal glands sx= decreased tears and saliva production DRY EYES AND DRY MOUTH, dry everything mucous membranes! chronic dry cough rx= alleviating symptoms! OTC artificial tears wear goggles artifical saliva/sugar free gum to chew room humidifier OTC lubricant for vaginal dryness shower with lukewarm water and avoid harsh soaps REGULAR DENTAL EXAMS *AVOID nasal decongestants--cause further dryness, other irritants= coffee, alcohol, nicotine acidic drinks sip water frequently!

separation anxiety fear of strangers time periods for both

begins 6 mo, peaks 10-18 mo, ends 3 years begins 7 mo ends 8 mo--fear of strangers

Meds to manage EPS (extrapyramidal side effects) antidote?

benztropine or trihexyphenidyl benztropine for= pseudoparkinsonism/dystonia

Greatest risk from laparoscopy?

bladder/bowel perforation! admin possible bowel prep before to decrease risk; indwelling catheter for bladder decompression during procedure give CO2 before to dilate abdomen, causes shoulder/back pain after

Carbidopa/Levodopa

combo med helpful in treating bradykinesia in parkinson's *never stop abruptly-->can cause akinectic crisis! (complete loss of movement) takes several weeks to come into effect can turn urine red brown AE= ortho hypo

Sulfa med SEs

crystalluria (drink lots of fluids) photosensitivity folic acid deficiency stevens johnsons syndrome

special considerations CPR/ defib infant CPR

do NOT stop to check pulse after initiate shocks, cont CPR!!!!!!! FOR TWO MIN, then check pulse *if NO SHOCK ADVISE, continue compressions! DO NOT check for pulse (wait 2 min then check) ALWAYS CHECK PULSE AFTER/EVERY 2 MIN (except if just delivered shock), no longer than 10 second pause *IF a first responder and someone already doing chest compressions, FIRST PRIORITY IS TOG ET DEFIB AND APPLY PADS (not bag valve O2) ADULT CPR: 30:2 ratio compressions of at least 2 in--no more than 2.4 in full recoil after each minimize interruptions (>60% time should be compressions) -hand placement center of chest, lower half of sternum rate= 100-120/min *if pt has advanced airway--continuous compressions and 10 breaths/min should be provided (1 breath q 6 sec)--via ambu bag *if pt has pulse but not norm breathing, deliver rescue breaths q 5-6 sec (10-12/min) w/ cont chest compressions *if pt has no pulse, deliver cycles of 30:2 defibrillator pad placement: 1. right of sternum below clavicle 2. left of anterior axillary line (5th-6th ICS) *recall, DEFIB for VFIB and Pulseless V Tach DO NOT DEFIB for Asystole/PEA *for asystole/PEA, just do CPRx2 min, oxygen, epinephrine q 3-5 min, check pulse q 2 min *keep providing this until circulation spontaneously occurs OR pt goes into shockable rhythm--then cab defib! *if pt asystole on monitor but awake and fine, check lead connections to make sure proper place & pulse scenario: you are alone and find PEDIATRIC pt pulseless not breathing, what is your first action? DO 2 MIN CHEST COMPRESSIONS If still no one comes after, THEN CALL 911 --if scenario was an adult pt witnessed alone, call 911 first! then CC --for pt with a trach and mechanical ventilator going into cardiac arrest, disconnect the pt from the ventilator and give resuce breaths using a bag valve device INFANT CPR: (<12 mo) single rescuer= 30:2 ratio check infants BRACHIAL pulse no longer 10 sec shout help nearby (<1 yr) *******brachial is located halfway between shoulder and elbow on medial aspect of arm--palpate with 2-3 fingers activate emergency response system (call 911) provide approx 2 min CPR at rate 100 compressions/min THEN retrieve the AED *chest compressions should be 1/3 AP diameter (1.5 in) and allow full recoil between two techniques for compressions: 1. two fingers (index and middle) on sternum just below nipple line (not too far!), with other hand support the back -->prefer if single rescuer or umbilical access needed 2. two thumbs on the middle third of sternum (preferred method) just below the nipple line, fingers encircling chest and supporting the back -->improves cardiac perfusion *do not lift thumbs/fingers during relaxation phase two rescuers: 15:2 ratio

Mumps

droplet precautions sx= HA, fever, malaise, parotid gland swelling isolation before and after appearance of swelling-->soft, bland diet complications: deafness, meningitis, encephalitis, sterility

kidney biopsy positioning

during: prone *have pt hold breath during needle insertion after: pt on affected site for 30-60 minutes; bed flat; bedrest 6-8 hrs (like liver!) pressure dressing applied and pressure on site for 20 min

crisis considerations

explore coping methods (how pt coped n past, and how to improve on current coping strategies)

bladder cancer

hallmark= PAINLESS HEMATURIA cause= #1= CIGARETTE SMOKING/tobacco use fam hx occupational carcinogen exposure high fat diet, artificial sweeteners

aPTT

heparin normal range= 25-35 sec 1.5-2.0x this is therapeutic--> therapeutic range on anticoag= 46-70 (1 1/2 -2x norm value) give IV and SQ

How does fever affect VS?

increased Temp, HR, BP, RR everything increase!! *recall in shock however, if have infection (septic) will see increase HR/RR and decrease BP

Operative vaginal birth (vacuum extractor or forceps)

indication= maternal exhaustion cardiac or CVD abn FHR/arrest of rotation forceps gently applied to side of fetal head, lock handles in place, and apply traction during contractions to facilitate rotation and descent of fetal head NEVER APPLY PRESSURE TO FUNDUS DURING OPERATIVE VAG BIRTH CAN CAUSE UTERINE RUPTURE *have pt empty bladder before *nurse tells HCP when contractions are palpated

CT considerations

not recommended in pregnancy unless benefits outweigh risk (contrast may be harmful to fetus) assess for allergies to seafood, iodine, and other contrast dyes when have contrast CT

Stress induced Hyperglycemia

occurs in hospitalized clients often r/t surgery, trauma, acute illness, infection esp those who are critically ill, even if not diabetic target glucose range= 140-180 in critically ill pts (to avoid hypoglycemia and minimize comps)

Valsalva maneuver contraindications

patients with increased ICP, stroke, head injury heart disease (MI, HF) portal HTN, cirrhosis--variceal bleeds abdominal surgery glaucoma, recent eye surgery (cataracts)

Piperacillin and Piperacillin/Tazobactam

penicillin antibiotic *check allergies before obtain specimen for culture and sensitivity (MUST BE COMPLETED PRIOR TO STARTING ABX!) obtain pt creatinine clearance results

scleral buckling

procedure to repair a detached retina post-op: avoid things that increase intraocular pressure!! (prevent N/V, bearing down, rapid movement of eyes) should be no drainage

How often check residual/patency of NGT? How much saline or water to flush NGT? irrigating? How often change NGT feeding bag?

q 4 hours! 15-30 mL or according to policy, irrigate with 30-50 mL every 24 to 72 hours what is considered abn residual? high gastric residual volumes >250 mL, in pts receiving enteral feedings

hysterosalpingogram

radiographic image of the uterus, fallopian tubes, and cervix *requires contrast medium (assess for allergies)

Esophageal cancer

risk factors= smoking alcohol obesity nitrates (pickled foods, beer) deficient intake fruits/veggies extreme hot beverages underlying esophageal disease GERD--> barrett's esophagous Barrett's esophagous: develops from obesity and uncontrolled GERD *salty foods at increased risk with gastric cancer, NOT esophageal!

Neuropathic Pain

sx= "numbness and tingling" conditions that cause= -diabetic neuropathy (most common): sock and glove pattern (felt on lower arm and leg extremeties) -autoimmune (guillane barre) -toxic (alcohol use)

pancreatic tumors surgery for this? diet?

sx= weight loss, jaundice, upper-mid abd discomfort (early) fatty food intolerance (belching), nausea (late signs) sx= whipple procedure!! diet= high cal, bland, low fat, small frequent feedings avoid alc

Zika Virus

transmit via mosquitoes, sexual contact, infected bodily fluids sx= low grade fever, arthralgias *teach pregnant: AVOID TRAVEL TO AREAS WITH ZIKA until after birth! can cause teratogenic effects= microcephaly, development dysfunction, encephalitis to prevent= mosquitos precautions (insect repellent containing DEET) -safe sex practice -routine zika testing

Pressure Ulcer/Injury Prevention

use emollients/barrier creams for skin foam padding on surfaces prompt incontinence care turn pt q 2 hrs DO NOT MASSAGE--Not helpful for PIs! risk factors= malnourished (prealbumin <16) norm 15-36 anemic poor oxygenation-->hypotension/vasopressors edema INFECTION (immunocompromised)/fever limit mobility older incontinence chronic illness long bone or hip fx

SLE considerations

*women with SLE should wait until they have been in remission for 5 mo before getting pregnant *wait 2 yrs after diagnosis before conceiving *women with SLE have higher maternity morbidity and mortality rates

Droplet precautions

-rubella, pertussis, mumps, diphtheria, adenovirus infections, influenza, haemophilus/meningococcal meningitis (bacterial), influenzae, PNA *viral meningitis does not require droplet -private rm, door can be opened -PPE (must wear mask in room--gown/gloves required if contact with bodily fluids) -surg mask on pt w/ transport -keep visitor 3 ft from pt doffing: wash hands then remove mask and throw away when transporting: have pt wear mask (transporter does NOT need to wear one just pt)

Meds to avoid grapefruit juice

ACLS A-anti-anxiety C- L- Lipid-lowering agents (statins) S- anti-seizure meds +dextromethorphan hydrobromide (antitussive)

AED placement

adult pads for adult: right of sternum, below clavicle other left of cardiac apex child </= 8: -->use pediatric pads! front and back *can place adult pads on child (as long as they dont touch or overlap), cant place child pads on adult

Nystatin

antifungal (rx candidal infections) teach= -pts wearing dentures are to remove and soak them in med -assess affected area -liquid suspension: swish med in mouth for several minutes then swallow -ensure shaken well before measured -take for at least 48 hrs after sx subside

clear liquid diet

any liquid can see through jello tea coffee popsicle!! ginger ale bouillon (broth), clear fruit juice without pulp (apple, grape) carbonated beverages (sprite, ginger ale) *exception: if pt has GI bleed, avoid red dyes in clear liquids (red gelatin, cherry popsicles) gives false lead of bleeding

Talipes quinovarus

club foot! sx= adduction/inversion of feet with either plantar or dorsiflexion rx= foot exercises regularly every 4 hours casts and splints to correct deformity changed every few days for 1-2 weeks, then every 1-2 week intervals changed

birth weight normals

doubles by 6 mo of age triples by 12 mo of age

laryngectomy post op speech techniques considerations

esophageal speech: pt swallows air then eructates it in esophagous electric larynx: holds battery powered device over side of neck to speak (cannot sing, whistle, or laugh using laryngeal communication) post-op: requires nutritional support for 10 days until wound heals (NGT), then gradually resume oral intake will require laryngectomy tube (like trach tube) so can breathe encourage cough/deep breathe difficulty with taste/smell post-op

MI considerations

everything elevated! ESR CK-MB elevation seen in 3-6 hrs, faster than troponin seen in 4-12 hrs myoglobin LDH ECG: elevated ST segment, T wave inversion, Q wave formation post-care: rest!! can use bedside commode 2,000L intake semi-fowler position

positional plagiocephaly

flat head syndrome due to infants soft, pliable skull care= -frequent alteration of supine infants head position side to side -minimize amount of time infant head rest against firm surface (car seat) -place pics/toys opp the favored (affected) side to encourage turn head -place infant in prone position 30-60 min/day for "tummy time"--monitored! NEVER PLACE INFANT PRONE, EVEN FOR DAYTIME NAP-->SIDS

Travel during pregnancy

get HCP approval for long distances *domestic travel usually allowed for healthy pts age <36W G safety: -carry updated copy of prenatal record -increase fluid intake (dehydration=thrombus) -secure lab belt: UNDER ABDOMEN, ACROSS HIPS -shoulder belts: LATERAL TO UTERUS BETWEEN BREASTS -wear compression stockings/unrestrictive clothing -avoid travel to Zika or Malaria areas, remote areas with poor medical care/lack sanitation -walk q 1-2 hrs

What are normal glucose ranges for non critically ill pts?

hospital pts: fasting= <140 non fasting (random blood glucose) <180 non-hospital norm pts: 70-110 is normal range

home health pt referrals

indicated for pts who will need eval if can adequately take care of needs at home (physical probs, conditions that may cause sx at home pose danger) *pts who may not have expected outcomes

induction of labor

indicated if concern of well-being of mother and baby (DM, HTN, postmaturity, fetal jeopardy) to be able to induce: fetus must be engaged head VERTEX presentation (occiput) mom has ripened cervix (soft & dilated) contraindiations: mother CANNOT HAVE CPD (cephalopelvic disproportion)--baby can't fit through mom's pelvis (too big, pelvis too small) external monitoring whole time *prep for amniotomy (ROM) oxytocin admin

Cholecystitis

inflammation of the gallbladder sx= murphy's sign! pain in RUQ that radiates to right shoulder (think gallbladder location) n/v--anorexia! restlessness, diaphoresis; low grade fever; leukocytosis indigestion fatty food ingestion (1-3 hrs before onset of pain) rx= NPO during N/V-->HIGHEST PRIORITY! (to avoid gallbladder stimulation) NGT to low suction for severe vomit position= semi-fowler's -IV fluids (during N/V) -analgesics (NSAIDs), antiemetics, abx if need, antipyretics if need

carpel tunnel syndrome test?

median nerve compression sx= pain, paresthesias over first 3 1/2 fingers, NUMBNESS, weakness rx= wrist immobilization splints! (particularly at night) *may require surgery to permanently relieve sx phalen's maneuver: flexion of wrist compresses nerve inside carpal tunnel teach= AVOID WRIST FLEXION/EXTENTION and elastic compression hose! (worsens sx)

Methods to warm a newborn

place skin to skin contact, cover with warm blanket place a hat/cap on babys head place the dry/diapered newborn under a radiant warmer (*only need to be diapered under this) *if blanket used to wrap infant, must be prewarmed *do NOT give warm bath, will loose heat to evaporation

what is the best method to increase med adherence?

write a schedule of when the med should be taken

Magnesium Dietary Sources

"Always Get Plenty Of Foods Containing Large Numbers of Magnesium" Avocado Green leafy vegetables Peanut Butter, potatoes, pork Oatmeal Fish (canned white tuna/mackerel) Cauliflower, chocolate (dark) Legumes Nuts Oranges Milk also: bananas

potassium dietary sources

"Potassium" Potatoes, pork Oranges Tomatoes Avocados Strawberries, Spinach fIsh mUshrooms Musk Melons: cantaloupe Also included are carrots, raisins, bananas, apricots, beans, celery

calcium dietary sources

"Young Sally's calcium serum continues to randomly mess-up" Yogurt Sardines Cheese Spinach Collard greens Tofu Rhubarb Milk

what is an acute subarachnoid intercerebral bleed OR cerebral aneurysm rupture manifested as?

"worst headache of my life" *worse than previous migraines in past cerebral aneurysm often can be asymptomatic and go many years undetected before rupturing

MAP (mean arterial pressure) formula

(SBP + 2DBP)/3 *tells the average pressure within the arterial system felt by the vital organs norm= 70-105 *if pt has >60, still considered adequate tissue perfusion (not shock state) MAP <60 will not allow for adequate perfusion to vital organs (under-perfused and ischemic)

MAP calculation

(SBP + 2DBP)/3 norm= 70-105 *need at least 60 to perfuse vital organs *indicates perfusion to organs/tissues

Wilms tumor

(most common) malignant tumor of the kidney occurring in childhood (nephroblastoma) sx= unusual abd contour (overdistended) once confirm dx: DO NOT PALPATE ABDOMEN--hang sign at bedside!! PRIORITY ACTION *do not massage, can disseminate cancer cells

ABG acid base imbalances

*ABGs are best test to evaluate pt's oxygenation (PaO2) and ventilation status (paCO2) metabolic acidosis= causes (DIARRHEA--looses bicarb!, DKA, lactic acidosis, renal failure, salicylate toxicity) --> treat by admin IV Bicarb (HCO3) metabolic alkalosis: causes= excess VOMITING (loose stomach acid) factors that can alter ABG draw: suctioning within 20 min prior to draw changes in pt's activity level/oxygen settings

Growth and Development normal/expected findings in children

*BOW LEGS ARE NORMAL FINDINGS *until 7 hrs old then have straight legs S3 heart sound is expected!

Antidote to stimulants (caffeine, methamphetamine, cocaine)

*Benzos! (Alprazolam)

Self blood glucose monitoring considerations

*DO NOT milk finger after sticking it (puts interstitial fluid mix with capillary blood, dilutes blood) okay to dangle hand before sticking finger with lancet to facilitate venous congestion stick finger on distal side of phalanx touch strip with large drop of blood hanging from fingertip , do not smear

Dementia

*affects recent memory loss-->pt will forget even when teach them something on spot *encourage to talk about past due to this (reminisce!)

float nurse assignments

*consider two factors: Pt that is MOST STABLE, unchanging, standard procedures PT that has condition MOST RELATABLE to float nurses home unit experience! *if float nurse is not confident for skills on that unit, first action is to: CLARIFY THE SKILLS/KNOWLEDGE THE NURSE IS ABLE/UNABLE TO PERFORM ON UNIT (dont tell someone else to go instead) *the float nurse can't refuse to go to a unit--legal disciplinary action can be taken!

St. John's wort drug interactions

*interferes with metabolism of other drugs - Serotonin syndrome when taken with antidepressants or stimulants--avoid!! -decrease INR in anticoags -digoxin -HTN crisis (MAOIs)

AMA (against medical advice) requirements

*pt must be LEGALLY COMPETENT to make educated decision to stop treatment disqualifications= -altered LOC or lack of -mental illness (danger to self or others) -chemical influence (under alcohol/drugs) -court decision (seeks custody after parents refuse life saving treatments) if pt is competent: HCP must explain risks of d/c treatment nurse must witness and doc discussion on risks of leaving AMA and pt's understanding of this "informed refusal" -should receive d/c instructions and option to return any time still

toddler growth and development

*temper tantrums/imitation!! all normal (not speaking is abn!) *need for control (autonomy) offer choices!! --when give med offer choices of juice with it -negativism is common (like to say no--think terrible 2's--so avoid asking y/n q's) *night fears common at this age too -->handle by looking under bed with child (acknowledge fear), reassure none there 15 month: WALKS ALONE CRAWLS UPSTAIRS ***builds 2 block tower throws objects grasps spoon names commonplace objects 18 month: (1 1/2 yr) ANTERIOR FONTANELLE USUALLY CLOSED walks backwards WALKS UP AND DOWN STAIRS with help scribbles ***builds 3-4 block tower ***VOCAB: 10 WORDS OR MORE great at mimicry, identifies common objects CAN USE UTENSILS! can hold drink from a cup! TOILET TRAINING 18-24 Mo turn 2-3 pages in a book *some may still be bottle fed at this time, is norm 24 month: (2 yr) early efforts at jumping WALKS UP/DOWN STAIRS ALONE ***builds 6-7 block towers turns book pages one at a time 300 WORD VOCAB (phrases of 2-3 words) states own name! obeys easy commands drinks from a cup! use doorknob to open door REFERRAL MADE IF UN-INTELLIGIBLE SPEECH by now CHEST CIRCUMFERENCE EXCEEDS ABD CIRCUMFERENCE head circumference increases by 1 in during 2nd year, then slows to growth rate of 0.5 in per year until age 5 AP DIAMETER NOW BECOMES 1:2 (before is 1:1) 30 month: (2 1/2 yr) walks on tiptoe jumps with both feet BUILDS 8 BLOCK TOWER stands on one foot has sphincter control (toilet training) WEIGHT SHOULD BE 4X BIRTHWEIGHT TODDLER ASSESSMENT: -encourage parental involvement -use age approp. games/toys if need -minimize physical contact initially, have parents remove outer clothing -keep med equipment out of sight -order: LEAST TO MOST INVASIVE (ears, nose, mouth toward end of visit) HOSPITALIZATION CARE: rituals and routines parents sleep overnight with child--rooming in take to playroom (good for children of all ages!) NUTRITONAL NEED: *toddlers have decreased need and appetite (slowed metabolic growth) *picky eaters about food choices and eat schedules *teach fam= DO NOT FORCE FEED or PRESSURE TO EAT MORE--leads to poor future eating habits instead... -offer 2-3 high quality food choices (provide options)--no y/n q's -keep portions small -avoid distractions during meals/snacks (tv, toys) -expose child to new foods repeatedly -offer 15 min cool down period before eating after physical activity consider for snacks: safety (not small, hard, sticky, slippery foods), could choke! -nutrients (high protein, vitamins) avoid empty calories= sugars -food borne infection (partially cooked eggs, raw fish/bean sprouts) healthy snacks= pieces of cheese, whole wheat crackers, banana slices, yogurt, cooked veggies, cottage cheese with thin sliced fruit

L/S ratio (lecithin/sphingomyelin)

- Used to evaluate lung maturity - LS stabilizes neonatal alveoli to prevent collapse on expiration - Normal value is 2:1 or ↑ (indicates lung maturity) - If mom has DM the ratio should be 3.5:1 or ↑ *if normal value and mother ready to give birth, labor will procede naturally (do not induce)

Neutropenic precautions

-private room -strict handwashing -avoid exposure to people who are sick -avoid all fresh fruits/veggies/flowers -ensure all equipment is disinfected

reconstituting a parenteral med

1.hand hygiene 2. withdraw air from vial (equals prescribed diluent amount) 3. inject diluent into vial (NS, Sterile water) 4. ROLL the vial (do not shake!) between palms of hands to gently mix solution (such as if powdered) 5. withdraw reconstituted med from vial into sterile syringe

calcium requirement for adolescents and adult females?

1000-1300 mg/day

normal fluid intake

1500-2000

To determine safe patient transfers

2 factors: can pt bear weight? yes (no assist/ 1 person stand-by) partially (1 person gait belt pivot transfer, or motorized assist device if cooperative) no (2 person w/ full body sling if uncooperative; motorized assist device if pt cooperative/has upper body strength) is pt cooperative? No? 2 person assist w/ full body sling

How many calories per week do you have to loose for 1 lb per week?

3,500 calorie expenditure= 1 lb weight loss

How early before procedure give sedative?

30 min prior

normal ICP pressure

5-15 mmHg

Normal blood gas oxygen level (PO2)

80-100 mm Hg

Beers Criteria

A list of medications that are generally considered inappropriate when given to elderly people due to their risk outweigh benefits: ex: sulfonylureas (gluburide)--prolong hypoglycemia (metformin OKAY to subsbtitute)

Dexamethasone

AE= HTN

tetracycline

AEs photosensitivity (wear sunscreen), diarrhea, GI upset, glossitis, dysphagia, super infection, hypersensitivity *nephrotoxic! take med on empty stomach--1 hr AC or 2 hrs PC with full glass of water, stay sitting up >30 min after (pill-induced esophagitis)--not at bedtime! *NOT SAFE DURING PREGNANCY or less than 8 yrs (will stain teeth)

Emergency/Trauma Assessment

Always think for ED q's and triage: first priorities are (primary survery) "ABCs" GCS/LOC E= exposure--remove clothing/prevent heat loss THEN (secondary survey) move into VS treat pain head to toe assessment

Meds that cause orthostatic hypotension

Anti-HTN (BBs, and alpha blockers--terazosin) diuretics antipsychotics (atypical) antidepressants (SSRIs) Narcotics Vasodilators (NTG, hydralazine) *avoid walking in hot weather, hydrate! (take meds at bedtime if approved by HCP)--not all tho sx= nausea! lightheadedness

Aminophylline

Bronchodilator AEs= palpitations, nervousness, tachycardia, nausea, seizures *decrease caffeine intake

trigeminal neuralgia DOC

Carbamazepine AE= agranulocytosis (severe leukopenia) infection risk!! report sx soft, warm food, high cal diet (foods easy to chew) placed on unaffected side; soft bristled toothbrush cotton pads if need to massage face

Hyperphosphatemia Hypophosphatemia

HYPER: rx= calcium acetate, sevelamer lanathanum carbonate norm phos= 2.4-4.4 HYPO: rx= muscle weakness, resp failure

What is body's response to fever?

Increased RR, HR, warm skin, and diaphoresis

Naegele's Rule

LMP- 3 mo, + 7 days + 1 yr= EDB (estimated date of birth) *LMP is the FIRST day of the last menstrual period!

delegation (RN to LPN/ UAP) things I missed

LPN: CAN MONITOR, CAN REINFORCE TEACHINGS, CAN PERFORM STERILE PROCEDURES (keep in mind, all on STABLE pts!) CAN take suicide pts who are stable (admin after attempt, needing PO meds)--will have 1-1 supervision CAN auscultate lung sounds, bowel sounds neurovascular checks (pulse, cap refill, numbness) Can admin enteral feeds/ program pump! can perform ostomy care CAN perform catheterization, suctioning CAN monitor color of drainage, stoma etc (and report abnormal findings to RN) CAN MEASURE and apply compression devices reinforce teachings already initially done by RN monitor pain/admin pain meds, titrate O2 levels, measure Peak expiratory flow with flow meter can monitor things, RN just must do initial admission, discharge and postoperative assessments! *okay to delegate tasks that the UAP would better perform to LPN if question only has RN and LPN in it! (and is not specifically asking which would be best for a lpn vs a uap)...it is okay to delegate tasks "below scope of practice" based on staff avaliability UAP: CAN (and must) REPORT, CANNOT REINFORCE TEACHINGS, CANNOT PERFORM STERILE PROCEDURES (foley cath specimen collection--they can perform urine specimen collection as long as not in foley, however) CAN TRANSPORT A PT TO THE MORGUE (just like can take fam members to waiting room) positioning: MUST have RN to assist with spine cord/unstable pts (8 hrs postop hip replace)--requires nursing assessment traction pts: -CAN perform ROM -can apply pneumatic compression devices -can remind pt to move frequently using overhead trapeze -do not log roll pt on own from side to side (if changing bed linens, have pt life self up over trapeze) CAN TEST BLOOD GLUCOSE! and obtain a clean catch specimen! CAN pick up blood from blood bank, and return! (as well as retrieve abx from pharmacy!) can measure VS prior to and at end of blood transfusion--RN MUST TAKE VS FIRST 15 MIN CANNOT reinforce teachings done by RN!! (this is LPN scope) but CAN reinforce procedures/principles of infection control regarding precautions--after nurse done initial instructions... (however, cannot call other departments to communicate pertinent pt info--i.e. telling x-ray pt is on airborne precautions so to maintain this) CAN remind pt to use incentive spirometer/ fam to keep HOB elevated (but nurse has to do first teaching!! move frequently using overhead trapeze (change linens while pt lifts themself with trapeze) can assist nurse during a procedure (holding part of pts body--tissue open while nurse inserts foley) CANNOT monitor something after nurse has assessed (this is scope of LPN) CANNOT ask pt pain level scale 1-10 and report back to nurse, nurse must do pain assessment! CANNOT escort a disgruntled fam member off the unit (done by unit security) cannot measure compression stockings (just can apply), cannot verify wrist restraints (things require eval/analyze) cannot report what urine looks like (is assess), just record I/O--can tally I/Os for entire unit CAN tell nurse what pt ate for lunch (is objective), and nurse will assess what this means CAN escort fam members to waiting room after pt goes into surgery CAN reapply NC if falls off, just cant titrate o2 (has to be at preset level) CAN only change dressings for chronic wounds requiring clean technique RN: must do ADPIE (assessment, dx, planning, eval, teaching) -must do IV meds/blood transfusions -monitor anticoag/antiplt infusions -baseline VS (then can delegate to LPN other VS after stable)

brainstem function and parts

Midbrain Pons Medulla Oblongata= rate and depth of respirations

What should be moved away prior to cardioversion/defib?

OXYGEN!! (turn off and move away) is flammable and may explode with electric currents

Creatinine Clearance test

24 hour urine collection done blood drawn for creatinine level at end of urine collection (to see how well kidneys cleared creat over 24 hrs) *do NOT eat high protein content before test (may increase creat clearance and alter test results)

EKG interpretation

PR 0.12-0.20 QRS <0.12

Gravida/Para

G - number of pregnancies (total) P - number of births after 20 weeks

Best way to detect subtle neuro changes in client?

GCS!

NSAID AEs

GI distress-take with meals!! tinnitus ototoxicity!! (indomethacin) black box (with cox-2 inhibitiors/ celecoxib_= increased ris for cardiovascular events!!

Nasoenteric tube considerations (nasojejunal, nasoduodenal)

Place using stylet with metal wire running through tube to facilitate advancement (can be done by nurse!) *have pt sip water while insert tube (like NG) *stop advancing tube when pt is inhaling or coughing and cont insert when pt able to swallow again *once tube inserted, MUST OBTAIN CXR correct placement in intestine, TEHN CAN REMOVE STYLET to allow tube feeds *NEVER REINSERT THE STYLET --when feeding tube in place (to avoid gut perforation) *if tube becomes improperly placed, must remove tube and start over *if pt start becoming dyspneic, crackles in lungs, FIRST action is STOP FEEDING ASAP AND CHECK TUBE LENGTH as could have dislodged to lungs!

Necrotizing enterocolitis

Pre-term infants have lower immune function, bacteria proliferate in bowel and cause ischemia and air in the bowel. Dx: thin curvilinear lines of lucency

Panic Attack

Priority intervention= REMAIN WITH THE PT room with as little stimuli as possible calm speaking, simple phrases and words anti-anxiety med if need pt take slow deep breaths if hyperventilation an issue

cor pulmonale

RSHF!

What is purpose of NPO prior to surgery?

Reduce risk of aspiration and post-op N/V

SCI (spinal cord injury) locations and S/Sx autonomic dysreflexia S/Sx & interventions

SCI= decreased HR/BP (altered temp, edema, loss of sensation/paralysis below level of injury) intervention= IMMOBILIZE CERVICAL SPINE locations= C3 and above= resp paralysis can occur! (higher in Cervical injury) worse the function for pt is *cervical injury= tetraplegia *thoracic injury=paraplegia (begins affect abd muscles) T4 and above= resp affected T11- T6= decreased resp reserve T1-T4= have good upper extrem muscle strength (still need wheelchair) L3-L5= may need crutches or canes for ambulate (pelvis func intact) L5-S3= waddling gait; can ambulate *if pt suddenly gets an SCI (car crash, etc) first interventions are/ suspected Cervical Spine Injury: 1. Assess for breathing and a pulse, patent airway 2. Apply rigid HARD cervical collar (to immobilize the spine) *not soft! 3. place on firm surface/backboard (after cervical spine been stabilized w/ collar) 4.-->move the client by logrolling if required 5. Perform GCS, obtain baseline VS (monitor for neurogenic shock) 6. If pt not breathing, or airway occluded, use the JAW-THRUST TECHNIQUE (lift jaw up w/ fingers) ***CONTRAINDICATED IN SCI= the head-tilt chin lift-->can hyperextend neck and compromise cervical spine! *pts with SCI should have their BP checked always when report HA because... AUTONOMIC DYSREFLEXIA= decreased HR/ increased BP, nasal congestion, pounding HA, profuse sweating, piloerection (goosebumps), nausea, blurred vision flushing *caused by sudden spike in BP due to stimulus at or above level of T6 SCI common triggers= bladder/bowel distention/irritation pressure ulcers interventions= FIRST THING: SITTING POSITION ASAP -->even before take BP (to reduce BP, reduces cerebral hemorrhage risk)! treat stimulus! (bladder/bowel= catheterize/fix kink in cath/remove fecal mass w/ impaction) (pain/tactile stimulation)= loosen restrictive clothing, give hydralazine IV slow med= notify HCP, nifedipine may be prescribed position= HOB elevated 45 or High fowlers (to reduce BP)

Citaprolam

SSRI!

osteoporosis what types of exercises?

Weight-bearing exercises

what is required in a kidney ultrasound?

a full bladder!

hoyer lift

a piece of equipment designed to raise a patient slowly above a surface to assist in transferring the patient to another surface obesity or can't move with other techniques 2 person job

Rule of nines calculation

4 mL x (weight kg) x %TBSA= IV fluid vol resuscitation for 24 hrs (mL) divide this ^ by /2 will give you first 8 hrs fluid vol resuscitation in mL

rotator cuff injury

4 shoulder muscles and tendons allow for rotation of arm tear can occur over time due to aging, repetitive use, injury, sports sx= SHOULDER PAIN AND WEAKNESS *severe pain when arm is abducted 60-120 degrees (painful arc)

Position with hip implants

abduction always!! do not flex beyond 60 degrees, internal rotate or adduct

complications of HRT (hormone replacement therapy)

abnormal clotting/DVT

Pneumococcal vaccination

admin beginning at 65 yrs, and every 5 years thereafter *high risk groups give younger than 65

hydrochloroquinolone

antimalarial, more commonly used to treat SLE exacerbations AE= retinal toxicity/ visual disturbances must have eye exams q 6-12 mo

baclofen

antispasmodic used in SCI/ MS AE= dizziness (ortho hypo)

ASA considerations

avoid "G" herbs contraindicated in peptic ulcer disease

Acute Diarrhea in children care

avoid anti-diarrheals (not recommended, can cause paralytic ileus in children) oral rehydration priority!! sx of dehydration--monitor (decreased wet diapers, etc) use skin barrier creams avoid the BRAT diet (stick to infants norm diet) -->brat doesnt provide enough energy

Pica

common substances= ice, cornstarch, clay, dirt, paper *often in pregnancy, with iron- deficiency anemia (order HgB and HCT levels to assess for anemia) *contributes to lead toxicity (plumbism)--watch!

atopic dermatitis

eczema! sx= pruitis, erythema, dry skin goal= alleviate pruitis, keep skin hydrated, prevent secondary infections rx= -tepid baths, gentle soap -short nails! avoid scratching!! -gently pat skin dry -soft clothing, wear long sleeves at night -avoid heat/low humidity -may need hypoallergenic diet

hepatomegaly

enlargement of the liver sx= boggy liver edge below the rib cage normal expected liver finding= soft, distinct liver edge even with bottom or right rib cage (right coastal margin)

subdural vs epidural hematoma

epidural=arterial (sx= loose consciousness at time of impact, then regain quickly and feel well for some time after injury= LUCID INTERVAL, then followed by quick decline in mental function that can progress to coma/death) subdural= venous, slower (sx not seen for 24-48 hrs after)

catheters with highest risk infection catheter considerations

femoral! (emergency line often placed, remove ASAP) PICC lines can stay inserted for weeks to months prefer subclavian or jugular cause lower risk PIVs should not be removed/replaced w/thin 72-96 hrs of placement unless complications arise

Ciprofloxacin

flouroquinolone abx known to put pts at risk for c. diff dont need to have blood draws avoid sunlight

palvik harness care

for DDH (newborns to 6 mo) *teach parents: worn full time 3-6 mo, HARNESS IS NOT TO BE REMOVED because of this recommend: sponge bath clothing underneath check skin 2-3x daily avoid lotions/powders gently massage for circulation

purpose of heat/cold rx

heat= helps aid in movement cold= helps decrease swelling/inflammation

CD4 low counts (infants, child, adult)

infant (12 mo or younger): <750 child 1-5 yrs : <500 child > 5 and adults: <200 CD4 lymphocyte percent <15% is consider severely immunocompromised!

Vitamin toxicity--which one would be the major concern

iron ingestion! (minerals/childrens multis arent major concern)

cloudy vs clear insulin?

isophane (NPH) is cloudy regular insulin is clear *regular insulin is only insulin that can be admin IV PUSH and IV!!!!!!!

dependent personality disorder

lacks self confidence depends on others for decisions!! AFRAID OF CONFRONTATION

Anti-dysrhythmics

lidocaine, procainamide, quinidine

Foods containing phosphorous

milk, dairy

normal SVR (systemic vascular resistance)

800-1200 dynes *indicates resistance in circulatory system (vessels) vasconstriction= increased SVR vasodilation= decreased SVR

para plegia hemi paresis

para= one half of body (lower) plegia= paralysis hemi= one half (side) of body (left/right) paresis= weakness

prone position

promotes extension of hip joint not well tolerated by persons with resp. or cardiovascular difficulties

cephalosporin considerations

puts pt at risk for cdiff (common SE= diarrhea) cross-sensitivity to pts w/ penicillin allergies! hold if anaphylactic rx, if mild rx (rash) may be able to still give first assess pts rx to allergy, then notify HCP

troponin levels

<0.5 ng/mL= normal (no muscle injury) *tells if have MI (cardiac muscle injury)

BNP (brain natriuretic peptide)

<100 pg/mL = norm marker for HF, helpful to dx heart failure exacerbations! can help distinguish cardiac from resp. cases of dyspnea

MAOIs (monoamine oxidase inhibitors) ex of drugs

selegiline phenelzine isocarboxazid tranylcypromine

toddler considerations

simple explanations for procedures (short, concrete terms)

COPD considerations

slowly progressive airflow obstructive-->chronic airway inflammation comprises ventilatory lung diseases: asthma, emphysema, chronic bronchitis, cystic fibrosis -->can cause COR PULMONALE (RSHF) due to constricted pulm vessels -->see POLYCYTHEMIA (lack O2 so body tries to compensate by making more RBCs) -have hypercapnia due to air trapping PaCO2 >45 -->pts MUST recieve influenza/pneumococcal vaccines as at risk for infections! -->seek medical help if increased sputum, worsening SOB lack of relief from prescribed meds -->diet= frequent, small, high calorie meals (conserve energy and meet nutrition) -BIPAP is used to remove retained CO2 in patients with COPD exacerbation--priority action if observe sx! (do not increase o2-->will increase CO2 even more! -use BIPAP/NIPPV to breathe in COPD exacerbation (if pts mental status becomes altered, likely that BIPAP is not removing enough CO2)--CO2 retention causes AMS meds contraindicated: cough suppressants (want to expectorate secretions) sedatives (benzos, narcotics)--depress resp. effort risk factors for COPD: (think resp. irritants) -smoking (biggest) -exposure to chemicals/dust -->r/t occupation (car mechanic, firefighter, coal miner) -air pollution -genetics! NOT OBESITY/diet to help with NUTRITION INTAKE: -avoid drinking fluids while eating meals (prevent stomach distention) -small, frequent meals high in calories/protein (COPD pts often loose weight due to energy it takes to eat) -perform oral hygiene before eating meals (avoid dry mouth from mouth breathing) -avoid exercise 1 hr before/after eating (fatigue) -avoid gas forming foods (broccoli, beans, cabbage) EMPHYSEMA= overinflation of alveoli pink puffers (refer to book p 276) (hyperventilation, SOB, weight loss, barrel chest) rx= admin LOW FLOW oxygen to prevent CO2 narcosis, give pt too much oxygen they will loose resp. stimulus to breathe (hypoxia) PURSED LIP BREATHING (prevent alveolar collapse during exhalation) (inhale 2 seconds through nose, exhale 4 seconds through pursed lips)--exhale twice as long as inhaling CHRONIC BRONCHITIS= inflammation of bronchioles blue bloaters (cyanosis, productive cough) sx= congestion, productive cough RHONCHI (low-pitched adventitious sounds when thick secretions obstruct upper airways--bronchiloles-sounds like moaning/snoring, primarily expiration but can be inspiration) to facilitate mucous secretion= -fluids! -cool midst humidifier -GUAIFENESIN (expectorant--cough)-->drink full glass of water after taking med, before bedtime -abdominal breathe with "huff"--forced expiratory cough -chest physiotherapy -airway clearance handheld devices (mouthpiece, mask, vest) cystic fibrosis= exocrine grand malfunction due to impaired sodium/chloride channel regulation, excessive mucous production causes obstruction, affects sweat glands, resp system, and GI system *sweat chloride test >60= diagnostic ASTHMA= main cause is due to inhaled allergens -->prevent! (med triggers NSAIDs, asa, beta blockers, gerd, emotional stress, URI, smoke, soaps/detergents, chemicals) *even after give albuterol, a sudden decrease in wheezing (could be silent chest)-->bronchial constriction and lead to status asthmaticus, resp failure so PRIORITY TO MONITOR ASTHMA/PNA pts even after give stabilizing meds!! *pediatric asthma: in child, frequent cough (esp at night) until child vomits is sigmal airway may be sensitive to stimuli "silent asthma" (allergens) meds teach: -rinse mouth and throat well after using MDI and do not swallow the water (prevent oral thrush) -use spacer with inhaler can help decrease this (fewer drug deposits) -SABA (bronchodilator-albuterol/ipratropium) first IF NEEDED, then steroid (beclomethasone) ***SABA is rescue drug on as need basis and IS NOT ALWAYS TAKEN WITH steroid -wash inhaler (SABA) 1-2x/week under warm running water and let it dry out (inhaler and mouthpiece, not canister) -take ICS (inhaled steroid) inhaler apart and clean it every day--think cause more comps with this -*do NOT omit ICS (Steroid) drugs (fluticasone, beclomethasone) if albuterol is effective, ICS are not rescue drugs, they are prescribed to be taken on reg schedule (morning/night) on long term bases to prevent exacerbations and should not be omitted even if SABA effective Fluticasone/Salmeterol= combo LONG ACTING drugs -teach= NOT to be taken for acute attacks *non-rebreather mask is good to use for this pt short term when have low O2 sats BEST INDICATOR ASTHMA ATTACK IMPROVING= increasing O2 sats!! then peak expiratory flow (wheezing decreased on auscultation is good but could aslo indicate swelling to point of little airflow going through lungs) CYSTIC FIBROSIS= autosomal recessive (both parents must be carriers of gene for offspring to have--25% chance) (affects excretion of pancreatic digestive enzymes (causes malabsorption of fat and fat soluble vitamins) & resp system (thickened secretions) expected findings: --blood tinged sputum from frequent coughing (only some not frank) -weight loss/appetite loss -fecal retention (no bm for over 48 hrs is expect) --prone to recurrent resp infections/sinusitis-->may lead to CHRONIC HYPOXEMIA, watch for alveoli damage and sudden onset PNEUMOTHORAX *if pt has pulse ox 90%-->this is PRIORITY FINDING, THIS IS ABNORMAL IN CF PATIENTS --> (requires urgent intervene, not like COPD or emphysema in which this is norm) -at risk for Diabetes Mellitus (pancreatic beta cells impaired) -at risk for lung infections/ sudden onset pneumothorax from collapsed alveoli (do physical activity as tolerated to help pulm function--don't limit) autosomal recessive gene, both parents are carriers; 25% chance of passing to offspring *life span shortened, typically only live into 30s med= pancrelipase-->replacement enzymes!! give with meals to help digest and absorp fat, proteins, starches when pt eats PANCREATIC REPLACEMENT ENZYMES: -->give just before or with every meal or snack--only when pt eats, hold if pt does not eat -->lifelong -->CANNOT CRUSH OR CHEW -->can sprinkle capsule contents on applesauce, yogurt, ACIDIC soft non temp foods, NOT MILK *fecal retention and impaction are common in CF due to salt secretion in intestines, decrease water intake (may cause no bm's in couple days--expect!) diet= (children tend to be hungry but thin (WEIGHT LOSS) since cant digest fat and calories, proteins, fat soluble vit DAKE) unrestricted fat diet! increased salt (high cal, high protein, high carbs) reproductive= thickened secretions lead to CF-related infertility *sweating increases salt loss, dehydration, hyponatremia (INCREASE SALT INTAKE DURING HOT WEATHER, EXERCISE, FEVER) GI sx= flatulence, abd cramping, diarrhea ongoing, steatorrhea (all malabsorption issues), weight loss, fecal retention/impaction encourage fluids for all! Loosens up secretions (3,000/24, 6-8 glasses) small frequent feedings rx (CF)= -CHEST PHYSIOTHERAPY DAILY!! (before meals to reduce vomiting/regurgitation) -DO NOT RESTRICT PHYSICAL ACTIVITY, do as tolerated (helps loosen secretions) 89-92% pulse ox is expected reading PaO2 of 70 is a stable oxygenation level for COPD HYPERRESONANT LUNG SOUNDS HEARD ON ASTHMA/EMPHYSEMA (overinflated lungs!) home care for COPD (d/c needs): PT WILL HAVE HOME OXYGEN THERAPY (watch for fire hazards!!) nebulizer equipment medical alert bracelet *DOES NOT NEED INCENTIVE SPIROMETER OR APNEA ALARM (not a prob with COPD) -->incentive spirometers used after surgery *VENTURI MASK= delivers guaranteed [oxygen] despite pt's RR, depth, TV BEST FOR COPD pts or pts with hypercarbia, hypoxemia, decreased tidal volume

Burn considerations

standard precautions aseptic technique!! fluid vol resucisation -->USE IV ROUTE!--risk for hypovolemic shock EMERGENT PHASE: PRIORITY ACTION FOR BURN PT= begin fluid resuscitation!! (first) Lactated ringers SOLUTION OF CHOICE then can treat pain--not as life threatening sx= *think fluid loss SEs HYPONATREMIA (fluid shifts and losses--dehydration) hypovolemia increased HCT and HgB (blood gets viscous) hyperkalemia (cell damage release K+) -->think sx of this= tall, peaked T waves, muscle weakness decreased peristalsis (SNS system activated in burn response) -->N/V, gastric distention, paralytic ileus prevent infection! -->remove clothing and wrap pt in clean towel/blanket after fire is out *do NOT apply ointment/soaps to second degree burns in emergent situations *do NOT apply oil (cooking fat) on burn (holds germs and makes infection more likely), if occurs okay to wash asap with soap and tap water to remove oil (dont need to notify HCP) complication: burn wound sepsis= (increased RR, decreased BP) -->curling's ulcer! may develop 24 hrs after severe burn injury; look for gastric pH less than 5.0-->acidic will causes DOC for pain mgmt= morphine (watch for constipation-->can cause ileus, explore alternative pain mgmt techniques) *wound debridement: most imp to plan adequate time for dressing change/provide emotional support *good to perform ROM exercises, decreases muscle atrophy Resuscitative/Emergent Phase: -right after finish this phase, next priority is admin enteral feedings--at return of bowel sound --wounds need calories/protein to heal! REHABILITATION PHASE: after wounds have fully healed, lasts about 12 mo goal= improve mobility/independence, minimize long term complications -counseling support -gentle MASSAGE W/ WATER BASED LOTION --minimize scarring -reconstructive surgery -PRESSURE GARMENTS--prevent keloids -ROM exercises--prevent contractures -sunscreen! protective clothing escharotomy= for full thickness burns, used to release constricting eschar (burned tissue) and allow reperfusion of limb (prevent further tissue ischemia/necrosis)

Tuberculosis (pulmonary) considerations

sx= progressive fatigue nausea anorexia weight loss irregular menses low grad fevers NIGHT SWEATS cough with mucupurulent sputum (can be streaked with blood)--Late signs SOB, dyspnea (late signs) *watch for wet bed sheets, can indicate development interventions: -increase oral fluid intake -sputum cultures prior to starting drug therapy -use incentive spirometer -nutrition assessments med regimen (2-3 meds) must be taken for 6 to 9 months-->MUST ADHERE! (even after sputum cultures come back neg) *isolate for 2-4 weeks after begin med regimen, BUT CAN SEND HOME TO FAM before this since they're already exposed do NOT have to wear mask at all times to prevent disease spread meds= isoniazid--hepatotoxicity **contraindicate if pt has elevated LFTs (drug induced hepatitis) rifampin--hepatotoxicity; red/organge discoloration of body fluids ethambutol-->ocular toxicity, used initially pyrazinamide--hepatotoxicity AEs= hepatotoxicity-->assess for sx (dark color urine, yellow skin) *discoloration of bodily fluids (rifampin, red)-->have pt wear glasses instead of contact lenses *need baseline LFT taken, toxic hepatitis AE= isoniazid *persons exposed but not active TB, under 25 low risk can get 6-9 mo isoniazid regimen as prophylactic treatment consider get tested if: traveled to endemic area (latin america, africa, middle east, asia); prolonged contact with indigenous persons dx= mantoux test (TST)-(given ID in forearm, 0.1mL of PPD, results in 48-72 hrs) tells if exposed and developed an immune response, not if active) results: >15 mm INDURATION (not just redness alone) is considered pos for any pt (measure just the induration) (means you have TB infection, latent) *pts w/ latent TB CANNOT TRANSMIT to others and are ASYMPTOMATIC --> refer to further testing with FOR DIAGNOSIS of active TB= 1.CXR 2.sputum cultures-->collect early morning, consecutive for 3 days (can give fluids/expectorants at night to help expel) 3. presence of symptoms *QuantiFERON-TB (QFT) blood test--is alternative to Mantoux (TST) test to also measure immune rx to TB, a positive test only shows youre infected, does NOT CONFIRM DX *is quicker, single visit, and results available in 24 hrs *measure induration across forearm (must be hardened palpable, not just erythema) CXR: perform on all pts with positive PPD test Quanitferon-TB Gold test (blood analysis) results in 24 hrs *gastric analysis--is diagnostic! culture sputum swallowed during night, wake up and asipirate after fast 8-10 hrs in AM (TB bacillus is dx! but does not thrive in acidic enviornment) SPUTUM CULTURE IS ONLY THING THAT DEFINITIVELY DX TB! rx affectiveness for active TB determined by 3 neg sputum cultures and cxr *if infection is latent, pt is not contagious only needs standard precautions MEDS THAT CAN COVERT LATENT TB TO ACTIVE: (immunosuppressant drugs, chemo, debilitating diseases (HIV), malignancies, steroids can convert this to latent to active--imp!!) DOT THERAPY: (Directly observed therapy) purpose= public health nurse provides and watches the client swallow every prescribed medication for at least 2 mo of therapy (to help improve med compliance in TB pts)

pnemothorax S/Sx

tachycardia diminished lung sounds tachypnea (rapid respirations!!) tracheal deviation

arteriovenous malformation (AVM)

tangle of veins and arteries forms during embryonic development become weak and dilated *imp: HIGH RISK FOR INTRACRANIAL BLEED (depend on location) -BP control -avoid engaging in heavy exercise (increase BP) -avoid HTN: smoking cessation, etc

What is an intravenous pyelogram?

think IVP= KUB is an X ray of the kidneys, ureter, bladder using contrast solution injected into veins (obtain PT ALLERGY INFO!!) *take cleansing enema night before to empty abdominal cavity for visibility during procedure *NPO 6-8 hrs prior

Bulge test

used to determine presence of fluid in the knee joint test by: having pt lay down and extend legs

Amphotericin B

Antifungal highly toxic to renal system

Hydroxychloroquine

Antimalarial, DMARD AE= retinal damage-- reg eye exams q 6 mo

Cisplatin

Antineoplastic AE= renal toxicity

Meds that cannot/can be given IV Push

CANT vanco (diluted IV over 60 min or longer) potassium chloride (lethal effects on heart) CAN metoprolol: 2.5-5 mg over 2 min IVP furosemide: 1-2 min, diuresis 5-10 min digoxin ampicillin: 1-5 min generally for all IVP meds

Hearing deficit sx

(child sx): behavior appears withdrawn, shy, timid monotone speech, difficult to understand speaks with a loud voice avoid social interaction may seem extremely inattentive when give directions appear "dreamy"

Acetylcysteine (Mucomyst)

*Antidote for acetaminophen toxicity (think acety's) MOA= loosen secretions (resp) AE= worsens bronchospasm

sickle cell crisis aka VASSOCCLUSIVE CRISIS

*autosomal recessive sx= (expected) *keep in mind, expected sx in sickle cell disease: low HgB, low HCT =anemia (give blood transfusion)--not priority unless pt symptomatic! -->swelling of hands and feet (dactylititis) (often first sign of disease in babies) "HOPS"-hydration, oxygenation, pain management, support for pain CRISIS= sx= swelling of joints! fever, jaundice (sclerae), tachycardia, murmurs, Hgb 7-10, pain (severe!)-->IF PT REPORTS SX OF CRISIS (SEVERE ACUTE PAIN), THIS IS PRIORITY) AS lack of prompt recognition can lead to irreversible tissue damage *priority for any pt with sickle cell is HYDRATION FIRST (prevent thrombus formation), OXYGEN SECOND, Pain= manage with morphine PRN (avoid cold compress-->vasoconstricts!) PAIN MGMT: -if pt is calm/relaxed, but reports severe 10/10 pain (dont suspect drug seeking abuse), pts w/ sickle cell often undertreated due to this, but risk is small. sickle cell hurts and pt needs pain med!! contact HCP to get higher dose, recommend PCA--better than PRN admin) *DEHYDRATION AND INFECTION CAN CAUSE CRISIS -->avoid by giving 3-5L fluids/day adults; 1600 child -->PCA morphine or hydromorphone hydroxyurea is med to give to help with sickling *frequent REST/BEDREST (in hosp) needed to avoid crisis from lack of O2 (dont play long sports) -watch movies, read, listen to music *AT RISK FOR ISCHEMIC STROKE --due to vasoocclusion (watch for stroke sx)= emergency!, may need blood transfusion *at risk for SPLENIC SEQUESTRATION CRISIS (large # sickle cells get rapped in spleen--causing SPLENOMEGALY) -->life threat, can lead to severe HYPOVOLEMIC SHOCK -->*if palpate rapidly enlarging spleen-->THIS IS PRIORITY (EVEN OVER POSSIBLE STROKE!)--------------------------------------------*pts at young age have some level of immunosuppression as spleens not functional due to infarctions from sickling=and spleen cannot kill bad bacteria--filer out RBCs (infection prone)

Alcoholism

*causes hypoglycemia, thiamine (vit B1) deficiency thiamine deficient-->Wernicke encephalopathy (WE) -->untreated can lead to death/ Korsakoff psychosis rx= all intoxicated clients are given: IV THIAMINE--first priority!! Before OR with IV GLUCOSE then magnesium, mutliple vit (folic acid)

C-reactive protein (CRP)

*elevated indicates acute inflammation *may indicate increased risk for CAD

Postoperative Potential Infections

*postop infections appear 3-7 days after surgery-->WATCH TIMELINES! if not this time yet, not infection (fever, WBC count, fatigue) Pneumonia w/ atelectasis -->cough w OR w/out sputum, tachypnea, SOB Surgical Site Infections -->redness, warmth, swelling, purulent drainage UTIs -->frequency, dysuria, urgency Peritonitis -->abd rigidity, rebound tenderness, shallow breathing r/t abd distention

Huff coughing

*used in COPD (weakened muscles and narrow airways prone to collapse) so teach... series of low pressure coughs to prevent overexertion: to do: 1. position= sit upright in chair with feet spread shoulder width apart and lean forward, shoulders relaxed; forearms supported on thighs or pillows; head/knees slightly flexed; feet touching floor 2. Perform a slow, deep inhalation 3. hold breath for 2-3 seconds 4. then perform quick, forceful exhalation, creating audible Huff 5. repeat the huff once or twice more to expectorate and mucus 6. rest for 5-10 regular breaths and repeat as necessary until all mucus cleared

How long do you need to stop herbal supplements prior to surgery? exceptions?

2-3 weeks (except multivitamins)

How often perform foley cath/perineal care? if leakage of urine observed?

2-3 x daily leakage can indicate obstruction first assess tube by inspection if find obstruction, remove kink or compression of cath tubing attempt to dislodge a visible obstruction by milking the tubing!-->this is okay here (start from point close to pt, work to end of drainage bag) if nothing works, notify HCP

newborn assessment order/normal vs abnormal findings

NORMAL: skin: -acrocyanosis (peripheral cyanosis hands and feet) --norm in newborn due to being cold (place skin to skin) for first 24 hrs after birth -->rx= put infant skin to skin w/ mom -erythematous first few hrs after birth, then pink -vernix caseosa-->do NOT attempt to remove! -lanugo (in extensive amount= prematurity) -milia (white papules) -mongolian spots (fade over 1-2 yrs of life) -telangectatic nevi (stork bites)--go away -nevus vasculosis (strawberry mark) --tell 7 yrs -nevus flammeus (port wine stain)--never fades -epstein's pearls (white pearl cysts on gums/palate)--go away few weeks -erythema toxicum neonatarum (firm white, yellow pastules surround with erythema) -PLANTAR CREASES UP ENTIRE SOLE -premature: fine wrinkles, few creases -full term: deep creases on entire sole -DESQUAMATION (PEELING SKIN) OF FEET (cracked, peeling skin may be present at birth in post-term newborns) umbilical cord= 2 arteries and 1 vein! head circumference-->33-35 cm; 13-14 in. (increased could be ICP/hydrocephalus) positional plagiocephaly= head flattened due to infant position and soft skull (norm, reposition to adjust) chest circumference==> 30.5-33 cm; 12-13 in. *chest circumference should be 1 inch smaller than head1 BP: 65/41 (arm and calf) *dont take BP in first set of newborn VS! RR: 30-60 *diaphgramatic/abd breathing, may have short periods of apnea (less than 15 sec) HR: 110-160 (180 if crying, 80-100 if sleeping) temp: 97.7-99.7F *take axillary NOT rectal *thermometer in place 3 min unless electronic weight: 2700-4000 g (6-9 lb) length: 19-21 in (48-53 cm) edema of scalp is norm after delivery cephalohematoma-->does not cross suture caput succedaneum--> think crosses suture breathing: bilateral crackles first 1 hour after vag delivery (fluid being pushed out of lungs) --RR 30-60, with periodic apneic pauses lasting <20 sec (shallow, irregular, abdominal breathing) heart: physiologic heart murmur expect first 48 hrs of life! (if its pathologic--congenital--other sx will be found: abn VS, cyanosis, poor feeding) fontanelles: anterior= diamond (closes by 18 mo) posterior= triangle (closes 8-12 weeks) eyes: eyelids may be slight edematous ears: parallel with inner and outer canthus of eyes chest: breast enlargement lasting up to 2 weeks may occur in males/females extremities: symmetrical legs/arms, creases hips abduct >60 degrees, foot in straight line genitals: -swollen labia, mammary gland enlargement, thin white vag discharge NORMAL first few weeks of life -females: pseudomenstruation (mild bleed) norm--resolve on own in a few days post birth -male may have undescended testicle (only one felt) at birth--will descend by 6 mo normal! (cryptorchidism) vomiting: normal: frequent vomiting since birth! (since they spit up often as they adjust to eating and digesting food) -tiny blood streaks is okay as long as not in excess amount and persists -vomit through the nose *cough is norm absent in newborns! --> bulb suction mouth then nose! urine/poop: SHOULD VOID BY FIRST 24 HRS -->(in first 48 hrs of life, 2-6 wet diapers q 24 hrs) -->by 3-4 days, 6-8 wet diapers q 24 hrs expect SHOULD PASS MECONIUM IN FIRST 24 HRS weight: *during first 3-4 days of life, a weight loss of 5-6% of birth weight is expected due to fluid excretion, ceases around 5 days of life *return to birth weight by 7-14 days. Newborns gain about 0.5 lb per week for the first 3 mo. (if weight loss >7% at any time--abn and report!!) ABNORMAL: -circumoral cyanosis (around mouth)-->can indicate hypoxia -assymetrical facial mvmnt= bells palsy -ptosis of eyelid! (should be symmetrical) -meconium ileus= could be Cystic Fibrosis! -floppy/decreased muscle tone= down syndrome -GREEN VOMIT: bile when intestinal obstruction and stool cannot pass -->emergency as can lead to perforation and peritonitis! -sacral dimples! (w or w/out hair tufts)--spina bifida *low grade fever--*take seriously! as infants have immature immune system, and could be only sx at this age (bacteremia!) Also sx= decreased UO, poor feeding, lethargy, hypothermia breathing: abn! sustained tachypnea >60 nasal flaring chest wall retractions grunting! MURMURS ARE NOT NORMAL--indicate congenital heart disease weight: >7% loss is abn and warrants eval! ASSESSMENT ORDER: RR (to not agitate child) HR/pulse auscultate Heart/Lungs, Abd--then palpate & percuss invasive procedures last (eyes, ears, mouth) elicit reflexes for motor function

ABO Blood Group Compatibility

O= universal donor AB= universal recipient Type A donates to: A, AB receives from: A, O Type B Donates to: B, AB receives from: B, O Type AB: Donates to: AB Receives from: A, B, AB, O Type O: donates to: A, B, AB, O receives from: O *KEY POINT: an Rh Positive pt can safely receive blood from Rh negative donor! *only when recipient is NEGATIVE, will attack donated rh POSITIVE blood (not okay) think negative is bad! attacks!!

skull fx s/sx

battles sign racoon eyes rhinnorrhea otorrhea

kidney biopsy biggest complication

bleeding! observe hematuria

peripheral IV considerations

change NO MORE FREQUENTLY than q 72-96 hrs, unless complications develop

lymphoma

hodgkins (presence of reed-sternerg cells in lymphatic tissue, predictable path of metastasis) non-hodgkins (widely disseminated) sx= classic is painless enlarged lymph node (often neck, underarm or groin), fever, unexplained weight loss (>10%), drenching night sweats, also (itching, fatigue), also may be asymptomatic!

refractory hypoxemia what disease process seen in?

hypoxemia that does not respond to O2 therapy continual decrease in PaO2 values seen in ARDS!!

domestic abuse/neglect

if pt shows signs of suspected abuse/neglect... PRIORITY ACTION: remove victim from potential sources of immediate danger (suspected abuser, etc) to prevent further harm *question and assess pt alone so abuser can't guide their answers

fluoxetine (therapeutic response)

increased energy level

Gemfibrizol

lipid lowering agent take 30 min before dinner monitor LFTs AE abd pain/cholethiasis

Lordosis vs Kyphosis

lordosis= pregnancy (concave in lumbar region) kyphosis= hunchback (convex in thoracic region)

cocaine s/sx

nasal septum deviation any effects seen on nose! sores, burns, disruption of mucuous membranes

Ferrous Sulfate

oral iron supplement rx= iron deficiency anemia *AVOID admin calcium supplements/antacids within 1 hr of med--decreases iron absorption *take ferrous 1 hr before or 2 hrs after meals CALCIUM DECREASES IRON ABSORP ORANGE JUICE INCREASES IRON ABSORP AEs= constipation (increase fluids)

priapism

persistent and painful erection, >2 hrs if occurs, medical emergency!! can lead to permanent erectile dysfunction sx: MOST CONCERN: bluish discoloration= ischemia! difficult voiding urinary retention meds that can cause= trazaone (antidepressant, no class), sildenafil

phlebitis infiltration S/Sx

phlebitis= warmth, edema, erythema, palpable venous cord, red streak infiltration= edema and coolness to touch, increased swelling at insertion site *avoid heat, apply cold/warm moist compress after d/c line elevate extremity to decrease swelling *if have pt showing signs of this, this is PRIORITY PT as immediate removal is necessary to prevent thrombophlebitis or emboli or bloodstream infection

normal vs abnormal findings in chest tubes

position for insertion= arm raised above head on affected side normal= -->CONSTANT bubbling of water in SUCTION CONTROL chamber (15 cm, 20cm), but should NOT FLUCTUATE -->WATER SEAL CHAMBER FLUID SHOULD FLUCTUATE OCCASIONALLY (kept at 2cm level to maintain neg pressure), THERE SHOULD NOT BE CONSTANT BUBBLING (Indicates air leak)!! -with inspiration and expiration/coughing/sneezing the white ball will fluctuate up and down (indicates air is passing through chamber THIS IS CALLED TIDALING)--and tube patency is good UNLESS the lung has fully expanded, there is obstruction of tubing (pt laying on it, kink in tube), -->water seal chamber filled 1-2 cm sterile water -->if suction used, fill sterile water to 20 cm or as ordered by HCP (no more than 20 cm usually indicated) -->first 24 hrs after surgery 500-1000mL drainage can occur, first 2 hrs 100-300 mL -->ONLY CLAMP CHEST TUBES MOMENTARILY (check for air leaks, change draining apparatus) -->clamping chest tube during transport= contraindicated NEVER DO! (need to disconnect wall suction, okay to temporarily do) abnormal= NEVER MILK THE TUBING ON NCLEX (looking for clots/kinks, can damage pt due to neg pressure applied, only performed if prescribed) -->NO FLUCTUATIONs in water seal chamber -->CONSTANT/continuous BUBBLING in water seal chamber (indicates AIR LEAK in system--found in BASE OF WATER SEAL CHAMBER-where the 7 numbers are), report to HCP -->if tubing is obstructed, inspect entire length to see where kinks/blockage is -->IF chest tube dislodged: apply pressure to site with dressing tented allowing 1 side to be Open to allow escape of air, ASAP report to HCP -->if tube becomes disconnected (and is not contaminated) wipe end of chest tube with antiseptic and immediately reconnect it -->if tube becomes disconnected from drainage system (and is contaminated): cut off contaminated end of tubing, attach sterile connector, reattach to drainage system -->if cant do this (Chest tube breaks, malfunctions, cracks), immerse end of chest tube 2 cm (1-2 in) below surface in 250 mL bottle of sterile water or NS until system can re-establish, notify HCP prep for these emergencies by always having at bedside: -2 chest tube clamps -250 mL bottle of sterile water or NS -antiseptic wipes CHEST TUBE DRAINAGE >100ML/HR MUST BE REPORT TO HCP (abn amounts of blood loss) or >3 mL/kg/hr for 3 consecutive hours >5-10 mL/kg in 1 hr hemorrhage (excess frank red blood drainage!! report emergency!! If chest tube drainage stops abruptly: need to see if this is expected finding by -auscultate breath sounds (lungs fully re-expanded?) -have pt cough and deep breathe -reposition pt (drainage may accumulate) chest tube removal: have pt take deep breath in, hold it, and bear down -give analgesic 30-60 min prior to procedure -get post op xray -cover site with STERILE AIRTIGHT PETROLEUM JELLY GAUZE DRESSING (full closure) *norm to find blood clots in tube for pt with hemothorax

Newborn assessment findings based on Gestational Age at birth (preterm vs postterm)

preterm: (expect) -lanugo -smooth, pink skin with visible veins -areolae barely visible, with no raised breast buds -very smooth foot soles, only faint red marks or possible singular anterior transverse crease -testes palpable in upper inguinal canal (not descended) postterm: (expect) -creases over entire sole -skin peeling

amiodarone

pulmonary toxicity is life threatening effect of med dry cough, pleuritic chest pain, dypsnea

How often perform trach care?

q 8 hrs and PRN

Rights of Medication Administration

right drug, right dose, right patient, right route, right time, right reason, and right documentation

strategies when speaking with hearing impaired:

speak in NORMAL tone, slowly dont over ennunciate or over exagerrate words or facial expressions

Blind pt interventions

speak in normal tone announce entry and exit teach cane sweep in front while walking walk slightly in front of pt holding elbow use clock face description to describe location of items (food)

Aseptic vs Antiseptic

sterile= aseptic clean= antiseptic

Activated Charcoal

treatment of choice for overdose often ineffective for some drugs (lithium, iron, alcohol)

What food to avoid with MAOis and why?

tyramine containing foods--> cause HTN crisis cured meats/smoked-processed meats strong aged cheeses, yogurt beer/alcohol/red wine pickled/ fermented foods soy/broad beans/snow peas sauces dried overripe fruits chocolate avocados dont eat leftovers, only fresh food as well *MAOIs are photosensitive! require sunblock! *begin tyramine free diet 2 weeks before start MAOis and cont. for 2 weeks after d/c

school phobia

childhood anxiety disorder BEST treatment= have child return to school immediately! (adjustment faster) gradual exposure if necessary do not let remain out of school, will only worsen prob

Promethazine

Antiemetic/Antihistamine SE= dry mouth, anorexia, constipation, ortho hypo If a pt has been n/v, need to assess hydration status as can exacerbate ortho hypo! *REMEMBER ORTHO HYPO= AFFECTED BY DEHYDRATION (lower bp)

Burns categories

(1st degree) superficial= sunburn, painful, red (2nd degree)superficial partial-thickness= erythema, swelling deep partial thickness= fluid filled vesicles, red, painful (3rd degree) full thickness= black, red, brown, slight painful deep full thickness= black, necrotic tissue

Car seat rules other safety considerations

(other safety) set water heater less than 120F crib slates no further than 2 1/4 " apart place baby FLAT BACK after EATING/SLEEPING no teething biscuits (choking) 0-2: rear facing car seat *place newborn 45 degrees angle to prevent airway obstruct, roll blankets/ car seat inserts on both sides/under crotch strap may be used to prevent slouching 2-7: forward facing car seat 4-12: booster seat 8-adult: seat belt *rules apply until child outgrows weight/height limitations of car or booster seat *all children <13 should sit in back seat! car seat safety: -do not wear bulky jackets/blankets between newborn and harness -secure harness snuggly against body w/ retaining clip near armpits

Jehovah's Witness

*NO BLOOD TRANSFUSIONS (no whole blood or components--RBCs, WBCs, Plts, Plasma) rx= if blood loss and shock is concern-->use volume expanders with fluids (NS, LR, Dextran, Hetastarch) acceptable of: -erythropoetin (epoetin alfa) IV iron which both stimulate bone marrow to produce more of their own RBCs

D50

*can cause extravasation, admin through large bore needle (sloughing, necrosis, phlebitis) *rapid admin can cause hyperglycemia *osmotic diuresis can occur due to this, watch UO, hypotension, sx of hypoglycemia (heart palpitations, tachy)

ovarian cancer

*dx usually made in later stages risk factors= previous fam hx ovarian cancer pt hx breast, bowel, endometrial ca nulliparity infertility heavy menses palpation of abd mass (late sign) sx= (often very subtle) PELVIC PAIN/PRESSURE, ABD BLOATING, abd firth increase early satiety, abd/back/leg pain, urinary frequency/urgency, GI disturb med= paclitaxel *admin antihistamines, steroids, H2RAs to avoid hypersensitivity rx *ovarian removal necessitates need for ERT

neonatal heel stick

*for congenital hypothyroidism, PKU -medial or lateral side of outer aspect of heel -*avoid edmatous/infected skin -warm the heel several min with warm towel compress or single use approved heat pad -cleanse site with alcohol -provide surcrose/pacifier to help with pain -automatic lancet to control depth of puncture *can also collect blood through venipuncture (is another good option!)

Anxiolytics

*give for anxiety and seizures Buspirone (no sedation, can still drive the "bus" in buspirone) SEs= dry mouth *low abuse potential, no withdrawal sx take as prescribed *******onset of relief occurs after 1 week of therapy, with full effects occurring between 2 and 4 weeks Benzos-->DANGER (sedative) Barbituates-->DANGER (sedative)

percussion and postural drainage techniques

*goal is to facilitate movement of thick secretions from lungs (good in CF)-->think of putting pressure on diaphragm to do so positions: supine with pillows under the knees (place pressure on diaphragm) in seated position leaning over a pillow (puts pressure on chest) knee-to-chest position with pillows under the chest and abdomen (raising hips/thighs helps facilitate remove by gravity) *NO STRAIGHT SUPINE OR FULL UPRIGHT POSITIONS

self breast exam

*imp to teach develop awareness of what breast feels like, looking out for any abn changes menstruating: feel 1 week after onset menstrual period nonmenstruating: first day of each month use 3 pads of fingers to inspect in mirror positions: arms at side, arms above head, hands on hips mammography: may be discomfort schedule after menstrual period (less sensitivity)

PCA pump

1 mg morphine with a lock out interval of 5-15 min for a total of 5 mg dose per hour requires cont IV solution (NS) TK and flush PCA med so boluses reach pt

what gage cath for blood transfusion?

14-22g!

Catheter size selection/gauge

14G -admin fluids/drugs in emergency/prehospital setting -hypovolemic shock 18G -somewhat stable adults who require large amounts of fluids -BLOOD TRANSFUSIONS/administrations (preferred cath size) 20-22G -general IV fluids and meds to adults -20G also acceptable for blood transfusion! (not good for blood administrations) 24G -children/older adults with small, fragile veins

Methylphenidate

CNS stimulant (amphetamine) *latest dose should be given no later than 6 pm 2-3 divided doses taken usually 35-40 min before meals AE= -loss of appetite -weight loss -tachycardia -increased BP *teach= -monitor BP/HR before start treatment -parents to weigh child at least weekly (can cause growth stunting) -report weight loss trends to HCP -prefer to give before meals (unless weight loss becomes serious prob, then can give after meals)

greatest inidicator of fluid resucistation MOST ACCURATE INDICATOR OF FLUID LOSS OR GAIN

DAILY WEIGHTS= best indictor for fluid loss or gain best indicator of successful fluid volume resuscitation? adequate re-hydration achieved? UO! (30mL/hr or 0.5mg/kg/hr) *if UP >30ml/kg/hr, goal successful! even if >50 and above high limit, still means successful fluid vol resusc

IM vs SQ routes

IM= need deeper in skin (bigger gage= smaller number, 20-22G, 1- 1 1/2 inch long) SQ= in fat tissue (gage size 25-20), 1/2- 5/8 inch size

Hyponatremia S/S

SALT LOSS S- Stupor Coma A- Anorexia/ apprehension L- Lethargy T- tendon reflexes L-limp muscles (*muscle cramps) O-orthostatic hypotension S- seizures/ headache S- Stomach cramping Rx= increase dietary sodium intake SAFER WAY= restrict fluids (water restriction) IV LR or 0.9% NaCl *normal serum sodium children= 138-145

testicular torsion hydrocele

TESTICULAR TORSION twisting of the spermatic cord, decreased blood flow to testes-->ischemia-->necrosis MEDICAL EMERGENCY! must be treated within 4-6 hrs HYDROCELE *fluid-filled testicular mass (not an emergency!) dont get confused sx= painless new onset bilateral swelling (most resolve before infants first bday)

calcium gluconate antidote for?

antidote for= hypermagnesmia treats= hyperkalemia *recall (mag, K+ direct relationship!) reverses tetany (due to hypocalcemia), INCREASES calcium levels *can cause extravasation-->ensure IV line patency! or else cellulitis will occur

Huntington disease (chorea)

autosomal dominant hereditary disease causes progressive nerve degeneration, impairs mvmnt, swallow, speech, cognitive abilities chorea (involuntary, tic-like movement)=hallmark sign! onset of disease= 30-50, death from neuromuscle/resp complications occurs within 20 yrs diagnosis *dx confirm with genetic testing pts who have a parent with HD, considering have biological children, should receive GENETIC COUNSELING

Disulfiram

aversion therapy med, promotes abstinence from alcohol *if pt consumes alc while taking, will get unpleasant side effects (HA, intense N/V, flushed skin, sweat, dypsnea, confusion, tachy, hypo)--.think like a bad hangover! bad rx if large amounts consumed can be fatal! teach: -does not cure alcoholism (med) -keep seeing therapist -educate about hazards of rx -teach SOURCES OF HIDDEN ALCOHOL: avoid in= liquid cough/cold meds aftershave lotions, mouthwash, colognes foods such as vinegar, sauces, flavor extracts -abstain from alc for 2 weeks after last dose of disulfiram cause rx can still occur -wear medic alert bracelet

acne vulgaris

avoid antibacterial soaps on face (harsh) use noncomedogenic products (do not clog pores) do not vigorously scrub white heads (gently cleanse)--inflammation will worse acne

toilet training infants

being 18-24 mo!! toilet training! CHILD IS READY WHEN ABLE TO COMMUNICATE AND FOLLOW COMMANDS, pull clothing up and down, express urge to defecate, walk and sit to toilet (should be able to remain on toilet for 5-8 min without crying) 2-3 yrs: bladder reflex control established 4 yrs: independent voiding activity by 5 yrs, should not have enuresis (bed wetting), expect nighttime control by now

melatonin

can be used short term to treat jet lag and fatigue when travel across time zines, but take once you reach destination not before you get there--prolongs sx

Fifth disease (erythema infectiosum)

caused by parvovirus B19 (mild rash illness), in school age children -->transmission= resp. secretions, period of communicability appears before sx onset (before rash), and ends when sx appear! not an emergent condition, unless pt is immunocompromised/hemolytic sx= bright-red facial rash "slapped cheek" fever flu-like sx, general malaise and joint pain (take NSAIDs) rx= recover in about 7-10 days *pregnant women avoid--part of TORCH! rx= most children do not require intervention

Who should recieve prophylactic abx prior to dental procedures to prevent what complication?

complication infective endocarditis (IE)! watch for fever, petechiae! *if pt has scheduled oral surgery, must notify surgeon ASAP if pt has: -hx or current congenital heart disease (at risk for develop endocarditis) -->unrepaired cyanotic defect, or repaired defect w/ prostethic material in current or for 6 mo after procedure -->repaired defect w/ residual defects at site or adjacent or patch/device -INR 2.5 -previous hx IE -presence of prosthetic valve -cardiac transplant who develop heart valve disease *need to place pt on prophylactic abx prior to procedure

bone marrow biopsy considerations

complications: bleeding and hematoma formation/infection most common site performed= iliac crest after done, apply pressure to site and sterile dressing applied

congenital hypothyroidism (cretinism) neonatal graves disease

congenital hypothyroidism: untreated can cause severe intellectual disabilities in infants--screen all infants after birth Increased TSH, decreased T4 levels sx= (think still slow metabolism, fluid retention sx) -difficult awakening, lethargy, hyporeflexia -HOARSE CRY (swelling of vocal cords from fluid retention) -dry skin -constipation -bradycardia -enlarged fontanelle -protruding tongue -umbilical hernia -poor feeding -jaundice rx= levothyroxine neonatal graves: is uncommon--r/t maternal hyperthyroid

what components determine the Standards of professional Nursing Practice?

criteria to determine if appropriate, professional care has been delivered (what reasonable, prudent, careful nurses would do in specific circumstances) -clinical practice statements of professional organizations -health care institution's policies and procedures -textbooks, current literature, expert consensus -Nurse practice act of the state or province/territory

Intrauterine fetal demise --at risk for?

death of baby in uterus after 20W Gestation (stillbirth)--retained dead fetus activates clotting cascade at risk for DIC! (draw coag tests, fibrinogen, CBC with plts asap) -->if see Q w/ fetal demise, immediate think PRIORITY ACTION= DRAW LABS!

Ramsay Sedation Scale

desired level of sedation= 3, pt is drowsy but responds to a voice command

Hepatic encephalopathy (early vs late stage sx)

early: impaired thought processes (difficulty describing things) insomnia/sleep disturbances writing changes late: (think very lethargic sx) lethargy, confusion, excess sleepiness -->indicates worsening!! extended sleep patterns flapping of hands, when arms extended hands facing forward, dorsiflex the wrists= (asterixis) *may aslo have fetor hepaticus (musty, sweet odor of breath) med= lactulose/rifaximin to decrease serum ammonia levels therapeutic= improved mental status electrolytes that precipitate: hypokalemia hypovolemia infection constipation high protein intake GI bleeding

CBT (cognitive behavioral therapy)

effective for disorders that have maladaptive reactions to stress, anxiety, and conflict (anxiety, eating, depressive disorders, smoking, sleeping) goal= pt learns self-observation and applies to more adaptive coping interventions methods: -educate about pt's specific disorder -self observation and monitor -physical control strategies (deep breathe, muscle relax exercises) -cognitive restructuring (challenge neg thoughts, learn new ways to reframe thinking) -behavioral strategies (desensitization practice--expose to situation causing prob and focus on practice new coping behaviors)

breathing during phases of labor

entering transition phase first stage: rapid, shallow breathing (pant)

subdural vs epidural hemorrhage subarachnoid?

epidural= arterial (rapid) sx= subdural hematoma= veinous (slow) think "sub" slow is emergent when occurs--assess for increased ICP, may need asap surgery to evacuate! sx= headache, gait disturbance, memory loss, decreased LOC-->emergency priority pt!! subarachnoid= recurrent bleed, high mortality (arterial) caused by aneurysm in brain

Vasopressor meds

epinephrine, dopamine

Erythropoietin

epogen/epoetin (IV, SQ)--pay attention to route! rx= anemia *indicated= HgB < 11! reduce or d/c dose when HgB >11 (prevent thromboembolism) *need adequate iron, vit B, folic acid for erythropoietin to work (may give these supplements with med) AE= HTN! PRIORITY ACTION= CHECK BP BEFORE ADMIN contraindication= uncontrolled HTN *takes total 2-3 mo to reach target HgB level, can get weekly or through dialysis or self admin at home

Galactosemia

error of carbohydrate metabolism

thoracotomy

expect= chest tube drainage to be sanguineous for several hrs then change to serosanguineous followed by serous yellow over few days (red-->pink-->yellow) expect 50-500mL drainage first 24 hrs *note color! bright red is concerning notify HCP, dark red is not

epidural block

expected findings: -some muscle weakness (3/5) may occur while analgesia in place (as long as findings remain stable not worrisome) -paresthesias can occur 2-24 hrs after surgery and during 4-6 hrs AE= can cause hypotension!--admin IV isotonic fluids!! take BP, turn pt to left lalteral position (alleviate pressure on vena cava), IV fluids still persists? IV vasopressors, oxygen *NEVER admin anticoagulants while one is in place!

drowning accidents

expected sx= hypothermia weak/thready pulse --until rewarmed (sometimes pt so cold can't detect pulse, so PT IS NOT DEAD UNTIL WARM AND DEAD) wheezing/crackles/ARDs if fluid ingested rx= warm the pt! -warmed IV fluids blankets warmed air -prep for mechanical ventilation/intubation dont get tricked! do not need warmed blood (unless blood loss occurs from trauma)

Glucose effect during pregnancy (fetus and mother)

fetus: after born, can get hypoglycemia due to amount of insulin used to being produced but rapid decrease in insulin requirements needed now out of womb mother: hyperglycemia (blood sugar increases during pregnancy) then decreases after birth hypoglycemia after birth due to sudden decrease in insulin requirements

Nonstress test (NST)

for antepartum evaluation of fetal well-being and oxygenation, performed during third trimester (begin after 28W) noninvasive test that monitors the FHR in response to the stress of fetal movement a doppler transducer(used to monitor the FHR) and a tocotransducer(used to monitor uterine contractions) are attached externally to a client's abdomen to obtain tracing strips. *client pushes a button when she feels the fetus move. *have pt eat snacks (to energize fetus) RESULTS: reactive= GOOD (2 or more accels of 15 bpm lasting 15 sec over 20 min interval, and return to FHR of normal baseline)

NG tube insertion considerations salem sump tube--blue lumen? meds contraindicated this route

for insertion: elevate HOB 60-90 degrees for bolus feeds: semi-fowlers is good! CONTINUOUS SUCTION ORDERS: -keep pt SEMI-FOWLERS -mouth care Q 4 HRS IS GOOD -TURN OFF SUCTION BRIEFLY DURING AUSCULTATION -keep air vent open and above level of stomach -if gastric secretions begin to decrease during suction, confirm placement before irrigating tube (aspirate contents to check pH) -assess drainage system for patency (tubing kink/blockage) checking pH contents: flush tube with 30 mL air before aspirating fluid in order to obtain easier fluid aspirations! can do!! *keep in mind, ONLY CHECK RESIDUAL Q 4 IF PT GETTING ENTERAL FEEDS (do not check on continuous suction NG tubes for pts!) AIR VENT ("blue pigtail") MUST REMAIN OPEN purpose- to provide cont flow of atmospheric air to drainage tube at distal end to prevent excess suction force -->if gastric content refluxes, INJECT AIR 10-20 mL into vent (DO NOT PLUG) -->must keep blue air vent above level of pt's stomach to prevent reflux use large barrel syringe to aspirate -assess gastric residual vol q 4 hrs -measure # cm at nare q 4 hrs -if pt sedated, keep them as minimally as possible to decrease aspiration risk -NEVER switch pts to bolus feeds, should always be continuous! (increase aspiration risk) measuring tube: from tip of nose to earlobe to xiphoid process (right below breast bone) then mark distance (at end) with small piece of tape that can be easily removed *if pt abd distended, no bowel sounds: first assess patency and draining of tube, if find not patent, then irrigate it with NS! salem sump tube: blue lumen making a hissing sound indicates air if freely exiting the airway, providing cont suction without pulling gastric mucosa *NG tube not a water-sealed drainage system (active bubbling isnt present like chest tube) steps to insert: (clean procedure) -high fowlers asssess nares -Measure, mark, lubricate tube -curve 4-6" of tube around index finger and release -instruct client to extend neck back slightly -gently insert tube just past nasopharynx ask pt to flex head and swallow forward advance tube to the marked point verify placement and anchor tube to pt *CXR to verifty, pH <5.5 is good IF UPON INSERTION: pt begins to cough and gag: pull back on tube slightly and then pause to give the client time to breathe *do NOT ask to swallow during coughing= aspiratioN! MEDS CONTRAINDICATED THIS ROUTE: -enteric coated (cant be crushed) -slow, extended, OR sustained release meds (okay to crush do double and extra strength ------------------*sx= expect in pt's w/ NGT a sore throat

functional disorder

functional disorder= a general dx for a genuine medical issue that medical science does not yet fully understand examples= epilepsy/ migraines *no effective treatment

food guidelines (for adults)

grains= 6-7 ounces veggies= 2 1/2-3 cups fruits= 1 1/2-2 cups milk= 3 cups oils= 5-6 tsp meat and beans= 5-6 ounces *young adults and older adults about the same equivalents teens= a little less child= about half equivalent of adult

Parathyroid

high calcium, low phos so if hyperparathyroid need diet low calc high phos

wound healing post-op diet

high protein, calories, vit C things that can impair wound healing: nutritional deficiencies= vit C, protein, zinc dehydration= Hypernatremia, elevated BUN

assualtive/aggressive/agitated patients--how to manage

initial action= speak calmly and assertively to the client to encourage control *assist pt to identify and express feelings of increased anxiety, frustration, and anger (utilize these methods before jumping to seclusion) clear others out of way only if can! *may not be initial action as situation can escalate rapidly (do not try to redirect ,distract clients attention, will frustrate more)

Cauda Equina Syndrome

injury to lumbosacral nerve roots (L4-L5), causing motor/sensory deficits-->medical emergency to prevent damage!! PRIORITY PT IF SEE sx= lower bakc pain, inability to walk, saddle anesthesia (inner thigh/buttocks), bower/bladder incontinence (late sign) rx= reduce pressure on spinal nerves; hey

Lactase deficiency (lactose intolerance)

is NOT an allergy to milk, is due to deficiency of enzyme lactase GI sx after ingesting milk products= flatulence, diarrhea, bloating, cramping rx= restricting lactose food: RESTRICT MILK/ICE CREAM dairy products, cheese, yogurt--can be tolerated usually depend on pt teach= -take enzyme supplement with meals containing dairy (to help digest the dairy consumed and decrease sx) -can still eat cheese and yogurt as long as they don't make pt feel sick (eat in moderation) *can also take lactase enzyme replacements (lactaid) to decrease sx *supplement calcium and vit d!

right side vs left side stroke effects how to work with receptive aphasia pts

left side brain: understand and speak language (so have aphasia w/ left CVA) receptive aphasia: trouble understand BOTH verbal and written words (hand gestures, visual aids more helpful) rx= ask simple yes or no questions! -use gestures and visual aids (pictures) to increase understanding (communication board) right side: pay attention, recognize, sensory, spacial awareness so right side CVA causes impulsiveness, unaware of deficits

shock BP level

less than 80 systolic

calcium carbonate

makes bones stronger!! think, makes "bones hard, makes bowels hard too" or high cal, hard bowel--low cal, loose bowel calcium supplements--take w/ food or w/in 1 hr meals (think vit with food)! take w/ food in divided doses (no more than 500 mg at a time) *take Mg and Vit D to help Ca Absorption SE= can cause CONSTIPATION (add fluids & ambulate) *no need for routine blood tests/labs

skeletal traction

metal wire/pin applied directly to bone to immobilize, position, or align fracature when cont traction is needed and skin not possible (bucks) ex= balanced suspension traction, skull tongs *NEVER REMOVE WEIGHTS, CAN CAUSE INJURY -->unless life threatening situation

Working Phase of Nursing

middle phase of nurse pt relationship in which nursing interventions take place

Oral Candidiasis (Thrush)

milk curd lesions on mucosa, may bleed when removed risk factors: immunosuppresed corticosteroid meds chemo/radiation high dose/prolonged abx dentures/infants

Neutropenia/Leukopenia

neutropenia: usually <1500/mm3 ANC <1000 (norm 2200-7700) severe neutropenia= <500 leukopenia= <4000 *Uworld Thrombocytopenia: <150 *however, >50 is where really serious, avoid IM injections/venipunctures

Foods containing iron

organ meats (red meat, poultry giblets) fortified cereals (instant oatmeals) oysters, clams, scallops (mollusks) egg yolks *NOT CHICKEN BREAST OR FISH (TUNA)

Renal calculi care

pain= SEVERE, SHARP, STABBING, (flank, back, or lower abdomen) radiates down to groin as stone travels down ureter admin analgesics at reg intervals fluids!! strain all urine AMBULATION (facilitates stone passage) monitored heat therapy okay avoid massages! *furthers renal colic

disorders of nerve impulse transmission (name 3)

parkinsons MS MG

therapeutic hypothermia

perform in pts within 6 hours of cardiac arrest and maintain for 24 hrs--then slowly rewarm pt *indicated for all pts who are comatose or DO NOT FOLLOW COMMANDS after ROSC! (improves neurologic outcomes/decreases mortality) how it works: cool pt to 89.6-93.2F (32-34C) for 24 hrs before rewarming use cool blankets, ice placed in groin, axilla, sides of neck, cold IV fluids *keep watch for bradycardia, core body temp, BP MAP >80, skin for thermal injury keep HOB elevated 30 keep pt NPO

pleural friction rub

pleurisy= stabbing chest pain increases on inspiration/and expiration with cough COMMON COMPLICATION OF PNA! can auscultate rub over lateral lung fields area inflamed (two areas rubbing together) sounds like squeaking, loud, rough grating sound heard ON INSPIRATION AND EXPIRATION (similar sound to crackles, but crackles only heard on INSPIRATION)

appendectomy

position: HOB semi fowlers (to reduce pressure on suture line)

Ebola virus

precautions= standard, contact, droplet, and airborne!! they have it all!! =impermeable gown/coveralls, N95 respirator (worn by nurse not pt), full face shield, doubled gloves with extended cuffs, single use boot covers, single use apron *pt placed in single pt airborne isolation room with door closed *visitors prohibited unless absolutely necessary for pts well-being (parent visit child) *log of all individuals is maintained entering/exiting room and these people are monitored for sx *Use of sharps, needles, procedures limited whenever possible doffing PPE: must be observed by trained observer: outer gloves first cleaned with disinfectant and removed inner gloves wiped between removal of every subsequent piece of PPE (respirator, gown) and removed last *no cure/current vaccines for ebola PREVENTION IS CRUCIAL

Anticipitory guidance

prepares pts and caregivers for FUTURE HEALTH NEEDS (anticipating the future)

gastric lavage

process of inserting large tube into stomach to clean out/irrigate stomach ewald tube is used (orogastric tube) decompress stomach first, then initiate lavage asap after *risk for aspiration, perforation, dysrhythmias--> insertion causes gagging/vomiting be ready with SUCTION AND INTUBATION EQUIPMENT AT BEDSIDE *due to complications, only indicated if OD is potentially lethal and can be initiated WITHIN ONE HR OF OD TO BE EFFECTIVE -use large bore orogastric tube (36-42 French) so large vol water or NS can be instilled in and out position= side lying or HOB elevated (minimize aspiration risk)

best way to promote sleep in pt

provide daytime activities! (even if pt on bedrest)

compartment syndrome hallmark

pt c/o pain unrelieved by pain meds sx= think 6 Ps pain with passive motion/unrelieved by meds pallor paresthesia paralysis pulselessness poikilothermia (Coolness) WATCH FOR VOLKMANN CONTRACTURE= (w/ distal humerus fx)-->restricts arterial blood flow from swelling-->causes wrist contractures and INABILITY TO EXTEND THE FINGERS--med emergency!! *if develops (in case) pt should have arm kept at torso level (level of heart) think when laying down even with body DO NOT ELEVATE ARM (keep at heart level) do not apply heat -nurse loosen tight bandaging/casting material *check circulation and change pt position (heat indicates pressure, pressure limits ciruclation) *if conservative measures fail, HCP do FASCIOTOMY to relieve compression (fasciotomy wound is prone to infection source!)

Goal of effective communication amongst caregivers?

reduce the number of medical errors!!

behavior modification-- how do you know its successful

requires pt readiness and motivation PT ACTIVELY TAKES STEPS TOWARD NEW BEHAVIOR (commits to change and has plans)

Preterm Labor Risk factors

risks= hx of preterm birth -->biggest risk factor! previous cervical surgery (cone biopsy) tobacco/drug use infection (UTI, peridontal)--medical disease maternal undernutrition--low socioeconomic status non-hispanic black women--african american maternal age <17 or >35 rx= side lying position rest!! relaxation good nutrition TOCOLYTICS= (terbutaline/MAG SULFATE, nifedipine, indomethacin) cont fetal monitor Before 34W G: -IM antenatal glucocorticoids: betamethasone/dexamethasone (promote surfactant development) -IV mag sulfate (fetal neuroprotection) <32W -antibiotics (penicillin) prevent group B strep (or obtain cultures 35-37 W G to determine need of abx during labor)-->GIVE EVEN IF MOM DOESNT CONFIRM IF HAVE YET -tocolytics (nifidipine, indomethacin) -monitor lab results, cultures (UTIs, Group B strep) etc. AROM is contrainidcated!

tricyclic antidepressants SEs

rx= depression, neuropathic pain, bed-wetting (enuresis) "mines" *priority teaching is to GET UP SLOW FROM BED "trypta" SEDATION, the 3 D's (like clonidine) ortho hypotension, dizziness, drowsiness, dry mouth, constipation, photosensitivity, blurred vision, urinary retention, dysrhythmias (ANTICHOLINERGIC effects!) toxicity: (OD) IF PT OD'S ON ONE OF THESE MEDS, THIS IS LETHAL AND PRIORITY PT NO MATTER WHAT is life threatening!! even small amount narrow therapeutic index and rapid onset of action can cause cardiac and neuro disturb (arrhythmia's, hypotension, seizures) *if pt switching from TCA to MAOI- MUST have drug free period of at least 2 weeks between the two (same like SSRIs!)

Bishop score

scoring system for assessment and rating of CERVICAL FAVORABILITY AND READINESS FOR INDUCTION OF LABOR scoring: (each category 0-3 points) based on cervical... consistency (firm, medium, soft, ---) position (post, mid-position, anterior, ---) dilation (0 cm, 1-2 cm, 3-4 cm, >/=5 cm) effacement (0-30%, 40-50%, 60-70%, >/= 80%) station (-3, -2, -1/0, +1/+2) *higher score (6-8)-in nulliparous women =likely successful induction

prostate cancer

screening= prostate specific antigen serum test risk factors= African American first degree relative with increased age >50 diet high in red meat, animal fat, dairy, refined carbs low fiber intake obesity *NSAIDs long term use can be protective factor against colorectal and prostate cancer!

When should expect embolism post-op? VTE?

second day post op; VTE= 6-14 days post op up to 1 yr!

postpartum psychosis

signs appear within 2 weeks after bith (like postpartum blues) -hallucinations -delusions -paranoia -severe mood changes -delirium -feeling someone will harm the baby PSYCH EMERGENCY! at risk for suicide/infanticide

Cyclobenzaprine

skeletal muscle relaxant think "cyclo--back" *decrease muscle spasms ANY MUSCLE RELAXERS: *contraindicated in presence of liver disease (most muscle relaxants!) --avoid alcohol --do not stop abruptly hepatotoxicity: leads to med toxicity and increased CNS depression

high protein diet

skim milk, eggs, meat

bariatric surgery--name? *most imp factor for rx weight loss

sleeve gastrectomy (remove part of stomach and remaining portion creates sleeve or pouch) *watch for complications post op! =severe abd pain (esp radiate to back/shoulder), w/ signs of sepsis (restless, tachy, oliguria) could indicate anastomotic leak-->PRIORITY ACTION= report to HCP asap!! diet post op= high protein, high fiber, low sugar low carbs! (prevent dumbing syndrome!) due to sleeve gastrectomy -->small frequent meals best foods: (full liquid diet) cream soups, refined cooked cereals, sugar free drinks, low sugar protein shakes/dairy foods MOST IMP FACTOR for successful weight loss= assessing familys readiness for change

schizoid personality disorder

social detachment inability to express emotion do not enjoy close relationships prefer to be aloof and isolated

social worker occupational therapist

social worker= helps with pt's discharge planning and health care finance assess adequacy of d/c setting, support systems, arrange for resources at home, or d/c to alternate setting (such as rehab facility) *social worker/case manager both good resources to use to advocate for pts needing d/c help! occupational therapist: promotes development of fine motor skills and ability to carry out ADLs

mononucleosis spread

spread by direct contact STANDARD PRECAUTIONS (not droplet!) avoid sharing utensils etc for about 3 mo--spread through saliva sx= swollen lymph nodes, fatigue, fever, sore throat, spleno/hepatomegaly PRIORITY PT= WATCH FOR SPLEEN RUPTURE (SX= sudden onset LUQ pain) *after 3 weeks, NOT CONTAGIOUS anymore *treatment is NOT abx! (viral infection) tx= rest, hydration, nutrition AVOID STRENUOUS EXERCISE/contact sports DUE TO RISK OF SPLEEN RUPTURE (mono causes hepatomegaly) complications= encephalitis, and spleen rupture

CKD stages and sx

stage 1- normal kid func (little to no sx, kid func reduced but other one compensates) polyuria/nocturia stage II- mid dyfunction; ; protein leak in urine, oliguria, edema stage III- mod kid dyfunction edema, fatigue, back pain, foamy/dark urine, low albumin restrict= sodium and phos stage IV-severe kid dysfunction dialysis N/V (acidosis), loss of app, sleep probs, dietician need, tingling sensation Stage V- kidney failure dialysis required/transplant all the sx

gastroenteritis

stomach flu acute= food poisoning *assess: does child attend day care center (place where infections promoted) *rotavirus vaccine can prevent severe acute gastroenteritis (diarrhea/vomiting)

when does TPA have to be given for stroke/MI? contraindications to thrombolytic therapy?

stroke= 3-4.5 hrs of LKWT MI= within 6 hrs onset inclusion criteria= (MI pts) chest pain last <12 hrs, EKG found acute ST elevation MI, no absolute contraindications! ABSOLUTE CONTRAINDICATIONS: -surgery within past 2 weeks -currently on anticoagulant therapy -head trauma/ ischemic stroke within last 3 mo -any current active bleeding/ bleeding diathesis (condition) -hx of intracranial hemorrhage -structural cerebrovascular lesion= AV malformation, aneurysm -suspected aortic dissection -BP >180/110 (aka uncontrolled HTN) AEs= bleeding!

skin biopsy

suspected malignant skin lesions are removed and examined microscopically by a pathologist *do not take Asa prior to (increase bleeding) *can have tanning apt next day (does not affect accuracy/results of biopsy) *can eat/apply lotion on skin beforehand!

Cold injury

sx= redness, swelling of skin (chilblains/pernio) blanched skin with hardness of the affected area (frostbite) priority action= REWARM AREA AS SOON AS POSSIBLE -immersion in warm water (104F) for about 30 min or until area turns pink (frostbite cases) -rewarm face with warm facecloths DO NOT MASSAGE BODY PART --risk tissue injury

pneumonectomy

the surgical removal of all or part of a lung on surgical side, breath sounds will be absent *assess for TRACHEA POSITION in sternal notch! shift could indicate increase pressure on operative side against mediastinal area position post op: side lying on surgical side to promote adequate lung expansion of remaining lung

INR/ pt ranges

therapeutic= 1-2 not on anticoag 2-3 for Afib pt up to 3.5 for heart valve disease *abx will increase INR ratio by causing vit K deficiency *INR slightly higher is expected when adjusting warfarin dose

Magnesium Sulfate

think hypermag sx cns depressant so see... resp despression, decreased DTRs, decreased UO therapeutic effect? (in preg)--> seizure activity stops! (prevents in preeclampsia, controls in ecclampsia) also for hypomagnesemia normal mag level= 1.5-2.5

Dental Avulsion

tooth separated from mouth EMERGENCY!! priority action= rinse (sterile saline, clean running water) and reinsert tooth into gingival socket (with finger) until stabilized by a dentist -->reimplantation within 15 min reestablishes blood supply increase probability of tooth survival if not possible, place tooth in commercially prepped solution, cold milk, or sterile saline SEE DENTIST ASAP!

Turner's vs. Klinefelter's syndrome

turners: female with only one x chromosome (x) kleinfelter's: male with extra x chronosome (xxy) *both usually infertile

sentinel event

unanticipated event in health care setting resulting in death or serious physical or psychological injury

Pharmacologic nuclear stress test

uses vasodilators to simulate exercise when pts unable to tolerate continuous physical activity, or target heart rate not achieved through exercise alone *use radioactive dye, to see where areas of adequate coronary perfusion are preop: -no eat drink smoke (NPO) at least 4 hrs, can have small sips with meds -avoid caffeine 24 hrs before -avoid decaffeinated products 24 hrs before -do not take theophylline 24-48 hrs before -avoid nitrates, dipyridamole, BBs before -consult with HCP how to take diabetic meds if need to before

Room assignments

*avoid infectious/potentially infectious pts with pts who are immediate post-op, immunosuppressed etc

Doxepin Hydrochloride

antidepressant AD= tremors, excitability

40 year old male

begins to evaluate life accomplishments vs goals look for mid life crisis!

Tetanus vaccine

booster need every 10 years

Asparin

contraindicated in pregnancy!! can cause fetal hemorrhage

Gastroparesis

delayed gastric emptying; stomach cant empty self in norm fashion so see N/V, heartburn, feeling full quickly when eating rx= antiemetics

Modified Trandelenburg

feet elevated 20 degrees HOB slightly elevated trunk flat used in shock!! return perfusion to heart

Heparin and Warfarin administration antidotes?

heparin antidote= protamine sulfate warfarin= vit K *can give together warfarin takes 48-72 hrs to reach affect, 3-5 days to reach peak levels *if level is INR 1.8--this is expected as anticoags are adminstered until reach therapeutic levels typical overlap is 5 days or until INR reaches therapeutic level! (for warfarin given with either heparin, enoxaparin, or dalteparin this is true) *if pt misses a dose of warfarin, usually still have therapeutic INR for 1-2 days, is NOT priority pt! therapeutic range= 1.5-2.5x control (INR 2-3) but up to 3-4x control (2.5-3.5) can be norm in artificial heart valve pts need to begin taking PO warfarin (4-5 days before) while pt is still on IV hep drip before d/c hep therapy for warfarin to reach therapeutic levels warfarin is contraindicated during pregnancy! *warfarin is long term med, give PO-->abx can affect warfarin!! *do NOT AVOID VIT K COMPLETELY, (could alter warfarin effectiveness), instead, KEEP VIT K INTAKE CONSISTENT DAILY to keep INR/PT stable! *avoid sudden increases/decreases in vit K *do not admin warfarin if >4 (2.5-3.5 in heart valve pts is highest) teach: -avoid NSAIDs while on -remove hazard fall items in home -admin for 3-6 mo following PE to prevent further thrombus formation -lifelong admin of med if pts have recurrent PE -soft toothbrush, electric razor -AVOID alcohol based mouthwash, avoid contact sports/rollerblading, avoid straight razor Heparin: IV or SQ MOA= keep current clot from getting bigger; help prevent new clots from forming HEPARIN INDUCED THROMBOCYTOPENIA (HIT)-->monitor for this when heparin infusions (heparin or LMWH= enoxaparin) if observe: plts below <150,000 or decrease >50% from baseline REPORT TO HCP ASAP, THIS IS A MED EMERGENCY, PRIORITY PATIENT!!!!!!! --> *HIT has paradoxical effect in which there is an increased risk for DVT and PE (not as much bleeding issue) *draw repeat samples to ensure accurate lab values obtained STOP HEPARIN (and begin other non-hep anticoag--argatroban), so not enoxaparin--to prevent thrombus risk *heparin is D/C'd prior to surgery! bleeding! *hx of HIT= NEVER SHOULD RECIEVE HEPARIN OR ENOXAPARIN (LMWH)

burn diet

high calorie, high protein, high carbohydrate vit B,C,iron

Psych pt/unit considerations

if caller asks about pt's condition, psych pt has prearranged telephone # they are given to talk with those whom they choose

IQ ranges

normal= 85-115 intellectual delay= IQ <70 *IQ below 55 need care, incapable of self maitenance high IQ= >130

quadriplegia

paralysis of all four limbs *but CAN move head/blow--use call light on head

hemodialysis AV fistula care

purpose= connect artery and vein to provide big enough vascular access through arterial blood flow for dialysis access frequent by 2 large bore needles to help fistula mature: -perform hand exercises (squeeze rubber ball) -palpate thrill, auscultate bruit (indicates patency)--should be able to hear right after create!! before hemo: check thrill and bruit every 8 hrs! tells blood circulating through graft, is good -obtain set VS and current weight check record to determine last post-dialysis weight -last post weight-current weight= ultrafiltration amount (fluid removed during session) -make sure pt EATS -admin prescribed meds (and hold those that would be dialyzed out) *D/C BP MEDS UNTIL AFTER RX (can cause hypotension then HTN) which include: -->ANTIHYPERTENSIVES -->vit B/C (water soluble) -->ABX -->Digoxin done for 3-5 hrs 3x/week blood shunted through dialyzer (artificial kidney machine) access through subclavian cath or AV fistula -->give IV hep when start to prevent clotting! *if develop N/V, fever, chills-->suspect blood stream infection AV fistula care: takes 2-4 mo for fistula to mature! squeeze small sponge in left hand several x/day touch site and feel for vibration (thrill) several x/day try not to sleep on left arm avoid restrictive clothing/jewelery do not use affected arm to carry heavy objects (>5 lbs) expected findings: EDEMA in first 2 weeks (elevate extremity) *report findings edema >2 weeks major complication= infection!! *if sx of infection at AV fistula graft site, not immediately life threatening! (dialysis grafts are prone to infection) still inspect, but not priority pt! Arterial steal syndrome: AVF complication anastomosed vein "steals" too much arterial blood, causes distal extremity ischemia Dialysis Disequilibrium syndrome (DDS): LIFE THREATENING! occurs during initial stages of one receiving hemodialysis -causes increased ICP! (sx= N/V, HA, restlessness, seizure, change LOC)--can lead to coma/death -if suspected, contact HCP ASAP rx= -the rate SHOULD BE SLOWED OR STOPPED

micrograms symbol

that weird "ug" lookin symbol

Hypocalcemia

CATS -->See CNS excitability effects Convulsions, Arrhythmia's, Tetany, spasms and stridor PROLONGED QT INTERVAL/ST SEGMENT TORSADES DE POINTS MAY OCCUR Rx= calcium diet PO calcium gluconate (IV) or calcium chloride with OJ to max absorption! *caution using these w pts on dig, causes cardiac depression admin phosphate binding antacids, calcitrol, vit D

Newborn first bath--steps

PROCEEDS IN A CEPHALOCAUDAL (HEAD TO TOE DIRECTION) place on warm surface (prevent heat loss through conduction) cleanse the eyes from inner to outer canthus--using clean washcloth or cotton ball cleanse the face using only warm water cleanse the body with warm water and mild soap wrap the newborn in a towel/prewarmed blanket shampoo the head and hair (last cause pt loses most of heat from head, while wrapped in warm blanket)

Muslim Diet/ considerations

-Ramadan: fast for one month each year from dawn till after dark (must eat before sunrise, after sunset) -Respect this -No alcohol -no pork -no fermented fruits/veggies halal prep: drain blood -humane process of animal slaughter (no hindquarters) cultural considerations: -in their culture, a man is not allowed to be alone with a woman other than his wife -covering up body is essential in women (in presence of man other than one not related to her) -*have female health care examine muslim woman (if not avalible, have another female nurse or staff member present) -husband will often ask to be with wife during exam, respect this -if semi-private assignment, put with another muslim woman or one practicing similar practices

Celiac diet sx expect?

-gluten free (not even minimal amount allowed)= FOR REST OF LIVES -cannot consume oats, rye, barley or wheat (no pudding, cereals, wheat bread) *DO INCLUDE: fruits/veggies high protein (meat, dairy, fish, beans, nuts) RICE, CORN, POTATOES are okay!! replace fat soluble vit, iron, folic acid -chocolate, candy, hot dogs may exacerbate (processed foods= read labels!) -read all food labels for gluten free label sx= diarrhea, foul smelling stools (esp if non-compliant with diet regimen)

condom catheter

-leave 1-2 in space between tip of penis and end of condom (prevent irritation and pool of urine) -use elastic adhesive if need in spiral fashion (wrap around condom) to secure device, do NOT use adhesive tape -if pt mobile, attach collection bag to leg DO NOT: RETRACT FORESKIN WHEN APPLYING IF UNCIRCUMSIZED--can cause paraphimosis!!

Orthostatic BP (how to perform)

1. have pt lie down at least 5 min 2. measure BP/HR 3. Have pt stand 4. Repeat BP/HR measurements after standing at 1 and 3 minute intervals abnormal finding= -drop in systolic >/= 20 or diastolic >/= 10! -experiencing lightheadedness/dizziness

Lyme disease

3 stages get from ticks--most common in summer sx: notify HCP if flu-like sx/bulls eye rash develops ASAP! stage 1- rash with lesion and clear center (concentric rings) at tick bite site (2-30 days) bulls-eye lesion, lymphadenomathy, flulike sx stage 2- if untreated develops in 1-6 mo cardiac conduction defects, neuro/paralysis (not permanent) stage 3- several years arthralgias (inflamed joints), chronic fatigue, cognitive disorders think prevention! cover clothes, insect repellent, check for presence admin abx 3-4 weeks, then IV penicillin G if ticks present, REMOVE WITH TWEEZERS (grab close to attachement site and do not cruch it during removal)

Nonpharmacological pain management for infants

admin sucrose for painful procedures have parents hold infant skin to skin nonnutritive sucking (pacifiers) are good swaddling infant

cast syndrome (superior mesenteric artery syndrome)--what at risk for?

bowel obstruction! -->bowel ischemia--> emergency!! overly tight cast, compresses duodenum sx= paralytic ileus, abd pain, distension, N/V rx= window cut out over abd portion of cast

Purpose of catheter irrigation (CBI) continuous bladder irrigation

for bloods and clots in tubing, after TURP (catheter applies direct pressure to bleeding tissue while tubing allows urine to drain) keep pt straight position (cath taped to thigh and should be kept straight to maintain traction) (avoid legs up to abdomen position)--indicates pain a large amount of fluid is expected in CBI (500mL) is okay! total output: *intake of CBI should nOT equal output= indicates obstruction! should be getting more output due to urine + CBI

Herbal therapy considerations

glucosamine= to improve joint function -->can cause hypoglycemia when taken with antidiabetic drugs garlic= lower cholesterol/BP Echinacea= rx common cold/flu -->worsening asthma/anaphylaxis have been reported

Fetility when is infertility dx?

greatest chances of conception= timing sexual intercouse near ovulation "fertile window" teach= track menstrual cycle (14 days after) is fertile window, best time to conceive--spike in FSH/LH hormones-- *can tell this also by monitoring cervical changes in mucous (thin, clear, slippery, stretchy) *can use ovulation predictor kits: detect surge of LH that precedes ovulation by 12-24 hrs Infertility= after 12 mo of frequent, unprotected intercouse for pts without med complications (advanced maternal age)

paranoid personality disorder

have pervasive distrust and suspicion of others *people people's motives are malicious and others are out to exploit/decieve them pt develops an INTENSE NEED TO CONTROL THE ENVIRONMENT, be self-sufficient *will not be able to control their anger when confronted

Supraglottic swallow

have voluntary control over vocal cords to protect from aspiration 1. inhale deeply 2. hold breath tightly to close vocal cords 3. place food in mouth and swallow while cont to hold breath 4. cough to dispel remaining food from vocal cords 5. swallow a second time before breathing

cystoscopy complications

hemorrhage (perforation) infection urinary retention position= lithotomy (for procedure) *norm for urine to be pink tinged after, have frequency, dysuria (up to 48 hrs) pt should NOT experience pain! -->indicates trauma *may feel burning sensation or frequency after with voiding for day or two--normal! teach= fluids!! avoid acl, caffeine 24-48 hrs after, analgesics, warm sitz baths for pain relief abnormal= NO BRIGHT RED BLOOD/CLOTS/inability to urinate, fever >100.4, chills, abd pain unrelieved by analgesia should occur after at all!

poison control considerations rx in ED?

if ingest toxic substance--do NOT induce vomiting (could cause aspiration) (only if indicated by poison control center, and save any substance comes out) AVOID GIVE LARGE AMOUNT FLUIDS when med ingested as may accelerate gastric emptying/ enhance drug absorption store in locked cabinets child proof containers leave meds/cleaning supplies in original containers never take meds in front of child rx= gastric lavage--intubate, position head down, left side, NGT insert, repeat NS irrigations until clear *must do in 60 min of ingestion! activated charcoal: within 30 min of ingestion and after emetic chelation (for heavy metals)--calcium EDTA, dimercaprol, deferoxamine--binds with chelating agents to be eliminated by kidneys cyanide poisoning= have bitter almond smell from pts breath

VBAC (vaginal birth after cesarean)--what at risk for?

increased risk for uterine rupture (from previous cesarean incision) increased risk with tachysystole s/sx uterine rupture: abd pain constant loss fetal station abnormal fetal HR (bradycardia--fetal decelerations) sudden cessation uterine contractions--HALLMARK

how to enhance breastfeeding/lactation? expression of breastmilk?

infant sucking let down/milk ejection reflex-->use warm shower/compresses expression of milk: can use to collect if breasts still full/for supplemental feelings use pump or manually express, store in fridge up to 4 hours, or can freeze up to 6 mo! *THAWED BREAST MIL SHOULD NEVER BE REFROZEN *keep in mind, many drugs cross into breastmilk so check with HCP before taking any meds!!!!!!!

bell palsy precautions

inflammation of cranial nerve VII (facial) eyelids do not close properly--> sx= eye dryness and risk corneal abrasions, or excess tearing in some pts (change lacrimation) -inability to completely close eye on affected side -facial muscle weakness= poor chewing, food retention -flattening of nasolabial fold -inability to smile symmetrically teach to help w/ sx: eye care -wear PATCH AT NIGHT (or tape eyelids) -use glasses during day (to protect exposed eye) -artificial tears during day for excess drying oral care: -chew on unaffected side to prevent food trapping -soft diet -oral hygiene after each meal (dental caries) avoid extreme temperatures (heat or cold) triggers sensitive nerve endings cause blinking/squinting (and cant with eye) perform isometric facial exercises (Blow or suck through straw) rx= corticosteroids (reduce inflammation) -eye/oral care *can drive! doesnt affect vision

Hemolytic Uremic Syndrome (HUS)

life threatening complication of E. coli diarrhea! red cell hemolysis, low plts, AKI anemia sx= petechiae or purpura low UO (AKI) pallor (anemia) ecoli is infected through contaminated food/water attacks GI system expected: (sx from e. coli infection) blood streaked stools, diarrhea dry mucous membranes (dehydrated) teach= (sx usually improve in about a week) -avoid fruit juices -cont normal diet -fluids!

Tiotropium

long-acting, 24 hour anticholinergic inhaled med for COPD *not a rescue med admin= capsule-inhaler system "hanihaler" powdered med dose contained in a capsule, pt places capsule in inhaler and pushes button which pokes hole in capsule, and as pt inhales powder is dispersed through the whole EMPHASIZE CAPSULE SHOULD NOT BE SWALLOWED BUTTON ON INHALER MUST BE PUSHED to allow for med dispense -rinse mouth after use this and inhaled steroids (beclomethasone, fluticasone, budesonide)

Oligohydraminos major complications? polyhydramnios

low amniotic fluid volume complications= umbilical cord compression pulmonary hypoplasia *to fight this: 1. neonatal personnel present at birth in case need pulmonary resuscitation 2. cont intermittent fetal monitoring polyhydramnios (>2000mL amniotic fluid) @risk for postpartum hemorrhage due to uterus over distention (oligohydramnios)= <500mL fluid vol

kidney diet

low sodium, potassium, protein, phos restrict fluid foods: unsalted veggies, white rice, canned fruits, sweets

Major AE of statins! MOA of statin

lower cholesterol, reduce risk of atherosclerosis and CAD AEs= MYOPATHY *look out for muscle aches, notify hcp asap *atorvastatin and colchicine use together increase rhabdomolysis risk also LIVER INJURY AE! watch LFTs statins MOA: reduce LDL (diabetic/ and not? pt <100) total cholesterol (<200) triglyceride levels (<150) TAKE AT EVENING OR BEDTIME (can be with meal)

who qualifies as a minor who can provide their own consent?

married, pregnant, or a parent over over 12 (or mature minors= 14-18) inquiring about STDs, HIV/AIDs, drug/alcohol treatment, blood donation seeking birth control, family planning outpt psych services or voluntary inpt admissions to psych facility emancipated/mature minors (14-18 yrs old) *pregnant minors: have right to give consent for infant *cannot give her own consent unless she fits into one of the above exemptions

hypertensive encephalopathy

med emergency!! sudden elevation in BP (HTN crisis)-->cerebral edema/increased ICP also sx of N/V, HA if pt has this, it is PRIORITY to give anti HTN meds!! triggers= acute HTN exacerbation, drug use, MAOI-tyramine interaction, head injury, pheochromocytoma sx= VISUAL IMPAIRMENT, EPISTAXIS, seizures, confusion, anxiety, coma, severe HA

percutaneous endoscopic gastrostomy (PEG)

minimally invasive procedure, performed under conscious sedation gastrostomy tube inserted through esophagus using endoscopy into stomach *used for long term feedings *tubes tract begins to mature in 1-2 weeks and NOT FULLY ESTABLISHED UNTIL 4-6 WEEKS post op *if PEG tube dislodges, NOTIFY HCP ASAP as early dislodgment (<7 days post-op) requires surgical or endoscopic replacement

cerebral palsy

neuromuscular disorder usually due to a lack of oxygen during birth sx= ataxia, rigidity, repetitive involuntary slow mvments, athetosis, spasticity age groups: newborn-cant hold head up, unable to feed infant- FTT toddler- developmental delay (physical and mental) rx= ambulation devices assist w/ feeding--food at back of mouth or either side of tongue toward cheek, apply slight downward pressure with the spoon *NEVER TILT HEAD BACK WHEN FEEDING-->choking! diet= high calorie

Erikson's stages of psychosocial development

newborn to 1 yr: trust vs mistrust toddler: autonomy vs shame and doubt preschool: initiative vs guilt school age: industry vs inferiority adolescent: identity vs role confusion 20 to 40: intimacy vs isolation 40 to 65: generativity vs stagnation 65 +: integrity vs despair

vital signs based on ages

newborn: HR: 120-160 RR: 30-60 infant: HR= 90-160 RR: 30-60 1-yr: HR= 100-160 30-60 (dont change)

Newborn hypoglycemia level hyperglycemia?

normal level =70-100, but 1st hr after birth glucose levels decreased to 40-60mg/dL (shouldn't be more than this), then stabilize in 2-3 hrs (>40 is still considered normal tho first 24 hrs after delivery (less than this should be confirmed with blood sample) <40-45 mg/dL= hypoglycemia! *if newborn asymptomatic and low BG (<45) if age 4-24 hrs, or <25 in age <4 hrs, initially treat with feeding (breastmilk if possible) causes= gest DM (causes rebound hypoglycemia in infant after birth), HYPOTHERMIA!! is another trigger! rx= monitor BG after birth, repeat in 4 hrs admin glucose carefully to prevent rebound hypoglycemia initiate feedings if not lethargic, reassess glucose right before feeding *if symptomatic, (lethargic, jittery), or BG does not increase with feeding (remain 40-45), then notify HCP and prep to give IV glucose! >125= hyperglycemia sx= jittery, irritability twitching, poor feeding weak-high pitched cry cyanosis, lethargy, irreg resp. effort eye rolling, seizures *no yawning or sneezing

fat emboli s/sx (fat embolism syndrome: FES) treatment?

occurs with long bone/pelvic fx pts, or w/ pancreatits/liposuction develops 24-72 hrs after repair *no specific dx tests! NO SPECIFIC TREATMENT--so early dx and mgmnt is critical to prevent: early stabilization of injury and surgery asap to repair long bone is recommended NURSE SHOULD MINIMIZE MOVEMENT OF INJURED EXTREMITY to reduce risk of fat emboli!!!!!!! sx PETECHIAE OVER NECK/CHEST-->differentiates FES from a PE! tachypnea, dyspnea, tachycardia sudden worsening chest pain anemia, thrombocytopenia resp compromise confusion/restlessness/anxiety/memory loss (hypoxemia) fever >101.4 hypoxia *not paresthesias in extremity/increased pain despite opioids= this is compartment syndrome!

Fluid vol overload/deficit VS Sx

overload HTN no temp change increase slight HR (tachycardia, bounding) increase RR (rales, dyspnea, SOB) (*oliguria NOT sx) deficit hypotension temp increase weak, thready pulse (increase HR) increase RR sunken eyeballs!-->dehydration! *dont have pt weigh daily (this is for fluid vol overload)

acromegaly

overproduction of growth hormone (GH), usually due to pituitary adenoma occurs adult onset ages 40-45 sx= ENLARGED EVERYTHING!! overgrowth of soft tissues heart sounds S3/S4 enlarged organs HTN, HF DM gigantism skin tags arthritis

purpose of amniotic fluid

produced by fetal kidney to: promote lung maturation prevent cord compression

herniated intervertebral disk surgical procedure?

protrusion of the central part of the disk that lies between the vertebrae, resulting in compression of the nerve root and pain sx= lack muscle tone, poor posture, sensory change, low severe back pain! rx= laminectomy pre op: fowler position, moist heat, firm mattress/bed board, isometric exercises abd muscles (support spine) post-op: calf exercises log roll q 2 hrs pillow between legs will see edema/HA post op (spinal fluid leak) cause pain compress nerve root maintain body alignment: straight back during ambulation-->erect posture all times!! use hardboard/firm mattress for bed AVOID PRONE POSITION avoid lift heavy objects

breast cancer

risk factors= *recall "CEO" CEO= hx of colon, endometrial, ovarian CA men= prostate cancer direct fam hx (mother, sister, daughter) age greater 50 yrs, female sex early menses (before 12) late menopause (after 55) no children first preg past 35 yrs genetic= BRCA 1/2 mutations modifiable risks: hormone therapy w/ estrogen/progesterone (combined oral contraceptives) -->increase risk if take after menopause postmenopausal weight gain/obesity hx smoking/alcohol consumption sedentary lifestyle diet intake of fat sx= dimpling, puckering ('peau d orange'), tenderness, retraction, discharge, change in color-- erythema, axillary adenopathy, rash, edema, warmth hard, irregular, non-mobile, nontender lump (enlarged lymph nodes) *fibroadenomas (benign) are round, small, painless, mobile lumps--no retraction, discharge, and may change size during menstrual cycle--not concerning!

radioactive iodine (RAI)

rx= hyperthyroidism *destroys thyroid gland and makes pts permanently hypothyroid, so they will have to take thyroid supplements rest of life teach: after ingesting, this med makes bodily secretions radioactive (separate beds, isolate laundry, separate toilet, avoid preg women, children, infants, sit sep on plane) *CONTRAINIDICATED IN PREGNANCY (confirm not preg. w/ preg test before prescribing) AE= radiation thyroiditis/parotitis (dryness/irritation to mouth) -->take sips of water or use salt/soda gargle solution RAIU test *to test thyroid gland for hyperfunctioning, by admin only low dose of radioactive iodine *scan performed 2,6,24 hrs to see preop: -hold antithyroid/thyroid hormone med 5-7 days before -premenopausal women take preg test (contraindicated if pregnant) -notify hcp if CT or XR has been recent performed can alter results -NPO 2-4 hrs before, eating can resume 1-2 hrs after -remove dentures, jewelry/metal around neck -fluids after!! -awake during procedure, should be no discomfort -ask when breastfeed can resume

Stevens-Johnson Syndrome severe form?

severe form= toxic epidermal necrolysis -->major cause of death from this is sepsis!--so think all care is sterile/reverse iso sx= widespread erythema, blistering, skin shredding *sterile, moist dressings applied to open areas of skin reverse isolation precautions oral feedings to promote wound healing (start early!)-may need NGT if cant do PO monitor sx hypovolemia maintain room temp 85F to avoid hypothermia--also warm products such as pads or single use warm blankets eye care (sterile, cool compresses applied for discomfort, lubricants) pain mngmt ATC *do not massage sites

thoracentesis considerations position

sitting up with arms over pillow on over-bed table side lying on bed (on unaffected side) complication= pneumo/hemothorax (puncture lung!), pulm edema, infection, bleeding watch for sx of complications post-procedure= diff. breathing, O2 sat decrease, asymmetrical chest expansion, tracheal deviation PRIORITY PT IF OCCURS! *also monitor post: level of alertness, lung sounds, resp. pattern, O2 sat

aortic stenosis aortic regurgitation

stenosis: narrowing aortic valve obstructs blood flow from left ventricle to aorta-->decreased EF sx= narrowed pulse pressure weak thready pulses exertional dyspnea anginal chest pain syncope loud systolic murmur over aortic area S2 soft or absent teach= risk of sudden death high in this population -->avoid strenuous activity before surgery! (exertion will exacertbate sx, restrict activity--even walking) regurgitation: bounding pulses (more blood pumped out each time, from buildup in LV from previous systole)

splenectomy--complication?

surgical removal of the spleen complications: overwhelming postsplenectomy bacterial infection OR rapid onset sepsis!--> due to inability to filter blood and remove certain microorganisms (spleen is part of the immune system!) *be on lookout for even any minor sign of infection (this is priority pt!)

Situations RN is obligated Reporter

suspected abuse (child, elderly, mentally ill, underage--sexual abuse!) *STDs/ reportable conditions by law must be reported (greater good and population must know) even if pt asks not to report under HIPAA--these are NOT protected by HIPAA *cupping is not sign of abuse (use to promote release of muscle tension)

pneumothorax

sx= tachypnea, increased Resp effort, resp distress low O2 sat, absent breath sounds on affected side diminished breath sounds decreased tactile vocal fremitus hyperresonance to percussion tracheal deviation?? tension pneumo rx= *when have pressure from affected pneumothorax pushing onto heart and unaffected lung (see tracheal deviation/ mediastinum shift) decreased venous return (hypotension)--due to SVC compression altered LOC 20 G needle insertion at the mid-axillary line for pleural aspiration care= for uncomplicated small pneumo, pt may have FLUTTER HEIMLICH VALVE placed and can still be safe d/c home: scant, clear, pleural drainage expected

Hyperglycemia sx/rx

sx= (think 3 P's + DKA Sx) excess thirst abdominal pain nausea fatigue blurred vision increased urination 10 units reg insulin unconscious= inject glucagon followed by a protein snack *in hospital, the recommended random glucose level for hospitalized clients is <180 (and before meals <140)

paralytic ileus

sx= abd discomfort, distention, N/V causes= abd surgery, anesthesia, analgesics (opioids), immobility (stroke) care= NPO NG suction to wall to decompress stomach IV fluid replacement antiemetics analgesics= NSAIDs, acetaminophen are okay

hallmark of IBS Irritable Bowel Syndrome

sx= abd pain diarrhea and constipation, combo of both! bloating, nausea, urgency, flatulence rx= lifestyle/diet modifications -daily record of symptoms, diet intake, stress -limit GAS PRODUCING FOODS: legumes/beans cruciferous veggies= cabbage, broccoli, onions fructose= honey, apples, bananas -GI irritants avoid (think GERD)-spices, fatty foods, dairy, hot/cold foods or drinks -avoid high fructose corn syrup, wheat, honey -stress reduction techniques (meditation/ yoga) -reduce daily caffeine intake, alcohol -exercise -stress reduction -well tolerated foods= proteins, breads, bland foods *DO NOT FAST/REDUCE ORAL INTAKE (even during exacerbations)

carcinoma of the larynx surgery?

sx= affects voice box so symptoms near throat sx= laryngectomy (partial or total) position post op= semi fowlers FEEDING TUBE PLACED due to edema from surgery, prevent aspiration after tube removed, high protein diet for tissue healing teach esophageal speech or artificial larynx (electro)

concussion

sx= brief LOC amnesia regarding event= RETROGRADE AMNESIA HA *non-strenuous activities for 1-2 days NOT EXPECTED: (indicate increased ICP) worsening HA/vomiting sleepiness/confusion also... visual changes weakness/numbness of body

bipolar (manic phase) considerations

sx= elevate mood, excess activity high risk behavior (excess spending, hypersexuality) easily distractable (neglect personal needs--hydration, nutrition, sleep, hygiene) avoid interventions that increase stimuli (will increase agitation), competition place in room away from activity do promote: walking, sweeping, dancing, painting (distract pt with light activities) -have pt participate in physical exercise with a staff member (just one!)--one on one interactions, no group! care= DO NOT ISOLATE-->increases agitation DO ASSIGN TO PRIVATE ROOM, HOWEVER -choose clothing for pt -quiet, calm environment, low lighting -limit # people coming in contact with pt concisely remind pt about rules, set limits on behavior -structured schedule activities diet= ENERGY AND PROTEIN DENSE FOODS, high calorie, finger foods, that are easily carried and consumed--"on the go" i.e. sandwiches, shakes, hamburgers, pizza slices, burritos, fruit juices, granola bars -avoid caffeinated drinks (aggravate mania)

oxygen toxicity

sx= pain behind sternum (chest pain), SOB *if pt recieving oxygen and has these sx keep in mind this could be occurring, but dont take them off o2 if they have other conditions requiring their O2 sat to be good (COPD) hypoxemia > risk than oxygen toxicity

Postpartum infection

temperature 100.4 F or higher on any two consecutive postpartum days exclusive of the first 24 hrs; chills; tachycardia abd pain, lochia foul odor, prolonged rubra phase elevated WBC rx= change peri pads frequently rinse perineum with warm water after void/defecate (cervical os stays open 6-12W after so more at risk for bacteria to enter uterus) encourage early ambulation!

Spinal immobilization indications

think "NSAIDs" *indications, think, are when pt has deficits that may alter their ability to feel spinal pain--need to immobilize so dont cause further injury! n= neuro exam (focal deficits= decreased strength/numbness) S= significant traumatic mechanism of injury A= alertness (altered LOC, disoriented) I= intoxication (lack awareness of pain) D= distracting injury (takes away from spinal pain) s= spinal examination (point tenderness over spine/neck pain on mvemnt)

Addison's disease

think "hypocortisolism"/hypoaldosteronism need more hormone, low aldosterone= low sodium so everything will be SLOW S/Sx= hyponatremia (salt cravings), hyperkalemia (met. acidosis/arrythmias), hypoglycemia (insulin shock), dehydration, HYPERPIGMENTATION ("eternal tan"), decreased BP, arrythmias, depression, lethargy, WEIGHT LOSS patho fractures, alopecia, HAIRLESS, fatigue, MUSCLE WEAKNESS, resistance to stress, emotional lability, N/V MOOD CHANGES!! VITILIGO (patchy, blotchy skin) Diet= high sodium, high carbs, high protein, low potassium MOST IMP INFO FOR PT TO KNOW *will need life-long hormone replacement (cortisol= hydrocortisone/prednisone) *protect from infection!-->will cause immunosuppresion *if see pt even with low grade fever, THIS IS PRIORITY PT!

Diabetes insipidus

think DI "Dry Inside" decreased ADH, so loosing fluids hemoconcentration of electrolytes (hypernatremia) high serum osmolality low urine specific gravity S/Sx of fluid vol deficit HYPERNATREMIA, polyuria, polydipsia decreased specific gravity (dilute urine) 4-30L/24 hrs= UO hypotension, hypovolemia Rx= desmopressin (vasopressin-DDAVP)= ADH (MUST TAKE NASALLY OR SQ FOR REST OF LIFE!) watch for signs of fluid vol overload/water intoxication since this will cause hold onto fluid watch for hyponatremia/hypokalemia also due to this reduce pts fluid intake while on med MEASURE SPECIFIC GRAVITY *report to HCP if sudden increase in weight gain! (med needs to adjust)

compassion fatigue

to help: attend child's memorial service continue contact with pt's fam for extended time after hospital stay okay to share personal emotions of loss or sadness with fam of dying child take time off work if need adequate rest, reg exercise, proper nutrition support systems!!

wound irrigation

to wash out debris and bacteria to ensure wound healing, decrease infection risk steps: analgesic 30-60 min prior don gown/mask to prevent fluids splash fill 30-60 mL sterile syringe with prescribed irrigation solution -attach 18-19G needle/angicath to syringe and hold 1 in about area (so not too much water pressure) -USE CONTINUOUS PRESSURE TO FLUSH WOUND until drainage is clear dry surrounding would area irrigate wound FROM LEAST TO MOST CONTAMINATED AREA

Ketoconazole

treatment of choice for candidiasis

mobility: from bed to chair (proper positioning)

wheelchair should be 45 angle to HOB on pt's unaffected side always pivot on stronger side!! always on DISTAL SIDE PIVOT! ------->if patient is weaker on left side, have them pivot on right side! assist to stand: grab pt around ribcage, push knees against pts, rock forward as stand steps: 1. make sure pt wearing nonskid shoes 2. make sure bed/chair brakes are locked 3. use a transfer belt (gait belt) 4. have pt transfer toward stronger side. (if pt weak on left, ask the pt to pivot on right)

Point of maximal impulse (PMI)

where the left ventricle impulse felt most strongly @ left 5th ICS, midclavircular line (where mitral valve is!) *if below this (5th ICS), indicates heart may be enlarged! *also feel apical pulse here as well! to assess: position pt supine or w/ HOB elevated 45 degrees

Normal urine output

30-50 mL/hr OR min= 0.5mL/kg/hr -->use this for eval childs!! max= 1-2 mL/kg/hr (for child!)

Sulfasalazine

DMARD/IBD (reduce inflammation, autoimmune disorders) *inhibits folate absorption--have pt take folic acid supplements

Akathisia

inability to sit still

toxic shock syndrome (TSS)

life threatening bacterial infection, primarily caused by prolonged tampon in vag (bacterial feeding ground) early treatment essential! to prevent other organ involvement sx= erythematous rash, fever (sudden), vomit, diarrhea, drop sys BP (shock!) abx

key to HTN Sx

may be asymptomatic!! pt thinks they dont have to take meds, educate they MUST BE COMPLIANT even with no sx

Procainamide HCL AEs

severe hypotension/bradycardia (think antidysrhythmic)

pospartum considerations

stable pts: delivered 12 hrs over intact perineum GBS (group Beta strep) receiving abx

calorie requirement adult fluid requirement

anywhere between 1500-3000 1800-2500 mL/day (1500-2000) think I/Os

Lung contusion

bruised lung life threat--bleeding into lung and alveolar collapse= ARDS sx to watch for= hypoventilation, O2 sat decrease, inspiratory chest pain can cause

Trazodone

anti-depressant, serotonin modulator AE= priapism (>3 hrs=alert!!), ortho hypo, sedation *alcohol contraindicated

Hypomagnesemia S/Sx and Rx

"Twitching" -->Mag is a CNS depress, so see CNS excitability! (similar to hypocalcemia neuromuscular excitability!) T- trosseau's/chovskeks W- weak respirations I- irritability T- torsades de pointes C- cardiac changes H- HTN, hyperreflexia I- involuntary mvemnts N- nausea (dysphagia) G- GI Issues Rx= increase diet mag, parenteral mag sulfate supplements may give calcium preps to countact danger Myocardiac dysfunction from rapid secondary mag infusions

if an Incorrect Med is given, steps to take

evaluate the effect of this med on pt notify the pt, the pt's HCP, and the nurse manager-->THATS IT complete an incident/occurrence report (if a death occurs, the nurse manager will notify the risk manager) an attorney is only involved if actual pt harm occurred

Psychiatric unit admissions Involuntary vs Voluntary criteria

Involuntary: -person is in imminent danger to self or others -person has grave disability (unable to care for self/basic needs) *dx of a mental illness is NOT enough to admin involuntarily

Rubella (German Measles)

droplet precautions sx= low fever, sore throat, maculopapular rash appears first on face then rest of body, sx subside after first day of rash *keep away from pregnant women--risk fetal deformity antipyretics/analgesics, rare complications arthritis, encephalitis *avoid ASA

Juvenile Idiopathic Arthritis (JIA)

a chronic arthritic condition affecting the joints that occurs before 16 years of age *at risk of de-conditioning due to decreased muscle strength and endurance sx= *joint pain that is worse in the morning joint swelling/stiffness high fever skin rash rx= first line mgnt for pain= NSAIDs TNF's for inflammation (enteracept, adalimumab) LOW-IMPACT, WEIGHT BEARING, NON-WEIGHT BEARING EXERCISES involve ROM and stretching will help preserve joints and strengthen muscles AVOID HIGH IMPACT ACTIVITIES ex= swimming, yoga, stationary bicycling, throwing/kicking a ball

true vs false labor

True Labor → contractions w cervical dilation, increased frequency, duration, intensity -progressively effacing and dilating -pain may start in lower back and radiate to lower abdomen -CONTRACTION DOES NOT DECREASE WITH REST False labor → irregular contractions (not progressively stronger), w/out cervical changes. -discomfort usually abdominal -CONTRACTIONS MAY LESSEN WITH ACTIVITY OR REST *SEDATION helps (key to distinguish)! Can reassure and d/c home. *expulsion of mucus, increased blood tinged vag discharge plug is NOT necessarily an indicator of true labor!

increased ICP nursing interventions

VS hourly: look for cushing's triad cluster care (minimize stimuli) elevate HOB 30-45 monitor GCS prevent valsalva (exhale while turning in bed) stool softeners, restrict fluids (1200-1500) avoid neck flexion, head rotation--use cervical collar/neck rolls for support

common missed q's

Which meds have most potential risk for injury? *looking for sedating meds a. amitriptyline ("amy trips on things") b. diphenhydramine c. alprazolam Which combo of meds should the nurse question? *no MAOIs with SSRIs a. sertraline and selegine b. lithium and ketorolac (no bipolars w/ NSAIDs) Which has the most potential for injury? a. Amitryptylline to treat fibromyalgia pain -->recall "amy trips on things" b. HA while on Phenelzine --> first sign of HTN crisis is HA!! c. taking St. John's wort with Sertraline -->no st. johns with SSRI d. d/c escitalopram day before taking isocarboxazid -->no mix SSRI and MAOI w/in 2 week period *example: priority lab value prior to surgery for pt with diverticulum: Cr 2.3 WBC 16,000 -->ans= Cr as is elevated & Adverse outcomes associated with declined renal func and effects from surgery, also elevated WBC is expected in diverticulitis! NEVER THE EXPECTED ANSWER

Tay-Sachs disease

autosomal recessive found in people with ancestry of northern eastern european jewish descent fatty acid destroys brain nerve cells leads to death by age 4

pulse pressure

dif between sys and diastolic norm= 40-60 *kaplan says 30-40 normal

pyloric stenosis (in infant)

gradual hypertrophy of pylorus onset 3-5 weeks, common in first born boys sx infant= fussy, hungry all the time; "hungry vomiter" (malnourished, DEHYDRATED SX, lethargic), PROJECTILE VOMITING (post prandial) *NONBILIOUS VOMIT OLIVE SHAPED mass just right of umbilicus (where pylorus is) elevated HCT/BUN! (hemoconcentration due to dehydration) metabolic alkalosis hypokalemia (due to vomiting acids) poor weight gain to r/o: -assess to ensure amount of milk consumed/mother's feeding technique (with burping) is adequate so no excess air swallowing or overfeeding is etiology -compare birth weight to current weight

pediculosis capitis

head lice check for lice rx= gamma benzene hexachloride (kwell) -->apply shampoo to dry hair, work lather for 4-5 min use hot water to launder clothing, sheets, towels in wash then place in hot dryer 20 min seal items that cannot be washed or dry cleaning in sealed plastic bags for 14 days vacuum furniture, carpets, stuffed toys, rugs, mattresses

Health Screening Tests (age performed)

hearing and vision 4, 5, then yearly during school cancer screenings: colonscopy, rectal exams start at 45 yrs colon=every 10 years sigmoidoscopy= every 5 years pap smear: start 21-29 yrs q 3 yrs if sexually active or 18 yrs perform annual 30-65 q 5 yrs mammography: 40-44 yrs optional 45-54: yearly 55 and older: every 2 years

Probiotics

helps maintain normal intestinal flora for pts on abx *enhance immune response, stabilize mucosal barrier foods include= yogurt, acidophilus milk (kefir), saurkraut, kimchi, cottage cheese (think fermented foods, dairy), pickles, tempeh, miso, kombucha some types of cheese (cheddar, mozarella, gouda, cottage), natto traditional buttermilk NOT egg whites! people who benefit: (anything causing changes in intestinal normal environment, have altered GI tract) antibiotic-associated diarrhea irritable bowel syndrome lactose intolerance

Cushing's syndrome

"hypercortisolism"/hyperaldosteronism -->too much, everything increased! (more aldosterone= hypernatremia) S/Sx= hypernatremia, hyperglycemia (+ketoacidosis), hypokalemia (met. alkalosis), increased BP, fatigue, weakness, OSTEOPOROSIS, purple skin striations, hirsutism (excess hair), emaciation, depression, decreased infection resistance, moon face, buffalo hump, obesity (trunk), mood swings, masculinization in females MOOD CHANGES!! WEIGHT GAIN!! *NOT WEIGHT LOSS, oligomenorrhea, acne IN LEGS (STRAIAE)--petechaie/brusing WEIGHT GAIN IN TRUNK (TRUNCAL OBESITY) Diet= high protein, low carb, low sodium, high potassium, low calorie, fluid restriction rx= hypophysectomy; adrenalectomy post adrenalectomy care: flank incision so dif to breathe, encourage coughing/deep breathing *prevent infection! decrease fracture risk monitor HTN *assure client most physical changes are reversible with treatment (aminoglutethimide or metyapone decrease cortisol production) *EDUCATE FIRST: pt should know about schedule for gradual withdrawal from drug steroids must be tapered! remember, sudden withdrawal can induce acute adrenal insufficiency= life threatening PRONE TO FLUID OVERLOAD AND HEART FAILURE d/t Na + H20 retention (hypernatremia) so measures to prevent this!! cause can affect respirations!

detached retina

#1 consideration: prevent increased intraocular pressure avoid interventions that may cause this assess for N/V s/sx= flashes of lights, floaters, loss of portion of visual field (either central or peripheral), is painless! may see ring/cobweb in field of vision

endometrial cancer

(cancer in lining of uterus) *often detect early due to: ABN VAGINAL BLEEDING *sx= HALLMARK= ABNORMAL UTERINE BLEEDING (heavy, prolonged, intermenstrual, and/or postmenopausal) watery discharge, menorrhagia lower back or abd pain risk factors= greatest= prolonged estrogen exposure w/out adequate progesterone (polycystic ovary syndrome, infertility/rx, late menopause, early menarche) >55 yrs postmenopausal bleeding obesity DM HTN ERT tamoxifen (med for breast cancer) internal radiation implants hysterectomy *comps= watch for hemorrhage, infection, thrombophlebitis protective factors= birth control pills w/ progestin (which thins uterine lining, not causing hyperplasia of tissue)

Varicella Zoster Virus Herpes zoster (shingles)

(chickenpox) airborne/contact precautions sx= generalized vesicular rash incubation period 13-17 days, transmissible period= beginning 1 day before rash, (fever and rash develop at same time) contagious until vesicles are crusted (takes about 1 week) *avoid asa due to reyes syndrome, use tylenol sx= also lymphadenompathy, anorexia, fever, malaise macules--papules--vesicles rx= cool oatmeal baths topical antihistamines applied to lesions for itching (diphenhydramine is good)! (RECALL, VARICELLA ITCHES, MEASLES DOES NOT) tylenol PRN for fever/pain *immunocompromised pts may need antiviral therapy until lesions crust over! -antiviral therapy (if immunocompromised)--cont. tell all lesions crust over *IF YOU HAVE NOT HAD CHICKENPOX, AND AROUND SOMEONE WITH SHINGLES, THEY CAN GIVE YOU CHICKENPOX (NOT SHINGLES) *If not had chickenpox and around someone with chickenpox, can get VZIG (if staff, exclude from caring for pts from 10th day after first exposure to 21st day after last exposure)--28th day if VZIG given Herpes simplex (shingles) sx= characteristic UNILATERAL, LINEAR FLUID FILLED BLISTERS (dermatomal distrubution) -painful! *if pt has, asap cover the affected area to prevent infection spread VACCINATION *vaccination will prevent--> however... --->do NOT give vaccine to immunocompromised pts/ do NOT give to people who had VSV (they develop immunity)!!!!!!! *expected sx from vacc: -discomfort, redness, A FEW VESICLES at site **teach pt to COVER VESICLES with clothing or small bandage to reduce transmission risk from any exudate (once vesicles have dried/crusted, no longer necessary)

Epi pen

(epinephrine auto injector) emergency rx for anaphylactic rx to allergens--give when first note signs of anaphylactic rx= dif. breathing, wheezing, stridor, shock, swelling of airway teach: DO NOT DELAY INJECTION--GIVE ASAP EVEN OVER CLOTHES give in mid-outer thigh, at FIRST SIGN of rx, can give through clothing (even many layers!!) 90 degree angle hold injection for 10 seconds in thigh, then massage site for an additional 10 sec seek immediate medical care (hospital, ambulance) after injection (10-20 min med effect can decrease and rx may resume) expect: tachycardia, palpitations, dizziness after admin carry always with you! always keep near a child in case! store at room temp in dark place

flouroquinolones

(levofloxacin, ciprofloxacin) abx with AE of ARF due to interstitial nephritis avoid sunlight monitor BG levels!! can lead to hypoglycemia/hypoglycemic coma! ------------------------- wait for two hrs to pass between consuming antacids, multivitamins, zinc, iron supplements, or sucralfate w/ this med

MERS (Middle East Respiratory Syndrome) + COVID precautions

(not fully understood the spread, but thought to be due to resp. secretions so... standard, contact, airborne = gloves, gown, goggles, AND N95 mask -->everything!! sx= fever, SOB, cough cause death in many afflicted MERS= incubation 5-6 days, or range 2-14 days

paracentesis position

(performed at bedside, local anesthetic) pre-op: position= high-fowler (or as upright as possible)-->OR sitting upright on edge of bed -witness the signed informed consent & verify -assess pts abd girth, weight, VS *empty bladder prior to procedure to avoid accidentally perforation! no NPO or bowel prep *AEs= hypovolemia (from rapid fluid loss)

postmortem care

(typically performed immediately to allow fam to visit decreased) reasons to delay care: -cultural/religious beliefs -last rites -death is considered non-natural (suicide), traumatic, or associated with criminal activity -->autopsy will be performed *if death is expected, DONT need autopsy (unless fam request) *if fam is not present at death, does NOT mean postmortem care has to be delayed (unless they request for specific reason as stated above) to perform: -standard/isolation precautions are maintained even after death -close eyes -leave dentures in place or replace if remove to maintain face shape!!!!!!! -place pad under perineum place pillow under head -remove equipment, soiled linens from room -straighten and wash body, change linens -remove tubes/ dressings *FAMILY SHOULD BE ALLOWED TO PARTICIPATE IF WANT TO, accomodate religious/cultural needs death of CHILD: -allow for bond of parents and child after death (take time, dont rush) to facilitate grieving process -be present as nurse, identify if parents want to help in cleaning/dressing child -let them cuddle, speak, read, sing to child if want

Necrotizing enterocolitis

*AFFECTS INTESTINE OF PREMATURE INFANTS Pre-term infants have lower immune function, upon initiation of enteral feeding, bacteria introduced and proliferate in bowel due to immunocompromised and cause inflammation and ischemia and air in the bowel. sx= abd distention/erythema of abd wall--> bile-colored vomit, hematochezia (bright red)/melena (dark) hypothermia, lethagry occurs 4-10 days after feeds started rx= *frequent abd girth measurements-->PRIORITY!! (watch for necrosis and perforation) -stop oral feeds, make NPO, NG tube then observe 1-2 days -parenteral IV abx and fluids, TPN nutrition given avoid tight diapering *avoid rectal temps!! avoid skin-to-skin care (cause additional stress) position= supine/undiapered (avoid abd stress)

ICP nursing care considerations

*During interventions, ICP should not exceed 25 mmHg and should return to baseline within a few minutes SPACE OUT CARE activities to decrease ICP stimulus AVOID CLUSTER CARE position: HOB elevated 30 degrees (semi fowlers) with head maintained in neutral position =promotes venous drainage dark, quiet, calm environment (reduce hall noise, alarms, TV) HYPERVENTILATE/pre-oxygenate BEFORE SUCTIONING (add O2 reduces CO2=vasoconstriction= decreased ICP) stool softeners manage pain (while monitoring sedation) manage fever (cool sponge, ice) while prevent shivering ensure adequate oxygenation

infant/newborn physical assessment steps adult PA

*INFANT ASSESSMENT: 1. OBSERVE: skin color, RR, activity level 2. auscultation (RR, heart, abd) 3. palpation and percussion (fontanelles, abd) 4. traumatic/more invasive things= examine eyes, ears, mouth (pupil dilation) 5. reflexes (moro--most jarring) count respirations for min prior to arousing newborn Toddler PA: (least to most invasive) -interact w/ parent friendly -play w/ child using finger puppet -measure child's height/weight -auscultate heart/lungs -take VS (BP cuff can perceive as painful) adult PA is HEAD TO TOE (appropriate for school age child as well)

Vaccines during pregnancy

*Tdap vaccine recommended for all preg women begin 27th week, to end of 36th week (passive newborn immunity to pertussis) *influenze inactivted can recieve at any point during pregnancy contraindicated= live vaccines! pregnant women are immunosuppresed! NO MMR, Varicella, nasal influenza

nocturnal enuresis

*abd if child over 5 yrs (called nocturnal enuresis) *attempt non pharm methods first: -limit caffeine/sugar intake -void before going to bed -avoid punishing, scolding, ridiculing child -encourage child to assist with changing soiled pajamas and limits (helps feel in control, but provide reassurance this is not punishment) -positive reinforcement for motivation (calendar showing wet/dry nights, rewards) -enuresis alarm (awakens child at night when occurs) -restrict fluids ONLY after evening meal (take small sips) *DO NOT have child wear diapers pharm methods if above doesnt work first, OR when short term improvement is desired (wanting to attend sleepovers/go to summer camp): -->oral desmopressin -->tricyclic antidepressants (tryptlines, mines) pharm methods: second line rx --high risk of relapsed when drug d/c'd

Hypoalbuminemia

*albumin= prevents fluid from leaking out of vessels *in severe liver disease, develop hypoalbuminemia, in which oncotic pressure decreases and fluid leaks into interstitial space -->sx= pitting edema periorbital edema ascites therapeutic effect from IV albumin= VS remain within pt's normal parameters

bottle/formula feeding considerations --what complication is often caused?

*causes engorgement since not breastfeeding =Swelling of the breasts resulting from increased blood flow, edema, and the presence of milk. (often in bottle feeding)-->so want to promote activities that DECREASE BREAST MILK PRODUCTION: engorgement usually resolves on its own in 5-7 days use tylenol/ibuprofen as prescribed to reduce discomfort *do NOT massage breasts (is painful, can increase milk flow, unnecessary in bottle) or use manual breast pump APPLY COOL/ICE PACKS for 15-20 min q 3-4 hrs both breasts (vasoconstricts and decreases milk flow) CABBAGE LEAVES where tight fitting, supportive bra 24 hrs/day (for 72 hrs) to decrease discomfort/let down effect AVOID WARMTH/HEAT-->promotes FORMULA FEED: if parents try to dilute it to save money, (with water), which they SHOULD NOT do, causes water intoxication in infant--> hyponatremia/ sx= irritability, lethargy, hypothermia, seziures

Transdermal contraceptive patch (Ethinyl estradiol and norelgestromin)

*combined hormonal contraceptive (CHC) absorbs through skin *wear for 3 weeks, then remove for 1 week AEs= INCREASED THROMBOEMBOLISM RISK (like oral combined contraceptives) -concern also about hx breast cancer as contraceptives may stimulate tumor growth *patch is contraindicated for obese pts >200 lb, wont absorb *contraindicated in any condition in which thrombus would adversely effect (HTN, ischemic, hepatitis, immobile, migraines, active breast cancer etc)

scarlet fever

*complication of group A strep droplet precautions (for 24 hrs after start of abx) sx= strawberry tongue enlarged tonsils cover with exudate fever, vomit, chills DISTINCT RED RASH= red, tiny lesions become generalize and desquamate, sandpaper like fine bumps rash appears within 24 hrs (group a strep) sore throat RASH + SORE THROAT CHARACTERISTIC SCARLET FEVER

Smallpox (Variola)

*dif from chickenpox fever present 2-4 days BEFORE rash onset, then sharply raised pustules (in chickenpox fever/rash develop same time) *pt infectious until scabs separate (3 weeks) AIRBORNE PRECAUTIONS, contact, standard *if exposed, admin vaccination within 3 days of contact *does not give lifelong immunity

somatic symptom disorder

*disorder develops from STRESS, results in unexplainable physical symptoms *seek medical care from multiple HCPs *try to get "secondary gains" (benefits from being sick) care= -limit time spent discussing physical symptoms with the pt -redirect to unrelated, neutral topics -identify pt's secondary gains -recognize factors that intensity sx (stress) -coping strategies (relax, exercise) *do not dispute validity of sx (what you are feeling isnt true)-->increases stress

sleep hygiene

*do NOT read in bed before sleeping, read in different setting *avoid non-sleep related activities, other than sex, in bed avoid caffeine, nicotine, alc, strenous exercise within 4-6 hrs of sleep *avoid strenuous activity or exercise within 4-6 hrs of sleep *avoid heavy meal right before bed or going to bed hungry (avoid naps during day unless shorter than 20-30 min) practice relaxation techniques (deep breathing) if stress if causing insomnia keep bedroom slightly cool, quiet, dark for comfort develop sleep wake schedule as much as can (same time go to bed and wake up)

Sputum Culture collection

*do not touch inside of specimen cup or lid -rinse mouth with water before collect! (to reduce bacteria in mouth interfering w/ sputum specimen) -inhale deeply a few times then cough forcefully -sit upright when collect -collect early in AM -may need nebulizer rx to mobilize secretions *is a sterile procedure!

Neonatal Abstinence Syndrome (NAS)

*drug withdrawal 24-48 hrs after birth due to maternal in utero exposure *most common due to hx of opioid abuse (heroin, methadone, morphine)--can also be benzos CNS excitability sx (opp effects of opioids which are depressants): diarrhea, vomiting poor feeding hyperactive/restless/ irritability(swaddle and gently rock newborn!) loose stools nasal congestion/ frequent sneezing/yawning! sweating, pupil dilation high pitched crying hyperactive reflexes, abn sleep pattern give pacifier between feedings keep infant upright after feeding quiet, dim lit environment, cluster care to minimize stimulation med= methadone, morphine (give opioid therapy)

mastitis

*goal= think want to ensure adequate milk drainage sx= dry, cracked nipples (portal of entry for bacteria) red, painful, warm, edematous breasts rx= systemic abx (cephalexin, dicloxacillin) WARM COMPRESS to promote drainage *cool compresses can be used in between for comfort as well rest, nutrition, hydration SOFT, SUPPORTIVE BRA (not tight) MASSAGE! (facilitates emptying) fluid intake!! CONTINUE BREASTFEEDING (q 2-3 hrs) +proper technique analgesics (tylenol, ibuprofen) -wash hands before and after feeding often occurs when women breastfeeding/lactating!

Extubated Patient Care

*high risk for aspiration, airway obstruction, resp distress position= high fowler -warm humidified oxygen is administered immediately after extubation -oral care -frequent cough and deep breathingM -use incentive spirometer -KEEP NPO (need bedside swallow screen)--no oral meds/ice chips until this is approved!!!!!!!

Metformin

*increases sensitivity of insulin and reduces glucose production in liver RISK OF HYPOGLYCEMIA IS MINIMAL (cause doesn't increase insulin production--even when take without food) SE= stomach upset (nausea, diarrhea) metallic taste in mouth AE= lactic acidosis (avoid w/ contrast--d/c 48 hrs before and restart med 48 hrs after!) *good DOC for elderly pts with diabetes (less risk for hypoglycemia)

PPD test results

*indicates exposure to TB disease 15 mm or greater= dx in pts without risk factors 10-14.9mm = dx for pts at risk (immigrants recent, drug injection, children less than 4) 5-9.9 mm= dx for pts with AIDs, immunosuprresed, transplant pts, cancer

dissociative identity disorder (DID)

*likely develop due to traumatic events and alternative identities serve to protect pt from stressful memories *pt may not be aware of alternate identities and be confused by lost time and gaps in memory! goal= integrate identities into one personality, while maintaining safety -develop trusting relationship with each alternate identitiy -encourage the pt to journal about feelings/dissociation triggers -listen for expressions of self harm in alternate identities -teach grounding techniques such as deep breathing, rubbing stone, counting cones to hinder dissociation episodes -allow pt to recall memories at own pace

pinworm specimen collection

*most common worm infection in US (spread by inhaling/swallowing pinworm eggs--found in contaminated food, drink, toys, and linens) *eggs hatch in intestines, lay eggs at night around the anus sx= anal itching (worse at night!), troubled sleep when person scratches, can get in fingers and spread to other surfaces Collect early in the morning after child awakens w/ a piece of Scotch tape touched to the anus -pinworms crawl outside the anus early in the morning to lay their eggs -not found in stool rx= antiparasitic meds

Narcotic addicted infants neonatal abstinence syndrome (NAS)

*narcotics, cocaine, barbiturates drug withdrawal occurs early as 12-24 hrs (has to be cleared completely from body first), up to 7-10 days after sx= CNS excitability! (since depressants) tremors, diaphoresis, tachypnea, high pitched cry hyperreflexivity, decreased sleep (yawning, sneezing) uncoordinated sucking (POOR APPETITE) non nutritive sucking (give pacifier) admin benzos/methadone to help relax reduce environment stimuli adequate nutrition wrap infant snugly, rock, hold tightly

percutaneous kidney biopsy

*obtain tissue sample through needle pre-op: -must d/c all anticoags, antiplts for at least 1 week -pt typed and crossmatched for blood -BP should be well controlled post-op: -monitor VS at least q 15 min -assess puncture site for bleeding complication= POST-PROCEDURE BLEEDING contraindication for procedure= UNCONTROLLED HYPERTENSION must be <140/90 before performing

suicidial precautions

*place patient in SEMIPRIVATE room near nurses station to reduce isolation! MOST IMP ACTION= PT IS PLACED ON ONE ON ONE SUPERVISION make rounds when nurses usually busy (breaks, change of shift) make sure pt swallows meds, encourage pts to express feelings--esp. anger; supervise during meals

Z-track technique

*recommended for IM injections (preferred site adults= ventrogluteal children= vastus lateralis) 1. pull skin 1-1 1/2 in. laterally away from injection site 2. Hold skin taught with non-dominant hand 3. insert needle 90 degree angle 4. inject med slowly while maintain traction 5. wait 10 seconds after injection and withdraw needle to maintain skin traction 6. release the hold on skin 7. apply gentle pressure at site, but DO NOT massage

Ocular chemical burns

*require emergent care to prevent permanent vision loss rx= COPIOUS EYE IRRIGATION WITH NS OR WATER BEGIN ASAP to flush chemical irritant out of eye *if before transport to ED, use tap water for irrigation *then in transport continue irrigation until pH of eye returns to normal (6.5-7.5) typically requires 30-60 min of time -may admin anesthetic eye drops prior to irrigation cause painful, but not priority -cover eye with eye patch, use eye drops to prevent muscle spasms, but also not priority

steroid med considerations (glucocorticoids)

*suppress immune response (look out for S/Sx of infection) *may develop mood swings/irritability while taking impaired wound healing elevates blood glucose yearly cataract checks (is SE) do NOT D/C ABRUPTLY DO NOT TAKE ON EMPTY STOMACH (can cause GI irritation) -->can cause GI bleeding?? watch for AE! -can cause fluid retention, worsen HTN *when take in combo with NSAIDs, can increase PUD risk *rinse mouth after take inhaled glucocorticoid to decrease risk of candida infection DO NOT ABRUPTLY WITHDRAWAL (slow taper to prevent adrenal crisis)

Hemorrhagic Stroke

*think blood vessel rupture in brain, causes increased ICP and potential seizures sx= SEIZURE (increased ICP) dysphagia (NPO!)--until swallow screen performed rx= prevent activities that increase ICP or BP -reduce stimulation, quiet dim lit environment -stool softeners -reduce exertion, maintain strict bed rest -maintain head midline position -seizure precautions!! -frequent neuro exams contraindications= NO MEDS THAT INCREASE BLEEDING (anticoags, ASA, NSAIDs)

Opioid withdrawal

*think is an opioid, so CNS depress so see excitability! sx= tachycardia, restlessness, N/V, pupil DILATION (recall opioids cause pupil constriction), insomnia-->yawning ex= heroin, codeine rx= opioid agonist (methadone, buprenorphine)--relieves discomort *if pt is an opioid abuser, put has surgery and needs pain meds, still need to be medicated, just need more potent opioid cause they have tolerance

Inaccurate Pulse Oximeter Reading causes

*think, things that cause low perfusion to fingers (arterial blood o2 sat) WHERE TO PLACE DEVICE= -->attach device to finger, toe, earlobe, nose, forehead FACTORS AFFECTING READING= black/dark fingernail polish, acrylic nails cold extremities, hypothermia, vasopressor meds (vasoconstriction) hypotension, low CO (HF, dysrhythmias), carbon monoxide poisoning PAD, excess movement, hypovolemic shock, smoke inhalation, improper sensor fit/position, edema ALSO IF THE PULSE plethysomographic waveform is erratic, irregular: can indicate: motion artifact! -->first check accurate position of pulse ox and pt, then go further if this isnt prob (ausculatate lungs, assist high fowlers, slow breaths, increase O2 if dont approve with other interventions first) -->electromagnetic inferference: lines still in regular wave form but spikes among each (for this remove pulse ox from pt and restart it)

Symptoms of depression in Adolescents

*vague somatic sx (HA, stomachache) irritable, cranky mood hypersomnolence/insomnia napping during daily activities low self esteem withdrawal from previously enjoyable activities outbursts of anger, aggressive, delinquent behavior, inappropriate sexual behavior weight gain or loss *also significant cause of suicide in adolescents

Growth and development Adolescent

*want to be just like peers, may ignore what parents tell them to do risk taking behaviors may be non-compliant in therapies due to false sense of security that nothing bad will happen to them (think immaturity)

umbilical cord care

*want to encourage drying so... expose to air frequently place the diaper BELOW the umbilicus (OTA) baths= SPONGE BATHS (until cord falls off), no basins--keeps cord from drying *does not need lotion/ointment applied *do NOT apply antiseptics (alcohol, dye, chlorhexidine)--irritating to skin expect: begins to dry around 24 hrs postpartum begins to shrivel and turn black in 2-3 days cord separates spontaneouly from umbillicus after 1-2 weeks *do NOT PULL ON CORD/HASTEN SEPARATION (let happen naturally) sx of infection: redness, purulent drainage, swelling umbilical cord (has 2 arteries, 1 vein): if only 1 of each, could indicate heart/kidney disease

Diabetic foot care

*want to keep feet warm (warm socks, bathe daily in warm water) -cut toenails straight across (prevents ingrown), use nail file along curves of toes -inspect feet DAILY -***use cotton or lamb's wool to separate overlapping toes! -wear clean absorpbent cotton socks -wash feet daily with mild soap and water (test water with thermometer beforehand) -gently pat feet dry, particularly between toes -use lanolin for dry cracked skin, but NOT between toes -use mild foot powder to absorp perspiration -wear clean, absorbent socks with seams aligned -daily exercise -wear closed toed, LEATHERY based shoes (no open toes/heeled/high heeled!) DONT DO: -go barefoot (wear sturdy leather shoes, inside AND outside) -use heating pads (avoid extreme temps--even on low setting) -avoid OTC products on cuts/abrasions (alcohol, iodine, strong adhesives) -avoid tight fitting garments -do not sit with legs crossed too long -do not open blisters and apply abx cream -do not wear open toed shoes instead of closed -do not self treat corns, calluses, ingrown toes: cleanse cuts/abrasions with mild soap/water -report non healing/infected injuries ASAP

school age growth and development

*watch for complications, child should NOT HAVE: enuresis: bed wetting encopresis: incontinence of feces lice!! apply 1nce a week, reapply 7 days if need later comb hair daily *in hospital, promote development by providing missed school work 6 years: FIRST PERMANENT TEETH APPEAR (begin loosing temporary teeth) takes bath without supervision ties knots concept of numbers (think first grade start learning math) 7 years: team/game sports develops CONCEPT OF TIME same sex playing preferred 8 years: help with household chores movement more graceful friends sought out 9 years: conflict between adult authorities and peer groups better behaved likes school conflict between needs for dependence vs independence 10-12 yrs: -->9 hrs sleep daily REMAINDER OF TEETH (EXCEPT WISDOM) ERUPT use telephone responsible loves convos raises pets develops beginning interest in opp sex ASSESSMENT: order= head to toe is good -respect wanting parents to leave room

Ethical and Legal Issues

*while parents have legal authority to make choices about child's healthcare, they do NOT when they do not permit life-saving treatment, or when child abuse or neglect is at hand in this situation, notify the hospital administration (who will obtain a court-approved custody)

Fall Risk Factors Fall reduction in homes

-Poor Vision -Cognitive dysfunction (confusion, disorientation, impaired memory/judgement) -Impaired gait or balance and difficulty walking (parkinson's) -Difficulty getting in/out of bed/chair (IV therapy, ambulatory aids- canes/walkers) -Orthostatic hypotension (rising pulse >20/min) -Urinary frequency or receiving diuretics -Weakness from disease process or therapy -Current med regimen that includes sedative, hypnotics, tranquilizers, narcotic analgesics, diuretics (antiparkinsonian) -age >60-75 (> 80 greatest risk) -carbidopa/levodopa; improper toilet seat/bed height reduce falls in home: most imp: REMOVE ALL AREA RUGS/INSTALL GRAB BARS -exercise regularly 30 min 3x/week -well lit, clutter free environment add night lights, remove or SECURE RUGS TO FLOOR WITH DOUBLE SIDED TAPE OKAY! -wear NONSKID shoes/slippers (both in and out of home) -use grab bars & non-skid mats in bathroom -review meds/SEs -wear electronic fall alert device -get regular visual exams *DO NOT WALK IN STOCKINGS AT HOME (should take stockings off before walking)--think like SCDs

anticoagulant considerations

-take med same time daily -periodic blood tests for warfarin and heparin -avoid actions causing trauma/injury (bleed)= razor bleed (use electric!), vigorous teeth brushing, contact sports -**AVOID ASA AND NSAIDs -avoid changing eating habits frequently (dramatically decreasing intake of vit K) -do not take vit K supplements -consult with HCP before herbal supplement (g's increase bleeds) -wear med alert bracelet

Chest tube removal

1. premedicate with analgesic (NSAID, Opioid IV) 2. provide HCP with sterile suture removal equipment 3. ***instruct pt to BREATHE IN, HOLD IT, AND BEART DOWN while tube is removed to decrease risk pneumothorax 4. apply sterile airtight occlusive dressing to site immediately after (petroleum gauze okay) 5. perform CXR within 2-24 hrs to assess for post op comps position= semi-fowlers or unaffected side

normal fetal heart rate/interventions for abnormal

110 to 160 bpm less than 80 warrants immediate intervention turn mother on left side (give fluids, O2), improves CO and relieves vena cava and aorta pressure, improving blood flow to fetus

Steps for Management of Chest Pain (and dont know cause)

ABCs position upright unless contraindicated oxygen if hypoxic OBTAIN BASELINE VITALS auscultate heart/lungs OBTAIN 12-LEAD EKG insert 2-3 large bore IV caths PRQST pain medicate pain (Nitro) cont. EKG monitoring baseline blood work (Cardiac monitors, serum electrolytes) obtain portable CXR assess antiplt/anti coag contraindicatins admin ASA unless contraindicated

Desmopressin

ADH (anti-diuretic hormone) (PO, nasal spray, IV, SQ) rx= diabetes insipidus risk= water resorption and intoxication!/ hyponatremia (watch specific gravity, serum sodium levels) ex= HA, mental status changes, weakness *recall hyponatremia can cause seizures, neuro damage!! watch for! TEACH= need to be on fluid restriction *effectiveness of therapy deemed by decreased UO!

estrogen therapy

AE= blood clots watch for sx dvt! expected SEs breast tenderness, enlargement, weight gain, N/V take with food if need GI disturb

Levetiracetam (Keppra)

AED-->*CNS depressant effects (all anti-epileptics have this) *minimal SEs compared to phenytoin so is preferred DOC so SE= drowsiness, somnolence, fatigue -->teach common first few weeks, improves 4-6 weeks AEs= suicidal ideation Steven's johnsons syndrome (All AEDs) (report rash, blistering, muscle/joint pain, conjunctivitis ASAP)

haloperidol AEa antipsychotic meds--what is the first thing nurse should do when giving?

AEs galactorrhea, lactation, gynecomastia postural hypotension (monitor BP q 30) dystonia (muscle contractions of face)-->no need to report NMS-->LIFE THREATENING! "hall-neuro" antipsychotic meds: monitor BP sitting and standing before and after each dose given

amputation phantom limb pain position? complications, hemorrhage

AKA-->wrap with figure 8 compression bandage (for edema) BKA--> *do NOT elevate residual limb (after first 24 hrs!)-->can cause hip contractures!--okay to do first 24 hrs phantom limb: (experience immediate post-op up to 2-3 mo) ***kneading massage on residual limb promote mobility==ROM, trapeze, firm mattress if PAIN LEVEL HIGH (>/= 7, priority pt!) to prevent hip contractures: position= prone q 3 hrs (3-4x/day) for 30 min; have pt roll from side to side avoid sitting in chair for >1 hr/day hemorrhage= tourniquet; mark area and observe q 10 min for increase figure 8 wrap plastic bandage to keep shape and prevent blood flow restriction *EXPECT SEROSANGUINOUS DRAINAGE POST-OP, NOT SAGNUINOUS (this is excessive and indicates hemorrhage!) --priority pt! contractures= start ambulation 1st/2nd day post op to prevent active ROM; crutch walk as soon as pt able to residual limb care: wash daily with soap and warm water thoroughly dry after inspect skin for signs of infection expose to air DO NOT APPLY LOTION only cotton or wool limb socks--keep all dry perform daily ROM

Acute Kidney Injury (AKI) chronic kidney disease (CKD) --> #1 cause? what are pts at risk for? causes of AKI (3) based on location

AKI: rapid, sudden decline in GFR; can be treated if caught early CKD: presence of kidney damage/decreased GFR for >3 mo -->#1 cause? HTN!! AT RISK FOR UNCONTROLLED HTN (HTN ENCEPHALOPATHY)= N/V & HA -->med emergency! PRIORITY PT expected labs: decreased HCT/ HgB--decreased erythropoietin production increased Cr/BUN @ risk for fluid overload/hyperkalemia--watch! teach pt w/ CKD: -sodium/potassium restriction -low protein, low phos diet (renal diet!) -monitor fluid intake close--fluid may be restricted (include gelatins/popsicles in I/O) -AVOID SALT SUBSTITUTES (high in K+) expected CKD sx: -*pruitis is common -nausea (due to azotemia--buildup of nitrogenous wastes) AKI: 3 phases oliguric phase: UO less than 0.5mg/kg/hr (100-400) see sx r/t fluid overload (HTN, edema, increase Ca/Na/ BUN/Cr), restless, confusion, seizures, n/v, enemia, CHF diuretic (recovery) phase: UO 4-5L per day (everything draining out!) sx= increased activity, Na/K loss, increased BUN serum chronic phase: retain fluid again (azotemia, anemia, acidosis) causes of AKI: prerenal: before kidney= decreased fluid vol/vascular obstruction HYPOVOLEMIA intrarenal (ATN-acute tubular necrosis)- happens to kidney: trauma, nephrotoxic drugs, transfuse rx, glomerulonephritis postrenal--after kidney= BPH, renal/urinary calculi diet= low sodium, potass, protein, phos, bedrest aluminum hydroxide for elevated phosphate levels

withdrawal symptoms alcohol narcotics barbituate amphetamine

ALCOHOL: CNS depressant (so see excitability!) inability to sleep stomach distress mild tremors irritability NARCOTICS: CNS depressants *very much like flu symptoms runny nose, fever, yawning, muscle/joint pain, diarrhea BARBITUATE: CNS depressant so see excitable Sx tachycardia, course tremors, seizures, N/V AMPHETAMINE: CNS stimulant (see depressed sx) depression, disturbed sleep, restlessness, disorientation

bronchoscopy

ANY PT JUST ARRIVING BACK FROM BRONCHOSCOPY REQUIRES PRIORITY ASSESSMENT FOR STABLE AIRWAY, etc! position= semi fowlers *assess for stridor/dyspnea from laryngospasm check VS q 15 tell stable complications= bleeding, pneumothorax, bronchial spasm WATCH FOR SX OF HEMORRHAGE post-op: expect= absent gag reflex for about 2 hrs *small amounts of blood-tinged sputum coughing up is OKAY!! decreased RR and lower O2 sat (mild sedation) unexpect= frank bleeding/clots

what are patients with acute pancreatitis at greatest risk for? sx

ARDS!-->monitor for resp sx (due to pancreatic enzymes releasing into systemic circuation cause inflammation) *can be due to alcoholic binge drinking, cholelithiasis also at risk for PANCREATIC ABSCESS! (infection sx)-->treat promptly to prevent sepsis *expected findings: ecchymosis (Turner's/Cullen's sign)--in severe elevated BG tachycardia! PAIN= severe penetrating abd (mid-epigastric, LUQ), radiating to back (retroperitoneal) steatorrhea N/V-->due to severe pain increased amylase/lipase HYPOCALCEMIA (*watch for trausseau/chvostek!) HYPERGLYCEMIA HYPOVOLEMIA -->hypoxia-->ARDS position- (to relieve pain)--flex the trunk! knee to chest (decrease abd pressure) semi-fowlers side-lying with HOB elevated 45 leaning forward *pain worsens with lying back *pain often made worse by high fat meal rx= hydromorphone IV for pain IV fluids NG tube to suction (suck out gastric secretions) NPO status!! (foods stimulate pancreatic enzyme release (which pt don't have)) at risk of developing: hypovolemia ARDS hypocalcemia!

Meniere's disease

Abnormal condition of excess fluid accumulation in inside of inner ear: can lead to a progressive loss of hearing, typically affects one ear sx= dizziness or vertigo--N/V, anxiety, hearing loss (muffled hearing), and tinnitus (ringing in the ears), fullness/pressure in ear (aural) *AS LONG AS PT SAFE FROM FALLING, THIS IS NOT PRIORITY PT IF SHOWING EXPECTED SX "drop attacks" pt reports feelings of being pulled to the ground PRIORITY= FALL PRECAUTIONS! safety! dark, quiet room avoid sudden head movements during spells reduce stimulation: no TV/flickering lights diet= salt restriction (prevent fluid buildup in ear) IV fluids for N/V (can consume K+/other electrolytes) -avoid nicotine, caffeine, alcohol (aggravates) -safety during attacks: assist with walking, bed rest -participate in vestibular rehab therapy rx= antihistamines, anticholinergics, benzodiazepines, antiemetics, sedatives, mild diuretics--adhere to meds!

allopurinol, colchicine

Allopurinol: Prevents gout! (prevents buildups of uric acid) (not for acute attacks) -->so don't take at signs of acute attacks; -->take w/ full glass H20 to help excrete acid, eat with meal for nausea -->takes a while for med to be effective, so cont to take NSAIDs with AE= RASH ALL OVER (very deadly)--even if mild, PRIORITY ACTION IS to stop taking med asap and report to HCP, may causes SJS and toxic epidermal necrolysis! (COLCHICINE IS FOR ACUTE ATTACKS, but does not relieve pain) pain with gout= take NSAIDs colchicine SE= diarrhea, abd pain, N/V for both: watch for renal calcuili! probenecid--for long term chronic gout

What is major complication of liver biopsy? positon before and after?

Bleeding-->monitor for sx of shock!! admin vit K IM pre-procedure to decrease risk check PT/INR/PTT before also blood type and crossmatch occur before also before= supine with arms raised above head (access between rib cages) -->tell pt exhale and HOLD BREATH while needle inserted *don't need to empty bladder (this is with paracentesis) after= right side with small pillow under puncture for 2-4 hrs (applies pressure), then supine for 12-14 hrs after that on bed rest

CABG (Coronary Artery Bypass Graft) MIDCAB?

CABG: sternal incision d/c antiplts/NSAIDs/herbals at least 5-7 days prior to surgery (asa, clopidogrel, prasugrel, ticagrelor, dipyridamole) POSTOPERATIVE COGNITITVE DYSFUNCTION: pts undergone CABG may experience this: probs with mem, language comprehension, concentration issues, -->some may even become teary or cry easily! -days to weeks following surgery, will resolve after complete healing occurred (4-6 weeks) NPO 6-8 hrs prior expected sx post-op: -itching, tingling, numbness at incisions (may be present for several weeks) Discharge CABG instructions: -smoke cessation, weight reduce, healthy diet, exercise (heart happy) -daily shower, wash surgical incision sites gently with mild soap/water and pat dry -do not apply lotions/powders/soak them AVOID TUB BATHS (risk infection) -do not lift heavy objects >5 lbs without HCP approval -light house work may begin in 2 weeks -do not lift, carry, push heavy objects until about 6 weeks after HCP approval -cardiac rehab program consider? -wear supportive elastic hose on legs, elevate when sitting to decrease swelling! *******-teach= if the pt is able to walk 1 block or climb 2 flights of stairs without sx (chest pain, SOB, fatigue) able to resume sexual activity! -notify HCP if experience fever >101, chest pain, SOB doesn't subside with rest, -notify HCP of any infection sx at incision sites (redness, itching, swelling, warmth, drainage) -*do NOT need to report itching, tingling, numbness at incisions (may be present several weeks due to nerve damage at site) MIDCAB: minimally invasive coronary artery bypass graft -->thoracotomy incision, higher levels of pain -->recovery time shorter, resume activities sooner

child abuse and child neglect

CHILD ABUSE: Abusers often have: -hx of growing up in domestic violence -hx of substance abuse -low self esteem -teenage parents are vulnerable to abusing child (lack of parenting skills) -often appear calm, well in control and abuse in private -unrealistic expectations for child, overly critical -stern authoritative approach to discipline -have ongoing alternative stressful factors in life -resentment or rejection of child -show little concern about childs injury, tries to conceal it, or be evasive (respond indirectly) sx suspicious of child abuse= -fractures!! always in young children, long bone (humerus or femur) -linear burns -contrecoup head injury -hematomas -retinal hemorrhage, gingival lesions when speaking to child about it: -speak in private -be honest about reporting requirements -language appropriate for child's age -avoid making assumptions of abuser -avoid tone of anger, shock, disapproval -reassure child this is not their fault/they aren't in trouble PRIORITY ACTION= IF ABUSE SUSPECTED, REPORT INJURY PER FACILITY PROTOCOL BEFORE DOING ANYTHING ELSE (PHYSICAL ASSESSMENT, ETC); however, if suspicious and have not conducted full physical assessment yet, do this FIRST--then report findings! (parent should remain to observe interactions) (do not separate mom and child unless in immediate physical danger from parent being there, or if authorities need to speak to child in private) CHILD NEGLECT: -supervisory= parent leaves child without adequate guardianship to ensure safety (parent leaving child to care for another child) NOT neglect= parent leaves to go to job they might potentially loose (indicates parents overwhelmed) *nurses must report to appropriate agencies (CPS, law enforcement)

carbon monoxide poisoning

CO toxicity causes= -SMOKE INHALATION --recall is airway issue, PRIORITY PT (is also leading cause of death in burn pts) -furnaces/water heaters fueled by natural gas/oil, coal or wood stoves, fireplaces, engine exhaust assess: CO levels at home, ask -similar sx in other fam members? illness in indoor pet? -fuel burning/heating/cooking appliances (toxicity increases in fall/winter due to increased use of heat sources in enclosed space) sx of toxicity= Vague! HA, dizziness, nausea (seizure, syncope, coma, ischemia, arrythmias severe cases) ABG= carboxyhemoglobin level= dx *KEY POINT: CO displaces O2 from Hgb, so hypoxia will not be reflected on Pulse Ox! will appear normal when pts satting is really not that good so... priority action= rx= HIGH FLOW O2 100% NRB AT 15L/MIN intubation/hyperbaric O2 for severe

Antrax (cutaneous and inhalation)

CUTANEOUS: a bacteria used to create biological weapons painless lesion with necrotic center, forms black eschar *transmitted by domestic/wild animals, contaminated materials NOT person to person *standard precautions (wear gloves, gown, resp mask) *decontaminate surfaces (bleach), dont agitate clothes-->put in labeled plastic bags rx= abx INHALATION: still standard precautions sx are airway involved, more systematic complications

CVP --what is it? swan ganz? pressure position

CVP readings= measures pressure in right ATRIAL (fluid vol) preload, estimates ventricular preload norm= 2-8 mmHg swan ganz cath= measures the... PAWP (pulm artery wedge pressure): gives pressure in LEFT VENTRICLE-preload status norm= 6-12 mmHg *>12= fluid vol overload <6= need vasopressors both to indicate fluid pressures HOB flat (pt supine) or elevated no more than 45 degrees

Calcium and Vit D foods

Calcium foods= think dairy and greens cheese, ice cream, green veggies, soy, almonds, tofu mixed foods of calcium/vit D: (fish, dairy, cereal) MILK, yogurt, salmon, sardines, cereal Vit D: (think fish and eggs) milk, egg yolk, cod liver oil, oily fish, tuna synthesize/absorp with sun!!

enema procedure insertion length how high hold tube how long pt retains solution enema solution? which first? admin oil or tap water enema?

Cleansing enemas: (NS, soapsuds, tap water) *relieve constipation by stimulate intestinal peristalsis 1. position= left lateral w/ right knee flexed (Sims) 2. hang bag no more than 12 in. above rectum to avoid rapid admin 3. lubricate enema tube tip 4. gently insert 3-4 in into rectum 5. direct tubing tip TOWARD THE UMBILICUS (anterior) during insertion to prevent intestinal perforation 6. encourage pt to retain enema as long as possible (5-10 min) 7. open roller clamp on tubing to allow solution to flow in by gravity *if pt reports cramping, stop for 30 sec, then restart by slow rate of admin insert: 3-4 inches adult, 2-3 inches child, 1-1.5 infant *infuse with tepid solution (warm water or NS + castile soap) *admin at ROOM TEMP OR WARMED (cold can cause cramping) *may warm by placing container of solution in basin of hot water OIL ENEMA BEFORE CLEANSING! softens stool then tap water promotes evacuation

Adenosine most common tachyarrythmia of childhood?

DOC for PSVT give fast! IVP 6 mg bolus over 1-2 seconds followed by 20mL saline flush may give increased repeat bolus dose twice if previous ones ineffective *give injection as close to heart as possible (antecubital area) *expect= brief period of asystole after given, then return to norm rhythm *can give through any IV line (peripheral or central) *flushing, dizziness, chest pain, palpitations common during and after med admin (vasodilates) most common of child= SVT! (HR= 200-300/min) sx= palpitations, dizzy, chest pain -can be life threat if untreated --> HF rx= vagal maneuvers (if pt is stable, help convert SVT to sinus rhythm) *place ice bag to pts face instruct to hold breath and bear down -->if ineffective, then admin adenosine or synchronized cardiovert!

Head Injury Patient Considerations

Discharging Patient: -ensure responsible adult is able to check on pt as LOC can change -educate to return to ED or HCP if note any sx of increased ICP in next 2-3 days -abstain from alcohol -avoid meds that can change LOC (muscle relaxants, opioids), avoid driving or operating heavy machinery *only clinicians can perform GCS/neuro exam, cant teach to pt's caregiver

fundal height

EMPTY BLADDER BEFORE HAVING HEIGHT MEASURED measure with a tape measurer (in cm)--start at pubic bone to top of uterine fundus not palpable until 12 weeks after 20 W gestation, fundal height is equivalent (in cm) to the # weeks gestation ex: 26weeks = 26 cm find this # using naegle's rule and EDB, then subtract that date from current date to find how many weeks gestation pt is= ans! 10-12 weeks= fundus slightly above symphysis pubis (kaplan says 12-14 W) 16W= fundus halfway between symphysis pubis and umbillicus 20-22W= fundus at height of umbillicus (then rises about 1 cm per week until 36W, after which it varies) 28W= fundus 3 fingerbreadths above umbillicus 36W= fundus just below the sternum cartilage (at xiphoid process) POSTPARTUM: *during 4th stage of labor (postpartum), 1 hr postpartum, fundal height should be AT THE UMBILICUS then decrease 1 cm q 24 hrs, so 48 hrs should be 2 cm below umbilicus at 7 days, fundus should be back at symphysis pubis cant palpate fundus any longer after 10-14 days at 6 weeks uterus should be back at pre-pregnancy size

ESWL (extracorporeal shock wave lithotripsy) Percutaneous nephrolithotripsy

ESWL: (lithotripter) external acoustic wave sent to area of calculi to break into smaller pieces to pt can expel easier, is non-invasive no bleeding expected after, should help decrease pain *often put ureteral stents during procedure to facilitate passage of stone fragments (stents removed in 1-2 weeks) expected sx: **hematuria is expected but should clear in 24 hrs (should progress bright red to pink) burning on urination also expected -may develop some bruising on back or side of abdomen after also! or flank pain care= -increase fluid intake -report any sx of infection! -encourage ambulation after to facilitate stone passage! (NO BED REST) Percutaneous: insert needle through skin to kidney with nephroscope and remove kidney stones to large to do with other methods position= prone post-op: may have nephrostomy tube to prevent stone fragment obstructions -increase fluid intake -expect some bruising, pain of back/flank -report any sx of infection -ambulation encouraged!! -->NEED TO MAINTAIN PATENCY OF THIS TUBE (if no drainage/ pt has flank pain) -->GENTLY IRRIGATE TUBE with small volume of NS using aseptic technique

Considerations by trimester

FIRST TRIMESTER: LMP? to 13W 6D SECOND TRIMESTER: 14W 0D to 27W 6D -improved nausea -increased fundal height (physically notice pregnancy) -quickening expected first around 16-20W -weight gain 1lb/week for normal BMI -increase iron rich foods (meat, dried fruit) -->increased fetal iron requirements after 20W -continue prenatal vitamins -preterm labor/preeclampsia warning signs begin at 20W routine screening: -Ultrasound 18-20W to eval fetal anatomy and placenta -gestational DM done at 24-28W (1 hr glucose challenge test) THIRD TRIMESTER: 27 W 0 D and on -as fetus gets bigger, fetal movements should NOT decrease--unexpected if do!! -common to have leg cramps -common to have dependent edema -exertional dyspnea/bladder pressure common (as uterus expands)

GTPAL

G- Gravida (total # pregnancies) T- Term (# preg delivered at 37 W 0D and after) P- Preterm (# preg delivered from 20W0D- 36W 6D) A- Abortion (# preg. ending before 20W 0D G)-->includes miscarriage or induced abortions L- Living (# of currently living children) *if pt is pregnant, the G will be greater than the # of birth (T, P, and A) combined

1-hour glucose challenge test (GCT) vs Glucose tolerance test (GTT)

GCT: is a screening test--not dx done at 24-28W Gestation can do any time of day, does not require fasting nurse draws 1 sample of blood after an hour of ingesting 50 g glucose solution for GDM: gestational DM -->if pts BG <140, GDM is not likely -->if pts BG is >140 requires 2 or 3 hr GTT (glucose tolerance test) to dx GDM GTT: 2 or 3 hr test nurse must obtain hourly blood samples requires pt to fast

Alternative Medicine Dermatologic Markings

Garlic application= garlic crushed on skin; heals infections but causes contact dermatitis and burns on skin Cupping: steam filled cup placed on skin, cause circular, bruised blemishes Coining: believe to remove illness from body (chinese, vietmanese), round surface (coin/spoon) firmly stroked on lubricated skin or back--produce weltlike linear lesions *keep in mind, any marks consistent with abuse (bite marks, cigarette burns, bruises in various healing stages, should be reported)

Tetralogy of Fallot

Hypercyanotic episodes "tet spells" unoxygenated blood enters systemic circulation often with hunger, crying, feeding, upon awakening rx= calm environment soothing quieting infant pacifier swaddling holding infant during procedures/times of stress frequent SMALLER FEEDINGS (limit sucking fatigue/reduces hunger) do not interrupt sleep whenever possible position= knee to chest (infant) squatting (older children) complication-->can cause heart failure!

SQ vs IM injections where to give IM injections infants?

IM= 1 to 1 1/2 inch 20-22 G deltoid, vastus lateralis, ventrogluteal (preffered) for ventrogluteal: pt supine, prone, or side lying with knee/ hip flexed vastus lateralis <7 mo SQ= 1/2- 5/8 inch 25-30 G 90 degree if 2 in tissue can be grasped (obese) 45 degree if 1 in tissue grasped (cachectic) ID= 5-15 degree angle AVOID MASSAGING apply firm pressure to reduce bleeding *rotate injection sites both IM/SQ to enhance drug absorption & prevent tissue damage! withdrawing from AMPULE: -flick upper stem of ampule w/ fingernail several times to ensure removal of med from ampule neck must use filter needle! (withdrawal then switch with injection needle (20G, 1 in) to attach to syringe) -breaks ampule neck away from nurse body using sterile gauze -dispose empty glass in sharps -DO NOT NEED TO INJECT AIR prior to withdrawal med -do NOT touch filter needle to glass when withdrawing -can withdrawal either with ampule flat on surface or inverting it

What is the only med compatible with TPN? what route should TPN be adminstered?

Insulin! (regular) through central line! (CVC or PICC) *Can be discharged home on PICC line for long term abx therapy!

Precipitous Birth (Precipitous Labor)--outside hospital

Labor that lasts less than 3 hours from onset of contractions to time of birth. May result form hypertonic uterine contracions that are tetanic in intensity. UTERINE TACHYSYSTOLE= >5 contractions in 10 min averaged over 30 min signs pt is in precipitous labor= -involuntary pushing/bearing down with contractions -grunting -reporting sensations of having a BM *if pt arrives at hospital in 2nd stage labor (pushing)-->first action is to APPLY GLOVES AND OBSERVE PERINEUM for presenting fetal part (see whether birth is imminent) • Conditions also associated with this type of contractions: - Placental Abruption - Excessive number of uterine contractions - Recent cocaine use (also possibly postterm delivery, LGA infant) rx= support infant's head, slight pressure to control delivery if NUCHAL CORD PRESENT (umbilicus wrapped around infant's neck), gently lift it over head rotate infant externally as exits shoulders, trunk dry baby, wrap in blanket, place on moms abd

Sepsis neonatorum

MEDICAL EMERGENCY in newborns sx= (don't display obvious signs of infection) -hypothermic/elevated temp -irritability -increased sleepiness, lethargy -poor feeding rx= start broad spectrum abx asap after obtaining cultures

sepsis sx SIRS/Shock/MODS

MODS= shock + 2 organ systems damaged (AKI, ARDS, low plts) Shock: below sx + hypotension despite adequate IV Fluids (2L NS) sepsis: below sx and infection source identified? Yes SIRS: hypothermia/fever, tachycardia, tachypnea (--often w/ low PaCO2 value), leukocytosis or leukopenia rx= treat causes asap and aggressive fluid resusc!

kidney transplant

MOST IMP TEACHING POINT FOR ANY PT WITH TRANSPLANT TO EMPHASIZE IS NEED TO TAKE IMMUNOSUPPRESIVE MEDS FOR LIFE (mycophenolate, tacrolimus, corticosteroids) --and potential AEs (nephro/hepato toxicity, infection susceptibility) donated kidney location is iliac fossa anterior to iliac crest (below normal kid location, by hips) given immunosuppresives: infection prevention!! gingival disease/cavities! watch for any s/sx of infection report asap! PT SHOWING SIGNS OF INFECTION, EVEN LOW GRADE, IS PRIORITY ASSESS (can develop sepsis if abx delayed!) *expect scant urine production for several weeks postop may need hemodialysis until transplant kidney functions well (2-3 weeks) *watch for rejection (can be acute or chronic) acute= days to months= decreased UO, increased BUN/Cr, fever, tnederness/swelling over graft site chronic= months to years, GRADUAL decrease in renal funct, proteinuria, gradual increase BUN/Cr

Cardioversion what is the most imp factor to remember with this?

MUST HIT THE SYNCHRONIZE BUTTON (unsynchronized cardioversion= defibrillation!) for pts with REGULAR RYTHM (tachyarrythmias w/ a pulse) use defibrillator pads rhythms used for: *SVT VTACH with a pulse A fib with RVR shock is synced and delivered on R wave *ensure on sync for these, if not shock can hit T wave and cause R on T phenomenon with shock and go into worse rhythm (vtach/fib) *if pt becomes PULSELESS, synchronized button should be TURNED OFF and DEFIB start

Discomforts of pregnancy (expected findings)

N/V (any time of day) dry crackers on arising small, frequent meals, avoid strong odors/ greasy foods constipation/hemorrhoids bulk foods, fiber, stool softeners, fluid intake, routine leg cramps increase calcium intake, dorsiflex feet (stretch), local heat breast soreness well fitted bra (may be worn at night--24 hrs!) backache good posture careful lifting, good shoes, pelvic tilt exercises heartburn small frequent meals antacids--AVOID THOSE CONTAINING PHOSPHOROUS decrease fatty/fried foods avoid supine position after meals dizziness support stokcings, monitor intake, slow deliberate mvemnts vertigo/lightheadedness (VENA CAVA SYNDROME) turn on LEFT SIDE urinary frequency kegels, decrease fluids before bed, report signs infection

opioid/narcotic pain meds AEs (morphine, codeine)

N/V is SE at first but tolerance develops quickly (take with food to help) AEs: constipation, hypotension, resp depression ortho hypo, Nausea/Vomit, dizziness, pruitis! TAKE WITH FOOD! (prevent GI disturb N/V) LONG TERM COMPLICATIONS= CONSTIPATION, prevent with docusate + senna, fluids, fiber (hypotension/pruitis/nausea not long term comps and can be treated with lifestyle accommodations) *hypotension can be rx with slow rising and fluids *nausea= antiemetics *pruitis= antihistamines *morphine= must be followed up 30 min after admin for assessment -->can cause burning during IV admin--reduce by diluting with NS and admin slow over 4-5 min CONTRAINDICATED IN PTS WITH HEAD INJURIES (SEs will mask serious worsening brain sx) head injury pts use NSAIDs or non-narcotics instead *also head injury avoid other CNS depressants (benzos, alc) *head injury= avoid driving, contact sports, heavy machinery, hot baths for 1-2 days *have someone stay with you

Administering (admin) meds to infant children?

NEVER put med IN FORMULA/BOTTLE FEEDING! place med in empty nipple to suck (elevate head) LIQUID meds: use oral syringe (to measure and admin), place med in small amounts into back/inside of cheek-->NEVER in back of mouth! -hold infant in SEMI-RECLINING POSITION children? preschool age: encourage participation in med prep (allow child to prep syringe)--helps gain sense of control -use positive reinforcement (for taking med), don't put in time out (this is better for undesired behavior) RECTAL SUPPOSITORIES: (<3 yrs) -position= supine with knees & feet raised -suppository PLACED AGAINST RECTAL WALL (not buried inside stool)--past external AND internal sphincters -use gloved fifth finger for insertion -lubricate tip with WATER SOLUBLE JELLY (not petroleum) -hold buttocks together several minutes, or until urge to defecate has passed -if bm in 10-30 min, observe stool for suppository >3 yrs: position= side lying with knees flexed use index finger IM Injections to infants: needle= 5/8 in for newborns, 5/8- 1 in for infants (think like SQ!) 22-25G is good use 1 mL syringe vastus lateralis (hep B, vit K)-- anterolateral mid third portion of thigh

general anesthesia expected s/sx nurse checklist to prep for OR when just arrive to PACU, what do you expect to see?

NURSE CHECKLIST PRE-OP: -sign informed consent -have pt void--reduce retention risk postop -ensure NPO status! -witness and doc correct surgical site is marked, verify w/ pt as well *18 G IV preferred, however, acceptable to have 20G if pt already has EXPECTED SX POST-OP: think recovering from sedative/anesthesia meds difficult arousal hypothermia (vasodilation/cool; environment) hyperthermia (blood products/surgical trauma) pinpoint pupils (opioids) *may have slight fever when recovering anesthesia *slight decrease HCT/HgB as blood loss occurs in surgery *paralytic ileus (absent/hypoactive bowel sounds)-->large intestine peristalsis takes 3-5 days to return--cannot d/c pt until able to be PO and passing flatus! *takes 24 hrs for peristalsis to return in small intestine (expect bowel sounds prior) *constipation (no bm) is expected after 3-5 days breathing: diminished breath sounds expected (painful when recovery from surgery with deep inspiration) -if hypoxic (snoring, use accessory muscles, obese, cyanotic, decrease O2 sats)-->likely due to occluded airway from anesthesia--so first action is head tilt chin lift to open! atelectasis is common after (hear diminished lung sounds)--alveoli become deflated/filled with fluid--encourage deep breathing, incentive spirometer, coughing (but not always priority cause expected post op) UO: expected to be low during first 24 hrs, should increase to norm 2nd day post op emotions: -recovering from anesthesia, may have altered mood (agitation, anxiety, tearfulness, somnolence, drowsiness)!! this is norm!! resolves as med wears off *2 hrs post op dressings: do NOT expect sanguineous drainage, do expect serosanguinous low grade fever expected 1 day post op due to inflammatory response from surgery, OR HYPOTHERMIA (temp <95) is expect immediate postop due to meds vasodilate *have pt do feet points and flexes in bed to help prevent VTE following surgery *third spacing can occur after extensive abd surgery, cause fluid shifts, hypovolemia, hypotension/tachycardia-->prerenal failure -->in this watch early SEPTIC/HYPOVOLEMIC SHOCK (this can be abn and priority pt!) N/V: nausea common complication from anesthetic SEs and decreased GI motility--so is expected but NOT safe, is a priority pt! pts reporting N/V should be turned asap on side so don't aspirate due to altered LOC sensation: paresthesias is expected from post-op analgesia 2-24 hrs after surgery! or analgesia meds will cause feeling until 4-6 hrs after d/c

what is the acronym to manage pts with chest pain? (ACS)--acute coronary syndrome

OANM oxygen aspirin nitro morphine

T Tube/ Open/Laparoscopic Cholecystectomy considerations

OPEN CHOLECYSTECTOMY: expect bile drainage! (dark greenish-yellow) this is normal two hours after T tube removal will cont to drain until wound seals change dressings if saturated (norm for first 24 hours post op, 500-1,000 mL/day initially will gradually decrease) *watch time-lines, if 3 days post op and see green-gray bile drainage--this is infection! should not still see drainage like this open= may have JP drain/t tube post=op: *CO2 is inflated to expand abd cavity during procedure, but can irritate diaphragm, cause shallow breathing and REFERRED SHOULDER PAIN -EARLY AMBULATION IS KEY within 8 hrs after surgery if possible (removes Co2) cough with splinting, incentive spirometer -EXPECT REFERRED LEFT SHOULDER PAIN-CO2 insufflated abd (rx relief with sims position) position= fowler's (45-60) LAPAROSCOPIC CHOLECYSTECTOMY: -small punctures through abd to remove gallbladder post op teach= -CAN resume activities quicker than open cholec. -diet: low fat (reg diet resume after a few weeks) -resume norm activity slowly as tolerated (most can return to work within a week) -remove surgical dressings the day after surgery! -can shower day after -watch s/sx of infection -NO BATHS UNTIL INCISIONS HEALED (not for a while)

oropharyngeal airway (OPA) Nasopharyngeal airway (NPA)

OROPHARYNGEAL (OPA) temporary artificial airway device prevent tongue displacement and trach obstruction in pts sedated or unconscious *when pts conciousness returns (coughs/gags) need to remove OPA --ensure device is easily removable! measure: flange next to pt's cheek, OPA curve reaches the jaw angle when inserting: -first suction upper airway remove secretions -insert with distal end pointing upward toward roof of mouth -once OPA reaches soft palate, rotate tip downward toward esophagus *NEVER TAPE IN PLACE, NEEDS TO BE EASILY REMOVABLE (pt may wake and take it out) NASOPHARYNGEAL AIRWAY (NPA): -used in alert/semi conscious pts (less likely to cause gagging) in pts with oral trauma or maxillofacial surgery -after insert, verify placement by auscultate the lungs -select size: measure tip of nose to earlobe, then select diameter smaller than pt's naris contraindicated in: -pts who may have HEAD TRAUMA (facial/basilar skull fx)--can cause more trauma -need c/t scan to r/o head trauma -also avoid if pt has bleed disrders (ASA, anticoags)

emergency contraception (EC)

OTC EC pills (plan B= high dose levonorgestrel) -->take within 3 days of unprotected sex! (after 3 days will not harm established preg but less effective) -->Copper IUD/ Oral Ulipristal (ella) offer EC up to 5 days after unprotection

otitis media (AOM) otitis externa

OTITIS MEDIA infection of middle ear children more prone due to short, straighter, more horizontal eustachian tubes *may develop from rhinitis (common cold, seasonal allergies) complications= hearing loss, spread of infection sx= (assess with otoscope) red and bulging tympanic membrane (from pus/fluid inside ear) inner ear pressure/ pain, fever rhinorrhea, N/V frequent pulling on affected ear refusal to eat restlessness, irritability *if tympanic membrane ruptures, see purluent fluid and pain relief in child, decreased fever *assess w/ otoscope, only insert speculum as far as outer cartilaginous part of external auditory canal! (do not insert into bony interior of ear canal) rx= amoxicillin *if sx do not improve within 48-72 hrs of abx therapy initiation, PT RETURN FOR ASSESSMENT screen after for hearing impairment/complete infection resolution! risk factors= -infants EXPOSED TO TOBACCO at risk!! -using pacifier -drinking from bottle when lying down -day care (but child still needs to attend) -breastfeeding helps prevent! teach for prevention: -eliminate smoke exposure -routine immunizations for infection prevent -reduce/eliminate use of pacifier after age 6 mo OTITIS EXTERNA infection of external ear sx= severe pain w/ direct pressure on tragus or pulling on pinna risk= excess water in ears from swimming/bathing tympanostomy tubes (can be used to facilitate drainage of middle ear fluid)--if see small piece of plastic in outer ear, indicates tube probably just fell out and not likely priority

PAD (peripheral artery disease) considerations PVD (peripheral venous disease)

PAD (beuguer's, raynauds) arterial-->away Sx= cool, shiny, dry, scaly skin; legs thin/shiny hair LOSS, thick brittle nails dependent rubor (red), cyanosis (gangrene) INTERMITTENT CLAUDICATION when walking (pain) also rest pain, decreased peripheral pulses, impaired sensation, ULCERS--non-healing on toe, small, circular, deep (think arteries deeper than veins) gangrene risk factors: smoking diabetes hyperlipidemia HTN Rx: assess pulses priority!! DANGLE LEGS OVER BED IS GOOD!!!!!!! (improves blood flow) do NOT cross legs, do NOT elevate keep legs below heart level regular exercise! (walk 30-40 min, 3-5 days a week) can do surgery (angioplasty, arterial bypass if need) meds (antiplt, vasodilators, anticoags) apply moisture lotions on legs daily DO NOT USE HEAT PADS--maintain mild warmth (lightweight blankets/ socks) smoking cessation avoid tight clothing diet= low sodium! for intermittent claudication= teach to walk to point of discomfort, then stop and rest, then resume walking until discomfort recurs PVD (thrombophlebitis, varicose veins, venous ulcers) venous-->return prob Sx= edema-->tissue hardens and appears leathery warm, thick, hardened brownish skin normal OR decreased pulses ULCERS= (due to above)--common on inside of ankle--large, irregular, w/ drainage, superficial (veins more superficial) pain-->*prolonged standing or by end of day causes increased pain due to edema buildup in pooled veins risk factors: prolonged standing oral contraceptives Rx= promote EARLY ambulation elevate legs to increase venous return TED HOSE/SCDs/COMPRESSION-->IS ESSENTIAL! avoid extreme temps (can loose sensation) do NOT soak feet, looses moisture and skin breakdown DO apply warm moist packs *ankle brachial index (ABI)= <0.9 indicates concurrent PAD and PVD at same time (will have to adjust levels of compression therapy)

gonnorrhea and chlamydia--at risk for?

PID and infertility! CDC recommends annual screening for each for all sexually active females <25 and older females with risk factors *recommend latex condoms

Postpartum Hemorrhage (PPH)

PPH= occurs <24 since birth (delayed >24 hrs after) Excessive bleeding after childbirth; traditionally defined as a loss of: 500 ml or more after a vaginal birth 1000 ml after a cesarean birth *accurate measurement of blood loss is done by MEASURING PERI PADS (1g=1mL) abnormal= MORE THAN 1 PAD SATURATED IN ONE HR large= blood loss >6 in saturated on pad in 1 hr (50-80ml) moderate= blood loss >4 in on pad in 1 hr risk factors: boggy uterus (most common) multiparity cervical/vag lacerations retained placental fragments! uterus wont contract until placenta detached overdistended uterus prolonged labor (more than 24 hrs) delivery of LGA (>8lbs 13oz) hx prior PPH polyhydramnios meds= magnesium, oxytocin, general anesthesia FIRST STEP: assess lochia SECOND: palpate uterus, massage only if boggy *if uterine atony present (boggy) asap massage fundus is priority action! admin UTEROTONICS: oxytocin,-->if excess bleeding still occurs after initial interventions (firm fundal massage, oxytocin, give below meds: misoprostol (give rectally, safe for HTN pts) methylergonovine, -->*CONTRAINDICATED in pts with High Blood Pressure (preeclampsia, HTN) cause MOA is vasoconstriction prostaglandin, carboprost AE= HTN, n/v monitor signs of shock! (blood loss) Secondary/delayed PPH: occurs >24 hrs, <6 weeks postpartum due to placental fragments, uterine subinvolution/infection

placenta previa abruptio placentae (placental abruption) placenta accreta at risk for?

PREVIA= placenta implants/covers cervix sx= painless, bright red vaginal bleeding (potentially profuse), soft non-tender uterus rx= immediate C section!! (or C section planned after 36 W G and prior to labor onset) *cannot deliver vaginally position= side-lying or Trandelenberg (take pressure off fetus) bedrest at least 72 hrs type and screen! for blood type (transfusion in case need from blood loss) two large bore IVs external fetal monitoring monitor pad counts for bleeding "Pelvic rest"= no intercourse, nothing per vagina *NO VAGINAL OR RECTAL EXAMS ALLOWED! amnio for lung maturity weigh pads for blood loss (1 g= 1mL!!) if bleeding ceases and stable pt prior to <36 W: can discharge home and manage in outpt setting -limit activity (on "pelvic rest")--modified bed rest, decrease physical activity/things that could cause contractions no douching, enemas, coitus, NO VAG EXAMS NST at least q 1-2 weeks teach: return to hospital immediate if bleeding recurs -additional Ultrasound performed 36W to reassess placental location ABRUPTIO= premature separation of placenta from uterine wall risk factors: cocaine abuse, maternal HTN (PREECLAMPSIA) sx= dark red, painful vag bleeding abd tender/back pain, painful, tense, rigid uterus uterine tachysystole--> contractions can occur (*recall uterus contracts when separated from placenta) major concern is fluid vol deficit (hypotension)! hemorrhage due to placental detachment, maternal shock, fetal distress rx= -requires immediate cesarean delivery (fetal distress, no longer perfused by placenta!!) -cont FHR monitoring -blood type and crossmatch -PIV access with 16-18G cath complications: at risk for DIC--watch sx! pulm emboli, infection, renal failure (blood loss) ACCRETA: placenta grows too deeply into uterine wall (myometrium), instead of the normal endometrium -detect on ultrasound -recommend pts who have to get C-section before term birth -major complication= LIFE THREAT HEMORRHAGE (during attempted placenta separation from uterus)--think 3rd stage labor so... rx= PRIORITY NURSING ACTION= -two large bore IVs 18G -blood type and crossmatch (in case blood transfusions necessary)

peritoneal dialysis considerations

PRIORITY ACTION IN ALL DIALYSIS= USE STERILE TECHNIQUE! dwell time= the time the dialysate sits in the peritoneal cavity for a bit--about 20-30 min while tubing clamped (watch for fluid overload/resp distress during this time--crackles!) if outflow is red-tinged, check if pt is menstruating also, blood tinged fluid around intra-abdominal catheter during the first few rounds is expected (due to SQ bleeding) PERITONITIS= complication *dialysate SHOULD NOT BE CLOUDY-->indicates peritonitis!! (low grade fever, chills, abd pain, rebound tenderness all sx) -->collect culture & sensitivity ASAP! *if effluent bloody or brown, may indicate bowel perforation (check menstruation) if INSUFFICIENT OUTFLOW OCCURRING: (most common from constipation) assess pts bowel patterns, admin stool softeners if need check tubing for kinks/clots (okay to milk if find!) **reposition pt SIDE-LYING or assist with ambulation--okay to do!! *be sure to maintain drainage bag below level of abd for proper flow (dialysate bag above at heart) -assess abd distension/constipation c/o pain/constipation are expected due to inactivity and first few rounds can warm the dialysate solution to reduce pain caused by cold solution WITH HEATING PAD, cabinet, or incubator (not with microwave!) referred shoulder pain during dialysis may indicate to rapid of infusion (need to slow infusion rate at this point) educate: take DAILY WEIGHTS-->make sure all fluid is removed from pt USE ASEPTIC TECHNIQUE drain by gravity only (no milking cath) diet= high protein for CAPD (continuous peritoneal) if intake 2L and only 1200L returned, need to assess last BM as a full colon can create outflow prob watch for PERITONITIS! s/sx= CLOUDY OUTFLOW, bleeding, fever, abd tenderness, low back probs, n/v, tachycardia, hypotension/hypovolemia **brown effluent can indicate fecal impaction from perforation! Pt position= fowler or semi fowlers

Cast care

PRIORITY EMERGENCY: lack of circulation--tingling expected sx= mild to moderate edema (warmth/throbbing), pain on movement/pain that improves with analgesics, itching, dry skin under cast DO NOT cover until dry! (48 hrs or longer) handle with palms not finger tips (ruins mold) avoid rest cast on hard surfaces keep affected limb ELEVATED above heart on soft surface until dry (decrease edema, increase venous return) *do NOT elevated if compartment syndrome develops do not use heat lamp, cover with heavy blankets watch sensation for pain= try elevation, ice, meds (if unrelieved--need to report!!) isometrics of joints above and below cast DO NOT PUT ANYTHING UNDER CAST (if itches= use blow dryer on COOL air) if fiberglass cast gets wet, dry with hair dryer on cool setting teach: swelling is common after cast applied apply baby powder, oil, elevate limb cover cast with plastic bag for bathing--avoid getting cast wet -report fould odors or hot areas, numbness/tingling -elevate effectived extrem first 48 hrs -reg perform ROM exercises and isometric to prevent muscle atrophy

PTSD (Post Traumatic Stress Disorder) Acute stress disorder (ASD)

PTSD--sx last for over one month after trauma sx= increased anxiety/emotional arousal (insomnia, persistent anger, rage, difficult concentrating, hyper vigilance, feeling jumpy) fearful mood reliving the event feeling detached from others, avoiding reminders of trauma (lack of interest in life/future goals), amnesia r/t event problems falling asleep, restless *when pt has high anxiety levels and pacing behavior, severe stress sx, this is PRIORITY attention pt as they are at risk for self harm or to others! *hallucinations, delusions, paranoia labile mood, lethargy is NOT sx PTSD priority nursing action= encourage client to TALK ABOUT THE TRAUMA can identify coping mechanisms, discuss event while controlling anxiety ASD--can occur in first month following trauma -assess ideas of self harm -assess for ineffective coping (drugs/alcohol) -assess impact of ASD on pt's daily life (job, relationships, sleep) -explain feelings/sx occurring after traumatic event (GOOD TO TALK ABOUT EVENT, DONT IGNORE IT!) -explore coping strategies

Pudendal nerve block vs Epidural

PUDENDAL is local anesthesia (lidocaine) into area innervating lower vagina, perineum, and vulva *indicated when birth is imminent (already progressed in fetal station, labor, effacement, dilation) so dont have to give epidural enable least maternal/newborn SEs to occur *does not relieve contraction pain but RELIEVES PERINEAL PRESSURE (In late second stage) *may also use in pts with epidural having forceps assisted birth or episiotomy EPIDURAL: admin first or early second labor stage (takes longer to take effect, harder to admin) *avoid IV NARCOTICS IN SECOND STAGE OF LABOR (too close too birth can cause resp. depression) *if give first stage, remember give AT PEAK OF CONTRACTION

Murphy's sign

Pain with palpation of gall bladder in RUQ causes pain and inability to take a deep breath (seen with cholecystitis)

Penrose drain/ JP drain/Hemovac

Penrose: a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing when changing dressing, remove one layer at a time to avoid dislodgment JP (jackson pratt): closed wound drain device self contained suction device, empty reservoir continually PRN ***attach drain to pt's gown/pajamas NEVER top sheet or mattress!! to empty device: 1. hand hygiene 2. pull plug on bulb to open device and pour drainage into small, calibrated container 3. emty device every 4-12 hrs unless it is 1/2 to 2/3 full before then-->DO NOT WAIT TELL GETS OVER FILLED (amount neg pressure from suction decreases) 4. compress empty bulb tell totally collapsed from side to side 5. clean the spout on bulb with alcohol and replace the plug when its totally collapsed to restore neg pressure Hemovac (closed wound drainage device) NORMAL FINDINGS= about 80-120ml/hr sero-sanguineous -sanguineous drainage during first 24 hrs! *if see > than this, priority action= notify HCP NEVER OPEN THE BULB until emptying (fluid will back up into wound again)

Pacemaker

Permanent: assess for electrical and mechanical capture electrical capture= pacemaker spike seen on cardiac monitor waveform mechanical capture= assess CENTRAL PULASE (auscultation of apical, palpation of femoral) demand pacemakers= most common implanted permanent pacemaker *sends electrical impulse ONLY if doesn't sense intrinsic heartbeat occurring at program threshold rate (ex: 40/min) -->so will see one spike to get beat going, then no spikes and normal beats if working properly *ensures electrical activity of heart corresponds with the pulsatile rhythm *compares pulse/auscultated rate to display on cardiac monitor to assess for PULSE DEFICIT= dif. between # of heartbeats (shown on EKG) - # of beats of pulse *pacemakers that are 100% paced is normal--means working right! *POST-OP PLACEMENT: priority is to initiate cont. cardiac monitoring to ensure proper pacemaker function! -if fail to capture, fail to sense, contact HCP ASAP -also assess for MECHANICAL CAPTURE= palpate pulse and compare to electrical rate on monitor -check VS Discharge teaching permanent pacemaker: -report fever, infection signs at incision site -carry pacemaker identification card, wear med alert bracelet -take pulse daily, alert HCP if below predetermined rate -avoid MRI scans -Avoid carry cell phone directly over pacemaker (hold it to ear and opp. side of pacemaker when talking) -notify airport security of device--no handheld screening wand over device -avoid standing near antitheft detectors, walk through at normal pace, do not linger at device -avoid lift arm above shoulder on pacemaker site until HCP approves (dislodgement) - OKAY TO USE MICROWAVES

Teratogenic medications

Phenytoin ACE-I's tetracyclines (doxycycline) Warfarin Lithium Valproate -->can cause NTDs! Methotrexate Isotretinoin

What is coomb's test and how does it affect mom and baby? Rh alloimmunization

Problem: Rh neg. mother, Rh pos. baby (only in this case!) *if baby is Rh neg, mom Rh pos, then everything's fine -->need to give Rh Immunoglobulin to prevent mother's antibodys (Rh) from forming and attacking baby's antigens (or else can cause hemolytic anemia) = will result in a neg. coomb's test (means no antibodies have been developed, good thing) *first verify mom is not Rh sensitized by checking for negative antibody screen (indrect coomb's test) --> (even if mom neg, still need to give Rh IgG! so... *then proceed with ADMINISTER Rh immune globulin *Rh immune globulin (RhoGAM) is admin to ALL Rh neg. pregnant pts at 28 weeks G and within 73 hrs postpartum, as well as after any maternal trauma *once sensitization has occurred (immune system is attacking), RhoGam is no longer effective *if coomb's test is positive screen--> then need to go to HCP for further clarification (cause admin RhoGam wont work) if HCP suspects excess fetomaternal hemorrhage, perform Kleihauer-Betke stain and may need to increases doses of Rh IgG admin to mom *if trauma occurs, can disrupt separate blood supply mechanisms and cause mom's antibodies to attack babies!--so first thing if neg mom is to perform indirect coomb's to see if sensitization

Counting Heart rate on EKG EKG ryhtms

Regular/irregular rhythm: if 6 second strip:count # of beats and multiple by 10 if no 6 second strip (12 lead): count # of squares in between R to R then divide # by 1500 (tip: count large boxes--5 small squares within each large box) second degree type 1: progressively lengthening PR interval, then finally QRS is dropped second degree type 2: QRS doesnt always show with every P wave, but every time QRS does show up, is same length PR interval

NRP neonatal resuscitation program algorithm

Resuscitation interventions at birth are initiated at 30 sec intervals, with continuous assessments of newborns adaption to extrauterine life FIRST THING= PROPER POSITION: place infant on back with neck slightly extended for adequate ventilation "sniffing position" *may need place a blanket/towel roll under newborn's shoulders to elevate chest 3/4- 1in above mattress (esp if large occiput) is newborn term gestation, good tone, breathing/crying? NO? -->provide warmth, clear airway, stimulate -->re-eval still NO? HR <100, gasping, or apnea then... provide Positive pressure Ventilation w/ spO2 when newborn's HR <100 -consider cardiac monitor re-eval (if HR still <100, & quality ventilation?) YES ... after 30 sec of quality PPV *if HR remains <60, begin chest compressions PPV w/ 100% O2 cardiac monitor ... re-eval (HR still <60?) IV epinephrine cont compressions/ventilations

Heart failure S/Sx (right vs left) Rx Diet

S/Sx (right vs left) Right= AW HEAD A-anorexia/nausea W-weight gain H- hepatomegaly E-edema (bipedal) A-ascites D- distended neck veins (seen upon 45 degree seating position) also: Polycythemia! (to account for decreased O2) Left= DO CHAP D-dyspnea O-orthopnea C-cough (frothy blood tinged sputum) H-hemoptysis A-adventitious breath sounds P-pulm congestion *also see: cheyne stokes, decreased renal func, weakness, edema/weight gain LEFT SIDED (PULM EDEMA) IS MORE DANGEROUS THAN RIGHT SIDED (PERIPHERAL EDEMA) Rx= meds, diet, DIGOXIN is DOC in heart failure!! furosemide-->admin Potass chloride supplement for non-K+ sparing diuretic Diet: LOW SODIUM (sodium restrictions varies on pt severity)--want cause increasing Na increases H20 low residue (reduce GI distension/abd pain) low calorie (aid in loosing weight, decreases heart workload) ADD POTASSIUM SUPPLEMENTS IS GOOD! (reduces fluid retention, BP, and counteract diuretics) earliest sign of HF= ventricular gallop -dilutional hyponatremia occurs due to excess fluid in relation to sodium content in body--still need SALT RESTRICTION complications= (of HF or MI) PULMONARY EDEMA (watch for pink, frothy coughed up sputum, SOB) --hear crackles at lung bases teach= -report weight gain of 3 lb over 2 days or 3-5 lb over a week -weigh daily at home -NSAIDS ARE CONTRAINDICATED IN HF PTS (cause sodium retention) -exercise training, cardiac rehabilitation programs -constipation? high fiber diet! if pt SOB, cough-->think HF can escalate to pulm edema-->auscultate is priority action!

suicide risk factors considerations

SAD PERSONS: S- sex (men kill selves more than women; women make more attempts) A- Age (teens/young adults, age >45) D- Depression (hopelessness) P- Prior hx of suicide attempt E-Ethanol and/or drug abuse R-Rational thinking loss (hearing voices to harm self) S- Support system loss (loving alone) O- Organized plan; having method in mind (with lethality and avaliability) N No significant other S- Sickness (terminal illness) protective factors= pregnancy, religion, parenthood ARTICULATE LONG TERM PERSONAL GOALS AND FAMILY MILESTONES *suicide contracts are not effective watch for feeling more energetic after starting rx

Cirrhosis

SEs pruitis (buildup bile salt beneath skin) increased skin breakdown risk--edema -ascites (SOB), edema, weight gain (low albumin) -bruising, bleeding (elevated INR/PT) -itching, scleral icterus, jaundice (increase bilirubin) -lethargy, asterixis, confusion, hepatic encephalopathy, coma (increased ammonia) -hepatomegaly -splenomegaly (thrombocytopenia) -spider angiomas rx= (mgmnt of ascites, and cirrhosis SEs) -position= semi fowlers/fowlers, side lying w/ HOB elevated -meticulous skin care -use specialty mattress, turn q 2 -provide distractions help pt mind of sx (TV, music, games) teach: (for pruitis sx) -cut nails short -wear cotton gloves, long sleeved shirts -baking soda baths, calamine lotion -cool, wet cloths (cool/soothe irritated skin) -admin cholestyramine--excrete bile salts and decrease pruitis -avoid temp extremes (hot baths/showers) -bathe with tepid water until pruitis subsides diet= high calorie, high carb, low fat, low sodium *do not totally restrict protein,(1.2.-1.5g/kg/day); restrict fluids (edema) NO alcohol meds= avoid hepatotoxic (acetaminophen, statins) avoid NSAIDs/ASA when HTN or varices present -avoid activties that increase intraabdominal pressure -seek med attention when bloody sx/ AMS Lab values= expect elevated: ammonia, PT/INR/aPTT times, bilirubin expect decreased: albumin, sodium

Serotonin Syndrome

SSRIs= sertraline Caused by: -SSRI + MAOI -SSRI + St. Johns wort -tramadol, ondansetron, dextromethorphan sx: think EVERYTHING HYPERACTIVE!!! mental changes: anxiety, agitation, disorientation eyes: mydriasis (dilated pupils) autonomic dysreg: hyperthermia, diaphoresis heart: HTN, tachycardia GI: diarrhea, hyperactive bowel sounds neuromuscular hyperactivity: tremor, muscle rigidity, clonus, hyperreflexia TRt: Cyproheptadine (serotonin blocking activity) Prevent: Need 15 days to switch MAOI to SSRI Need 30 days to switch SSRI to MAOI

stages of labor postpartum assessment (normal vs abnormal findings)

STAGE 1: beginning of labor to complete cervical dilation: includes 3 phases 1. latent (0-5cm): contractions 10-30 sec; 5-30 min long *pain manageable, able to follow directions 2. active (6-7 cm): contractions 40-60 sec long; 3-5 min *demeanor gets a bit more serious, pain increases 3. transitional (8-10 cm): contractions 45-90 sec; 1 1/2-2 min apart *feel rectal pressure (have to go bm), fear, irritability, self doubt *will see BLOODY SHOW (PINK/DARK BROWN) is common during this stage! *coach breathing techniques, show support now (increased maternal anxiety here) STAGE 2: complete dilation to birth of baby phases as progress in station (0-->+5) urge to bear down stronger, increase dark red bloody show, contractions less time apart *delay pushing UNTIL pt gets to this stage! complete dilation position= upright/lateral is better than lithotomy! STAGE 3: birth of baby to expulsion of placenta slight gush of blood and lengthening of umbilical cord, check for remaining fragments *prepare to admin oxytocin to start uterus contraction: indications= CANNOT ADMIN OXYTOCIN UNTIL PLACENTA HAS EXPELLED/separated from uterus -->so look for signs of this: -gush of blood from vagina (happens when placenta separates) -uterus begins contracting (pt feels cramping) -cord extends out of vagina *pts BP should NOT DROP--has enough extra blood volume to compensate from blood loss during delivery POSTPARTUM ASSESSMENT: STAGE 4: first 4 hours after delivery of placenta in the first 1-2 hrs: VS q 15 min (BP, pulse) fundus q 15 min (position at level of umbilicus first 12 hrs post-birth), then descends 1 cm q 24 hrs after; back to norm uterus 10 days after lochia q 15 -->*never should be foul odor= infection! rubra- days 1-3 (bloody, fleshy odor, may be clots, tissue debris) *should not contain LARGE clots, but small are considered normal serosa- day 4-9 (pink/brown with fleshy odor) alba- day 10 (yellow-white) normal lochia odor is "fleshy" or "musty" odor= endometrial infection VS: temp (norm slightly elevated first 24 hrs after) temp >100.4F (38C) is abn requires eval! *SOAKING 1 PAD IN </= 1 HOUR IS ABNORMAL (1 pad in 2 hrs is okay!)--in immediate postpartum Labs: WBC is ELEVATED first 24 hrs postpartum (up to 30,000!) Normal to have discomfort during fundal palpation (if pain increases, requires eval) urinary: measure first void (may have urethral edema/retention) kegels (hold for count of 3, 10x/day TID) *avoid diuretics such as caffeine *warm sitz baths used 12-24 hrs after delivery (sit in warm shallow water to relieve pain, itching, edema in vaginal area) think "sitz, sit down bath" bonding: emphasize touch/eye contact! en face position (mother and infant are face to face) analgesics during labor: when give IV narcotics (nalbuphine, butorphanol, meperidine) give DURING PEAK OF CONTRACTIONS TO DECREASE FETAL SEDATION AND subsequent newborn resp. depression

Trichomonas vaginalis

STI sx -may be asymptomatic -profuse, frothy, yellow-green malodorous vag discharge noted -pruitis, dysuria, dyspareunia (pain during sex) rx= PO metronidazole teach: -abstain from sexual intercourse until infection sx cleared (about 1 week after rx) -have partner treated simultaneously to avoid reinfection -use condoms to prevent future infection -recall SEs of med -vaginal douching NOT RECOMMENDED (gets rid of good vaginal flora) -clean vag using unscented products, wear breathable undergarments

Scopolamine Fentanyl

Scopolamine transdermal patch for motion sickness anticholinergic! teach: -dispose of patch out of reach children/pets -remove old patch before apply new one (replace q 72 hrs) -place on hairless, clean, dry area behind ear -wash hands with soap/water after handling patch -apply patch >4 hrs before start traveling Fentanyl (transdermal for pain) *transdermal penetrates skin deeper--for severe CHRONIC pain -replace patch q 72 hrs, must remove before apply a new one -must fold used patches and discard immediately (OPIOID MEDS MUST BE dispose securely= flush down toilet, discard in sharps) - no heating pads -apply to flat, intact skin, clean with little hear (upper back, chest)--even if pain not there! is systemic absorption *do not use for post op treatment--takes 17 hrs for effects-- or intermittent/temp pain Topical Analgesic patches (lidocaine, capsicum) -deliver drug locally, so place near site of pain (1 in away is fine)

Prioritization Q's

TYPICAL S/SX (EXPECTED) FOR DISEASE PROCESS WILL NEVER BE THE RIGHT ANSWER spouse w/ pt reporting client threatened suicide OR schizophrenic pt hearing command hallucinations to harm a neighbor SCHIZOPHRENIC PT! pt is alone, and safety of self and others is priority *pt ALONE should be addressed first! spouse is with other pt (not alone) and can call other help in meantime, police, etc *pt has AMS, begins vomiting-->think this is AIRWAY ISSUE, RISK FOR ASPIRATION--> PRIORITY PT! suspicious visitor: this is a priority!! jeopardizes safety of others *code pink= infant abduction *infant who is lethargic w/ diarrhea for 12 hrs or 17 yr old w/ severe acute abd. pain -->lethargic infant!! ABCs & mental status priority! then acute pain *infants high percent body is water, dehydrate quick, electrolyte disturb

Sick day rules for diabetics

Take insulin or oral anti-diabetics as usual. -->DO NOT SKIP/WITHOLD DOSE because illness increases blood sugar (even if pt is hypoglycemic or does not eat a meal) encourage soft foods and liquids (8-12 oz/hr) for nauseated pt to get down, recheck blood sugar in 30-60 min Never eliminate insulin doses; snack in between Test blood glucose every 1 to 4 hours! test for urine ketones frequently -maintain hydration -increase or decrease dose of insulin PRN based on blood glucose levels If you can't follow usual meal plan, sub soft foods (gelatin, 1 cup cream soup, ½ cup custard, 3 squares graham crackers) 6 to 8 times a day. If vomiting, diarrhea, or fever persists, take liquids (1/2 cup regular soda oj, or broth, 1 cup Gatorade) every ½ hour to 1 hour to prevent dehydration and to provide calories. Report extreme fluid loss to provider - may be dangerous

umbilical cord prolapse

The greatest risk of vaginal delivery of a breech infant is umbilical cord prolapse! may occur after ROM! sx= fetal bradycardia with variable decels (VEAL CHOP) produces ABRUPT fetal heart rate decel--fetal brady priority action (if ROM and see FHR brady)= PERFORM STERILE VAG EXAM TO ASSESS FOR PROLAPSED CORD -->if feel prolapsed cord, MANUALLY LIFE fetal presenting part off cord, leave hand in place, call for help rx= 1. elevate presenting part (with hand) to keep off cord 2. call help 3. TRANDELENBERG OR KNEE TO CHEST POSITION ALSO WORK (take fetus pressure off cord) 4. admin o2 5. force IV fluids

What is the key priority in pts who are immunosuppresed?

Using careful hand washing and aseptic technique to PREVENT INFECTION (

VEAL CHOP

V- Variable C- Cord Compression (also seen with persistent fetal bradycardia!!) *also turn pt on left side, admin o2, start IV *if perisitent fetal brady, do above first then notify HCP and prep for immediate cesarean E- Early Decels H- Head Compression A- Accelerations O - OK L-Late Decels P - Placentac perfusion prob -->d/c oxytocin, turn pt to left side, admin oxygen, increase IV flow rate

Paget's disease

a bone disease of unknown cause characterized by the excessive resorption (loss) of bone tissue, followed by abnormal bone formation sx= bow legged, kyphosis, pain!!, enlarged skull, shortened trunk with longer arms watch pathological fractures, rest, analgesics meds= calcitonin (maintains calcium in bone), "dronates"

spina bifida

a congenital defect that occurs during early pregnancy when the spinal canal fails to close completely around the spinal cord to protect it spina bifida occulta: (mildest form), gap in between vertebrae--see dimpling at site sx= TUFT OF HAIR, hemangioma, nevus, or dimple along the BASE OF SPINE-->ASAP finding! may have bladder/bowel incontinence meningocele: bulging sac like lesion, filled with spinal fluid but NOT spinal cord myelomeninocele: contains spinal fluid AND spinal cord! (worst form) *is chronic prob sx= paralysis of lower extremities, club feet, dislocated hips, scoliosis, kyphosis, neuro bladder, prolapsed rectum EDUCATE= prevention is proper maternal folic acid intake!! PRIORITY ACTION= risk for infection COVER AREA WHERE STERILE, MOIST DRESSING dx= high levels alpha-fetoproetin amniocentesis Rx= none for spina bifida occulta meningo/myelo have surgcal repair BUT: **corrective surgery cannot change child's disability-->educate! (nothing can return func of body innervated below site of myelomeningocele) post-op: position on abdomen or semiprone with sand bags cover lesion moist sterile dressings, watch resp. difficulty, infection, meningitis, shock *RISK OF HYDROCEPHALUS-->Measure head circumference wheel-chair bound children increased obesity risk-->calorie restricted diet

ankylosing spondylitis

a form of rheumatoid arthritis that primarily causes inflammation of the joints between the vertebrae sx= early morning low back stiffness/pain (worse in morning and improves as day progresses with activity) -kyphosis rx= NSAIDs teach: think, actions that promote extension of spine SPINE -quit smoking and perform breathing exercises -include spine stretching activities as swimming, racquet sports -proper posture, daily stretching -manage pain with moist heat and NSAIDs -take immunosuppresant and anti-inflam meds as prescribed -rest during flare ups -sleep on backs with firm matress

Raynaud's phenomenon

a peripheral arterial occlusive disease in which intermittent attacks are triggered by cold or stress episode: digital arteries (fingers) impair blood flow and turn blue, feel numb/cold then blood flow returns to digits and skin turns red and throbbing/tingling sensation felt (this is EXPECTED!) *episodes usually resolve 15-20 min once trigger has been removed (rewarming of fingers) *implement stress management strategies (yoga/tai chi), avoid vasoconstrictors (cocaine, ergotamine, pseudoephedrine); wear gloves handle cold objects, dress in warm layers esp. in cold, avoid extreme abrupt temp changes, avoid excess caffeine/tobacco products *may be prescribed CCBs if non-pharm methods unsuccessful

fetal assessment of well-being contraction stress test

a regular pattern of 10 movements in 1 hr twice a day is good indicator of well-being fewer than three movements in 1 hr should be reported! contraction stress test: *looking for late decels after 28W (just like NST)--either use nipple stimulation or oxytocin to eval fetal response to stress of labor (uterus contracts) position= semi fowlers/ side lying position positive= BAD --decels with at least 50% of contractions, potential fetus risk, may need cesarean negative= GOOD --no late decels with minimum of 3 contractions lasting 40-60 sec in 10 min period *this may send pt into premature labor so monitor post test for signs

obstructive sleep apnea (OSA)

a sleep disorder characterized by temporary cessations of breathing (apnea 10 sec or more) during sleep and repeated abruptly awake w/ loud snort sx= HYPOXIA & HYPERCAPNIA excess daytime sleepiness/fatigue irritability sore throat morning HA snoring during sleep witnesses episodes of apnea waking with gasping/chocking sensation frequent arrousal from sleep dysrhtymias, HTN, increased risk MI, stroke, HF rx= avoid alcohol, reduce weight, CPAP/BIPAP (BIPAP better if pt cant exhale over CPAP pressure) -->cause BIPAP has pressure settings and can lower the exhalation pressure setting CPAP: deliver pos. pressure to keep airway open during sleep *if pt starts to become hypoxic and hypercapnic, w/ CPAP on, FIRST CHECK TIGHTNESS OF STRAPS as loose fit could mean air escaping and not working avoid sedative meds (benzos, opiates, antihistamines, antidepressants) *IF PTS HAVE TO HAVE SURGERY, GO UNDER GENERAL ANESTHESIA, RECIEVE OPIOID PAIN MEDS increases closure of airway even further! (opioids/benzos), so ENSURE THESE PTS ARE ON CPAP -->THIS IS PRIORITY PT TO ASSESS AFTER GIVING PAIN MEDS

Guaic test

a special chemical test to identify occult blood in the stool is not sterile collection, use tongue blade to collect stool (bed pan is easiest) note dr's order over what time period to collect avoid red meat--false pos reading bright red blood (lower GI bleed)=hematochezia black tarry stool= Upper GI bleed (melena)

pleural effusion

abnormal accumulation of fluid in the pleural space prevents lung from fully expanding expect= absent/diminished breath sounds in lung base decreased tactile fremitus dullness on percussion sx= dyspnea with nonproductive cough CHEST PAIN with respirations (like in pleurisy) diminished breath sounds rx= THORACENTESIS! (remove fluid)

Types of miscarriages (spontaneous abortion) *recall most miscarriages happen very early on in preg (first trimester)

abortion= pregnancy that terminates before period of viability= 20W all abortion sx= UTERINE, vaginal BLEEDING/CRAMPING neg or weakly pos urine preg test Threatened: show signs might miscarry (light bleeding) but dont and can still have a norm healthy baby -->sx= reg vag bleeding, cramping, cervix CLOSED, soft uterus rx= Rest!! avoid sex activity, avoid stress Inevitable: you will miscarry, heavy bleeding, severe cramping OPEN CERVIX (DILATION AND EFFACEMENT) rx= monitor for hemorrhage, D & C Incomplete: miscarry but some pregnancy tissue remains in uterus (may need D&C) to remove extra tissue; parts of products expelled Complete: all preg tissue left your uterus; vaginal bleed/cramping can cont several days Missed: baby has died but stayed in uterus CERVIX IS CLOSED may have some bleeding/cramping, or asymptomatic -->D & C 4-6 weeks, 12 weeks dilate cervix Habitual: occurs 3 or more times cerclage (to correct weak cervix which dilates too early in preg causing abortion) *save all tissues, admin Rho(D) PRN, VS, hydration, bleeding, cramping monitor

Shaken Baby Syndrome (SBS)

abusive head injury severe physical child abuse sx= bleeding within brain and eyes (think like increased ICP sx) vomiting, irritability, lethargy, inability to suck or eat, seizures, inconsolable crying *no usual external signs of trauma except where child held (small bruises), caregiver does not provide a hx of trauma

Linezolid

abx for vanco and methicillin resistant bacteria, PNA, skin infection *HAS MAOI type properties so...do not consume tyramine foods (can cause HTN crisis) *DO NOT ADMIN WITH SSRI!-->serotonin syndrome can resume SSRI 24 hrs after linezolid d/c'd AE= diarrhea, HA -->report however cause could be serotinin syndrome

Metronidazole

abx! take with meals to decrease GI upset--SE may experience metallic taste in mouth when take, not a prob may cause darkening of urine (brown, rust-colored) may cause stevens johnsons! (rare)--asap report sx= rash/skin peeling *DO NOT DRINK ALCOHOL while on (think this with all abx!) and until 3 days after therapy

Implied consent court order

acceptable type of consent given in specific situations: (when pt is unable to give consent themself) -emergency -rx is required to protect pt's health -it is impractical to obtain consent -it is believed that the client would want treatment if able to consent court order: obtained when parent is refusing necessary life saving care for child (can't do this, get a court order)

hydrocephalus

accumulation of CSF in the ventricles of the brain (increased risk with spina bifida) sx= increased ICP s/ sx (high pitch cry, convulsions,irritability, vomiting) unusual somnolence -->lethargy fronto-occipito circumference increase widened distended tense fontanelles sunset eyes, nystagmus rx= ventriculoperitoneal (VP) or ventrocular atrial shunt! (connect ventricle cathether to peritoneal or atrium) *complications= blockage/infection-->watch sx of INCREASED ICP (vomit, change LOC, HA, vision changes) post op: postiion on unoperated side FLAT, DO NOT ELEVATE head observe increase ICP shunt modified as child grows, watch malfunction *increased allergy risk if myelomeningocele present

delirium considerations

acute change in mental status often reversible and r/t underlying medical condition (can be hyperactive and agitated or hypoactive and decreased LOC) risk factors: advanced age underlying neuro disease (stroke, dementia) polypharmacy (opioids, anticholinergics) infections (fever, pos culture) coexisting med conditions ABG imbalance electrolyte disturb (hyponatremia) impaired mobility (early ambulation prevents) surgery (post op setting) untreated pain/inadequate analgesia (adequate pain control prevents) -hypoxia -dehydration, malnutrition -metabolic disorders (hypoglycemia) this can indicate worsening infection (PNA, UTI), electrolyte imbalance, drug-drug interaction, hypoglycemia, hypoxemia, dehydration, stroke, alcoholism, pain, vision impairment requires asap assessment! DELIRIUM FROM DEMENTIA watch for new onset agitation/confusion in someone with dementia= could be delirium safety is priority! place pt near nurses station, with one on one supervision to measure= CAM assessment tool -acute/fluctuating change in mentation -altered LOC, inattention -disorganized thinking sx of delirium= has a SUDDEN ONSET altered LOC acute mental status changes FLUCTUATE WITH INATTENTION disorganized thinking (includes hallucinations!) -->NOT JUST ALERT AND DISORIENTED (wrong)--this could be dementia, which is progressive and slow in onset (with normal attention) *sleep wake cycle disturbances= reverse in pts with delirium --nurse should promote daytime wakefulness and nighttime sleep (even if pt didnt sleep that night)--helps to reorient them

cardiac tamponade

acute compression of the heart caused by fluid accumulation in the pericardial cavity CAUSED BY PERICARDIAC EFFUSION hemopericardium= blood in pericardial cavity LIFE THREATENING-->can cause obstructive shock, decreased CO, cardiac arrest! PRIORITY PATIENT IF HAVE s/sx= BECKS TRIAD narrowed pulse pressure (norm is 40-60 mmHg)=(hypotension) muffled or distant heart sounds/tones distended neck veins pulsus paradoxus (exaggerated fall in pt's BP during inspiration > 10 mmHg) tachycardia tachypnea dypsnea *pulse pressure= difference between sys and diastolic rx= EMERGENT PERICARDIOCENTESIS *mediastinal chest tubes-->often placed after cardiac surgery to drain fluid from pericardial cavity-->if this is here, watch for sx of cardiac tamponade! (auscultate heart sounds) sx= chest tube drainage markedly decreased can cause buildup of fluid

anaphylactic shock

acute onset= develops 20-30 min CORRECT ORDER OF ACTIONS: call for help--FIRST ACTION stop infusion (if IV) maintain airway: non-rebreather high flow O2 (remove stinger/allergen if can) IM epinephrine (REPEAT q 5-15 min)-->mid-anterior lateral thigh-->MOST IMP MED TO GIVE (ONLY ACCEPTABLE RX FOR THIS) elevate legs VOL FLUID RESUSC IV fluids NS, (after epi!) vasopressors bronchodilator (albuterol)--recall dilators before steroids antihistmaine (diphenhydramine, loratadine)--modify hypersensitivity rx corticosteroids (methylprednisone) *cricothyrotomy or trach with severe laryngeal edema if needed

Hirschsprung disease

aganglionic colon (distal large intestine--descending colon) missing nerve cells NO PERISTALSIS, NO STOOL PASSSED sx= distended abd (distal intestinal obstruction) not passed stool (failure to pass meconium)--within expected 24-48 hrs refusal to feed BILIOUS (green) vomiting RIBBON-LIKE STOOL may be seen!! failure of internal anal sphincter relaxation fatal complication= HIRSCHSPRUNG ENTEROCOLITIS (Inflamed colon-->sepsis-->death) sx= fever, lethargy, explosive, foul smell diarrhea, rapid worsening abd distention

Varciella Zoster/ herpes zoster

airborne precautions also require contact precautions if open lesions are present!

down syndrome s/sx newborn

aka Trisomy 21 *at risk if MATERNAL AGE >35 sx= intellectual delay (<70) marked hypotonia low set ears low nasal bridge protruding tongue short stature epicanthal folds oblique (upslanting) palpebral fissures large fat pads at nape of short neck short neck with excess skin (NUCHAL FOLD) round head with flattened occiput SINGLE TRANSVERSE PALMAR CREASE WIDE SPACE BETWEEN BIG AND 2ND TOE broad hands with inward curved little finger -->AV canal defect (heart) (both atrial and ventricle defects) complications: resp infections, heart diseases, hearing loss

metabolic syndrome

aka insulin resistance syndrome-->increased risk Diabetes/ CAD characterized by 3 or more of this criteria: 1. increased waist circumference (>/=40 in med, >/= 35 women) 2. Blood pressure (>/= 130 sys, or >/= 85 diastolic, or on drug rx for HTN) 3. Triglycerides >150 or drug rx for elevated triglycerides 4. HDL <40 in men, <50 in women, or drug rx for low HDL 5. Fasting glucose levels >100 or drug rx for elevated BG mneumonic= "WE BETTER THINK HIGH GLUCOSE" (waist circum, BP, Triglycer, HDL, Glucose)

Amblyopia vs Strabismus myopia vs hyperopia

amblyopia= lazy eye strabismus= cross eyed pitosis= drooping of upper eyelid myopia= nearsighted hyperopia= farsighted (also blurry up close) *presbyopia= blurry vision up close (but age related) *surgery=laser surgery *in myopia, -may need to squint eyes or close one eye to clearly see -sx= HA, dizziness strabismus: patch STRONGER EYE (to strengthen weak eye) *may require surgical if nothing else work *if left untreated, amplyopia can occur

Amoxicillin/Clavulanate

aminopenicillin for rx resp infections teach= -can take with/wout food (admin w/ if GI disturb) -shake well prior to admin -give evenly at spaced intervals throughout day -ensure child receives full therapy course -use specific calibrated device to measure exact dose (dropper/oral syringe, plastic measure cup, measuring spoon) NOT a tbspn/tsp SEs N/V, diarrhea AE= allergic rx (watch for sx)

Clonidine

anti HTN (alpha 2 agonists)--also methyldopa! SE= hypotension dizziness, drowsiness, dry mouth (the 3 D's) AEs! is highly potent, do NOT abruptly d/c-->can cause serious REBOUND HTN (taper over 2-4 days) transdermal patch: replace q 7 days *can be left in place during bathing apply to dry hairless area upper arm or chest DO NOT SHAVE BEFORE APPLYing (cuts, scrapes) wash area/hands with soap/water before do not touch sticky side of patch rotate sides of application do not wear more than 1 patch at a time fold in half removed patch sticky sides and discard out of reachchildren/pets do not remove patch if experience AEs (dizziness, slow pulse)--contact HCP first NEVER STOP PATCH ABRUPTLY (rebound HTN)

Ipratropium tiatropium umeclidinium

anticholinergic MOA= block bronchoconstriction; dry up secretions tiatropium= long acting (peak effect of 1 week); capsules NEVER swallowed but inhaled! ipatropium= FAST ACTING (good with acute asthma attacks *must d/c ipatropium before taking tiatropium

Dicyclomine (Bentyl)

anticholinergic! manages sx of IBS

Anticholinergics

anticholinergics= tiotropium, ipatropium, benztropine, oxybutynin, dicyclomine hydrochloride trihexyphenidyl drugs that have these SEs= Atropine, dicyclomine, tricyclic anti-depress (amitriptyline), antihistamines (diphenhydramine)! also antiparkinsonians! (benztropine, amantadine, levodopa, trihexylphenidyl) atypical antipsychotics SEs GI - Slows motility, spasm, constipation (*contraindicated in paralytic ileus) Urinary retention Eyes - Dilates pupils *DO NOT GIVE TO GLAUCOMA PTS* --blurred vision Heart - Increase HR Resp - bronchodilator (Atrovent) Xerostomia (dry mouth, dry as a bone) Drowsiness/sedation (mad as a hatter) HEAT INTOLERANCE flushing (red as a beet) *AE= difficulty urinating (dry as a bone)--may become severe if not treated! *also, decreased sweat production may cause hyperthermia-->BE CAUTIOUS IN HOT WEATHER AND DURING PHYSICAL ACTIVITY rx= bulk forming foods, fluids avoid locations that can cause hyperthermia (hot weather) contrainidcated in: (think AEs!) glaucoma (narrow angle), urinary retention--> BPH! constipation-->paralytic ileus!

rivaroxaban, edoxaban, apixaban

anticoagulants--rx/prevent VTE *lower bleed risk and less monitoring than warfarin *avoid NSAIDS, HERBS that increase bleeding risk while taking! (increase spontaneous bleed risk) teach= contact HCP if sx of neuro impair (could be epidural hematoma! increase spon bleeding!)

Metoclopramide (Reglan) SE?

antiemetic, improve GI motility (gastroparesis) rx= gastroperesis (stomach cannot empty itself in normal fashion) expect: diarreha, HA AE= extrapyramidal effects! tardive dyskinesia!! *may impact pt's ADLs

urinary elimination, urine pH? terms: anuria oliguria polyuria dysuria

anuria--less than 100mL/24 hrs oliguria-- 100-400/24 polyuria-- >2000/24 hrs dysuria-- painful urination urine pH= 4.5-8 1000-2000mL output/day 1mg/kg/hr (0.5/mg/hr) 30-50mL/hr

rapid response criteria

any HCP worried about the client's condition OR acute change in any of the following: (HR, RR, Sys BP, O2 sat, LOC, UO)--think VS and neuro/uro -HR <40 or >130 -Systolic BP <90 RR <8 or >28 O2 sat <90 despite O2 UO <50/ 4 hrs LOC (acute change) recovery position: for an unconscious pt still breathing, place pt on left or right side (looks like sims) w/ top leg flexed (maintains airway and ensures pt does not choke on vomit)

Failure to capture (pacemaker)

appears on monitor as pacemaker spikes not followed by QRS complexes pacemaker malfunction causes= failing battery, malpositioned lead wires, fibrosis at tip of wires SX= bradycardia, hypotension PRIORITY ACTION: if pt is symptomatic from inadequate perfusion (dizzy, hypotensive) --> use TRANSCUTANEOUS PACEMAKER (with external pads) to normalize HR/BP until permanent pacemaker is repaired/replaced

wound culture how to obtain

apply clean gloves and remove old dressing 2. hand hygiene, apply sterile gloves, cleanse wound with NS (flush/swab with gauze)--removes drainage and debris, *IRRIGATE FROM LEAST TO MOST CONTAMINATED remove sterile gloves 3. hand hygiene, clean gloves, swab wound bed with sterile SWAB from WOUND CENTER TO OUTER MARGIN *avoid contacting skin at wound edge (could contaminate) 4. place swab in sterile specimen container, avoiding to touch outside of container 5. apply any prescribed meds after obtain cultures 6. apply new dressing (all with clean gloves), then remove gloves 7. label specimen and doc procedure

phlebotomy (venipuncture)

apply tourniquet 3-5 in above site (no longer than 1 min) if so, remove for 3 min before reapply ***do NOT make further attempts if blood draw unsuccessful after 2x (get another to help!) *insert needle bevel up 15-degree angle *advance stylet 1/4 in until blood return seen (do not advance fully!) *choose arm without IV line (if both have, perform puncture DISTAL TO SITE--below) *pulsating red blood means artery was access (apply pressure at least 5 min, followed by pressure dressing) alcohol skin prep (clean circular motion from insertion site outward)--let dry fully before begin!! (chlorhexidine-clean in back and forth motion) *avoid ventral aspect of wrists (palm of hand towards ceiling)--more risk for nerve injury tube filled and gently inverted 5-10x (mix anticoag solution with blood)--do NOT vigorously shake! *if obtaining a capillary specimen (finger), use 3 or 4th finger on side of fingertip with puncture perpendicular to ridges venipuncture contraindicated in upper extrem w/: -weakness/paralysis -infection -AV fistual -mastectomy/lymphedema IV site selection: *avoid antecubital space if possible since inhibits mobility/positional

DNR considerations

applying O2 by NC is not resuscitative can do if pt has DNR (for comfort) ----------------------------------DNR is used to prevent resuscitation (if heart stops/resp arrest), is NOT used to provide direction for nutrition supplementation or other things etc (feeding tubes)

intellectual disability

appropriate care: consistently assign same staff (familiar environment) foster playtime with developmentally appropriate toys reinforce parent's limit setting measures (time out) to prevent self injury, positive reinforcement for good behaviors communicate using visual demonstration appropriate play activities w/ moderate ID= simple puzzles coloring books modeling clay watching cartoons/fave movies sticker books connect the dots puzzle book playing with large ball (beach ball) simple board games/cards being read to aloud

Aortic dissection

arterial wall tears apart (can be caused by HTN) sx= "ripping" chest pain that radiates to back (tearing, moving, abrupt) if descending (back/abd pain)--think location complication= cardiac tamponade or arterial rupture-->medical emergency, priority! rx= emergency surgical repair pre-op: goal= decrease risk of aortic rupture -->maintain norm pressure= IV BETA BLOCKER

Aspiration PNA

aspirated materal causes inflam response and medium for bacterial growth-->*recall, NOT an infectious process so interventions do not include infection control measures rx= thicken liquids SIDE LYING/LATERAL position in bed (esp if decreased LOC) -swallow 2x before take another bite -fully awake and elevate HOB to 90 when eating ---sit upright for 30-40 min post meals ***facilitate swallow by FLEXING NECK to chest antiemetics (closes epiglottis) watch pocketing food AVOID OTC cold meds when sick (dries mouth) -smoking cessation -brush teeth/use antiseptic mouthwash before and after meals

ARDS What is one of the most common causes of ARDS? (direct and indirect)

aspiration- direct sepsis- indirect *increased fluid permeability into alveolar space sx= refractory hypoxemia (hallmark sx), noncardiogenic pulmonary edema, lungs stiff, noncompliant increased WOB, tachypnea, alkalosis, atelectasis if find pt in ARDS--activate rapid response! and while waiting steps to perform: 1. high fowlers position 2. oropharyngeal suctioning 3. admin 100% O2 NRB 4. assess lung sounds 5. notify HCP

assault vs battery

assault: threat/attempt to harm person battery: actually causing harm to person *if pt is psychotic, unless their is a court order, they still have a right to refuse a med!!

enteral feeding considerations

assess GI residual q 4hrs/ tube plcement at reg intervals *no less than q 4 hrs in intubated pts *may hold feeds if residuals >500mL check residual q 4 hrs -->for cont. feeding or check before each bolus feeding ALSO VERIFY GASTRIC PH BEFORE START FEEDING (after collect residual amount)--before each time?--safety! flush tube with 30 mL of water after checking residual, during feeding, before and after med!! position= HOB elevated semi fowlers!! keep elevated 30-60 min after feeds to decrease aspiration risk keep endotracheal cuff inflated (25 cm) if have prevent aspiration avoid bolus feedings pt at high risk aspiration **before initiating tube feedings, ALWAYS NEED TO VERIFY TUBE PLACEMENT (check gastric pH. assess tube length and compare to measurement at time of insertion) pH gastric should be </= 5!!!!!!! if tube becomes obstructed: -FIRST ACTION= FLUSH TUBE WITH large barrel syringe and aspirate WARM WATER in back and forth motion through tube -->if this doesn't work, may use digestive enzyme solution kit (leave in tube for 30 min-1 hr before flush/aspirating)

guaiac fecal occult blood test (gFOBT)

assess for microscopic blood, screening tool for colorectal cancer steps for sample collection: 1. assess for possible test result interferences= ingestion red meat w/in 3 days, bleeding meds (anitcoags, antplts, iron, NSAIDs, vit C, steroids) 2. obtain supplies, nonsterile gloves 3. open slide's flap and use wooden applicator to apply 2 separate stool samples to boxes on slide 4. close slide cover and allow stool specimen to dry 3-5 min 5. open back of sldie and apply 2 drops of developing solutioon to boxes on slide 6. assess color within 30-60 seconds positive guaiac= test paper turn blue (think like nitrazine test!) means presence of blood in stool

culturally competent care

assess the client's belief about the current illness--to see what their understanding/interpretation is *to help grad nurses improve their culture knowledge: -provide workshop designed to teach about cultures encountered at work *do this PRIOR to assigning them to culture pts

A patient is just return post-operatively, what is the most imp assessment?

assess the effects of their sedative meds by asking them to do a movement if they can, they will likely be able deep breathe and do everything else effectively as well

urine dipstick test

assesses for glucose, protein trace amounts of protein: (<150 mg/day) may show up as neg or trace protein on dipstick -typically considered norm and does not require further eval but... -could be due to fever, strenuous exercise, prolonged standing -ask if pt has had any recent illnesses

case manager roles/responsibilities

assesses pts needs decreases fragmentation of care (obtain health info from pts home) coordinates care and communication between HCPs makes referrals ensures quality standards being met arranges for home health and placement after d/c *don't visit pt daily personally *does not reconcile home medications (this is HCP and primary nurse)

dysphagia diet

at risk for aspiration so... thickened liquids!! modified food consistency (pureed, mechanically altered, soft) food on stronger side of mouth turn head to opp side of CVA (hemianopsia), turn head during meal towards affected side NO STRAWS--just cup or glass sit up all the way (90) TILT NECK SLIGHTLY

Bupropion hydrochloride

atypical antidepressant *can be sustained release (SR), extended release (XL), immediate release *ALL MEDS MARKED SR OR XL SHOULD NOT BE CHEWED, CUT, CRUSHED *can take w/ or w/out food, same time each day AE= seizures teach- -limit alcohol -do not double up on med if dose is missed -weight loss may occur when taking med -takes several weeks to feel meds effects (like any anti-depressants) -watch for increase energy/suicidal thoughts!!

clozapine AE

atypical antipsychotic to treat schizophrenia not responding to usual rx agranulocytosis-->frequent WBC monitor *causes severe, dangerous leukopenia (esp neutropenia) *must have WBC >35000 and an ANC (absolute neutrophil count) >2000 before start clozapine so MUST OBTAIN BASELINE CBC AND ANC BEFORE START *monitor labs regularly throughout therapy (once a week initially) report sx infection asap (fever, sore throat) SEs= ortho hypo, prolonged QT, hyperglycemia, dyslipidemia, weight gain, hypersalivation

nephrotic syndrome

autoimmune disease, affects children age 2-7 *is NOT INFECTIOUS collection of sx due to GLOMERULAR injury: sx= 4 classic: massive proteinuria hypoalbuminemia-->causes third spacing: edema hyperlipidemia additional= decreased UO, fatigue, pallor, weight gain loss of appetite (ascites) hypovolemia (reduce plasma volume, but increase in tissues!) *increased susceptibility to infection! (during relapses, limit visitors to minimize risk) rx= corticosteroids immunosuppresants (cyclosporine) loss of app. manage (make foods fun and attractive) infection prevention -daily dipstick urinalysis testing--monitor proteinuria diet= when in remission: REG DIET W/ NO SALT (helps with edema), FLUID RESTRICT if weight gain/edema teach= high risk for relapse/after recovery, several times a year -test daily for proteinuria (to detect relapse) weigh child weekly keep diary of results

systemic lupus erythematosus (SLE)

autoimmune disorder body attacks own tissues and cells (causes vasculitis, arthritis, nephritis), comes in flares and remissions chronic inflammation of different parts of body (mild to severe)--flare and remission mild= skin, joints, muscles severe= kidneys, heart, lungs, blood vessel, CNS DVT sx= elevated ESR (normal <30) positive antinuclear antibody (ANA) titer anemia leukopenia thrombocytopenia BUTTERFLY SHAPE RASH (flat or raised) across nose and cheeks (often during sunlight exposure and flare) -recurrent oral ulcers ABN FINDING= LUPUS NEPHRITIS increased BUN, Cr, abn urinalysis *need early recognize and aggressive immunosuppression rx to preserve renal func! meds= *no cure to SLE, but rx w/ immunosuppresants (corticosteroids) or immunomodulators (hydroxychloroquine) teach= -avoid physical/emotional stress situations (healthy lifestyle, no smoking) -avoid sun exposure/UV light radiation when can -notify HCP if have fever, avoid sick people contact -get annual vaccines! -only cleanse rash with MILD SOAP meds= azathiprine (immunosuppresant)

myasthenia gravis (MG)

autoimmune neuromuscular disorder characterized by deficiency Ach (remissions and exacerbations) sx= skeletal MUSCULAR WEAKNESS (no atrophy, no sensation loss) produced by repeated mvmnts, disappears with rest *muscles stronger in morning, become weaker with day's activity diplopia, bulbar signs (dysphagia, dif. speech) resp distress, ptosis dx= tensilon test: give ach (edrophium= anticholinergic) and pos result= sig increase in muscle strength in 5-10 min med= anticholinesterase drugs before meals! (AC) -pyridostigmine is first line to inhibit ach breakdown (if pt has prescribed--THIS IS PRIORITY MED TO GIVE ON TIME) neostigmine= give med to increase muscle strength (on time before meals for pt) to increase swallowing-->MUST BE GIVEN ON TIME diet= semi-solid foods (easier to chew) preferred over solid and liquids rx= *assess airway assess muscle groups TOWARDS END OF DAY (when weaker) *admin meds before eating (anticholinesterase, corticosteroids, immunosuppress) -->semi solid foods prefer over solid foods *eye patch for diplopia (2-3 hrs) *restful environment (regain muscle strength) *recieve annual flu/pneumococcal vaccine myasthenia crisis: (when too little of med given, noncompliance, illness, surgery)--is exacerbation of MG -->need to give anticholensterase! asap! cholinergic crisis: (when med dose too high, excess ACH) -this is when give anticholinergic drug

Marfan Syndrome

autosomal dominant disorder affective connective tissues of body sx= Distinct, slender body type--very tall/thin *abnormalities of AORTA/CARDIAC VALVES (aneurysms, tears, leaky) heart valves -->may require replacement/repair--major morbidity and mortality cause in these pts!! *pregnancy CONTRAINDICATED *50% chance of passing to offspring teach= CONTACT SPORTS DISCOURAGED due to risk cardiac injury and sudden death=PRIORITY -may need preventative dental abx if have valve replacement -increased scoliois risk -annual eye exams (have ocular issues)

autosomal dominant conditions sex linked

autosomal dominant: (affected offspring MUST have an affected parent) BRCA-1/2 type II Dm Marfan syndrome polycystic kidney disease Huntington's disease Achondroplasia (dwarfism) sex linked= hemophilia, color blindness, duchenne muscular dystrophy -most likely affects males (inherit from mother, who gives them x chromosome)

Sex during the postpartum period

avoid intercourse for 3-4 weeks postpartum *avoid oral contraceptives *breastfeeding does not provide protection against pregnancy, need alternative contraceptive

Sunburn care

avoid prime daylight time (midday) increase fluid intake (avoid dehydration) pain relief (OTC analgesics--tylenol, ibuprofen) tepid baths, cool compress, aleo vera, calamine (reduce inflammation) *AVOID CORTICOSTEROID CREAMS (HYDROCORTISONE) CAN BE DRYING TO SKIN

GERD diet RISK FACTORS considerations, infant?

avoid spicy, caffeine HIGH FAT/fried FOODS alcohol minty--peppermint acidic (tomatos, fruits, citrus) chocolate carbonated drinks risk factors: female! obese over age 45 caucasian smoking NG tube adults: HOB elevated using pillows, sleep with sit upright after small, frequent meals avoid tight fit clothing eliminate diet (foods above) cluster fluid intake between meals! chew gum to promote salivation (clears acid from esophagus) -refrain from eating at bedtime and/or lying down immediately after eating infant: (will spit up after feeds) "GER" @ risk aspiration/apnea-->know CPR! HOB elevated 30 feedings changed to small, frequent feedings -burp during and after feeds -hold baby upright 20-30 min after each feed -keep calm and upright whole time!! -no active play at least 30 min after feeding -no car seat after feedings

antacids

avoid taking within 2 hrs of other meds!! decreases their absorption best to take before meals or HS? sulcrafate--avoid giving within 30 min of eachother (take sucralfate 1 hr AC and antacid 1 hr PC)

MAO-I contraindications

avoid with these meds: can cause HTN crisis! SSRIs!! -->can cause serotonin syndrome, NMS, HTN crisis! "tines/lines" --need drug free period in between tricyclic antidepressants ("tripyt-mines")-->avoid taking until >3 wks off maoi's diphenhydramine anti-convulsants dextroamphetamine sulfate hydrocodone/acetominophen cocktail st johns wort/ ginseng carvidopa/levodopa OTC meds with ephedrine/pseudoephedrine (nasal decongestant) dextroamphetamine

breastfeeding

avoid: creams (clogs) soap (is drying) massaging (makes tender) do! wash breasts with warm water only feed q 2-3 hrs to avoid breast engorgement (8-12x/day) contraindications: (maternal) active untreated TB HIV infection (in developed countries where formula is readily available) Herpetic breast lesions active varicella infection chemotherapy/radiation active substance use disorder (infant)= galactosemia proper feeding techniques: -feed on demand when infant exhibit signs of hunger (rooting, sucking, reflex) -position newborn "tummy to tummy" (moms and babys tummy facing each other) -mouth in front of nipple, head in alignment with body -ensure proper latch -feed at least 15-20 min each breast -insert finger beside newborns gums to break suction before unlatching -alternate which breast is offerred first at each feeding if struggle with ineffective breastfeeding, DO NOT: -supplement with formula feeds -use artificial nipples *interferes with moms ability to exclusively breastfeed its OKAY to: -have mom use electronic breast pump or hand express small amounts, to feed to newborn by syringe, cup, spoon -if ineffective breastfeeds occur >24 hrs, refer to lactation consultant

latex allergy diet atopic allergy

avoid: apple, avocado, banana, kiwi, carrot, celery, chestnut, melons, papaya, peaches raw potato and tomato *spina bifida is latex allergy risk! condoms, gloves, balloons, catheters *think: TROPICAL FRUITS/VEGGIES atopic= allergy to environmental factors (pollen, dust, animals ,feathers, grass trees, weeds)

reflexes--when do they disappear?

babinski--1-2 years most others-- 3-4 months (moro, tonic-neck, grasp)

impetigo

bacterial skin infection characterized by isolated pustules that become HONEY COLORED crusted and rupture, HIGHLY CONTAGIOUS -->notify parents first action (contacts HCP for abx and antibacterial soap) -->to remove scab, soak in warm water/NS or burrow's solution compress to loosen, gently cleanse with mild antibacterial soap & remove, then only apply topical ointment after all this! caused by stapphlococcus aureus, left untreated can cause ACUTE GLOMERULONEPHRITIS (sx= periorbital edema) NO LONGER CONTAGIOUS AFTER 24-48 HRS! ON ABX (during this time avoid contact close with others), lesions typically heal within a week treat= *prevent contamination! handwash before and after touch area isolate infected person clothing and wash in hot water infected person fingernails short, prevent scratching ***keep infected area covered with gauze when in contact with others (school)

skin traction devices (3)

balanced suspension/thomas-pearson: realigns femur fx/knee using pulley system if weights on floor, feet touching bed, have pt reposition self by bending unaffected leg to push up in bed, will re-establish traction pull bucks: relieves muscle spasms legs/back w/ weight (8-20 lb) used at end of bed -if no fx= may turn to either side -if fx: turn pt every 2 hrs to unaffected side (immobility is leading cause of prob with bucks!) -->elevate HOB 15-20, elevate foot of bed for countertraction, strict bedrest -use trapeze for moving -dont elevate knee gatch -place pillow under legs, not heel russels: pulls contracted muscles with sling and traction (leg lifted off bed) -can loosen sling for skin care -check popliteal pulse (sling under knee) -place pillows under leg -ensure heel is OFF bed -do NOT turn from waist down -lift client, not leg to provide assistance

what do upper and lower GI series use to visualize anatomy?

barium! ingestion (upper GI series) instillation= enema (lower GI series) is a contrast dye *uses fluoroscopy to visualize colon, detect polyps, ulcers, tumors, diverticula preprocedure: -cathartic to empty stool (miralax, mag citrate) -clear liquid diet follows the day before procedure *avoid red/purple liquids -do NOT eat/drink 8 hrs before -place in various positions, may feel abd cramps/ urge to defecate postprocedure: -EXPECT STOOL CHALKY, WHITE (barium contrast) passed--for up to 3 days! -take laxatives! barium is constipating! (mag hydroxide) -drink lots of fluids/high fiber diet *if pt is constipated still after 3 days, not good as can cause perforation and is priority pt!

bilirubin levels infants phototherapy

bilirubin levels peak 3-5 days after birth normal is 0.2-1.2--Uworld 12 or less??-kaplan phototherapy is considered 13-15mg/dL Phototherapy rx: expose skin as much as possible patch eyes (remove patch q 2 hrs) cover genitals (diaper) increase fluids (prone to dehydration with therapy)-->(milk or formula, NOT water) -->green stools, monitor UO -assess incubator temp while newborn inside (temp on low heat setting) -do NOT apply lotions/ointments--can absorb heat -allow fam to feed newborn -only remove newborn from lights for feedings! *expected findings= bronzing of skin (will go away) and green stools

age appropriate toys growth and development

birth-2 mo: mobiles 8-10 in from face (in crib) 2-4 mo: rattles, cradle gym 4-6 mo: bright colored toys (small enough to grasp, large enough for safety) 6-9 mo: large toys with bright colors, movable parts, noise makers 9-12 mo: books with large pictures, large push-pull toys, teddy bears toddlers: push pull toys, low rocking horses, dolls, stuffed animals, stacking and nesting toys/blocks soap bubbles preschool: (very imaginative, enjoy dramatizing) child imitative of adult patterns and roles. offer playground materials, housekeeping toys, coloring books, tricycles with helmet color with crayons puppets, dolls playing dress up medical kits puzzles with large pieces, clay finger paints school age: construction toys use of tools, household objects, sewing tools, table/board games, sports (like to imitate adulting) puzzles adolescents: maintain peer contact/visitors

Adoption concepts with children Piagets cognitive development theory

birth-2 years = sensorimotor 2-7 yrs= preoperational (magical thinking, poor causuality references, egocentric) -->a child may believe adoption is their fault, a scraped knee is due to their misbehavior 7-11 concrete operational (able to reason if concrete objects used to teach) *child may imagine how life would be dif if had biological parents *may be sensitive to physical differences between adoption fam and them (develop self esteem issues) 11+ formal operational (abstract thinking/reasoning) *child would not like differing from peers, think introspectively about adoption *be open and honest in communication imp at this age

Von Willebrand Disease

bleeding disorder caused by a deficiency of von Willebrand factor, plays imp role in coagulation rx= RICE (help with pain/inflammation) meds= major bleed areas: vWF replacement minor bleed areas: desmopressin/topical therapies teach= notify HCP signs of bleeding use humidifier/nasal spay to keep moist mucosa (reduce epistaxsis risk) avoid NSAIDs/ ASA (anti plts) avoid contact sports soft toothbursh, gentle floss! report heavy menstrual bleeding (soaked pad <3 hrs)--can be managed by desmopressin

Osteoporosis

bones become increasingly porous and brittle dx- BMD (bone mineral density) T-scores scores </= 2.5= have *often no sx until first fracture occurs! so prevention is so imp--esp those at risk risk factors: age over 60 post menopausal--women??? alcohol/smoking/steroids immobility/sedentary life inadequate calcium/vit D intake caucasian/asian small stature/lean build goal= prevent bone fracture--esp hip! teach: diet high in calcium (leafy green veggies), vit d (sunlight!), proteins meds= biphosphonates -smoking cessation/alc avoid WEIGHT BEARING EXERCISES SO IMP!! walking, eliptical exercise, dancing, and weights! (on long bones) 30 min 3x/week ROM exercises, meds (ERT for post menopause), dronates prevent patho fractures: hard surface, firm mattress, back board back brace or splint for support *avoid high impact exercise: running/jumping-->patho fx

osteogenesis imperfecta

brittle bone disease (fracture, break easily) rare genetic condition--autosomal dominant *watch for hemorrhage sx= blue sclera bow leggs opalescent, brittle teeth goal= MINIMIZE FRACTURES -check BP manually (avoid cuff overtightening) -lift infant by hand under broadest body parts (back, buttocks) -reposition infant frequenting to avoid molding of bones

Theophylline

bronchodilator (rx asthma) *narrow therapeutic range (10-20) toxicity > 20 (think like phenytoin!)--> CNS stimulation AE= HA, insomnia, seizures, N/V, arrhythmia AE= *SEIZURES/ARRYTHMIAS most serious! teach= *avoid cimetidine and ciprofloxacin with as can dramatically increase levels *draw blood 30 min after dosing!

Plague (bubonic/pneumonic)

bubonic: rodent to man, fleas standard precautions rx= abx pneumonic: droplet precautions--person to person tranmit sx= resp probs rx= abx

How to move in Buck's traction

bucks= SKIN TRACTION bucks= immobilizes hip/femur fractures/ reduce pain & spasm boot/traction tape applied to affected extremity and weight pulls the limb to traction position= SUPINE WITH FOOT OF BED raised for countertraction (max fowlers= 20-30 degrees)--NO MORE THAN THIS in a single, straight, movement body remains as a single straight unit (leg should remain in straight, neutral position)--DO NOT MOVE PT SIDE TO SIDE OR USE WEDGE PILLOW, KEEP IN NEUTRAL POSITION if pt sliding down in bed: use arms to lift self with overhead trapeze; push down on unaffected foot to lift body OR tilt the mattress (slight trandelenberg) and raise HOB= keeps legs straight, prevent slide down, counter pulls weights care: -reg assess vascular/skin status often (when change made in another 30 min) -(can loosen velcro straps if boot too tight, tighten straps if boot too loose -provide fracture pan for elimination needs -weights should be FREE HANGING AT ALL TIMES, never place on bed or touch floor!! *have staff member support weight while pt repositioning in bed

growth and development considerations by child age TYPES OF PLAY?

by 2 yrs: builds 6-7 block towers, can retrieve objects when asked 3-4 yrs: follow simple directions/commands, names colors, can put toys away alone 4: sentences of 4-5 words 6 mo: birth weight doubled 12 mo: birth weight tripled sit from standing with no assistance pincer grasp 17-24 mo: thumb sucking normal! (most prevalent when child hungry/tired) *as long as thumb sucking stops BEFORE PERMANENT TEETH begin to erupt (this is good, wont affect teeth) *teach= dont punish child for thumb sucking/ using pacifier 4 yrs: skipping/hopping on one foot 4-6 yrs: imaginary friends adolscent: RAPID GROWTH takes place wisdom teeth appears age 17-21 growth: 6-12 yrs--> 2 inches/yr; 4.5-6.5 lb/yr PLAY: infants-->solitary play (alone, but enjoys presence of others/w/ parents, interest centered on own activity) toddlers-->parallel play (play alongside but not with each other) preschool-->associative play (no group goal, follow leader)--strongly influenced by each other's toy school age-->cooperative play (organized, rules) (formal game, task) 1-2 children direct activity and assign roles while others follow

minerals and functions

calcium: bone formation, muscle contract deficient= rickets/ porous bones/tetany phos= bone formation deficient= rickets flouride= dental health deficient= dental caries iodine= thyroid hormone synthesis deficient= goiter sodium= ostmotic pressure, acid base balance deficient= fluid/electrolyte imbalance potassium= water balance in cells, heart contractility deficient=arrythmias iron- hemoglobin synthesis definient= anemia

seizure considerations

call for help! STAY WITH THE PATIENT DO NOT place anything in mouth *during status epilepticus, can give med if seizure is not stopping *ease pt to floor w/ pillow under head if standing *position: during= place pt on LEFT LATERAL side (RESCUE POSITION)with head flexed forward and tongue falling forward after= place on side to prevent aspiration -pad side rails -RAISE ONLY UPPER SIDE RAILS (not all 4!) -loosen restrictive clothing around neck and chest *use suction equipment after seizure subsides -remain at bedside while noting duration and sx of seizure have at bedside= suction (perform if need after seizure ends) O2 equipment--bag valve mask padded side rails intubation supplies --in case for after! dont have: do NOT need intubation tray, oral airway, tongue blade, CPR cart *NEVER restrain during seizure seizure phases (4): 1. prodromal: warning signs that precede seizure 2. aural: before seizure pt experiences visual or other sensory changes 3. ictal: period of active seizure activity 4. post-ictal: recovering from seizure, may have confusion, HA *in syncope, only brief LOC without prolonged post event confusion TONIC CLONIC/ COMPLEX PARTIAL: -altered sensory perceptions -awareness of odors (aural), postictal confusion, incontinence FEBRILE seizures: unknown etiology most common in children 6 mo-6 yrs -don't need seizure meds just give antipyretics (tylenol, ibuprofen) in children >6 mo to control fever -cool damp compresses, air circulation, loose clothing--after seizure to cool down! *NO tepid baths for infant ABSENCE SEIZURES: typically in children (age 4-12) -daydreaming episodes or brief (<10 sec) staring spells -appearance of inattention or daydreaming -may have slight loss of body tone (drop objects in hands), but still retain most of postural body tone -absence of warning and postictal phases -absence of other epileptic activity (no myoclonic, tonic clonic activity) -unresponsiveness during seizure -no memory of seizure -pt may have mult throughout day -rx= AEDs Epilepsy: -for pts with, not necessary to go to ED after seizure unless status epilepticus occurs -requires lifelong anticonvulsant med -avoid seizure triggers (alcohol, sleep deprived, stress) -wear med alert bracelet *call 911 if SEIZURE LASTS MORE THAN 5 MIN status epilepticus= seizure last >5 min or two or more seizures w/in 5 min period w/out person turning normal in between them) sx= grunting; dazed appearance rx= IV benzos (diazepam, lorazepam) recal route prescribed when IV form unavaliable *if pt have outside home, teach parents to give child this rectal dose before coming to ED *IF PT HAS SEIZURE ACTIVITY AND RECEIVING BENZO, IS PRIORITY PT STILL TO ASSESS AS airway issue, could occur again, and need to ensure safety measures are there in case (aspiration, padded rails) vocab: tonic= body stiffening clonic= muscle jerking atonic= loss of muscle tone "drop attack" myoclonic= brief muscle jerk tonic clonic= alternating stiffness/jerking

"time-out" before surgery steps

called before initiation of surgical procedure *the pt is involved in the time out portion--before administration of sedation--have pt clarify surgical procedure to be done *verification of consent is done BEFORE pt arrival in OR *instruments are not identified as right and left sided *circulating nurse identifies pt by name and DOB *the circulating nurse and HCP agree the left eye is operative eye

Ultrasound in pregnancy

can be done as early as 5W to confirm pregnancy! to see position, number of fetuses, structures, possible sex (but not diagnostic)-->amnio is dx *MUST HAVE FULL BLADDER TO ASSIST IN IMAGE CLARITY

Group B Streptococcus (in pregnancy)

can be transmitted to newborn during labor->neonatal sepsis/PNA *test all preg clients at 35-37 weeks *admin prophylactic abx if pos. If GBS status is unknown, abx typically indicated when ROM has been >/= 18 hrs, maternal temp >100.4, or gestation <37W

PEEP (positive end expiratory pressure)

can cause barotrauma!! *usually kept at 5 high values 10-20 (effective for ARDS), but in other cases over-distends/ruptures alveoli--barotrauma, air can escape cause SQ emphysema/ pneumothorax and decreased venous return (hypotension)

Norepinephrine IV infusion considerations

can cause extravasation stop infusion ASAP, d/c tubing aspirate drug from ret of IV cath while pulling it out elevate extremity of above heart to reduce edema notify HCP, antidote= PHENTOLAMINE (vasodilator for adrenergic agonists--norepi, dopamine, rx extravasation)

organ donor/ donation considerations

can do if 18 or older *requests to fam about organ donation are done usually by HCP or specialized nurse *OPS (organ procurement services) are notified for every client death -->if pt deemed appropriate to be a donor, OPS works with hospital staff to approach fam about organ donation *continue cardiac/resp support and medical care while organ donation is discussed/and or performed (contact OPS before life support removed so physiological support is continued in event pt is viable donor) *life support only withdrawn if pt not candidate for donation or pt/family does not consent *even if fam requests life support withdrawal, first PRIORITY ACTION is contact OPS to see if pt viable donor, then ask fam and withdrawal if decline

Bed bug

can inhabit any environment and travel/spread easily in clothing, bags, furniture, bedding *common misconception is they only go to dirty environments--this is false! teach= -treat the ENTIRE HOUSE for bed bugs with pest control (launder clothing in hot water use highest temp on dryer to kill, then store clothing in tightly sealed plastic bags to prevent additional infestation) -can cause rash on pts, esp children, inclined to scratch--alleviate rash/itching until its gone -all members of house hold will be afflicted

apnea monitor infant

can leave baby for brief periods of time can remove during baby's bath *do NOT need to watch monitor all the time--will alert you if infant stops breathing

HPV (human papilloma virus)

can often causes cervical cancer sx= often asymptomatic, gential warts are typically painless rx= get pap smears q 6 months, annually?? if have vaccination against HPV before sex activity begins (9-26 yrs; recommend 11-12) SAFE SEX PRACTICES teach= can be spread through sexual contact (anal, vaginal, oral) even if sx not present

Leukemia

cancer of white blood cells, affects bone marrow and thus blood cells (RBCs) as well sx= anemia, pallor, (anything like anemia bleeding decreased O2 production) dx= bone marrow aspiration (sternum/iliac crest), apply sterile dressing after monitor for infection/bleeding! (dont bang joints) admin packed RBCs diet= high cal, high vitamin (loosing blood) neutropenic cautions PRN bone marrow transplant

What is the main rule of a kosher diet? jewish

cannot eat meat and milk/dairy in the same meal (no milk at least 3-6 hrs after meat) *two meals of dairy, one meal of meat NO pork--no gelatin (only animals that chew their cud) only fish scaled (no shellfish--crab, lobster, oysters) no birds of prey, diseased animals, those who die natural death kosher= blood drained at any time can consume: fresh fruits/veggies, grains, tea, coffee *eggs are NOT considered a dairy food! *capsules also coated in gelatin=non-kosher (ask pharm if gelatin free form available= tabs) JEWISH ARE OKAY WITH BLOOD TRANSFUSIONS

Mechanical Ventilator Considerations

care= HOB at 30-45 monitor resp status pause sedation daily to assess weaning readiness perform oral care with chlorhexidine solution q 2 hrs, followed by ET suctioning place manual resuscitation bag at bedside monitor ET tube depth enteral feeds with dense calories and protein monitor gastric residual volumes never mute alarms tidal volume- total amount RR in and out low tidal volume= ventilator delivering lower amount of air than set -->can be due to disconnection, loose connection, leak positive pressure ventilation (PPV)= deliver pos pressure to lungs (preset volume and concentration of O2, with varying pressure) sx= increases intrathoracic pressure (HYPOTENSION, reduce CO) *if pt deteriorates and can't troubleshoot cause (cant confirm if tube displaced): manually ventilate with resusc bag at 10-15 L/min *if pt intubated and O2 sat begins to drop: first ASSESS: AUSCULTATE LUNGS (to confirm tube displacement) *if pt in resp distress: AUSCULTATE LUNG SOUNDS (determine if pt has airway, see if ET is displaced)

Autism

cause unknown, however, strong evidence there is a GENETIC COMPONENT to ASD, onset before age 3 *if have sibling with it, higher chance of having it! sx= abnormal social interactions and communication skills patterns of behavior that are restrictive and repetitive (preoccupation with single toy, insist on same play routine, and repetitive behaviors when playing with toy) *care= STRUCTURE ROUTINE AND CONSISTENCY is critical (determine with fam usual home habits, meal time, play time etc) -->helps pt decrease anxiety, know what happens next -avoid pt overstimulation (limit # visitors, not giving tons of choices) have parents bring in a few toys -->keep CALM ENVIRONMENT, MINIMAL STIMULATION= private room away from nurses station -hypersensitive to touch (distract/hold by parents during procedures) nurse actions: -use quiet, monotone voice when speaking to child -use eye contact and make gestures carefully -move slowly -limit visual clutter -maintain minimal lighting -provide child with single object to focus on common nursing diagnosis= impaired social interaction aeb unresponsiveness to people

Fasting

causes a # of health probs: increased stress muscle damage fluid loss increased hunger depletion of essential nutrients fatigue, HA, dehydration, dizzy, muscle weakness *fasting for more than 1-2 days can lead to heath probs (stated above) *fasting will cause body to go into starvation mode (use protein, fat, and stored carbs as energy sources)--no one component is spared *appetite may be suppressed during a fast after the first few days/hrs however, once reg intake resumed, hunger will return back to norm *INITIAL WEIGHT LOSS DURING FASTING IS PRIMARILY FROM FLUID LOSS

name two neuromuscular disorders

cerebral palsy muscular dystrophy

skull traction devices (2)

cervical (skull tongs): hyperextends head/neck of cervical vertebrae fx to realign/relieve pressure -never lift weights--must cont. traction -no pillow under head during feeding -hard to swallow, may need suctioning halo fixation device (vest): immobilizes cervical spine -cleanse area around pins sterile technique (use sterile water, chlorhexidine) -if prescribed, half strength peroxide or saline/sterile swabs 1-2x/day -keep vest liner clean and dry, change PRN when soiled, cool blow dryer to dry and protect skin -foam inserts under pressure points prevent injury -keep correct size wrench at bedside all times in case emergency -place small pillow under pts head when supine to reduce pressure on device *only HCP can adjust pins!! *AVOID GRABBING DEVICE FRAM WHEN MOVING/POSITIONING PT, CAN LOOSEN SCREWS

cervical cerclage

cervical insufficiency (painless, premature cervical dilation) *to prevent preterm delivery, usually in pts with hx of 2nd trimester loss or premature birth heavy suture placed to keep cervical os closed (about 12-14 W if hx) or up to 23 W G if signs of cervix insufficiency noted teach= recognize signs of preterm labor (low back aches, contractions, pelvic pressure) and ROM -bed rest only a few days postop -remains in place until 36-37 W G

What to do upon ROM? prolapsed cord?

check FHR--to assess for fetal distress prolapsed cord: sx= premature ROM, presenting part not engaged, fetal distress, protruding cord rx= call for help!! push against presenting part to relieve pressure on cord position= trandelenberg/ knee to chest (to take pressure off cord/fetus) monitor FHR for unchanged!

When should childs first dentist trip be?

children have their first dental visit within 6 months of their first tooth eruption OR by their first birthday -first tooth usually erupts around 6 mo of age -most children have all primary teeth by age 2-3

scleroderma

chronic progressive disease of the skin and internal organs with hardening and shrinking of connective tissue/skin (no cure), prevent comps expected s/sx= raynauds, pulm fibrosis (dry cough, dyspnea), heartburn, dysphagia *watch for malignant HTN, can cause renal crisis--if see abrupt onset HTN and HA= PRIORITY!

Psoriasis

chronic, autoimmune skin condition, due to rapid turnover of epidermal cells sx= silver plaques on reddened skin *no cure, goal= slow turnover, heal lesions, control exacerbations rx= avoid triggers (stress, trauma, infection) topical therapy= corticosteroids, moisturizers phototherapy= UV light, sunlight is good!! systemic meds= methotrexate, infliximab avoid alcohol

how to obtain urinalysis sample/urine culture & sensitivity

clean catch specimen= mid stream! *first AM void is preferable as overnight specimen more concentrated culture= cleanse external meatus with povidone iodine soap and water before test; then obtain midstream specimen

how to collect urine specimen from foley cath?

clean collection port with alcohol swab 2. aspirate with sterile syringe 3. use aseptic technique to transfer specimen to sterile specimen cup sterile procedure??

ear drop instillation

clean gloves pt side lying affected ear up (child place prone or supine with head turned to appropriate side) warm ear drops room temp (hand or warm water) pull pinna up and back (Pts >4 yrs) (<3 pinna down and back) instill drops 1cm/1/2 in away above ear canal (avoid med dropper touching ear canal) apply gentle pressure to tragus instruct pt lay side laying 2-3 min/ several min place cotton ball for 15 if need, absorbs excess med(avoid in infants)

nipple care postpartum

clean with warm water, NO SOAP (drying), dry thoroughly absorbent breast pads if leaking occurs apply breast milk to nipple and areola after each feeding and AIR DRY apply WARM compresses after each feeding and air dry to breastfeed: position nipple so infants mouth covers large portion release infants mouth from nipple by inserting finger to break suction (rotate positions)

oral care

cleanse mouth with NS!! AC and HS soft bristle viscous lidocaine for oral pain water soluble lubricating agents for dry mouth avoid hot liquids/spciy acidic foods *avoid antiseptic mouthwashes w/ alcohol

full liquid diet

clear + non clear liquids milkshake, soups, custard + all clear liquids

cleft lip/ palate breathing complication

cleft lip= fissure in lip or up to nasal septum -->repair in 1-3 mo cleft palate= fissure in hard or soft palate -->repair in 12-18 mo before child develops altered speech patterns rx= surgical repair! preop: (think increase oral intake, decrease aspiration risk) feed soft nipple, special lambs/cross cut nipple -use squeezable bottle -tilt the bottle so nipple is always filled with formula (no air) point DOWN AND AWAY FROM CLEFT feed slowly (20-30 min) feed q 3-4 hrs (no more frequent-tiring) BURP OFTEN (infants suck in air) --UPRIGHT position when feed post op: assess infant's ability to suck airway (suction and ET tube at bedside) -avoid hard objects (tongue depressors, pacifiers, straws, utensils) -can use elbow restraints but take off -position supine with HOB elevated after feeding -encourage caregiver soothing suture line= use LOGAN BOW to secure, support, and stabilize -keep clean and dry (cotton tipped dip in saline, apply thin coat abx ointment) position= SIDE LYING ON UNAFFECTED SIDE cuddle, rock, to comfort elbow restraints if need CAN breast/bottle feed 12 hrs post op if bottle: place in rear of mouth to avoid suture site in front of mouth BREATHING COMPLICATION: upper airway congestion rx= place infant on one side (promotes drainage of mucus from upper airway and breathing through nose) *dont raise HOB! wont promote adequate drainage

QI projects--what do they address??

clinical issues/standards on an entire UNIT-on whole unit probs; ex= meds prescribed STAT not available in timely manner; CAUTI increase on unit

How to do a 24 hr urine collection

collect urine over full 24 hr period pee into large containers given to you by doc store container in cool area until can turn into lab (refrigerator, on ice) *don't save the first urine, flush this out then start the collection (start time here)--imp. to record time then empty bladder in toilet so start time coincides with empty bladder (at exact time next day, empty bladder if can for a final time and collect in jug) *you will given a dark plastic jug containing powder that absorbs into the urine you will collect in the jug (protects urine from light and adjusts acidity) at end of 24 hr period try to urinate at same time began if can, then take collection to lab ASAP Can drink as much fluid as want to before test *if one specimen gets messed up, thrown out, start over next morning at same time (usually done AM to AM), AFTER PT'S FIRST VOIDING and end it at same hour the next morning after morning void

myocardial infarction (MI) most common complication? s/sx?

common complication= dysrhythmias! --> PRIORITY ACTION FOR ANY PT WITH CHEST PAIN= PERFORM ECG (even before VS!) *high specific indicator of MI= TROPONIN (even more than creat kinase) levels increase 4-6 hrs after onset, peak 10-24 hrs, return baseline 10-14 days dx= troponin, ekg findings, and pt sx report men: SOB, dizziness, sweating or cold/clammy skin, N/V, pain (neck, jaw, left shoulder, arms & epigastrum) women/elderly: (atypical) *asociated sx with no chest pain= dyspnea, diaphoresis (cold sweats) Nausea!/V jaw/shoulder pain belching, indigestion dizziness, fatigue, generalized weakness epigastric burning pain or gas anxiety pain feels like= sharp, intense, stabbing! often occurs in morning hours (heart pumps more slowly, more relaxed) PRIORITY ACTION, someone comes in showing sx of MI= OBTAIN 12-LEAD EKG expected findings after MI: slight increased temp N/V rx= OANM, then cath lab/clot busters (PCI), angioplasty (baloon/stent placement) -oxygen -aspirin -nitro -morphine--KEY: chest pain unrelieved after morphine= MI! surgery (PCI, CABG)-->contrast dye used! post op teach= -no baths (showering okay if avoid soak wound) no heavy lifting prevent infection ABNORMAL-->PRIORITY! *watch for development of pulmonary congestion, heart failure, cardiogenic shock sx= new s3 sound, crackles, JVD

morning sickness

common preg prob during first trimester (some can get during 2nd/3rd) due to rising hormonal levels rx= several small meals (high protein/carbs, low fat) drinking fluids BETWEEN meals (clear, cold, carbonated beverages)--avoid abd distention -high protein snack before bedtime and on awakening foods/drinks with ginger are great! high in Vit B6 foods are great! (nuts, seeds, legumes)--helps process certain proteins

toxic megacolon

complication of IBD--life threatening! is severe inflammatory colon distention more common seen in ulcerative colitis than chron's *can be associated with C. diff infection and other forms of infectious colitis *can cause intestinal perforation! sx= bloody diarrhea, fever, abd distention, N/V, pain rx= NGT decompression, IV fluids, abx *if SEE THESE SX--> SUSPECT TOXIC MEGACOLON AND PRIORITY PT!

gastrectomy (gastric bypass) considerations dumping syndrome= from Billiroth surgerys! Billiroth I= gastroduodenostomy Billiroth II= gastrojejunostomy

complications include DUMPING SYNDROME: *occurs when gastric contents enter too rapidly into duodenum-->fluid shift into small intestine sx= hypotension, abd pain, N/V, dizziness (after eating), tachycardia, generalized sweating (think like hypovolemic shock from fluid shift!) take measures to prevent this: recline for 30 min after eating drink fluids between meals (not with!) 30 min after LIMIT CARBS (simple sugars and syrups) add high proteins, high fat, high fiber (take longer to digest) eat SMALL, FREQUENT meals *complication if pt N/V post-op= WOUND DEHISCENCE AND EVISCERATION (esp when pt obese) address priority and give antiemetics so dont place stress on sutures position= HOB elevated (except if have dumping syndrome then lay supine for SHORT period time after eating) *if pt has clogged NGT, do not try to reposition or irrigate by yourself, contact HCP--could cause hemorrhage/perforation

Types of hearing loss test with? weber vs rinne

conductive= external/middle ear disease sensorineural= inner ear disease test with weber test! tuning fork placed midline head, see if hear sounds evenly both sides if louder in affected ear (conductive) if louder in unaffected ear (sensioneural) weber: tuning fork placed mid forehead (hear sounds equally both ears)= norm rinne= tuning fork place on mastoid process, when pt no longer hears vibrating sound, place in front of ear canal--and should still hear considerations for care for pt with hearing loss: -approach pt from the front -visibly gain the pt's attention before speaking -stand directly facing patient -post hearing impairment sign at door -room lights on so they can lip read -facial expressions and gestures are helpful -speak at NORMAL VOLUME, DO NOT SPEAK LOUDLY (Creates higher pitch hard to understand) -ensure hearing aids are functional and in place before attempting to speak to patient

vaccine considerations

consider: -assess for allergies to components: neomycin, gelatin, yeast, screen latex allergy immunocompromised (AIDs, CORTICOSTEROIDS, CHEMO) pts should not receive live vaccines= varicella zoster, MMR, rotavirus, yellow fever common misperceptions of contraindications to getting immunized: these are NOT contraindications to getting vacc'd: penicillin allergy (is fine) mild illness (w/ or w/out elevated temp) mild site rx (erythema, swelling, soreness) recent infection exposure current course of abx

elderly problems/considerations how to promote better sleep?

constipation nocturia? eating: decline ability to chew/altered taste perception (can cause impaired nutrition) incontinence is NOT an expected finding in elderly!! altered mental status= when see this in elderly always think INFECTION!! *confusion is NOT normal finding in elderly consider: high protein diet to slow degeneration process of aging sleep: avoid clock in room reg bedtime routines postpone further procedure explanations teach how to call for help (all decreases stress) isolated systolic HTN is common!: sys >160 but diastolic <90 (not a priority) need socialization!! promote--isolation tends to be prob in older adults IV Therapy: -decreased GFR-->can cause hypervolemia! -use an infusion pump -fragile veins lead increased risk IV infiltration -fragile skin may tear easily (use nonporous tape) -minimize tourniquet pressure, skin protect solution -use smallest gauge cath indicated for pts therapy (24-26) as veins are more fragile -vein sites to promote independence: non dominant arm, avoid back of hand -5-15 degree angle of insertion, veins more superficial!

Poison Ivy

contact dermatitis rash 50% of people in contact with plant develop rash sx= linear appearance where plant brushed skin develops 12-48 hrs after exposure, can last severa lweeks teach= -most imp to FIRST THOROUGHLY WASH THE AREA (to remove oily resin and prevent it spread!) -apply cool, wet compresses -apply topical cortisone -discourage child from scratching are

tinea capitis (ringworm of the scalp)

contagious fungal infection, lives on scalp surface sx= scaly, pruritic, erythematous, circular patches with hair loss transmission= contact with infected persons, pets, objects (hairbrush, bedding, towels, hats) rx= 1% selenium sulfide shampoo apply/wash scalp several times each week + antifungal med (griseofulvin oral suspension) pt takes several weeks to months teach= -do not d/c med early even if symptoms gone, need to ensure keratin shed completely -take med with high fat foods LIMIT CONTACT WITH PETS SE griseofulvin= photosensitivity

Narcotics (opiates)

contraindicated in head injuries cause CNS depress and mask signs of increased ICP ex= tramadol, hydromorphone SE= typical is N/V!! also ITCHING is common AE of narcotic used in PCAs! *after give, reassess pain and sedation level during peak effect= 15-30 min after! not 1 hr!

coup-contrecoup injury what parts of brain are affected based on lobe? s/sx?

coup/contrecoup= frontal and occipital lobe frontal= memory, speech (broca!), executive func occipital= vision temporal= hearing/smell! (wernicke) parietal= light touch (think paresthesias), graphesthesia (able to identify writing on the skin by touch), proprioception (awareness of body position) broca= expressive speech (frontal lobe) -easily frustrated when attempts to speak -speech is limited to short phrases requiring effort (speech sparse and nonfluent) wernicke= language comprehension (temporal) -pt misunderstands and inappropriately responds to verbal instruction (due to miscomprehension) -speech fluent and voluminous but lacks meaning global aphasia: (most severe aphasia) -damage to mult language areas -inability to read, write, or understand speech -pt unable to understand speech and is completely nonverbal

Meds to give for NMS (neuroleptic malignant syndrome) S/Sx of NMS

dantrolene (*think also given in malignant hyperthermia-->both malignants!) bromocriptime *meds that trigger NMS= haloperidol/fluphenazine S/Sx: high fever, severe muscle rigidity/stiffness altered mental status autonomic dysfunction (pallor, tachycardia, HTN/hypo, diaphoresis, convulsions, loss of bladder control, resp distress, , tiredness, tremors *if observe NMS, hold med, assess pt, notify HCP

what med to treat malignant hyperthermia? sx?

dantrolene!! cooling blanket, fluid resusc rx hyperkalemia IS AN INHERITED CONDITION--screen for fam hx of this! *med likely to cause= SUCCINYLCHOLINE (paralytic used for intubation/general anesthesia) -->d/c if MH occurs triggered by certain drugs used to induce anesthesia, life threatening muscle abnormality sx= hypercapnia (earliest sign), generalized muscle rigidity (jaw, trunk, extremities), hyperthermia (later sign) -->can exceed 105! flushed profuse diaphoresis tachycardia, tachpnea hyperkalemia, cardiac dysryhtmias, myoglobinuria

osteomalacia

decalification of bone due to VIT D DEFICIENCY also: intestinal malabsorption (Ca), CKD, lack of sunlight sx= porous bones on xray, weak, soft, painful, tenderness, muscle weakness, BOWED LEGS, kyphosis diet= HIGH VIT D! calcium, and phos! expose to sunlight/UV irradiation, OTC vit d supples avoid patho fx --assist with ADLs-->use cane/walkers to prevent falls! encourage light to moderate activity

Digoxin (Lanoxin)

decrease HR, increase contraction of heart reducing workload, increase CO rx= HF and afib MAY CAUSE DYSRHYTHMIAS-->watch for! *safe to give as long as HR >60--assess this by listen to APICAL RATE for full 1 min! norm level 0.5-2.0! *hypokalemia can potentiate toxicity early toxicity sx= N/V, abd pain, anorexia later toxicity sx= arrhythmia's (brady), heart blocks (diziness/lightheadedness) other toxicity sx= lethargy, confusion, fatigue, weakness alterations in color vision, scotomas, blindness teach= *check pulse and if low <60 or skips beats, hold med and notify HCP AE= nephrotoxicity (dig almost exclusively excreted by kidneys) watch increased BUN/Cr Dig in Infants teach: -hold dig if pulse <90-110 for infants and young children and if <70 in older child -do not mix drug with foods/liquids (kid may refuse) -oral liquid in side and back of mouth -do not give extra dose/increased if mix, notify HCP if miss more than 2 doses -wathc for N/V, slow pulse rate= toxicity -give water or brush teeth after admin to remove sweetened liquid -notify HCP if feel dizzy/lightheaded (toxicity= bradycardia/heart block)

Cesarean section considerations

def between general surgery: will give less narcotic so that less med crosses placental barrier-->which could cause resp. depression in infant after: most imp is encourage cough, deep breathe, in order to decrease effects from anesthesia most imp intervention= prevent fluid electrolyte imbalances (hemorrhage/shock= life threatening complications!) *post-op: major complication= PE from hypercoaguable state--watch for sx! *chest pain, recent onset anxiety, restless, tachycardia, hemoptysis)

Parkinson's disease

deficiency of dopamine sx= tremors (pill roling), akinesia (loss voluntary mvmnt), motorized (propulsive gait), dysphagia, slurred monotonous speech masklike facial expression, drooling, constipation, dementia, depression flexed elbows, wrists, hips, knees trembling of extremities shuffling, short-stepped gait reduced arm swinging forward tilt of trunk stooped posture rigidity bradykinesia decreased exercise ability--constipation DOES NOT LEAD TO PARALYSIS! progressive but slow disease (does not impair intellect, sensory) rx= "freezing" can happen-->goose step walk (shift weight from one leg to another) walk with wider base, swing arms when walking turn slowly with small steps meds= anticholinergics (for tremors) *watch airway due to drooling-->aspiration! stage 4= pt is immobile (perform ROM), cannot ambulate/perform activities with small muscle dexterity

When to expect dehiscence/evisceration post op?

dehiscence= partial/total separation of skin/tissue layers to prevent: (promote good wound healing) -stool softeners -antiemetics -abdominal binder -tight glycemic control (decrease infection) -splinting abdomen -good caloric intake typically seen 6-8 days after surgery common in abd surgery, obese, poor wound heal evisceration position= (decrease tension on wound) low fowlers (15 degrees) less stress W/ KNEES BENT! OR supine with hips/knees bent rx= -Remain w/ pt and call for help -*cover open area with sterile gauze soaked in normal saline, notify HCP -put in position, absolute bed rest -assess VS, repeat q 15 min -prep to return to immediate surgery (asap make NPO--even with meds!)

Rhabdomyolysis

destruction of muscle fibers, released into blood (after intense muscle injury (exercise, trauma, heat stroke)--> produces myoglobin (protein in muscle tissue) in blood--> excess can cause kidney damage (ARF) sx= dark, often bloody urine oliguria fatigue ELEVATED CREATININE KINASE LEVELS (>15,000)--recall seen with muscle damage rx= PRIORITY ACTION= rapid IV FLUID RESUSCITATION w/ NS= priority!! to flush out myoglobin and keep from damaging body

Reye syndrome

develops in children with recent viral illness such as varicella or influenza *risk increases if use ASA to treat viral illness in children (use tylenol/ibuprofen instead) causes= acute encephalopathy & hepatic dysfunction sx= elevated serum ammonia levels vomiting altered LOC--seizures/coma DUE TO MEDS CONTAINING SALICYLATES (ASA, bismuth subsalicylate) AVOID in childhood!!!!!!! *okay to take tylenol, ibuprofen

What is a myelogram? interventions?

diagnostic test using contrast dye injected through a lumbar puncture in order to view the spinal canal through either an x ray or CT (identify tumors, cysts, herniated disks) post-procedure: HOB elevated semi fowlers (to reduce seizure risk!)--watch meds lower seizure threshold (phenothiazines, neuroleptics) encourage fluids to make up for lost CSF! monitor VS/neuro maintain bedrest 24 hrs BRP!

Cancer considerations diets chemotherapy care

diets: increase cancer risk: nitrates (prepared lunch meats, sausage, bacon) high fat (animal fat) increase intake red meat increased alcohol to decrease cancer risk: avoid above and add HIGH FIBER!! :) diet during cancer= high calorie, high protein small, frequent meals encourage fluids but NOT with meals low microbial diet during chemo (immunosuppresion) -->wash fruits/veggies; make sure meats/eggs well cooked; eat cooked veggies (avoid raw fruit) chemotherapy care pain meds (3 teirs) ATC + breakthrough meds given skin care: AVOID SOAPS/POWDERS wear loose, cotton clothing stomatitis can develop (5-14 days after) -->rinse w/ saline/chlorhexidine, soft toothbrush, avoid floss, hot temp/spicy foods neutropenic precautions! *no staff w/ cold/sore throat allowed private room when possible no fresh flowers, standing water, clean room daily hand hygiene!! CHEMO AEs: -bone marrow suppression!! (decreases RBCs, WBCs, and plts) -->lowest counts 7-10 days after therapy initiation ("nadir" period) -->give Filgrastim (neupogen) and pegfilgrastim to stimulate neutrophil production -anemia! -->give epoetin to stimulate RBC production -can cause tumor lysis syndrome (cell lysis)= cancer rx kills cancer cells and causes release of intracellular components!= nucleic acid, uric acid, potassium, and phosphate! -->give allopurinol/rasburicase & IV hydration to prevent -->uric acid: 4.4-7.6 AE= HYPERkalemia, HYPERphosphatemia, HYPOcalcemia, HYPERuricemia (watch for AKI) CONSIDER: IN PTS immunosuppressed, even low grade fever needs to take seriously cause can rapid develop into life-threatening sepsis staff who can care for: anyone who doesn't have cold! pregnant (chemo nurse will take care of chemo meds) injection influenza vac float nurse (chemo nurse will take care of chemo meds) *expected SEs of chemo: -bone marrow suppression (depleted RBCs, WBCs) *alopecia, mucositis, ulcers! N/V

Fibromyalgia

disorder of widespread musculoskeletal pain (w/ fatigue, sleep, memory, and mood issues) sx= point tenderness at multiple sites meds= duloxetine (SSRI)--pain relieving effects, used for chronic pain relief that interferes with normal sleep patterns in these pts *also used for diabetic neuropathy also: pregabalin, amitriptyline--for insomnia associated with

Colles fracture

distal radius, "dinner fork" deformity *occurs when pts try to break a fall with outstretched arm or hand common in women w/ osteoporosis/osteopenia!! rx= assess neurovascular analgesia RICE! teach pt to move fingers to reduce edema

cataracts

distorts your vision and objects due to clouding of lens sx= opaque (cloudiness of the) lenses painless, gradual loss of visual acuity w/ blurry vision decreased color perception scattered light on the lens producing glare and halos--worse at night assess: "can you tell me what you have difficulty seeing?" goal post op= AVOID ACTIVITIES INCREASE INTRAOCULAR PRESSURE -bending, lifting >5lb, sneezing, coughing, straining bm, rubbing eye -sleep on two pillow with head elevated to decrease pressure diet= high fluids, high fiber stool softener expect: (post op) itching "sand" in eye blurry vision --1-2 weeks to improve mild pain photophobia

Scoliosis

do NOT need bed boards--doesn't prevent lateral curvature of spine high cal diet can shower with brace

defibrillation

do NOT touch bed when using!! check equipment q 8 hrs, must remain plugged in at all times do not place paddles over electrodes (should not occur but if occurs can safely still be done) rhythms= V fib/pulseless V tach *DO NOT SYNCH RHTYM (THIS IS FOR IRREGULAR, pulseless RYTHMS)

pt scheduled general anasthesia surgery and insulin prescribed morning off--what do you do?

do not give morning dose of Isophane or reg insulin and monitor blood gluocse (dont want to throw into hypoglycemic episode--will peak if give while pt is NPO)

Myelodysplastic Syndrome (MDS)

does not produce adequate blood cells expected to have low CBC counts

CVS (chorionic villus sampling)

done between 8-12W G ultrasound used to guide and get sample of fetal placental tissue (catheter inserted and used to suction piece of tissue sample) MUST HAVE FULL BLADDER dx= fetal karyotype (chromosome structure), sickle-cell anemia, PKU, down syndrome, duchene muscle dystrophy *complications= spontaneous abortion, ROM, bleeding *Rh neg mother should receive Rho(d) immune globulin after test to prevent Rh isoimmunization

urinary catheter insertion position

dorsal recumbent

tubal myringotomy

drainage and ventilation of mid ear expect purulent drainage 1 day post op--means successful procedure

Pertussis (whooping cough)

droplet precatuions sx= severe cough with high pitched whooping sound 4-6 weeks, vomiting, URI 1-2 weeks, posttussive emesis (thick mucous plug) rx= help loosen secretions! bedrest/hydration, hospitalize infants -->offer small fluids frequently give pertussin IgG, erythromycin watch PNA, airway obstruction, hernia, dehydration humidification of oxygen restful environment *prophylactic rx for family recommended DO NOT ADMIN COUGH SUPPRESSANT (pt needs to cough up mucous plugs)

two main considerations for meningitis rx

droplet precautions (can usually d/c after 24 hrs begin abx therapy) -incubation period 1 week (will see sx by then) sx= photophobia, stiff neck, fever, severe HA, n/v, change LOC IF SEE SX, THIS IS A LIFE THREAT EMERGENCY AND PRIORITY PT sx in infant: (<2) frequent seizures high pitched cry poor feeding vomiting fever or hypothermia irritability nuchal rigidity bulging fontanelle possible but not always there -->complication of bacterial meningitis in infants= hydrocephalus -->MONITOR THIS BY WATCHING FONTANELLE SIZE/HEAD CIRCUMFERENCE -draw blood cultures before starting abx -obtain CT SCAN (to assess for increased ICP or mass lesions, may contraindicate LP due to risk of brain herniation) -perform LP if indicated, for CSF exam and cultures -monitor for seizures PRIORITY ACTION= 1. ISOLATE PT 2.*INITIATE ABX THERAPY IMMEDIATELY FOLLOWING LUMBAR PUNCTURE kernig's: hip pain with leg flexion to 90 brudzinski: legs flexed when head lifted (painful!) bacterial CSF= purulent, turbid (cloudy), glucose present -->will show abx therapy good! viral CSF: *however, presence of blood in CSF makes dextrose test (which tests for CSF) unreliable as blood also contains glucose position= HOB elevated 30 degrees, head and neck midline -restful, reduced stimulus environment -seizure/droplet precautions -pt ON BED REST

Diptheria

droplet precautions--until 2 successive neg nose/throat cultures obstained bedrest watch resp distress antitoxin therapy sx= represents common cold, pharyngeal lymphaednatis, white gray pharyngeal membrane (in back of throat)

pulmonary edema

due to acute left ventricular failure, fluid backs up into pulm space (into alveoli)--can be life threatening! sx= hx of orthopnea/ paroyxsmal nocturnal dyspnea anxiety and restlessness tachypnea frothy, blood tinged sputum (pink) crackles on auscultation treatment= 1. improve oxygenation 2. diuretics--------------------------------------------------------------*if pt exhibits sx of this, this is UNEXPECTED w/ heart failure, and is PRIORITY PT TO ASSESS

postpartum depression (PPD)

due to decreased estrogen/progesterone after birth *occurs during first year often by 4th week aka "baby blues" *maternal sx lasting greater than 2 WEEKS should prompt further treatment sx= sad, crying, tearfulness irritability, difficulty concentrating hostility towards spouse fatigue appetite/sleep disturb *if observe potential for suicide, decreased energy level, or decreased responsiveness to infant--this is not baby blues and indicates more serious pathology

fibrocystic breast disease

due to estrogen/progesterone hormone fluctuations during menstrual cycle, these are benign sx= cysts, nodules, lumps that are more tender, swollen and/or noticeable prior to menses *typically resolves after menopause teach= report ASAP any NONCYCLIC BREAST CHANGES (not related to menstrual cycle), which may be malignant -greater than age 40 should receive yearly breast exams by HCP care for cyclic pain w/ this= -reduce caffeine/sodium intake -take vit. AEB complex -supportive bra -utilize cold compress -take NSAIDs

bowel perforation

due to increased intraluminal pressure-->leads to peritonitis position= semi fowlers prep pt for emergency surgery!

Neonatal sepsis

due to infection at birth prematurity maternal--beta hemlytic strep premature ROM, prolonged ROM, prolonged delivery, c section, forceps aspiration meconium fluid sx= hypothermia vomit diarrhea, feed intolerance poor sucking, lethargy apneic episodes dehydration, lack weight gain rx= admin prophylactic abx 7-10 days get cultures! to give abx temp d/c oral feedings (poor sucking) tranfuse WBCs if need IV gamma globulin-- prevents infections, enhances weakened immune systems

Recall major AE with all antidepressants

during the first few weeks drug therapy isnt working, but after can cause INCREASED SUICIDAL IDEATION WHEN DRUG BEGINS WORKING (increased energy) *this is priority topic to address first when working w/ depressed pt on one of these meds claiming it doesn't work!

Coronary arteriogram (angiogram)

dx study of coronary arteries, heart chambers and function access through femoral or radial artery IV line start for sedating meds teach: -NPO 6-12 hrs prior (think like cardiac cath!) -pt may feel warm or flushed while contrast dye being injected -apply compression to access site -pt may have to lie flat for several hours to ensure hemostasis -pt can go HOME SAME DAY (if dx study= gram) -if angioplasty or stent placement, may require 1-3 day stay in hospital -sedating meds given, but not general anesthesia

AFP (alpha-fetoprotein) test

dx test done at 16-18W (blood test sample from vein in arm) predicts NTDs, threatened abortions, fetal distress *decreased AFP levels indicate possible down syndrome *has high incidence of false pos results, so imp to follow up with US or amnio

fecal incontinence (encopresis)

dx when child >/= 4 hrs and occurs *more than likely due to functional constipation (no physical etiology) retentive= child cant help, dysfunctional sphincters rx= regular toileting habits (5-10min after meals for 10-15 min) disimpaction followed by prolonged laxative therapy diet changes (fiber and fluids) quiet activity while toileting (reading) have a REWARD SYSTEM FOR EFFORT (not success!)--give each time child even tries keep diary of tracking episodes, etc in elderly pt: -priority is prevent skin breakdown! -removal stool promptly from skin by gently cleansing perineum w/ mild soap -dry area and apply: -use a thick perianal skin care barrier cream -clean dry linens and clothing provide *AVOID INCONTINENCE BRIEFS unless other measures have failed (can further cause skin irritation)

what defines a person who has HIV to now having AIDS AIDs considerations

dx= CD4/TC counts below 200 *AED opportunisitc infection! (cause dont have immune system to fight off) *sx manifestation may take 10-12 yrs! infections: PNA stomatits/esophagitis candiasis meningitis karposi sarcoma (most common malignancy) CMV (cytomegalovirus) kaposi sarcoma: (reddish purple brown non pruitic spots on leg, composed of cancer and blood clots) rx= if closed lesions: shower daily using mild soap from pump dispenser, then pat the skin dry if open lesions: clean area carefully with soap/warm water daily, and cover them with sterile dressing limit personnel caring for pt (immunosuppressed) *remove standing water left in containers or equipment (can act as culture medium) AIDs= UNIVERSAL (STANDARD) precautions *soiled clothing= standard precautions + double biohazard bags *can develop AIDs dementia comlex--one of most imp complications of HIV (forgetful to disoriented) TRANSMISSION= blood/bodily fluids (blood, semen, vaginal secretions, breast milk) sexual contact breast milk! sharing drug needles SALIVA IS NOT FORM OF TRANSMISSION meds= antivirals *teach= no effective cure BUT antivirals will slow disease progression diet= high protein, high cal (pt is anorexic, diarrhea) rx= minimize social isolation (visitors are fine! no precautions needed) do not share toothrbushes, razors safe sex avoid crowds, mouth care, good nutrition, rest

Diagnostic signs of pregnancy (presumptive, probable, and positive)

dx= hCG measured in blood/urine= diagnostic! presumptive= changes felt by women amenorrhea, N/V "morning sickness," BREAST TENDERNESS, fatigue, quickening (maternal perception of fetal movement between 16-20W), URINARY FREQUENCY; leukorrhea increases during pregnancy!! probable= changes observed by examiner uterine enlargement souffle and contractions (soft blowing murmur sound auscultated over uterus due to increased vascularity) positive urine preg test (hCG)! Hegar's sign chadwick's sign braxton hicks contractions (false labor pains) ballottement (push on uterus & feel fetus impact) fetal outline palpation skin pigment changes= chloasma, linea nigra, areola darkening straie gravidarum positive= definite signs of pregnancy fetal heartbeat heard with doppler palpation of fetal movement/or visible fetal movements visualization of fetus by ultrasound

anemia sx, diet? interventions? dx?

dx= men Hgb <13, women Hgb <12 think lacking O2 mild/moderate sx: (lacking O2!) palpitations diaphoresis fatigue dyspnea usually followed by exertion severe sx: tachycardia--to maintain CO pallor! dyspnea/ SOB fatigue diaphoresis sensitivity to cold loss of appetite syncope dizziness HA heart complications (angina, HF) *resp depression is NOT expected finding with anemia! (may occur with narcotics/oversedation) NO N/V!! just lacking oxygen so sx of this! diet= high in iron, protein, vitamins small easily digestible meals frequent rest periods frequent turning/reposition anemia will increase CO! due to decreased oxygenation ALSO, when HgB low, this indicates hypervolemic (rbcs diluted from excess fluid)

fluid overload s/sx

early: change in respirations, HTN later: HF (hypotension), temp decrease

Salicylate toxicity (poisoning)

early: resp alkalosis (trying to breathe out) later: metabolic acidosis + respiratory acidosis hyperthermia, tinnitus, gastric distress (nausea), epistaxis, sweating, headache, CNS change bleeding, hypovolemia, fever rx= induce vomiting! gastric lavage/activated charcoal *watch dehydration-->IV fluids! reduce temp with tepid baths/hypothermai blankets watch seizures IV sodium bicarb to increase acid excretion vit K if need for bleeding *ask first: how much ASA did pt swallow? then when?

Signs of increased ICP In adult (Early/late)

early= altered LOC= first sign!! restlessness, confusion, pupillary changes (fixed, dilated), HA contact HCP!! late= cushing's triad bradycardia, slowed, irregular respiration, & hypertension (increased SBP or widening pulse pressure) =dif between sys-dia. cheyne stokes respirations (slow, irregular) (*some say bradypnea/ abn breathing pattern is other sign in triad) vital sign changes tonic clonic seizures

effacement station dilation

effacement--thinning and shortening of cervix (0-100%) station--level of presenting part of fetus in relation to imaginary line ischial spines (zero station) -5 (above)--> +5 (below) *stations above +1 can cause N/V, trembling/shivering dilation--opening of cervix os during labor (0-10cm)

How to walk with walker?

elbows flexed 20-30 angle w/ hands on grips rubber caps placed on all 4 legs lift and move walker forward (8-10 in), 6 in okay, just don't extend too far *can use tennis balls to help slide, but do NOT slide with rubber tips to walk: move walker forward, then step forward with "bad leg", support weight on arms, follow w/ "good leg" nurse should stand behind pt with gait belt PRN for balance to sit: grasp armrest on affected side, shift weight to good leg and hand, lower self into chair

implantable cardioverter defibrillator (ICD)

electrical device implanted in chest cavity (subclavian vein) with electrodes to heart (over pectoral muscle); applies shock to heart to stop potentially life-threatening arrhythmias pts often get if have hx or recurrent VT *nurse should monitor for ICD firings (pt reports or shows on cardiac monitor), and pt stability afterword *if ICD is repeatedly shocking and unable to convert arrhythmia to stable one, nurse should promptly OBTAIN MANUAL EXTERNAL DEFIB (can perform synchronized cardiovert and defib with this) and initiate measures to prevent arrest teach post op= refrain from lifting affected arm until approve by HCP to prevent dislodgement of wires firing ICD may be painful (blow to chest) may drive after HCP approves travel not restricted (carry ICD identification card)

Weight loss strategies for Obese pts

eliminate sugar beverages (soda OR fruit juice/alc) -realistic goals: 1-2 lbs per week to loose -health meals, small and frequent -exercise 30-60 min/day -adequate sleep (7-9 hrs/night)

burn phases (emergent/resuscitative) then intermediate

emergent/resuscitative: first 24-48 hrs *fluid loss, hypovolemia, hyperkalemia (hemoconcentration), increased HR decreased BP --> can affect renal system!! first 8 hrs-->give rapid infusion LR/plasma, then 16 hrs give slowly intermediate: next 2-5 days after burn *decreased edema, fluid vol restored, hypokalemia, increased BP, diuresis give PRBCs watch fluid vol status/ catheterize dressing changes are sterile technique!! gown, mask, gloves (think on burn unit) full thickness BURNS TO FACE are highest priority-->can cause AIRWAY CONSTRICTION DUE TO EDEMA AND SWELLING

Adoption considerations (for moms at birth)

encourage mom to hold newborn, name baby, take pictures (to create mems and facilitate grieving process) -notify staff who may interact with pt of the adoption plan -offer birth mother chance to say goodbye -use phrases illustrate adoption as "decision of love", not abandonment *do NOT wait tell after birth to discuss adoption (acknowledge early to plan care and encourage pt's wishes of how to proceed in the process with the birth)

esophagogastroduodenoscopy (EGD)

endoscope down esophagous to visualize upper GI structures *complication= perforation of tract peritonitis-->sepsis watch for sx of: -sudden temp spike (even low grade fever) -increase pain/tenderness restless, tachy expected sx= -absent gag reflex (prolonged would be more than 6 hrs, and notify HCP) -sore throat (use saline gargles)

endoscopic retrograde cholangiopancreatography (ERCP)

endoscope passed through mouth into duodenum to assess pancreatic/biliary ducts *uses contrast media complication= perforation of organs during procedure-->causes acute pancreatitis! LIFE THREATENING COMPLICATION OF ERCP= ACUTE PANCREATITIS sx= acute epigastric/ left upper quad pain radiating to back increased amylase/lipase

BPH (benign prostatic hyperplasia)

enlargement of the prostate gland-->causes urinary obstruction, incontinence, possible infection risk factor= increasing age!! (over 50) sx= difficulty voiding/straining (hesitancy) feeling bladder incomplete emptying increased urgency to void nocturia or frequent urinating (more than once in 2 hrs) urinary retention weak or intermittent stream of urine PSA (prostate specific antigen) *normal <4 mg/mL, increased in BPH, prostate cancer complications= increased UTI risk (incomplete bladder emptying) diet= acid-ash (rx infection) meat, fish, eggs, cereals (minimum fruits, veggies, milk)-->makes acid residue excrete in urine meds= finasteride (takes several months to decrease size of prostate) rx= TURP (remove prostate gland obstructing flow) or suprapubic cystostomy (can test voiding ability by clamping cath 4 hrs, let pt void, unclamp cath and if residual <100 then remove cath -abx CBI after TURP: remove blood clots, *urine MAY BE REDDISH-PINK INITIALLY after cath remove, EXPECT DRIBBLING/LEAKAGE AROUND WOUND --keep leg straight if traction on cath (taped to leg or abd) to prevent bleeding teach: avoid heavy lifting, straining, prolong travel potential for impotence *sal palmetto/lycopene are herbs used to help BPH! avoid large amounts fluid/caffeine avoid meds= anticholinergics, antihistamines, decongestants (urinary retention SE)

Proton pump inhibitors (PPI)

ex: omeprazole, pantoprazole, esomeprazole think "prazoles" are PPIs! MOA= suppresses gastric acid production in stomach; for pts w/out hx GERD/ulcers, PPIs prescribed to prevent stress ulcers from develop during surgery or major illness AE= PNA C diff calcium malabsorption (osteoporosis)!!! teach= -take before meals -increase calcium and vit D intake!

SSRIs examples contraindications

ex= "lines/tines/prams" citalopram, escitalopram, sertraline, fluoxetine, paroxetine *can give safely with benzos! (think SSRIs cause insomnia) --> "lams/pams" (alprazolam, lorazepam, zolpidem=hypnotic) AEs= suicidal thoughts, ortho hypo, sexual dysfunction, insomnia, weight gain *also anticholinergic SEs *sex dysf. may decrease after 2-4 week waiting period, or switch to bupropion contraindications MAOIs NSAIDs/ antiplts Tricyclic anti's triptans? lithium?

H2RAs

ex=cimetidine, famotidine, nazatidine" -->"idines"

pulsus paradoxus

exaggerated fall in systemic BP >10 mm during inspiration (<10 is normal) --may indicate cardiac tamponade! **seen in cardiac tamponade how to measure: difference between the pressure heard at the first Korotkoff sound during expiration and the Korotkoff sounds heard through inspiration and expiration (first take pts SBP using manual cuff, then inflate BP cuff to at least 20 mmHg above this previously measured SBP, then deflate and listen for first korotkoff sound, then take not of this and subtract from the next sounds heard throughout inspiration and expiration as cont deflating cuff)

SBFT (small bowel follow through)

examines the anatomy and function of the small intestine using xray images taken in succession *barium ingested, x ray taken q 15-60 min to visualize barium as passes through small intestine *can identify ileus, malabsorption syndromes (increased motility), fistuals, or obstructions teach to prep: -fast 8 hrs prior -test take 60-120 min unless abn finding observed -drink fluids!! (excrete barium) -chalky stool expect 24-72 hrs after barium *IF BROWN STOOL DOES NOT RETURN AFTER 72 HRS, OR ABD PAIN OR FULLNESS PRESENT, CONTACT HCP

Beta Blockers

examples: Cardivelol AEs= bradycardia, bronchospasm/bronchoconstriction , depression, decreased libido with erectile dysfunction *withhold BBs if sys <100 or HR <60, notify HCP *notify HCP if <50 HR, hypotension, or becomes symptomatic before/after admin *do NOT ABRPUPTLY D/C BB'S-->can cause rebound HTN contraindications hx of asthma/resp problems

menopause postmenopause expected vs unexpected s/sx

expect: hot flashes (if debilitating take HRT= can cause *thrombotic complications/uterine or breast cancer risk risk of excess iron (cause stopped bleeding) osteoporosis (take biphosphonates) unexpected: vaginal spotting/bleeding-->(pre or post menopause) is most common sign of endometrial cancer! postmenopause teaching= -consume dietary calcium -weight bearing exercises -consider dietician: (to help with weight gain/cholesterol monitoring--which is associated w/ postmeno hormone changes) -low cal diet rich in fruits/veggies -seek support to cope with emotional sx

Tonsilitis (Streptococcal) complication? tonsillectomy care

expected findings tonsillitis: dehydration (not swallowing, sore throat) pulling at ears (otitis media--often accompanies tonsillitis) 1. trismus (inability to open mouth: due to tonic contraction of muscles used for chewing) -->indicates PERITONSILLAR/RETROPHARYNGEAL ABSCESS sx= deviated uvula, hot potato/muffled voice, pooling saliva, airway emergency!! rx= tonsillectomy/incision drainage 2. most common bacterial cause of tonsillitis= group a strep: fever white exudate on tonsils serious complications (from group a strep) =acute glomerulonephritis, rheumatic fever (RF), scarlet fever (sandpaper-skin like rash) rx=abx RF= inflammatory disease of heart occurs 2-3 weeks after streptococcal A infection, autoimmune rx dx= fever, arthritis, carditis, erythema, arthralgias, elevated ESR, mitral regurg/stenosis + recent streptococcal infection Tonsillectomy/adrenoidectomy: primary concern= post-op bleeding!! sx of bleeding: increased swallowing or clearing of throat, pallor, restlessness, vomit of blood vomit bright red blood EMERGENCY!--hemorrhage! rx= -teach pt to limit coughing, gargling, clearing of throat -limit physical activity -discourage milk products (coat throat and promote clearing of throat) -avoid oral mouth rinse, gargling, vigorous tooth brush expected post op findings: (5-10 days) ear pain (otalgia) when swallowing (referred throat pain) halitosis (bad breath)--mouth odor white, fluid filled exudate/scabs in throat (resolves/sloughs off on own) low grade fever--tylenol teach= *avoid things may cause bleeding do NOT drink through straw --increase pressure avoid suctioning -->do NOT resume strenuous activities/contact sports for at least 7-14 days post op (bleed risk)

Diarrhea (expected v unexpected)

expected: most bouts diarrhea are self limiting and last <48 hrs experiencing >48 hrs, or accompanied by fever/bloody stools should be eval by HCP

Addisonian Crisis

extreme, sudden drop in BP -->can lead to shock/death if not promptly treated aggravated by stress (physio or physical) and sudden withdrawal from replacement hormones S/Sx= N/V, abd pain hyponatremia, hyperkalemia, dehydration, hypoglycemia (all more severe), hypotension, tachycardia, fever weakness and confusion Rx= Fluids! 0.9% or D5W NaCl HIGH DOSE HYDROCORTISONE IV PUSH IV glucose or glucagon potassium excreting meds: insulin with dextrose or sodium polystyrene sulfonate vasopressors/hydrocortisone **increase steroids/SODIUM INTAKE during times of stress rest! -->priority to prevent crisis!

GCS scoring system

eyes= /4 verbal= /5 motor= /6 *<8= comatose -->need airway protection! intubate! -->think, "8 is when you intubate"-->so if pt has GCS of 9 and is declining, this is PRIORITY PT as need to intubate for AIRWAY protection *a drop in 1 point score in 1 hr is significant

pulmonary embolism risk factors

factors to consider in thrombus formation= (Virchow's Triad): venous stasis hyper coagulability of blood endothelial damage immobility!! obesity pooling of blood in pelvic cavity *D-Dimer is lab test measures for clot degradation--appears when blood clot dissolves! (measure for pts suspected of PE, to see if can r/o DVT/PE) post op c section pts at great risk! *greatest a fib pts! sx= anxiety/restlessness, pleuritic chest pain/tightness (while inhaling, sharp stabbing) SOB, tachycardia, tachypnea and cough (dry or productive with bloody sputum) hypoxemia, hemoptysis unilateral leg swelling, erythema, tenderness r/t DVT *note fever is NOT sx, so if see pt with SOB, cough, fever--this is likely PNA or some other infectious process

Cardiac Arrest (Code Blue) Algorithm for pregnant pt?

family member presence: *allow fam member to stay in room WITH STAFF MEMBER explaining interventions being implemented (do not have them stand in corner on own) *if they become disruptive, then escort from room If pt has ICD, allow 30-60 sec for it to complete its therapy cycle before applying external defibrillation pads *initiate CPR in pulseless client with ICD (it cannot sense pulseless rhythms) meds= CPR q 2 min, then check if shockable rhythm epi q 3-5, then amiodarone FOR PREGNANT PT: (heart is displaced toward left due to uterus pushing on diaphragm) *PLACE HANDS ON STERNUM SLIGHTLY HIGHER THAN USUAL DURING CHEST COMPRESSIONS -->manually displace the uterus to the pt's left side to reduce pressure off vena cava and aorta (use rolled blanket or wedge under right hip of pt) *if ROSC does not occur within 4 min of CPR, emergency cesarean section is indicated *delivery should occur within 5 min of initiating CPR

Atyplical S/Sx of MI for women

fatigue SOB

agoraphobia

fear and anxiety of being in (or anticipating) certain situations or physical spaces *concerned about trouble escaping or getting help in event of panic attack/sx (fear panic attack appearing in public) *often feel need to be accompanied by friend to experience these situations, or just stay home to avoid examples, fear of being: -outside the home alone -in a crowd or standing in line -traveling in bus, train, car, ship, airplane -on a bridge or in a tunnel -open spaces (parking lots, markets) -enclosed spaces

foley catheter--indications how far insert foley catheters in male v female? steps for insertion?

female: 2-3 in, see urine, then advance 1 in more male: 7-9 in, then when see urine, advance 1-2 in more indications acute urinary retention/obstruction prolonged immobilization when bedrest essential facilitate healing when open perineal wound peri-operative use for surgical procedures end of life comfort *NOT used for incontinence UPON INSERTION, if see NO URINE RETURN: leave cath in place and insert a new cath higher in perineal area!!!!!!! (serves as a marker for new cath to ensure right hole) steps for insertion: USE nondominant hand to gently spread labia dominant hand cleanses labia/meatus w/ soaked cotton balls/swab sticks CLEANS IN ANTEROPOSTERIOR DIRECTION (from clitoris to anus) use new swab each swipe CLEANSE LABIA MAJORA FIRST-->LABIA MINORA--> THEN URINARY MEATUS (WORK OUT TO IN)

hydatidiform mole (molar pregnancy)

fetus replaced by edematous, cystic chorionic villi: results from overproduction of tissue that is supposed to develop into placenta (but doesn't)= lack of viable pregnancy two types 1. partial= abn placenta with some fetal development 2. complete= abn placenta with no fetus sx= dark, red/brown vaginal discharge until preg is evacuated excess N/V and gestational HTN ELEVATED hCG LEVELS uterus greater than size for expected dates no fetus by ultrasound, no FHR (preg will not be viable) rx= curettage to remove all molar tissue that can become malignant (uterine evacuation) *teach= majority NOT cancerous but small % can become (choriocarcinomas) teach: discourage preg 1 yr hCG levels monitored 1 yr (if cont to be elevated= unexpected, consider hysterectomy/ chemo)= malignant GTN oral contraceptives 1 yr--NO IUD! admin Rho(D) to Rh neg women-required! MALIGNANT GTN (gestational trophoblastic neoplasia): rapidly growing tissue that continues to grow even after evacuation of molar pregnancy (causes hCG levels to increase) -->leads to gtn= invasive mole, choriocarcinoma *teach pt to AVOID PREGNANCY DURING F/U CARE AFTER MOLAR PREG TO ALLOW HCP TO MONITOR FOR RISING hCG LEVELS (cont. for 6-12 mo postpartum)

hazardous material decontamination

first ask: has pt been decontaminated? no? is pts condition life threatening? yes? then health workers put on protective garment and provide care to stabilize pt before decontaminating, environment sealed (seal off air vents, cover floor from entrance to treatment room) decontamination: (after pt stable) pt washes off complete body themself (soap and water) clothes removed and placed in hazard bag waste water collect in container *first thing if pt is stable and is not fully decontaminated is to take them to shower and cleanse!

ventricular tachycardia interventions based on type

first assess if pt has a pulse V tach w/ a pulse: assess if pt stable or unstable stable= antiarrythmic meds (amiodarone, procainamide, sotalol) unstable= synchronized cardioversion V tach w/out a pulse: Defib! and CPR

Isoniazid

first line drug to rx latent TB infection (or combo w/ other drugs for active TB) AEs peripheral neuropathy (tingling hands/feet, numbness) -hepatotoxicity teach= increase vit B6!! -avoid acohol intake and acetominophen (hepatotoxic) *take with food if GI irritation concern -avoid aluminum contain acids w/in 1 hr of taking -report changes in vision/ sx of hepatotoxicity (jaundice, dark urine, vomit, fatigue)

flail chest open pneumo pneumo S/Sx

flail chest= rib fx causes paradoxical breathing open pneumo= (aka SUCKING CHEST WOUND) penetrating injury; hyper-resonance; diminished breath sounds on affected side; tachycardia -->priority action: apply sterile occlusive dressing w/ petroleum gauze (taped on 3 sides) pneumo--internal collapse (disease, trauma, surgery); rapid RR (tachypnea); hypotension, cyanosis, dyspnea

herbs to decrease cholesterol

flax/flaxseed -decrease med absorption -N/V/ flatulence garlic -increase bleed effect -increase hypoglycemic insulin effect -may stimulate labor green tea -stimulant effect -mult drug interactions (anticoags/plts/bbs) soy

nutrition during pregnancy/lactation how much weight gain during pregnancy? diabetes, sickle cell, cardiac complications adolescence tend to deliver...?

folic acid! to prevent NTDs and megaloblastic/macrolytic anemia! avoid caffeine! limit to 200-300 mg/day weight gain during preg: BMI <18.5= 28-40 lb total BMI 18.5-24.9= 25-35 lb BMI 25-29.9= 15-25 lb BMI >30= 11-20 lb first trimester: all women gain 1.1-4.4 lb second/third trimester: under/normal BMI gain 1 lb/wk overweight BMI= 0.6 lb/week obese BMI= 0.5 lb/wk diet= high servings than normal adult (increased in pregnancy and increased even more in lactation) in pregnant: pt needs diet high in folic acid, protein, iron, omega 3 fatty acids, whole grains *avoid BACTERIAL CONTAMINATION (listeria, toxoplasmosis)= unpasteurized milk, unwashed fruits/veggies, deli meats, hot dogs (unless steaming hot), raw fish/meat *avoid fish high in mercury intake (shark, swordfish, king mackerel, tilefish) *avoid High VIT A foods (liver) lactation= >500 cal/day (lactation); 300 for pregnancy *at NO Point during pregnancy should weight reduction be attempted pregnancy= 400 mcg folic acid/day diabetes= may need C section, unable to handle glucose requirements of labor sickle cell/cardiac= unable to handle increased O2 demands, c section usually indicated adolescent mothers tend to deliver premature babies

Phenylalanine diet what is PKU test called?

for PKU--to avoid brain damage (intellectual disability in fetus) from amino acid imbalance foods NOT allowed: meat, eggs, milk, beans, bread, nuts, dairy (think proteins!) cause cant digest protein! (think P and P) -->replace w/ protein substitutes lifetime dietary restrictions! can have: fat, fruits, veggies, jams, low Phenylalanine milk safe phenyl levels= 2-6 mg/dL PKU test= guthrie test (heel stick), obtain after ingest protein no later than 7 days post delivery. --collect as close to d/c as possible! --collect capillary blood from infants heel -->apply WARM back prior to vasodilate autosomal recessive, deficiency in enzyme to process phenylalamine, metabolics accumulate in blood and can be toxic to brain cells/neuro damage if not controlled *place infant on Lofenalac formula (low phenylalanine) *special infant formula required *cannot exclusive breastfeed cause can transfer to baby

labor pain considerations

for low back pain: massage sacral area opioid: morphine increased risk resp depression mother and fetus, preferred is BUTOPHANOL/ NALBUPHINE--less resp. depression risk

ischemic stroke

for pt with acute stroke sx "brain attack" require... rx= PERMISSIVE HTN (let pt have high BP after stroke to maintain cerebral perfusion distal to area of blockage) for first 24-48 hrs keep sys no less than 170 mmHg no higher than 220/120 *usually resolves on own, not concerning UNLESS HTN is extreme high: Sys >220, or Diastolic >120 or contraindicated in another condition pt has: acute ischemic Coronary disease, HF, aortic dissection

Crutch gait patterns

four-point gait: (full weight bearing status) affected side crutch first, then opp foot, then other crutch, then other foot (resembles walking) two point: (partial weight bearing status) affected crutch and leg move together, then opp crutch/leg move together at same time three point: the norm crutch you see (non-weight bearing status) swing to: "swing to cructhes" move both crutches forward, then swing/move both legs forward and place leg at place crutches located swing through: "swing through crutches" move both crutches forward, then move both legs forwards swinging PAST crutch placement

Contraction characteristics duration, frequency, intensity

frequency: -->measured from beginning of contraction to start of next, or peak to peak -->should be no shorter than 2 min apart-->if so need to report -->2-5 contractions q 10 min duration: how long contraction is -->should be no longer than 90 sec, if so report potential risk uterine rupture/ fetal distress -->norm= 45-80 sec intensity: strength of contraction at its peak (mild, mod, strong) think nose, chin, forehead -->25-50 mmHg is norm -->should not exceed 80 mmHg resting tone: tension in the uterine muscle between contractions *allows for fetal oxygenation between contractions -->norm= 10 mmHg *should NEVER exceed 20 mmHg, sign of uterine hyperstimulation!

intussusception

frequent intestinal obstruction during infancy and children <6 sx= (some may only have general sx--diarrhea, lethargy, irritability) hallmark= **red, CURRANT jelly stools (blood and mucous) BILIOUS emesis, palpable SAUSAGE shaped right sided-abdominal mass, dehydration (absence of tears) screaming and drawing knees up to chest (episodes) sudden, crampy abd pain **intermittent pain (comes and goes q 15-20 min), with sudden abd pain= screaming and drawing up knees, inconsolable crying may appear normal between episodes PERITONITIS can develop (bowel ischemia): fever, abd rigidity, guarding, rebound tenderness MEDICAL EMERGENCY! rx= AIR ENEMA (hydrostatic) to unfold intestine IV fluids (hydrostatic saline) *or barium (but air safer than barium) NOTIFY HCP IF PASSAGE OF NORMAL BROWN STOOL -->indicates rx success and need to stop care

Tinea corporis (ringworm)

fungal infection of skin, nails, hair IS NOT A WORM INFESTATION--common misconception sx= itching (discourage scratching= spreads) RED, SCALY BLISTERED RINGS on skin/scalp, grows outward as infection spreads HIGHLY CONTAGIOUS, spread via contact from one person to another! or infected animal to human, with shared surfaces (hats, towels, linens, clothing) (do not share personal items, clean surfaces frequently, practice hand hygiene) rx= prescribed shampoos/topical or oral meds anti-fungal cream--apply 2x/day to infect areas may take 1-4 weeks to complete rx based on infection severity

safe patient positioning and turning techniques

gait/transfer belt for partially weight bearing pts 2 or more caregivers to uncooperative/unable to assist pts (comatosed, medicated) full body sling to move/transfer nonparticipating pts 2-3 caregivers for cooperative pts weighing LESS than 200 lb 3 or more caregivers to move cooperative clients weighing MORE THAN 200 lbs

DTaP vaccine considerations

give antipyretics (excluding salicylates!!) to relieve discomfort *tylenol okay cool (NOT COLD) cloth on injection site for 15 minutes wrap and comfort child for signs of irritability

tube feeding considerations How often change continuous tube feeding bags?

give at room temp clamp tube between feedings to prevent intro of air/liquid loss clean procedure q 4 hours HCP orders feed amount (You dont change)

Parenteral Nutrition (PN) considerations

given over 24 hrs(change IV tubing/filter q 24 hrs) keep solutions refridgerated, warm to room temp before use if new solution of PN unavailable, hang D10W OR D20W at same rate until it is (to cont give glucose for insulin to process)--or else pt will go into hypoglycemia after d/c TPN: isotonic glucose given to prevent rebound hypoglycemia NEVER ABRUPTLY WITHDRAWAL--taper off slowly!! or else cause hypoglycemic rebound syndrome IF STOPPED ABRUPTLY: immediately take fingerstick glucose to check sugars! (can cause rapid onset hypoglycemia) lipids are given TPN! if peripheral TPN--never give over 2 weeks long, high risk of infection, not preferred central TPN preferred initial rate: start at 50mL/hr and gradually increase to 100-125 mL/hr as tolerance permits UO should be at least 30mL/hr for therapeutic monitor BG--PRIORITY!! (should be 140-180 for hospitalized adult pt) monitor I/O, daily weights monitor vs q 4 hrs complications: sepsis/infection: no blood draws/meds through PN line pneumothorax: never start PN until placement confirmed with CXR hyperglycemia/hyperosmolar coma: monitor BG and admin insulin PRN hypoglycemia: hang 10% dextrose if PN d/c'd suddenly fluid overload: do not "catch up" PN if behind (on rate) fluid deficit: high sugar from PN cause osmotic diruesis, watch for dehydration! air embolism: pt turn to left side, do valsalva maneuver during tubing/cap change; lower HOB, give O2 -->*think head down position prevents air from reaching the brain (think cause air floats up??) at bedside: have finger stick blood glucose supplies in case

depression--suicidal indicators for concern

giving away prized possessions wrapping up business affairs (never have to work again) isolation from friends increased energy levels expressions of hopelessness and despair ("why do you bother with me?") *sleep deprivation is NOT a warning sign

gestational diabetes

glucose tolerance 1 hr test at 24-28 weeks (think like weight gain average!) for all women at average risk= -25 and older -obesity -fam hx diabetes first degree relative -HTN, preeclampsia/ecclampsia -recurrent UTIs, vaginitis -polyhydramnios/ LGA infant (>4000 g) -glucosuria/proteinuria 2 or more occasions -unexplained death/stillbirths -hispanic, african american, native american, asian american -hx abnormal glucose tolerance gestational DM: hyperglycemia after 20W G (insulin needs in pregnancy increases here) *usually can control by diet DO NOT USE ORAL HYPOGLYCEMICS-->TERATOGENIC! test 3 hr glucose tolerance (give 50 g concentrated glucose and screen start 1 hr after) normal findings= 1 hr= <180 2 hr= <153 3 hr= <140 *two or more abn findings= pos! complications: maternal infections--UTI, yeast infection (bacteria love sugar) HTN hydramnios (>2000 mL amniotic fluid) macrosomia (LGA) (>4000g/ 9lb) congenital anomalies (NTDs) prematuriy, stillbirth, spon abortion resp distress syndrome watch for ketoacidosis-->coma and death! Poorly controlled gestational DM in mother can impact fetus: -polycythemia! (increased HCT) -hyperglycemia in utero-->then hypoglycemia at birth -circulatory viscosity -macrosomia-->shoulder dystocia -organomegaly -hypertrophic cardiomyopathy

Mandibular Fracture

goal= patent airway *if pt begins choking on oral secretions, asap clear airway with SUCTIONING via oral/nasopharyngeal route *if ineffective, cutting wires may be necessary *even if pt has not had rx for fracture yet, SUCTION THEM!!--PRIORITY ACTION have a wire cutter taped to HOB at all times, including during travel turn pt to side if pt has excess secretions/begins to vomit

venous thromboembolism

goal= prevent embolism! FIRST ACTION (pt c/o leg pain) esp after surgery place pt on bedrest, elevate extremity, get anticoagulant therapy started THEN can apply compression stockings *ambulation only begins after anticoag therapy

normal/expected signs of pregnancy assessment including: goodell chadwick hegar

goodell--softening of cervix chadwick--bluish discoloration of cervix hegar--softening of the uterus breasts: tender, enlarged abdomen: stretches, straie blood volume: increases 30% (increase HCT), peak 28W CO: increased 750 mL/min ventilation: decreased tidal volume 3rd trimester (pressure from uterus) digestion: increased peristalsis due to increased pressure skin: STRAIE GRAVIDARUM CHLOASMA LINEA NIGRA MINUTE VASCULAR SPIDERS mouth= hyperemic (bleeding gums)= normal, use proper mouth care to help prevent umbilicus pushed out by 7th month, darkened area more active sweat/sebacious glands urinary: frequency and stasis from pressure endocrine: increased estrogen/progesterone, decreased LH/LSH/oxytocin weight gain: *want steady consistent increase (based on pre-pregnancy BMI) IN GENERAL 24-28 LBS BMI <18.5= 28-40 lbs BMI 18.5- 24.9= 25-35 BMI 25-29.9= 15-25 BMI >30= 11-20 first trimester= 2-4 lbs second= 12-14 (babies really growing) third= 8-12 (babies gain about a lb/week in last month, everything here about baby getting bigger, everything has developed at this point) *hemorrhoids! observe bright red bleed in stool (common during preg), begin to shrink follow birth *carpal tunnel syndrome expected (tingling/burning hand sensation) labs: it is NORMAL FOR WBC TO INCREASE (even in absence of infection) up to 15000 anemia: common complication of preg: ABN IF: HGB <11 in first/third trimester= low <10.5 in second trimester= considered low BP: normal= SVR to decrease during first trimester, lowest point 24-32 W, then third trimester BP returns to pre-preg baseline Fetal movements: reassuring is when 4 movements/hr or 10 distinct fetal movements within 2 hrs *abnormal= increase BP >/= 30 sys or >/= 15 mmHg diastolic, even in absence of HTN--needs to be reported!

muscular dystrophy duchenne= most common for of childhood MD

group of hereditary diseases (x linked recessive) characterized by degeneration of muscle and weakness; muscles hypertrophy sx= muscle weakness, lordosis, scoliosis, waddling gait, joint contractures calf muscle hypertrophy (enlarged muscles) (seen in GOWERS sign)= use hand to rise from squat/chair to help get up due to muscle weakness thigh atrophy -frequent tripping/falling -walks on tiptoes rx= watch stumbling/fall! (use brace/wheelchair) eliminate floor hazards to prevent injury! active/passive ROM-->participate in gentle, regular exercises (swimming) to avoid atrophy intense PT light spinal braces/long leg braces help ambulate balance between activity and rest, prevent contractures *leading cause of death is cardio/resp probs (watch for infections!) *no cure, most die by 20-30 from resp failure

TORCH infections

group of maternal systemic infections that can transmit across the placenta or by ascending infection (after ROM) to the fetus; infection early in pregnancy may produce devastating fetal deformities, whereas later infection may result in overwhelming active systemic disease and or CNS involvement causing severe neuro impairment or death of newborn Toxoplasmosis Other (parvo- B/19, varicella/shingles, group B strep, Hep B/A, AIDs) Rubella Cytomegalovirus Herpes Simplex Virus (shingles) toxo--may come from infected cat feces, undercooked meat, soil contaminated fruits/veggies (watch when gardening! thoroughly wash all fruits)

Central venous catheter (CVC) considerations

hand hygiene use non sterile gloves when working with aseptic handling of catheter hubs! (alcohol pads, chlorhexidine, povidone iodine) **always allow antiseptic to DRY before using hub have multiple lumens to admin incompatible drugs at same time (drugs do not mix together into same lumen) lumens= blood, drugs, and PARENTERAL nutrition (TPN) *dont confuse with EN!= given through GT or PO *if CATHETER OCCLUSION occurs: -first reposition the pt (head, arm) -then assess IV tubing for clamps, kinks, and precipitate -attempt to flush device again -if occlusion remains, contact HCP--dont force *10 mL is good syringe flush size (no smaller) *if heparin flush, ensure dose is minimum possible (10 U/mL to prevent HIT) when collecting blood specimens: -cleanse specimen bag with disinfecting wipe -proper and immediate transport of specimen to lab -avoid place specimen in clean areas (nursing station) -place specimen in biohazard bag

HELLP syndrome

hemolysis, elevated liver enzymes, low platelets sx= RUQ pain, N/V, malaise (think like preecclampsia), may have visual change, HTN, proteinuria think "DEATH IS COMING" = DIC (loss of ability to clot) start bleeding out of all orifices, life threatening! rx= give birth ASAP meds= corticosteroids (help babys lungs), antiseizure, blood transfusion

Thrombotic Thrombocytopenic Purpura (TTP)

hemolytic anemia with erythrocyte fragmentation, hemolysis, thrombocytopenia, decreased renal func, fever *risk for bleeds!!

sx of organ dysfunction by category

hepatic: fatigue, dark urine (bilirubin excretion) kidney: proteinuria, lethargy pancreatic: malaise, glycosuria (think pancreas makes insulin)

standard precautions (universal precautions)

hepatitis C; latent TB HIV/AIDs toxic shock syndrome *poison ivy (rash not considered contagious!) urushiol oil is what spreads (pustules do not contain) *wear mask, gown, gloves if contact with bodily fluids/procedures which may spray them -->this does NOT APPLY TO ORAL MEDS (dont need to wear PPE) *do NOT need mask if have draining wound (just gowns/gloves) like ulcer etc. not likely going to spray in face like blood would!

Hernia considerations

hiatal hernia= abn movement of stomach into chest due to diaphragm weakness (may be asymptomatic) sx (like GERD)= chest pain, heartburn, dysphagia, SOB *pain exacerbate by increased abd pressure/supine position teach= -obese--loose weight -avoid increase abd pressure (lifting, weights) -sit up for several hrs after meals -sleep with HOB elevated at least 6 in (reduce upward mvmnt of hernia) -may need surgery if cant control by home mngmt -avoid caffeine/tobacco -offer small, frequent, low fat meals -avoid GERD foods (spicy, mint, chocolate, tomatoes) -fluids!! post-op: avoid activities that increase intraluminal pressure! (coughing, heavy lifting) 6-8 wks if sneeze/cough unavoidable, teach to splint incision and keep mouth open while doing so -elevate scrotum with ice packs to decrease swelling (inguinal hernia) -->PRIORITY W/ INGUINAL HERNIA= WATCH FOR SBO-->if see sx severe pain, abd bloating N/V-->this is PRIORITY PT! -assess for difficulty voiding (males stand when voiding to empty bladder) -ambulate early turn deep breathe

hyperparathyroidism

high ca, low phos *ca cns depressant, so depressed sx sx= fatigue, muscle weakness cardiac dystyrhmias renal calculi (watch for hematuria!!) back pain excess urination pathological fractures abd discomfort/diaphoresis (high ca in serum, low in bone) BACK ME -increase fluid intake to decrease renal calculi acid-ash juices monitor potassium levels IV furosemide and saline to promote ca excretion IV phos for rapid lowering of ca level prevent fractures diet= low ca, high phos

high fiber, high roughage diet low fiber, low residue Benefits of fiber

high fiber: whole wheat, raw fruits/veggies, bran, corn, seeds low residue--exact opposite (more "unhealthy food" processed, white bread, pies/cakes Fiber benefits: regulates bowel movements helps prevent colorectal cancer promotes weight loss improves glycemic control reduces risk of vascular disease (reduces cholesterol)

Signs of increased ICP in infant (early/late)

high pitched cry, irritability, poor feeding; increased frontal occipital head circumference early signs: projectile vomiting, increased BP, widening pulse pressure bulging fontanelles, increased head circumference late signs: sunset eyes, bradycardia, decreased motor/sensory responses, cheyne-stokes respirations *recall increased ICP in infant can indicate HYDROCEPHALUS-->is emergent situation!!

Crohn's disease diet

high protein, high calorie, low fat, low fiber avoid foods irritating to GI tract, cause GI inflammation= spicy, high fiber= bran, corn, whole wheat, raw fruit/veggies, seeds

Scabies

highly contagious spread by mites direct person to person contact sx= intense itching (esp at night) burrow track skin rash mark rx= 5% permethrin scabicide cream (1 to 2 applications) for infants/children: -massage cream on all skin surfaces from head to feet, avoiding close contact with eyes teach= -all people in close contact with pt during lengthy 30-60 day incubation period should seek rx -wash and dry clothing on hottest settings -DO NOT need to discard stuffed animals (seal in plastic bags >3 days) -DO NOT fumigate living area expect sx- -itching will cont for several weeks after treatment

fractured hip/ total hip replacement (arthroplasty) considerations post-op femur fracture considerations

hip fracture s/sx: shortening of affected extremity adducted OR abduction depending on mechanism of injury (break off from hip) externally rotated (leg direction) muscle spasm groin/hip pain with weight bearing ecchymosis and tenderness over thigh and hip *keep in mind, femur fx can result in EXCESS BLOOD LOSS (>1000) as very vascular! *not abn for blood loss to cause drop in HgB 1 or 2 levels (not worrisome post op unless HgB <7-8, then need blood transfusion) so PRIORITY ACTION= ASSESS SUCTION DEVICE DRAINAGE amount/dressing *even priority before abduction pillow! contraindication to surgery= INFECTION (can transmit to new wound) d/c anti-plts 7 days before surgery! total hip replacement: (think hip) WANT LIMB ABDUCTION (do by abductor wedge pillow or 2-3 pillows between legs), turn pt as ordered (but not on operative side unless HCP approved) keep heels off bed, use trapeze to lift self, dont sleep on operated side do not have outward rotation -->indicate dislocation of prosthesis goals= AVOID ADDUCTION AND HIP FLEXION limit flexion to 60 degrees first 6-7 days then 90 degrees first 2-3 mo (can flex opp leg/do gluteal exercises) ***avoid crossing legs beyond midline, bending hips over, pulling legs up to waist *do not elevate HOB >45 use walker to begin ambulation then crutches (do NOT full weight bear, only PARTIAL WEIGHT BEARING)--prevent dislocation walking is great exercise! in 3 mo able to return to ADLs, except strenuous sports *also do isometric exercises (gluteal setting, leg raises, abduction exercises) if thromboembolism occurs: do NOT put in high fowlers, apply O2 and notify HCP asap! expected sx: low HCT (blood loss during surgery) femur fracture: (think leg) want legs in neutral position *normal alignment is required! (use trochanter roll to keep leg from externally rotating) when ambulate: NO weight bearing on affected leg initially to prevent dislocation at home d/c care: (think things to prevent flexion and promote safety/stability) elevated toilet seat shower chair and hand held shower use a grabber (to pick up items or reach for items) sitting in chair: use armrests and HIGH firm seat (place hands on armrests for support while lowering selves into seat and rising from it) *do NOT need hand break in car (by time can drive, will not be necessary)

AE of Thiadzide diuretics

hyperglycemia! hyperuricemia blurred vision, dry mouth photosensitivity, ortho hypo muscle cramps (hypokalemia-->most concerning!) amongst the reg effects hydrochlorothiazide, CHLORTHALIDONE

HHNKS

hyperglycemic, hyperosomolar nonketotic syndrome (type II) high sugars, no ketones DEHYDRATION--> osmotic diuresis hyperglycemia -->severe levels happen more slowly since insulin present (type II) and may not be noticed until late slower onset, harder to fix (older pts) sx= blood glucose >600 neuro= blurry vision, lethargy, obtundation, coma *altered mentation more pronounced!! hemoconcentration serum osmo >320 bicarb >18 rx=

allergic rhinitis

hypersensitivity to specific allergen triggers (dust, pollen, mold, animal dander) rx= reduce exposure -instill HEPA air condition filters -keep windows closed, stay indoors -hypoallergenic pillow/mattress covers -reduce/remove carpet and area rugs -mop hard floors and damp dust furniture at least once a week -vacuum carpet with HEPA filter vacuum at least once a week *unless allergic to animal dander, dont need to get rid of pets

Epispadias vs Hypospadias

hypo= opening is on ventral side of penis think hypo "below" epispadias= opening is on dorsal (back side) of penis *no circumcision is performed as foreskin is used in surgical repair post-op surgical correction: cath or stent to maintain patency while new meatus heals UO is IMP INDICATION OF URETHRAL PATENCY -->ABSENCE OF UO OVER 1 HR INDICATES KINK/OBSTRUCTION AND NEEDS F/U--is PRIORITY!

Somogyi effect

hypoglycemia followed by rebound hyperglycemia response to low glucose levels during night also causes morning time hyperglycemia (like dawn phenomenon) but for dif. patho reason treatment is dif! adjusting the timing of insulin administration: LOWER the dose of insulin before bed. changing the type of insulin. eating a snack with the evening insulin dosage

Signs of hypoglycemia rx?

hypoglycemia is LIFE THREATENING condition (more than hyperglycemia) is priority pt if see!! sx= irritability tachycardia, heart palpitations diaphoresis nervousness hunger tremor/trembling cold, clammy/moist skin weakness altered LOC--confusion visual disturbances headache slurred speech if left untreated, will progress to coma! factors that increase BG: -infection, illness, steroids rx= (if conscious) 15 g quick acting carb -drink 1/2 cup (4 oz) fruit juice OR reg. soft drink, 8 oz LOW fat milk, 1 tbsp of honey/syrup, 6 hard candies, commercial dextrose products *then recheck finger glucose q 10-15 min after after BG stabilizes, give meal or serving of carb + protein/fat= -followed by peanut butter crackers, cheese *chocolate bar is too concentrated carb will put into hyperglycemia! if unconscious, unable to swallow= IM glucagon (also SQ ,IV, gel available) IV glucose preferred (if severe hypoglycemia) Dextrose D50W IVP *watch for rebound hypoglycemia when give these

submersion injury

hypoxia resulting from submersion in a substance, usually water. *pts who undergone need to be evaluated asap and observed for at least 6 hrs after for new or worsening resp failure!

NSAIDS Side Effects examples

ibuprofen, ASA, ketorolac, naproxen, indomethacin, celecoxib analgesic, anti-inflammatory, anti-pyretic, anti-plt (ASA) AEs GI distress (n/v)-->take med with food/milk or antacid! *can exacerbate asthma sx and nasal polyps so contraindicated in these pts! -->STEVENS JOHNSONS SYNDROME-->watch for rash! (ibuprofen) NSAIDs CAN CAUSE BLEEDING (ASA) signs of bleeding (dark stools etc) *avoid alcohol, increased bleeding risk! TINNITIS -->IS AN AE, not normal! earliest sign of aspirin toxicity!! tachycardia HTN, Heart failure (NSAIDs can cause fluid/sodium retention)--contraindicated in pts with HF *can cause bronchospasm in pts w/ asthma (ibuprofen and ASA)--be aware for! kidney injury (with long term use) --> NSAIDs are nephrotoxic!!-->CONTRAINDICATED WITH KIDNEY DISEASE/PEPTIC ULCERS **increases risk of THROMBOTIC EVENTS -->CAUTION IN PTS WITH cardiovascular disease (increase risk of MI, stroke, HTN, HF) cardiovascular events! NSAIDS MUST BE AVOIDED THIRD TRIMESTER (risk of premature closure of ductus arteriosus in fetus) *during first/second trimesters, NSAIDs only take if benefits outweight risks under supervision of HCP

newborn priority actions first 10 min after birth

identificiation bands on infant and mother cap/hat on newborns head apgar scores VS (except BP!)-->hard to obtain with mvmnt and crying, often get artifact *do NOT admin hep B vaccine within first 10 min

Pregnancy: In labor considerations

if ROM has occurred, encourage voiding if fetus is still high in station (neg) to encourage descent of fetal presenting part take temp always after ROM

UAP refusing to do a delegated assignment--what does nurse do?

if UAP says, "i dont need to do that im too busy, not my pt--why dont you do it? -->no need for nurse to give explanation to UAP as to why this needs to be done -->repeat request and to let them know when this assignment is completed (completely disregard their obstinence) if UAP states, "I cant do that" -->need to first assess why cant in case they dont have knowledge UAPs can perform ROM!

Foreign body considerations

if child aspirated: 50% children asymptomatic! at beginning-->PRIORITY PT sx= choking, distress, gagging, cyanosis (circumoral), inability to speak! if launched in eye: shield BOTH eyes with eye patch (do not attempt to remove, flush with water, etc) impaled object in person: DO NOT MANIPULATE/REMOVE THE OBJECT *stabilize is first priority! (avoid hemorrhage, further trauma) --> *exception-->first responders may remove impaled object if it obstructs airway/prevents CPR

DPaT injection

if fever occurs, it is usually low-grade and appears within the first 24- 48 hrs

Asthma: Peak Expiratory Flow Meter & MDI spacer purpose

if pt in asthma exacerbation, PRIORITY ACTION= HAVE PT TEST THIS! (earliest sign exacerbation in child= cough) quantifies severity of asthma exacerbation pt takes every morning right when wake up teach= EXHALE AS QUICKLY AND FORCIBLY as possible through mouthpiece green: 80-100%; good, no intervention needed yellow: 50-79%: take bronchodilator (rescue inhaler) q 4 hrs for 1-2 days and call HCP for follow up care red: <50%: (take rescue inhaler, go to ED, severe airway constriction emergency!!) teach= move indicator to 0 or lowest # on scale before use device -personal best reading= highest peak flow pt obtains usually over 2 week period -can use after a short acting bronchodilator rescue MDI to eval response MDI: spacers attach to MDI to hold med in chamber long enough for pt to inhale med directly to the airways (improves chance of getting med into lungs) steps to use: shake MDI attach to spacer breathe out (EXHALE completely) **before! seal mouth and hold breathe 10 sec rinse mouth with water (no left over med) wait min before take next dose (as prescribed) always admin bronchodilators before steroids avoid allergens/triggers (hot/cold/damp/drafts) if using steroid med in inhaler, brush teeth after to avoid oral candidiasis!

pscyh pt behavioral considerations

if pt is acting out, attention-seeking, reward pt when presenting with acceptable behaviors pt should not be given one staff member or constantly changed, staff should maintain undivided consistent treatment approach! all the same

mastectomy

if pt reports wet sheets post op, could indicate hemorrhage from site and needs to be investigated for potential bleeding! *prevent lymphedema: -PRIORITY FIRST ACTION=elevate arm to heart level to reduce fluid retention! implement gradual hand/arm exercises (perform isometric exercises) -use intermittent pneumatic compression sleeve/compression sleeves--OKAY! -avoid vaccinations/BP draws/Venipunctures in affected arm (use opp arm at MOST DISTAL SITE) -MASSAGE TO MOBILIZE FLUID--massage is good! -watch temp extremes/infection -place sign on bed, and restricted extremity armband on pt --------*goal return to norm full ROM in arm in 4-6 weeks (slowly initiate post op arm exercises) position= semi fowlers with affected arm ELEVATED (enhance fluid removal/circulation, prevent edema) NORMAL FINDINGS post op: tingling, numbness, itching at site -also may find a lymph node that is palpable, superficial, small (0.5-1 cm), mobile, firm, nontender--this is NORMAL finding ABN= tender, hard, fixed, enlarged node tender could be due to inflammation, but HARD OR FIXED COULD BE MALIGNANT

subclavian triple lumen cath

if resistance met when flushing, secure cap, notify HCP, who may order streptokinase to dissolve clot...if unsuccessful then lumen labeled as clotted off

priority for autograft onto extremity

immobilizing graft--is essential for vascularization, keeping graft stable, and promoting healing takes 7-10 days for graft to mature rejection does not occur immediately, but becomes a priority after removing dressing in 3-5 days

Azathioprine

immunosuppressant-->cause bone marrow depression, increase infection risk! rx- autoimmune conditions, prevent organ transplant rejection AE= leukopenia -->watch and report! (infection risk) fatigue, nausea

ectopic pregnancy

implantation of the fertilized egg in any site other than the normal uterine location (frequently in fallopian tubes) sx= abd pain (dull, unilateral) after 4-6 weeks of normal pregnancy-->progresses to colicky, sharp, severe pain if rupture occurs! REFERRED SHOULDER PAIN ridid, tender abd, N/V (may report) amenorrhea; followed by vag spotting/ bleeding--> gradual oozing to frank bleeding pos preg test (low hCG and HCT levels in urine) missed/delayed menses palpable adnexal mass on pelvic exam *untreated can lead to tubal rupture, hemorrhage, hemodynamic compromise -->SHOCK!! ECTOPIC RUPTURE =EMERGENCY sx= hypotension (dizziness, tachycardia) referred shoulder pain tenderness, rigidity, low grade fever (peritonitis signs) *SHOULDER PAIN IN PT WITH ECTOPIC PREG INDICATES INTRAABDOMINAL BLEED (ruptured ectopic pregnancy) rx= Emergent surgical intervention (IV fluids, blood transfusion), prep for surgery Rho(D) if need causes: PID (pelvic inflammatory disease) previous tubal surgery congenital anomalies of fallopian tubes STIs intrauterine devices

Hypokalemia S/S and Rx

in general= results in muscle weakness/paralysis "A SIC WALT" Alkalosis Shallow respiration Irritability Confusion and drowsiness Weakness and fatigue Arrhythmias- irregular heart rate, tachycardia Lethargy Thready pulse MUSCLE CRAMPS PARASTHESIAS (also abd distension, decreased bowel sounds) PROMINENT U WAVES ON ECG; inverted T waves/ depressed ST segment Rx= oral K+ supplements/increase dietary intake can give NO MORE THAN 40MEQ K+ through PIV! *need cardiac monitor *watch for dig toxicity

chain of command--always follow!! nurse charge unit director nurse supervisor --aids in resolving interdepartmental issues disaster scenarios radiation disaster

in stage of emergency, nurse must first notify the nurse supervisor, who will decide whether to enact the disaster plan in radiation disaster, greatest good for greatest number: treat those furthest away first radiation disaster sx: (think like chemo) sx= damage to oral mucosal ulcerations vomit/diarrhea (like chemo!) low blood cell counts (like chemo)

Infertility

inability to conceive after 12 mo of unprotected intercourse (women <35), or 6 mo in women >35 risk factors: endometriosis maternal age >35 polycycstic ovarian syndrome recurrent chlamydial infections -->cause PID! pelvic inflammatory disease (PID) very low or very high BMI

SIADH

inappropriate ADH excretion, causes fluid retention common causes= *things that secrete ADH--CNS system disorders SMALL CELL LUNG CANCER= #1 stroke, trauma, neurso surg desmorpessin, carbamazepine PNA S/Sx of fluid vol overload--but also N/V, anorexia (Na Imbalance), decreased DTRs LOW SERUM OSMOLALITY (diluted) low serum sodium (HYPONATREMIA--DILUTED) high specific gravity (dehydrated urine) Rx= admin diuretics 3% Hypertonic Na to correct hyponatremia/oral salt tablets !!!!!!! shift fluid back to vasculature reduce fluid intake 1000 mL/24 hr vasopressin receptor antagonists (inhibits ADH) (=conivaptan) daily weights, straight I/Os, seizure precautions (hyponatremia)

sundown syndrome

increased confusion and agitation during the late afternoon and evening in pts with dementia *Due to inadequate lighting, pt excessively fatigued (common behavior= wandering) rx= promote normal day/night cycle= -limit daytime napping increase light exposure during the day restrict caffeine later in the day provide night light in the dark -*distract, redirect, reassure pts of safety *do NOT attempt to reason with pt (can increase confusion/agitation) if observe pt wandering, tell them "its time to go back to bed now"

cullens vs turners sign; balances sign

indicate retroperitoneal bleeding cullen's= ecchymosis over umbilicus turner's= ecchymosis over flank balance's= dullness over spleen when pt on left side; indicates spleen rupture

decorticate vs decerebrate

indicates sign of brain stem damage (late sign) decorticate= flexion and internal rotation of forearms and hands decerebrate= MORE OMINOUS extension of arms/legs (straight out) pronation of arms toes pointed down head/neck arched back

Anorexia Nervosa (AN)

indicators: obsessive about when, how much, and what they eat as little as 200cal/day, BMI <18.5kg--LOW WEIGHT time of day very precise become obsessed with food and exercise (think about eating all the time) reports of BINGING may occur (binge, purge) -wearing oversized, bulky clothing (hide weight loss) fasting, dieting excessive exercise sx: *think lack of nutrition so slow metabolism sx bradycardia, hypotension, hypothermia, constipation, fatigue, muscle weakness, COLD intolerance, amenorrhea, enlarged parotid glands, LANUGO, hair loss, dry skin, osteoporosis, arrhythmia's WEIGHT LOSS OF 25% BELOW NORM BODY WEIGHT fluid/electrolyte imbalances (hypokalemia, met alkalosis) *goal of therapy= increase pt's self esteem, self worth, and self acceptance, promote socialization rx= assist pt in reflecting on triggers of disordered eating maintain strict record of protein and calorie intake remain with pt for duration of meal (and 1 hr after to prevent any purging) weigh the pt each morning prior to any oral intake, after voiding, wearing same clothes (weight gain goal of 2-3 lbs per week) base activities/interventions off of this making jewelery *do not focus on food initially, but encourage participation in meal planning as client nears target weight REFEEDING SYNDROME: potential FATAL complication of nutrition rehabilitation in chronic malnourished pts (getting enteral/oral/parenteral feeds) (pancreas makes less insulin due to decrease intake-->enteral feeds w/ glucose cause increased insulin again--> most prominent sx: shifts PHOS, POTASSIUM, MAG "PPM" INTRACELLULARLY= HYPO __everything__) other sx= fluid overload, Na retention, Hyperglycemia, thiamine deficiency *so monitor anorexic/chronic alcoholism, malnourished pts for this syndrome and decreased electrolytes!!

Cold Stress in infant

infant UNABLE to SHIVER/INCREASE ACTIVITY to respond to cold oxygen consumed is diverted to help metabolic process occur risk factors= preterm neonates sx= irritability/lethargy (AMS) poor feeding, high gastric residuals, emesis weak cry and suck METABOLIC ACIDOSIS cyanosis tachypnea (early), apnea/HYPOXIA (late) HYPOGLYCEMIA mottling of skin bradycardia hypotonia causes= decreased brown adipose tissue hypoglycemia! recall relationship to hypothermia hypoxemia, intracranial hemorrhage or CNS abn rx= -frequent temp monitoring -cover scale in warmed blankets before weigh -diaper changes under radiant warmer warm environment delivery room (22C, 72F) dry and wrap in pre warmed blanket place cap on head place on mothers abd, skin to skin *DRY NEWBORN COMPLETELY OF AMNIOTIC FLUID FIRST PRIOR TO OTHER INTERVENTIONS (applying wristband etc) *incubator, warming panel if need *transfer swaddled newborn to NICU etc if need in prewarmed incubator

toys based on age

infant: rattle older child: colorful blocks

Osteomyelitis

infection of bone (often from ortho procedures or fx, joint prosthesis) pain swelling redness, fever, leukocytosis, increased ESR asepsis wound care! PROVIDE COOL (decrease inflammation), avoid heat! lightweight clothing diet= high protein (w/ carbs, vitamins, minerals) avoid exercise to affected area support extremity with splints, pillows

Croup (laryngotracheobronchitis)

infection of the upper airways in children characterized by a barking cough sx= rhinorrhea, tachypnea, inspriatory stridor, seal like barking cough unstable= stridor, severe retractions (mild barking cough is somewhat stable) rx= nebulized racemic epinephrine, oxygen (if need)

pelvic inflammatory disease (PID)

inflammation and infection (chlamydia, gonorrhea) of organs in the pelvic region (female reproductive organs); --fallopian tubes, ovaries, endometrium sx= fever, leukocytosis, maliase, vag discharge, abd pain risk= 20 yrs of LESS, multiple sex partners, vag douching, smoking, hx STDs, (chlamydia and gonorrhea most common causes!) hx PID, IUD placed w/ in last 3 yrs recent abortion or pelvic surgery rx= abx severe infections can cause adhesions that produce sterility *infection is not contagious just by being in same room--is STD!

ulcerative colitis

inflammation and ulceration of large intestine ex= abd pain, frequent bouts of BLOODY DIARRHEA, anorexia, anemia *fewer than 4 bloody stools/day= mild disease diet= low residue, HIGH PROTEIN, HIGH CALORIE (rice, breads, pastas, cooked veggies, canned fruits, tender meats) meals and snacks low fiber (avoid raw fruits/veggies, whole grains, fried foods, alcohol, tobacco, highly seasoned foods--things that stimulate intestine) fluids!! small frequent meals meds= sulfasalazine *take folic acid supplements with this -make sure pt is med compliant -take multivitamins containing calcium daily -admin analgesics PRN -strict, hourly I/O monitoring -avoid dietary triggers (FAT, processed, caffeine, alc, dairy, nuts/legumes, cereal, tobacco)

osteoarthritis

inflammation of cartilage! of the joint caused by wear and tear over time; degenerative, no remissions (causes bone spurs, calcifications, ulcerations)--breaks down cushion between ends of bones (joints) sx= hererdens and bouchard's nodes over fingers contracture joint stiffness at rest morning stiffness lasting subsides after 30 min arising ASSYMMETRICAL PAIN in weight bearing joints! (pain exacerbated by weight bearing activities) CREPITUS W/ MOVEMENT--esp over knee joints decreased joint mobility and ROM atrophy of muscles due to disuse unexpected= FEVER! (no fever expected with OA) rx= use HEAT!! pain management, rest, activity, exercise (warm up exercises before) MAINTAIN FUNCTIONAL POSITION (optimal)--promotes movement *do not exercise if have severe joint pain those at risk: (think things that cause wear and tear, stress on joints) obesity trauma to joints osteomyelitis

appendicitis

inflammation of the appendix (often from fecal matter obstruction) RLQ pain (periumbilical region progresses to RLQ, cont, severe) anorexia, vomit, diarrhea (initial onset of pain is seen at umbilicus) MCBURNEY'S POINT (right where top of appendix located, tenderness when pressure applied, and rebound tenderness when pressure released) guarding avoid coughing, sneezing, deep breathing, lie with right leg flexed to avoid pain must be treated within 24 hrs, to avoid peritonitis priority actions= fluid resusc IV fluids (NS/LR) to prevent circulatory collapse (vomit) avoid interventions that increase intraluminal pressure= *place pt on NPO status! (presurgery) *AVOID HEAT TO ABDOMEN-->increase perforation risk *can give analgesics (morphine)/ antiemetics EMERGENCY= PAIN IS SUDDENLY GONE (indicates rupture)-->peritonitis, sepsis

cystitis

inflammation of the bladder common UTI--bacteria-- but can also be from radiation, drugs, chemicals *females more prone or if have catheterization, instrumentation sx= urgency, frequency, dysuria, hematuria, pyuria (pus) suprapubic pelvic discomfort, strong urine odor, cloudy urine (bacteria) sensation of bladder fullness pain= DULL, CONTINUOUS, MAY HAVE SPASMS over suprapubic area *if cystitis left untreated, can go to pyelonephritis! encourage fluids!! flush it out cranberry juice to acidify void q 2-3 hrs obtain clean catch midstream specimen for urinalysis

Bronchiolitis

inflammation of the bronchioles common viral illness in children caused by RSV! sx= rhinorrhea (runny nose), congestion, tachypnea, cough, wheezing (mild sx) vomiting -->can develop into resp. distress (severe sx) (difficulty feeding-->dehydrated) *if irritable= hypoxia! PRIORITY PATIENT goal= O2 sat >90%! *breastfeeding should continue additional fluids ***use saline nose drops and suction nares with bulb syringe to remove secretions prior to feedings and at bedtime suction, hydration, oxygenation *family DOES NOT need prophylactic treatment for RSV bronchiolitis infection (for pertussis is recommended, however)

Diverticulitis

inflammation of the diverticula (in LLQ, descending, sigmoid colon) pt may be asymptomatic! cause= chronic constipation sx= LLQ pain palpable , tender abd mass fever increased C reactive protein leukocytosis with a left shift *at risk for perforation/abscess formation!! watch for sx indicating this= diffuse progressive pain in other quads of abd abd pain, rigidity, guarding, rebound tenderness, palpable mass/cont fever despite abx (abscess) sx= abn amount of bleeding/bright red blood found in stool care= allow colon to rest, inflammation to resolve think REST REST REST, GIVE BOWELS REST -IV abx therapy, analgesics (morphine) NPO status NG suction IV fluids--IV infusion NS bedrest avoid straining low-residue (to let bowel rest) *avoid procedures that increase intraabd pressure/increase peristalsis-->can cause rupture! ex= no enema, laxatives, lifting, straining, coughing, bending, rectal tube *BARIUM ENEMA CONTRAINDICATED to prevent reoccurence of diverticuli-->prevent constipation!! diet= HIGH FIBER; fiber supplement (psyllium or bran) fluids! exercise avoid high fat foods/red meat

Acute Glomerulonephritis (AGN)

inflammation of the glomeruli of the kidney (which are kidneys filter systems), membrane damaged so protein/RBCs filter in GFR decreased so see fluid retention sx! sx= periorbital and facial generalized edema HEMATURIA proteinuria fever chills, pallor, weakness (lack RBC) in body, anorexia-->N/V uremia (BUN) hypertension--> edema, oliguria (impending renal failure), HTN flank/abd pain, weight gain, dyspnea, lung rales, fluid overload URINE= tea colored, cloudy (presence of protein and blood)--hematuria is expected!! *is CAUSED BY GROUP A BETA STREP INFECTION elsewhere in body (tonsillits, PNA, URI, skin, etc!) latent period of 2-3 weeks after infection before AGN appears rx= restrict sodium/water if oliguric (edema) diet= high calorie, low protein (think renal diet, and kidneys holding onto protein) bedrest meds= analgesics, abx, corticosteroids, antiHTN, immunosuppresive, diuretic (prn) daily weights for fluid status! complication= SEVERE HTN--watch for!

pyelonephritis

inflammation of the kidney (usually caused by e coli) sx= flank pain, fever -->*R/O CYSTITIS IF HAS THESE chills, malaise, CVA tenderness (lower back) dysuria, urinary frequency, N/V pain= DULL FLANK PAIN, EXTENDING TOWARDS UMBILICUS (CVA) encourage fluid!!, bedrest priority actions= (pt is not usually priority as comps dont occur for over a few hrs if happen) *HAVE IV ACCESS, so this is priority to establish so pt can have fluids/abx-->TREATMENT IS DEPENDENT ON THIS, SO PRIORITY PT if dont have patent IV access *GET BLOOD/URINE CULTURES to give abx (to determine most effective one to give) pregnancy: imp to assess if pt has sx cause preg pts with pyelonephritis at risk for preterm birth!

pericarditis

inflammation of the pericardium (sac surrounding heart)-->can cause increased fluid in pericardium (PERICARDIAL EFUSION)-->pressure on heart, cant eject blood (cardiac tamponade) sx= pericardial friction rub (scratchy, squeaking sound) pleuritic chest pain that is SHARP (on inspiration) ***ST SEGMENT ELEVATION= is expected in almost all ECG leads with this! (so not MI concerning) *in MI-->ST segment elevation only seen in localized leads (depends on vessel that is occluded) pain often relieved with sitting upright, leaning forward pain exacerbated by coughing, inspiration position= fowler's priority: MONITOR FOR SX CARDIAC TAMPONADE-->life threatening!! THIS IS PRIORITY FINDING--unexpected! (JVD, distant heart sounds, hypotension (narrowed pulse pressure) rx= NSAIDs or ASA, + colchicine position= fowler with support (bedside table) to lean on

pharyngitis

inflammation of the pharynx caused by group A strep (bacterial) can lead to renal (glomerulonephritis) or cardiac (rheumatic fever) if untreated teach: must complete full abx course replace toothbrush after 24 hrs on abx SOFT DIET, COOL LIQUIDS may return to school/daycare after 24 hrs abx and afebrile give acetominophen/ibuprofen test siblings <3 yrs age! (may have minor sx and be infected)

bursitis

inflammed fluid filled bursae (which cushions joint) sx= decreased mobility, esp abduction!, pain!! *dif with ADLs, self care deficit! immobilize w/ splints, pillows, slings--rest! apply alternate heat/cold promote exercise ROM modify activities relative to limitations (ADLs) cortisone injection PRN (decrease swelling), drain bursae

Thalassemia

inherited disorder from Mediterranean ancestry, causes decreased HgB-->anemia-->fatigue

trauma/abuse/rape pt considerations

initial expected goal is to get pt to begin expressing feelings about event (to gain acceptance and perspective) want them to state they are not at fault how to assess the caregiver who is suspected of abuse: *open ended questions, nonthreatening, nonjudgemental attitude = -caregiver's perspective on the child's behavior -routine caregivers for the child -methods of discipline used with the child -caregiver stress, support, coping systems,person or persons who care for the child when regular caregivers are away

Dopamine

inotropic agent (increases heart contractility and rate) vasoconstrictor AEs= tachycardia, dysrhythmias, MI

tonometer

instrument used to measure intraocular pressure norm= 10-21

insulin and potassium effect

insulin shifts potassium out of cells causing hypokalemia ex: if pt has insulin due, but is hypokalemic...then first notify HCP, may need to give potas supplements, then give insulin (to avoid life threat cardiac arrythmias)

Brachytherapy Teletherapy

internal radiation sealed source= mechanical implant at source unsealed source= liquid given, spreads throughout body *danger greatest first 24-96 hrs nursing care: *no pregnant or people under 18 allowed in room private room!! with sign on door, keep door room closed do NOT ASSIGN PREGNANT NURSE THIS PT dosimeter film badge always TEACH PT IS TO BE ON BEDREST (prevent dislodgement) limit close contact to 30 minutes per 8 hour shift, rotate staff performing care during one shift! verbal exchanges make from pts doorway visitors must remain at least 6 feet apart (3 hrs per day recommended-kaplan?) encourage pt self care--have them stay at least 6 ft away from pt (think of covid!) LEAD APRON ONLY worn if nurse has to spend any length of time at close distance (but not for routine care)--put yes for care requiring physical contact *loose, soft clothing and bed sheets cleanse skin daily lukewarm shower, using mild soap, pat skin dry after avoid temp extremes (ice packs, heat pads)--cool, humid place shield from sun avoid OTC oils, creams, ointments--only use approved ones by HCP; avoid applying bandages, tape to area if implant gets dislodged: *ensure lead container and long handled forceps in room --CANNOT EVER TOUCH IMPLANT *use long handled forceps to pick up and put in lead container ONLY RADIOLOGY HANDLES RADIUM IMPLANT UPON REMOVAL (nurse should never handle radium implant) diet= low residue, lots of fluid (bm's stain, give enemas) indwelling cath to prevent excess mvnt when peeing *pt is to remain on bedrest/frequent rest periods while radiation is in place (prevent dislodgement, radiation can cause fatigue also) *if pt has a wound, there is a 6-8 hr window period to safely close it

sterile vs clean procedures (catheter irrigation, catheter insertion, intermittent self catheterization)

irrigate= sterile insertion= sterile self cath= clean

irrigating eye/ear position; instilling drops ophthalmic meds

irrigating ear/eye: tilt head toward affected side fluid flow from inner to outer canthus lie on affected side to facilitate drainage recall OD (right eye), left eye (OS), both eyes (OU) eye drop: 1. Remove dried secretions with moistened warm water/NS sterile gauze pads by wiping from the INNER TO OUTER CANTHUS 2. place pt in supine or sitting position with head tilted back toward side of affected eye 3. rest hand on pt's forehead, hold dropper 1-2 cm (1/2- 3/4 in) above the conjunctival sac 4. pull lower eyelid down gently 5. tell pt to look up toward ceiling w/ thumb/forefinger against bony orbit 4. instill drops, or (if ointment), squeeze thin strip onto lower eyelid from inner to outer edge without tube touching eye 5. -close eyes gently for 2-3 min after applying ointment 6. apply pressure to lacrimal duct for 30-60 seconds *do NOT massage, rub eyes! *can use eye drops during day, ointment during night due to blurred vision ointment/gels cause

lumbar puncture considerations (for child) what is common symptom experienced after lumbar puncture?

is a sterile procedure! position= (same as adult) but make sure can hold child! must keep still! 1. flexed sitting with arms and legs immobilized 2. side lying with head and knees tucked headache! relieve by drinking PO fluids up to 3,000 patient should lay flat at least 4 hours post-op (4-12 hrs) position post= prone or supine (prevent HA from fluid loss) HA should resolve within 24 hrs for child: need to restrain to ensure pt safety *if observe clear fluid leaking at site, indicates site not sealed off properly and need a blood patch (blood into epidural space) to seal off contraindications for LP= increased ICP

what is a holter monitor?

is an ambulatory cardiac monitor= wearable device to take home for 1-2 days, keeps track of heart rhythm electrodes placed on pt's chest after done pt takes monitor back to HCPs office to recall print and analyze readings *do NOT bathe/shower with device on, sponge bath if device stays dry DO NOT BATHE DURING TESTING PERIOD (leave device on)--but cont all other norm activities *trigger the event marker on the device whenever pain/symptoms occur *avoid contact with all electrical devices (shavers, electric toothbrushes/blankets) *keep a diary of activities while monitor is on *go about normal daily activities

IV fluids considerations and indications

isotonic: 0.9%NS/LR (not as good for) =dehydration indications: *used to replace electrolytes, restore fluid balance, hypovolemia, fluid vol deficit choice for burns, surgery, blood loss hypotonic: D5W, 2.5% DW, 0.45% NS (shift fluid back into cells) indications: dehydration (DKA); hyperglycemia hypernatremic- think Na Follows water, will decrease in serum) CONTRAINIDCATED IN BURNS GI fluid losses (diarrhea, vomiting), increased ICP! hypertonic: D5NS, D5LR/ D10, D20%, 3% NaCl, colloid solutions (albumin, dextran) (decrease cellular swelling) indications: increased ICP, edema (third spacing) hyponatremia--think Na follows water, will increase in serum, blood loss, post op surgery *may cause N/V or diarrhea, temp cramps since high concentration (like dumping syndrome, pulls fluid in fast period) if observe= slow down rate of administration!

HIPAA rules and exceptions

it is OKAY to list pt's last names ONLY on whiteboards at nurses stations *a visitor talking about a pt's condition is not violation of HIPAA--only applies to staff members *must shred report sheets at end of shift *its okay if one pt hears report of another pt if they share the same room by a nurse (this is inadvertent) *its okay to call a patient by their FIRST AND LAST NAME in waiting room as long as no other info is given *transporting employee does not need to know patient's condition (dx), just their position/transfer into (PPE) if applicable

interventions to establish regular urinary elimination

kegels! triggering techniques--things to promote voiding (valsalva, crede, stroking thigh) intermittent catheterization: performed q 2-3 hrs, if only 150 mL output, extend q 3-4 hrs, then 4-6, NEVER MORE THAN 8 hrs apart toileting schedule: first thing morning, before and after eating, bedtime, before and after activity bladder train: give fluid measured q 2 hrs, attempt to void 30 min after, then gradually extend time bladder can hold *clamp indwelling caths intermittently before removal

Nephro/urolithiasis

kidney stones= nephro, ureter stones= urolithiasis sx= severe pain!! flank pain with renal, radiating flank pain with uro diaphoresis, n/v, chills, fever, hematuria, WBCs and bacteria in urine causes= hypercalcemia, dehydration, immobility, gout, increase intake oxalates *so decrease calcium, purine intake in diet! avoid vit D! *decrease sodium in diet as sodium increases calcium in urine *strain urine and check pH for stones-->then send to lab for analysis to determine what compound stones made of *oxalates from plants (so found in spinach, swiss chard, wheat germ, tea, cola, chocolate, peanuts)

total knee arthroplasty (TKA)

knee replacement (knee joint) *expect sanguineous dressing 1 day postop (25mL/hr) remove drain 24 hrs post op unless drainage excessive >1500mL/24 hrs post-op: immediate Physical therapy is priority! (isometric quadriceps on first day) -total hospital time recovery is 3-5 days -can apply cold packs intermittently for swelling -can use continuous passive motion device -PT SHOULD BE FULL WEIGHT BEARING BY D/C (after 3-4 days) -use knee immobilizer to maintain extension during ambulation and at rest for about 4 weeks -use walker/crutches to help with ambulation activities complication= contractures!! prevent by maintain knee in extended position w/ knee immobilizer, or pillow placed UNDER LOWER LEG OR HEEL (no pillow behind knee, causes contracture due to flexion)

hemophilia considerations genetic?

lack (hemo A factor VIII), Hemo B factor IX excess bleeding from joints and muscles is most common (esp knee) can cause joint deformities, alter ability to ambulate; most frequent sites of bleeding= JOINTS! (esp knee) hemarthrosis (bleed into joint cavity) can occur -->over time chronic swelling and deformity! sx= JOINT PAIN with bleeding NURSE SHOULD ASSESS FOR ABILITY TO PERFORM ACTIVE ROM as JOINT PAIN can indicate HEMORRHAGING sex linked: x-linked recessive trait transmitted from female to male factor VIII deficiency primary rx= replace missing clotting factor! -->then, 'think RICE' rest, ice, compression, elevate *elevate affected joint to prevent flexion contracture! PRIORITY ACTION= DESMOPRESSIN is DOC (DDAVP)--stimulates release of factor VIII or IV factor VIII administer! then do CT scan to assess for intracranial bleed if pt shows sx (n/v, lethargy, HA, irritability) bedrest (joint pain) -->during episodes--joint elevation +ice/cold pack analgesics (ASA CONTRAINDICATED!) bleeding! plama or factor VIII cyroprecipitate (replacement clotting factor) avoid contact sports (do swimming, golf), IM injections diet= regular nursing actions: -admin coagulation factor replacement IVP (primary treatment) = factor VIII or factor IX -ADMIN VACCINATIONS SQ WHENEVER POSSIBLE (avoid IM) -use smallest gauge -apply firm, continuous pressure to site for 5 min -avoid procedures that cause bleeding (rectal temps, IM injections) -avoid ASA/NSAIDs (bleeding)-->use acetaminophen for pain relief! -control bleed using ice packs (vasoconstrict) -do not rub/massage injection site (hematoma risk!) -perform neuro assessments Q 30 MIN FOR 6 HRS teach= -wear med alert bracelet at all times -encourage non contact sport such as swimming, jogging, tennis -use protective equipment (helmets, padding) -dental hygiene to prevent bleeds necessary with soft toothbrushes!

surgical procedure for herniated intervertebral disk? procedure considerations

laminectomy: remove 1 or more herniated disk to give access to spinal cord or relieve pressure on nerves/pain pre-op: position: fowlers w/ mod hip and knee flexion isometric abd. muscles to support spine traction or TENS to relieve pressure/reduce pain apply moist heat to reduce pain post-op: log roll q 2 hrs w/ pillows between legs assess lower extremity circulation status support neck, straight back during ambulation ERECT POSTURE ALL TIMES! AVOID PRONE POSITION--do not sleep on stomach use firm mattress for bed/hardboard avoid heavy lift/straining *will see edema post op cause pain cause compression on nerve root (HA), spinal fluid leak?

lumbar puncture position and steps considerations normal CSF pressure?

lateral recumbent (side lying)/fetal position at edge of bed (head, back, and knees flexed) OR sitting upright lean over pillow -->will show spine better steps: verify consent gather lumbar supplies/tray explain procedure have pt EMPTY BLADDER appropriate position label containers as collected; apply bandages to insertion site consider: remain flat in bed for 4-8 hrs after test (prevent post- HA) may feel discomfort/pain radiate down your leg when needle is inserted (nerve endings touch) can have analgesics after procedure if have HA fluids NOT restricted before test general anesthetic NOT used no compression bandage used after increase fluid intake at least 24 hrs post op! normal CSF pressure= 60-150 mmH20

crutch considerations

lead up stairs with the strong leg, followed by crutches, then weak leg lead down stairs with the crutches with weak leg first, then strong leg "UP WITH THE GOOD DOWN WITH THE BAD" when walking: move affected leg forward at same time as crutches, then strong leg follows do not lean on crutches to support body weight (support weight on hands and arms pieces NOT AXILLA to avoid "CRUTCH PARALYSIS" =damage to radial nerve at axilla) sx= MUSCLE WEAKNESS/HAND ARM TINGLING/NUMBNESS tripod position: place crutches 6 in in front and 6 in to the side of each foot *crutches should be kept 8-10 in out to the side elbows flexed 20 to 30 degree angle wear RUBBER soled (or non skid soled) slippers or shoes--prefer without laces look forward not down at feet when walking! crutch height: should be 3-4 fingers below the axilla (1-2 inches space below) keep rubber tips on crutch dry, rest crutches upside down on pads when not using *recall p. 315 crutch walking gaits (four point, three point ,two point, swing to swing) WALKING GAIT PROGRESSION: 3 point-->2 point-->4 point when standing up from a chair: hold hand grips of both crutches in the hand of the affected side, move to chair's edge, hold armrest with hand on unaffected side to sit: back up to chair, move both crutches into hand on affected side, hold armrest with unaffected side and lower body steps to ascend upstairs: 1. assume tripod position, then bear body weight on crutches 2. place unaffected leg onto stair 3. transfer body weight to the unaffected leg and raise the body onto the stair 4. advance the affected leg and crutches up the stair 5. realign the crutches with the unaffected leg on step before repeating the process

Premature infants weight nutrition requirements

less than 2500g less than 37 W *everything underdeveloped, so need diet high sodium, calcium, protein than normal to help with growth calories= 100-200/kg/day *use small preemie nipples effective to easen sucking for small infants vitamins given orally

expected vs. unexpected findings during pregnancy assessment considerations

leukorrhea (first trimester) expected= milky white vag secretions unexpected= green, yellow, foul smelling *expect to have (pink/brownish mucoid discharge toward labor!) breasts sensitive/sore: rx= COOL compresses to sides of breasts, well fitting supportive bra *NO WARM compresses or massaging weight gain: excessive weight gain= >6.6 lb (3kg)/month inadequate weight gain= <2.2 lb (1kg)/month first trimester= 2-5 lbs second/third= 0.66-1.1 (0.3-0.5) lb WEEKLY braxton hicks contractions: feelings of tummy tensing and relaxing constipation/hemmorhoids--expected due to pressure of growing fetus: rx= high fiber, high fluid, reg exercise (moderate intesity--walk, swim, aerobics), bulk forming supplements (psyllium, methylcellulose, wheat dextrin) LAXATIVES NOT RECOMMEND IN PREG heartburn: expect GERD due to uterus leg cramps--common at end of day (low calcium) take Ca supplement if ordered, stretch backache/ pelvic pressure/earache/sinus congestion (fluid retention--increasing blood volume) uterine cramping--is expected as uterus enlarges in lower abd inguinal region *not abnormal in absence of vaginal bleeding!! urine: urinary frequency common in first trimester skin= Normal findings cholasma--darker pigmentation of nose/cheeks "mask of pregnancy" -->condylomata acuminata (anogenital warts) caused by HPV--painless, fless colored bumps --> PUPPP pruitic raised lesions on abd straie (discomfort but not harmful to pt) hot flashes/chills--NOT NORMAL, report to HCP painful genital lesions-->ABNORMAL! HSV! DOPPLER: detects fetal heart rate by 10-12W quickening: (awareness of fetal movements) occurs 18-20W primigravidas, 14-16 multigravidas

Hypertensive Crisis

life-threatening-->causes severe organ damage! (sys >180, dia >120) sx= HTN encephalopathy (severe HA, confusion, N/V, seizure) blurred vision, papilloedema risk for hemorrhagic stroke so... PRIORITY ASSESSMENT= LOC rx= IV vasodilators (nitroprusside sodium) -cont monitor BP, UO, telemetry goal= DECREASE MAP NO MORE THAN 25% to maintain MAP of 1110-115 (then pressure can be lowered further next 24 hrs) imp!! lower bp SLOWLY (too rapid may cause decreased perfusion to organs)

Kock Pouch (Continent Ileostomy/Ileal conduit) ileostomy considerations/ complications??

like ileal conduit but does NOT have continuous flow! ureters transplanted to isolated portion of ileum (pouch) with one-way valve catheter urine is drained from -at pts control for drainage, must drain at reg intervals ILEOSTOMY: -stool is liquid (in small intestine); large intestine is formed -external ostomy appliance: cut 1/8 in larger than stoma -diet= low residue immediate post-op, then transition to reintroducing fibrous foods one at a time -teach to thoroughly chew foods -foods to avoid= high fiber, stringy veggies, seeds/pits/ edible peels -may consume fruits (pitted, peeled, cooked)= peach, banana, potatos ileostomy complications: sx= N/V, abd distention, bloating, pain, decreased stool= bowel obstruction!

insulin types and peak levels

lispro (humalog)- rapid acting peak in 30 min-3 hrs, give to pt eating within 15 min, postmeal hyperglycemia regular --short acting peak in 2-5 hrs, lasts 6-10 hrs best for IV use, DKA isophane--intermediate acting onset of action 1-2 hrs peak 6-14 hrs duration 12-18 hrs (give 2x/day) keep in mind, since has a long peak--if take at bedtime (often do), can cause morning hypoglycemic levels--help prevent by EAT A BEDTIME SNACK W/ PROTEIN/CARBS glargine (lantus)--long acting: works over 24 hrs, no peak level; given usually in evening; once a day (if pt is NPO for 12 hrs, HCP may hold glargine dose) ----------------------------------------------*detemir: long acting, given once or twice a day

when to hold insulins? lispro? prandial v correctional?

lispro (rapid) prandial= fixed dosage when eating to prevent hyperglycemia-->hold if BG <70! correctional= if hyperclycemic -->hold if < 150 (think cause less than this is about norm)

Intrahepatic Cholestatis of Pregnancy

liver disorder exclusive to pregnancy sx= generalized, intense itching, but NO rash (often in hands and feet and worsens at night) *increases risk of intrauterine fetal demise--IS PRIORITY PT IF FIND! rx= meds ursodeoxycholic acid labor induce at 37W G feal surveilance and labs for elevated bile acids

Chest physiotherapy (CPT) used for cystic fibrosis?

loosens secretions in resp for airway clearance in CF: use HFCWO vest (high frequency chest wall oscillation vest) *can give bronchodilators during or before test, perform test at least 2x per day and PRN, can do with percussion with own hands or vest--mult dif ways! *do NOT eat 1 hr before or 2 hrs following, can cause GI upset n/v with therapy

Death rattle

loud rattling sound with breathing that occurs in a client actively dying med to help relive= atropine drops SL or scopolamine patch (anticholinergic effects dry secretions)

Borborygmi

loud, gurgling bowel sounds signaling increased motility or hyperperistalsis; occurs with early bowel obstruction, gastroenteritis, diarrhea

Hypoparathyroidism

low ca, high phos (hypomagnesmia) *recall ca cns depress so sx= excitability sx= tetany, muscular irritability (spasms), parasthesias seizures anxiety, dysphagia, laryngeal spasm dysryhmias dense bones (high ca in bone, low in serum) rx= emergency= IV calc gluconate over 10-15 min calcitrol for acute hypocalcemia (0.5-2 mg) ergocalciferol 50,000-400,000U diet= high phos, low ca *vit D absorbs cal and phos institute seizure precautions!

Renal Diet

low sodium, potassium, phos limit fluids (increases sodium, decreased GFR causes fluid retention) foods good: apples, pears, grapes, pineapple, blackberry, blueberries, plums

Torsades de pointes rx

magnesium IV!! one cause is hypomagnesemia *may also need defibrillation

Albuterol

major common SE is tachycardia! (expected), tremor, palpitations, restlessness, and Hypokalemia! -->reduce these SEs with use of a spacer/chamber device this effects usually diminishes after pt has been on for a week or longer shake in canister before inhalation

fractures

major complication= fat emboli (long bone fx) AIRWAY/BREATHING ISSUE compartment syndrome --CIRCULATION ISSUE rx= immobilize joint above and below fx

congenital anomaly of the heart

malformations of the heart that are present at birth when have cyanotic heart defect (like tetralogy of fallot), have chronic hypoxemia and body tries to compensate by making more RBCs to carry O2 (polycythemia)= HgB >22 or HCT >65% *increased blood viscosity increases risk for thrombus/stroke

malpractice vs negligence

mapractice= KNOWINGLY didnt follow through on standard of care, duty, breach of duty, causation, and actual injury/harm suffered by pt! negligence= UNINTENTIONALLY failure of person to perform act that would be reasonable part of their job they should have known to do (act of omission or commission) *failure to provide competent care

hard of hearing

may cause pt to be suspicious of strangers DOES NOT cause speech difficulties

Rubeola

measles, airborne precautions *increase in international travel and unvacc'd children have caused resurgence of disease (even though there is 99% in reduction due to MMR vaccine) sx= fever maliase, follow by cough and kopliks spots and buccal mucosa, coryza (copious clear mucuous), conjunctivitis erythematous maculopapular rash with face first then turns brown after 3 days when sx subside (is not pruitic--no itching lotion to be applied) isolate until 5th day, bedrest first 3-4 days seizure precautions!! humidifier, dim lights skin clean, hydration *take vit A supplement (can cause deficiency) *have pt family received MMR vaccine as prophylaxis within 72 hrs of exposure *avoid calamine lotions (measles rash does NOT itch, this is good for varicella!)

Jugular Venous Distention (JVD)--how to measure?

measure with HOB elevated 30-45 degree angle observe prominent pulsation and distention of neck veins

DKA what is #1 cause?

metabolic acidosis (or partially compensated), ketosis, and hyperglycemia, dehydration #1 cause? =infection! (then surgeries, skip insulin) #1 Nursing Dx= DEFICIENT FLUID VOL r/t osmotic diuresis 2/2 Hyperglycemia AEB ...sx (can result in hypovolemic shock!) sx= more rapid onset of sx than HHNKS! high sugar (250-500) kussmaul respirations (deep, rapid RR) -->DO NOT HAVE PT BREATHE INTO PAPER BAG TO TREAT (this breathing is good as it is compensatory to blow off excess acid, by having them breathe in paper bag they would reverse this process & pt be acidotic again) ketones (fruity breath) metabolic acidosis (Low pH, low HCO3) initially hyperkalemic (before insulin rx) then hypokalemia (from insulin therapy) osmotic diuresis hyperventilation (kussmaul) abdominal pain common! bicarb <18 serum osmolality <320 (still hemoconcentrated but not as much as HHNKS) lethargy 1. first treat dehydration (from osmotic diuresis due to high bg) with NS or 1/2 NS 2. then admin insulin (reg insulin IV) *when glucose <200-250, switch to D5W to prevent hypoglycemia until ketoacidosis resolved *ASSESS POTASSIUM level prior to insulin therapy (insulin puts K in cells)--watch for hypokalemia w/ insulin! 3. give potassium EVEN IF PT NORMOKALEMIC! (3.5-5) to prevent hypokalemia from insulin admin ...however... (potassium should NOT be given until level is for sure known to be norm or low, and urinary voiding observed) *never given as rapid IV bolus either! INSULIN DEFICIENT= HYPERKALEMIA INCREASED INSULIN=HYPOKALEMIA -because.. pts with insulin deficiency (as in DKA, will have increased K+ levels--going extracellular) -once give insulin, serum K+ will drop asap as insulin shifts K+ back into cells (cause hypokalemia)

osteopenia

more than normal bone loss for pt's age and sex Must have adequate vit D and Calcium intake! good food choices that combine both= think fish and dairy milk, yogurt, sardines, salmon, cereal! calcium= think "dairy and greens" cheese, ice cream, tofu, soy, almonds, green veggies vit D= think vit "deep sea"= fishy things tuna, oily fish, cod liver oil, egg yolk

West Nile Virus

mosquito borne disease (encephalitis) occurs during summer months esp humid weather rx= avoid mosquitoes, use insect repellent wear long sleeves, long pants, LIGHT COLORS, avoid outdoor activities at dawn and dusk when theyre most active *do not get from dogs, raw fruits (these are other infections)

Retinoblastoma

most common childhood intraocular malignancy, under age 2 sx= white glow of pupil (leukocoria) absent red reflex (when pic taken) asymmetric or differing color in affected eye fixed strabismus (Constant deviation of one eye from the other, cross eyed) visual impairment is a late sign rx= radiation therapy enucleation (eye removal), fit for prosthesis *siblings should undergo screening, is hereditary!

dust mites

most common trigger for perennial allergies common sites of exposure? bed linens! wash sheets q 1-2 weeks with hot water **need HIGH temp (not warm/cold) to kill vacuum mattress regularly (avoid carpeting at home or VACUUM DAILY), allergy proof mattress/pillow covers

iron deficiency anemia

most common type! most common chronic nutritional disorder in children sx= glossitis spoon figner nails "koilonychia" decreased serum albumin, transferrin, gamma globulin Rx= dietary iron supplements PO or IV iron dextran (meat, shellfish, poultry, eggs, green leafy veggies, dried fruits, dried beans, brown rice/oatmeal) (IV iron has high incidence of anaphylaxis so monitor for!) *eat foods rich in Vit C to enhance absorption take on empty stomach with ascorbic acid *avoid dairy at same time (calcium), decreases absorption --consume products 2 hrs B4 or 1 hr after take iron if GI upset, take with meals can stain teeth grey! take with straw INFANTS AT RISK FOR IRON DEFICIENCY ANEMIA: -preterm gestation -exclusively breastfeeding/breastmilk -delayed intro to solid food -consuming cow's milk before age 1 yr (can cause GI blood loss) -insufficient dietary intake in toddler's common cause= EXCESS MILK INTAKE (>24 oz/day) *milk is poor source of iron *limit milk intake in toddler's 16-24 oz/day *need iron supplementation (oral iron drops, iron fortified cereal/formula) if breastfeeding: if preterm, starting at 2-3 mo if term, start at 4-6 mo then eat iron rich food: leafy greens, red meats, poultry, dried fruit, fortified cereal

Cancer pain chronic pain

most effective pain mgmt= ATC (chronic pain) *teach= cont to admin long acting opioid even if pt states they are not in pain (do NOT taper dose) *likely will develop higher tolerance and not be as prone to resp depression effects as pts only on immediate opioids

Behavior modification therapy--most imp factor?

most imp factor= all staff members understand and are compliant with treatment plan observe pt behavior at reg intervals to obtain baseline info r/t pt acting out causes (best way in order to modify rx)

BUN is affected by?

muscle mass, level of hydration, (dehydrated= increased BUN) diagnosis of anemia, GI bleed dietary intake of protein (increased intake will increase BUN) fever elevated in shock state: decreased renal perfusion

amyotrophic lateral sclerosis (ALS) (lou gehrig's disease)

muscle wasting, spasticity, atrophy progressive, degenerative, nerve cells to weaken and die, voluntary motor system (causes multifactorial) no cure, life span 3-5 yrs post diagnosis sx= usually begins upper extremities (distal portion) fasciculations (muscle twitching) **WHEN CONDITION GETS TO POINT WHERE START TO HAVE RESP/SWALLOWING ISSUES-->THIS IS PRIORITY PT TO ASSESS: any sx including resp insufficiency (usual cause of death) dysphagia, atrophy, dysarthria, tongue fatigue cognitive dysfunction! constipation rx= airway #1 priority!-->BIPAP for support -mobility devices -communication assistive devices med= riluzole (slows progression of disease), spasms, uncontrolled secretions, dyspnea meds to decrease sx

Malnutrition

muscles become fatigued and weak sx= UNINTENTIONAL WEIGHT LOSS (if pt reports sx of malnourished, ask about this!) WEIGHT GAIN IS BEST INDICATOR OF PT RESPONDING TO MED THERAPY (steady weight gain over specific period) *albumin (even if norm), not as accurate (may not reflect change over 2 weeks) *prealbumin is more accurate! --over 2 days shows

furosemide

must give slow IVP over 1-2 min-->fast acting diuretic! (no more than 4mg/min IV) must give slow IV no more than 4mg/min in doses >120! (use formula: ordered/ (4mg/min)= ____min (desired dose in min) to prevent: OTOTOXICITY= AE not hypokalemia! (slower infusion will not prevent hypokalemia from occurring)

what to do if pt prescribed SSRIs and MAOIs?

must taper the existing med and d/c, then follow with a 2 week washout period without either med then pt can begin taking new med

Multiple sclerosis

myelin sheath destruction. *leads to paraplegia or complete paralysis sx= early: diplopia, vision/sensory changes, (optic neuritis--blurred vision)--if pt in hosp w/ MS showing this, this is expected and can STILL BE D/C'd safely! late: cognitive/bowel changes ataxia, spasticity, muscle incoordination, swallow/speech difficulties, nystagmus, tremors, incontinence, sexual dys, emotional instability, FATIGUE--(DO NOT ADVISE PT TO INCREASE DURATION OF EXERCISE, balance exercise with rest) rx= eye patch diplopia AVOID TETRACYCLINE/NEOMYCIN (increase muscle weakness) wide base walk + ADD ASSISTIVE DEVICES (appropriate to suggest here as this is a chronic disease which will require cane/walker as progresses) fluid intake! warm baths, bladder bowel training social activities *balance exercise with rest due to fatigue (encourage ambulation! ROM/strengthening stretching exercises) *avoid overexposure to heat/cold (sensation changes damage)

Myxedema and Myxedema Coma Hypothyroidism

myxedema= severely advanced hypothyroidism-->causes SLOWING of all bodily functions hypothyroidism causes= ELEVATED TSH, DECREASED T3/T4 (levothyroxine--therapeutic effect= DECREASES TSH to create a euthyroid normal state) sx= all have to do with decreased metabolism dry skin and brittle hair--HAIR LOSS, alopecia, sensitive to cold, obesity, macroglossia, nonpitting edema, depression, myalgia, arthralgia HYPER cholesterolemia, forgetfulness, slurred speech, confusion, weight gain, menstrual irregularity (can be low or high), anemia rx= hormone replacement (levothyroxine) or liothyroine is necessary!! -->sx are reversible w/ treatment!! provide adequate rest slow and simple terms to speak, allow extra time for them to speak, think diet= high protein, low calorie (think slow metabolism, obese), small frequent feedings, increase fluid coma= severe hypothyroidsm (due to off med, illness, chemo, surgery) need IV levo asap! (may take a week for med to kick in) *if resp status is severely decreasing, first priority however is ENDOTRACHEAL INTUBATON, THEN IV LEVO -slowed organ func, hypothermia, dif breathing LEVOTHYROXINE: take 30 min before a meal consistent every morning

amniocentesis

needle puncture of the amniotic sac to withdraw amniotic fluid for analysis (use US to guide only if necessary to avoid trauma from needle to placenta, fetus) done at 16W, possible after 14W-->to detect genetic disorders (hemolytic disease of newborn) done at 30W to assess L/S ratio to determine lung maturity ALSO CAN TELL GENDER BLADDER MUST BE EMPTIED IF >20W G *tests results take 2-4 weeks *complications= premature labor, infection, amniotic embolism, abruptio placentae *teach pt to monitor fetal mvement, and report abd discomfort, fever, fluid loss after asap! *Rh isoimmunization--to avoid rh neg mother get rho(d) immuneglobulin after procedure

non bilious vs bilious emesis

non-bilious= contains food, not green has not been digested so pathology proximal to pylorus pyloric stenosis bilious= green, digested (has bile) pathology distal to pylorus hirschsprungs disease

Magnesium Sulfate toxicity?

norm levels= 4-7 mEq/L during normal administration, nurse care includes: -assess DTRs q 1hr - toxicity sx: when >7 mEq/L absent or decreased DTRs resp depression decreased UO mild: nausea, flushing, HA, hyporeflexia hypocalcemia, somnolence resp/cardiac arrest rx= stop mag therapy antidote= calcium gluconate!! (IV bolus)

Lead Toxicity (Plumbism)

normal blood lead levels </=5 mcg get Blood lead level screening for ages 1-2, up to 6 if never done yet sx= PICA (eat flaky paint chips, taste sweat, watch in children) (GI and CNS affected) N/V, adb pain, poor app, constipation irritability, sleepy, decreased acitivity, increase ICP anemia risk= LEAD POISON AFFECTS NEURO SYSTEM (permanent cognitive impairment) *norm level= <5 mcg/dL chelation therapy (rx for iron, mercury, arsenic, lead poisoning) promotes excretion in stool and urine meds= ethylenediaminetetraacetic acid (EDTA), dimercaptosuccinic acid, calcium disodium, succimer, and dimercaprol MILK IS FLUID OF CHOICE, calcium binds and leads to excretion goal= prevent cont exposure!! teach= do not drink out of pottery with lead glaze handwash before eat MOP/WET dust hard surfaces (dont vacuum--spreads in air!) use COLD WATER for consumption (hot water dissolves lead from old pipes) flush taps several minutes to clear out contaminated water before use

Carboxyhemoglobin

normal level <5% nonsmokers < 10% smokers *pts with this will often have norm pulse ox % readings (CO falsifies it) *cause oxygen saturated with HgB, pulse ox cant correctly identify and differentiate it Carbon monoxide (CO) poisoning= greater than norm levels! sx= nonspecific HA, dizziness, fatigue, nausea, dypsnea rx= asap admin O2!! (at risk severe hypoxia)

phenytoin toxicity

normal levels= 10-20 (is an AED) SEs of reg. phenytoin levels= hypotension, arrhythmia's folic acid depletion increase in body hair rash decreased bone density (osteoporosis) can make urine/sweat red-brown is expected! risk for toxicity increases with decreased liver function (older adults at risk due to increase likelihood of impaired liver func) toxicity sx= CNS EFFECTS -horizontal nystagmus, ataxia (early) -dysarthria, lethargy, confusion, coma encephalopathy (decreased mentation)= late AEs (that do not indicate drug toxicity!) STEVEN'S JOHNSON's SYNDROME (SJS) GINGIVAL HYPERPLASIA (swollen, bleeding gums) *if pt develops gingival hyperplasia, do not stop med (this is just AE have to work with) S/Sx to d/c Med= -hypersensitivity to (fever, skin rash, lymphadenopathy) Isoniazid (if given in combo with phenytoin) PAUSE TUBE FEEDINGS 1-2 hrs after med admin to ensure absorption (or else may cause seizures), avoid antacids, calcium contain products for 1-2 hrs, can decrease drug absorption *NEVER ABPRUPTLY WITHDRAWAL PHENYTOIN EXCEPT IF SJS OCCURRING (SEIZURE RISK) -->immediate d/c notify HCP and rx to prevent MODS *can decrease the effectiveness of some meds (oral contraceptives, warfarin) *need alternate non-hormonal birth control (condoms, copper IUD) in addition or in replace of to combat AEs: -diet high in folic acid and calcium (osteo) -soft bristle toothbrush (gingival) -regular dentist visits

epistaxis

nosebleed home mgmnt: -direct, continuous application of pressure to soft, compressible area below nasal bone for 5-15 min (promotes clot formation) -hold COLD CLOTH or ice pack to bridge of nose to induce vasoconstriction -keep pt quiet and calm position= sit upright, tilt head forward can be managed at home, only seek emergent care if breathing issue or excess uncontrollable bleeding not able to be controlled by home measures, or result from traumatic injury

client confidentiality

nurse is obligated to share client information with personnel directly involved in pts care *if pts asks for strict confidentiality, have to be honest and tell them this

incident report--due to cause by medical error rather than pt's underlying condition!

nurse should NEVER doc in pts chart an incident report was filed or refer to incident in med report *risk manager is to receive report within 24 hrs and investigation with begin exs to fill out: pt/fam refuses treatment as ordered AND refuses to sign consent (if pt just refuses PNA vaccine--this is autonomous decision--, and acquires PNA, this is not reason to fill out incident report) pt/fam voice dissatisfaction with care and situation cannot or has not been resolved failure to report change in pts condition; incident with staff member regarding safety; diagnostic delays; error in treatment; preventitive errors; system failure, equipment failure; communication failure; physical/verbal/sexual assault occurs; staff/visitor falls (regardless whether they accept or refuse rx); pt falls w/ or without injury-----------------------------------------------DOES NOT INVOLVE MANAGERIAL ISSUES (staff consistent shows up late, etc)

nosocomial infection

occur after over 48 hrs of admission or up to 90 days after discharge at risk young children, elderly, immunocompromised long stays invasive devices overuse abx surgical incisions

Therapeutic communication

occurs between nurses and clients ONLY encourages the clients to express thoughts, feelings, anxieties PURPOSE= to promote growth/change in pts *does not include SOCIAL conversation DO NOT ASK WHY, EVEN IF THE STATEMENT SOUNDS GOOD, NEVER DO IT. *do not leave the pt, esp if they express emotion/start crying, stay with them and let them collect themselves with you there *good to state factual info: if pts parents asking about child's condition, good to say "we have the bleeding under control"

Guillian-Barre Syndrome (GBS) Symptoms

often develops from a prior resp/GI infection Flaccid paralysis (Ascending) (loss of sensation) absent DTRs Respiratory failure-->MOST THREATING SIGN (priority thing to watch for! Urinary Retention paralytic ileus DVT diaphoresis and facial flushing assess: -serial spirometry (measure forced vital capacity FVC= gold standard to assess ventilation--a decline indicates impending resp failure and requires ET intubation)-------------------------------------*KEEP IN MIND, IF PARALYSIS IS NOT AT DIAPHGRAM YET (ONLY 0+ on DTRs and at knees, pt is not priority assessment until paralysis gets to resp level!)

ascites

often occurs in liver cirrhosis pts, accumulation of fluid in peritoneal space *rx= paracentesis complication= hypotension give IV albumin after paracentesis increases intravascular oncotic pressure resulting in INCREASE INTRAVASCULAR FLUID VOLUME (keeps VS stable) *albumin does NOT directly reduce ascitic fluid volume

nonrebreather mask

one way valve between bag and mask preventing exhaled air from entering bag and diluting oxygen concentration exhalation valves located on sides of mask that flutter (close on inhalation to prevent entry of room air and open on exhalation to prevent reinhalation of exhaled air) *liter flow must be high enough (up to 15L/min) to keep bag at least 2/3 inflated during inhalation and prevent buildup of CO2 in bag INCREASE OXYGEN FLOW IF NOTICE RESEVOIR BAG FULLY DEFLATING ON INSPIRIATION deliver 95-100% oxygen concentration

Histoplasmosis

opportunistic fungal infection most common in immunocompromised pts (HIV, malnourished, TNF factors, corticosteroids) from spores found in soil containing bird/bat droppings (inhaled fungal spores) sx= asymptomatic OR mild PNA like sx (fatigue, fever, dyspnea, cough) *in reg healthy people condition is self limiting and no rx needed *immunocompromised can develop chronic pulmonary infection or disseminated infection--treat in hospital

Progestin-only pills (POPs)

oral contraception *must take pill at SAME TIME EACH DAY for it to be effective *if pill is taken even >/= 3 hrs late, must use barrier contraceptive method--this is advised until pill is taken correctly for 2 days *take additional POP if diarrhea/vomit occurs within 2 hrs of last dose (inadequate absorption) SE= breakthrough bleeding (no inactive pills in pack, no menstruation) *low risk for thrombus--as no estrogen in these pills! *for ANY ORAL CONTRACEPTIVE, BACKUP CONTRACEPTION IS REQUIRED FOR 7 DAYS AFTER STARTING PRESCRIPTION

Thiazolidinediones

oral hypoglycemics ("glitazones") AEs= worsen heart failure, bladder cancer, fluid vol overload, MI contraindications: -heart failure -volume overload

Methods of contraceptives

oral: AE= N/V (first 3 mo), vag infections increased risk contraindicated in: HTN, thrombophlebitis, DM, hx Cardiovascular disease if miss 2 or more pills, contact HCP and must use alternative method of birth control for rest of cycle report DVT sx! methoxyprogesterone hormone injections: effective for 12 weeks at a time MPA/estradiol injections: monthly dose, contraception within 5 days of LNMP IUD: AT RISK FOR PID WITH THIS! *check for presence of string routinely, esp after each menstrual period (report missing, shorter, longer) *at risk for infection, cramping, excess menstrual flow first 2-3 mo condom: use ***water based lubricant, NOT petroleum based if breaks, apply contraceptive foam/cream ASAP female (Vag) condom: barrier method but not required to stay in place like diaphragm so no risk for TSS *do not use at same time male partner using condom *allow some protection, but higher failure rates risk infection Diaphragm: risk for INFECTION (UTI)/ TSS *do not insert more than 6 hrs prior to coitus use with spermicidal gel applied to rim and inside dome before reinserting *remove at least once q 24 hrs to decrease risk TSS *need to reassess placement if loose or gain significant weight (childbirth) subdermal implant (levonorgesterel) *effecctive for 5 yrs natural fam planning: ***predicting ovulation: changes in cervical mucous consistency thick, cloudy, sticky= nonfertile thin, clear, slippery, stretchy= ovulation sterilization: vasectomy= not fully sterile until 3 mo post-op, must use contraceptive during this time tubal ligation (for females)--resume intercourse after bleeding ceases

orchitis prostatitis

orchitis: --complication of mumps, virus, STI inflammation of the testes rx= ice packs to reduce swelling bedrest scrotal support prostatitis: inflammation of prostate gland, usually caused by bacterial infection --may be lower UTI comp (same sx) sx= rectogenital pain, burning, urinary hesitancy, urgency rx= sitz baths--relieve sx abx--full course! fluids! (clear liquids) -avoid coffee, tea, caffeine NSAIDs tamsulosin, alfuzosin (alpha-adrenergic blockers) help relax bladder and prostate -ENGAGE IN SEX/MASTURBATION to reduce discomfort r/t retained fluid (use condom) -stool softeners to avoid straining *may need suprapubic catheterization (inserted through tummy) in severe cases (urethral cath is contraindicated due to risk of exacerbating)

Mannitol

osmotic diuretic rx cerebral edema/acute glaucoma AE= fluid overload-->pulm edema (if duresis not actually occurring, such as pt as CKD)

vancomycin AEs considerations

ototoxicity (enhanced if given with furosemide) nephrotoxicity (monitor BUN/Cr levels 2-3x/week) rx= MRSA/Cdiff WATCH FOR RED MAN SYNDROME (can happen with rapid IV infusion) *is a rate related NOT allergic rx prob *rx= reduce infusion over a minimum of 60 min sx= hypotension, flushing -premedicate with antihistamines if pt has this syndrome therapeutic level= 10-20 *monitor vanco trough levels before the 4th dose, should obtain about 15-30 minutes prior to admin of next dose infuse over at least 60 min monitor bp (can cause hypotenison) flushing of skin (red man syndrome)--hypersensitivity observe IV site q 30 for extravasation anaphylaxis -verify patency of IV line before admin (watch for thrombophlebitis)

aminoglycosides toxicity

ototoxicity and nephrotoxicity (*assess for hearing, balance, and UO) gentamycin/streptomycin! neomycin, tobramycin, amikacin

Full-term infants weight? nutrition requirements how many diapers/stool/day? type of feeding and why? breastfeed (type of liquid and when) formula introduction of solid foods--type and when what to avoid first year due to high risk botulism?

over 2500g > 37W cal= 120cal/kg/ day (note less than premature) 6-8 wet diapers/1 stool daily at least breastfeed prefer, provide immune boosting elements formula lacks colostrum secreted first (contains antibodies, more protein/minerals) breast milk secreted 2-4 days (more fat/lactose) if formula: avoid cows milk first year (modified), then can have unmodified *formula is NECESSARY FIRST 12 MO LIFE (then cows milk is acceptable) *first type of milk can be introduced at 12 mo, but SHOULD BE WHOLE MILK (not non fat!)--brain needs nutrition FORMULA CONSIDERATIONS *child should be cradled when fed *before initiating formula feeding in newborn, check reflexes and ready for feeding (bowel sounds, cry, gag reflex, give sterile water to check for esophageal atresia) *dont need to do in breastfeed, start right after birth as colostrum is readily absorbed by GI and resp system -warm bottles in a pan of hot water or under warm tap water for several minutes -test formula temp. on inner wrist before serving to infant (want lukewarm, not hot) -NEVER DILUTE OR OVERCONCENTRATE A FORMULA -discard any formula left over in bottle after feeding FORMULA: keep all bottles, nipples, caps as clean as possible -wash tops of formula cans w/ hot water/ soap -REFRIDGERATE UNUSED, prepared formula or unused opened formula, BUT USE WITHIN 48 HRS or discard american academy pediatrics recommends SOLEY BREASTFEED FIRST 6 MO LIFE in book says about 4-6 mo ready to start introducing foods concurrently with breast/formula for first year: 4-5 mo: cereal first introduced always!! (rice), then stained fruit 5-6 mo: strained veggies/meat 7-9 mo: chopped meat, potato, mashed/baked, hard breads, finger foods *wait 4-7 days between each new food introduced to infant *can introduce simple finger foods 6-8 mo before children even have teeth! *can prepare rice cereal w/ formula, breast milk, water *can home make baby food (by mashing at home) *egg/OJ, more allergenic foods, introduced last (least allergenic first) *keep everything fed in small portions (<1 tbls) *feeding infants who are disinterested may contribute to obesity NO HONEY FIRST YEAR DUE TO BOTULISM RISK

hip spica cast

pain is most common sx of circulatory impairment from cast -->assess blanching of feet! *recall, blanch= good sign, normal skin does this *non-blanchable= likely blood under skin (petechiae, purpura)

Papnicolaou (PAP) test cervical cancer

pap smear Commonly used to screen/diagnose cervical cancer. prep: avoid intercourse 24 hrs before, avoid douching 24 hrs before cervic CA risk factors= -HIV HPV (MOST IMP) hx of STDs infection with other STDs (gonorrhea, chlamydia-->increases likelihood of HPV infection) sexual activity before 18 multiple sex partners oral contraceptive use tobacco!! low socioeconomic status *almost all cervical cancer is due to persistent HPV infection recommendations for testing: those <21 do not need *typically initiate >/=21 yrs regardless of age of onset of sexual activity *age 21-29 should be screening q 3 yrs in US *d/c pap testing at age >65 in US

cesarean birth (c section)

perform if: dystocia (difficult/abnormal labor) previous c section breech presentation or CPD fetal distress maternal gonorrhea/herpes type 2 infections prolapsed umbilical cord HTN states of preg placenta previa/abruptio placentae fetal anomalies (hydrocephaly) two types of incisions: vertical= more blood loss, for emergency cases low-segment transverse= less blood less, can attempt VBAC prep: IV fluids insert indwelling urinary cath lower narcotic doses of drugs than routine preop med monitor for hemorrhage (massage fundus if boggy, inspect excess bleeding, shock-VS) splint incision site with pillow to deep breathe encourage ambulation! position= encourage frequent turning to prevent surgical complications complications= at risk for DVT (preg increases hypercoaguable state)

vasectomy

permanent male sterilization *sperm will still be produced, but are absorped by the body (vas deferens tract for ejaculation cut and sealed off) teach= ALTERNATIVE BIRTH CONTROL USED until HCP confirms semen samples taken at f/u appointment are FREE OF SPERM *can take several months for remaining sperm to be ejaculated or absorbed

Delusions considerations types?

persecutory: paranoid (believe they are being persecuted, harmed, followed, poisoned) method= avoid interventions that causes pt to focus/think on delusion more DO: -focus on the pts feelings secondary to the delusion -focus on reality and verbally reinforce it DONT: *do not confront pt, explore delusion

Bacterial conjunctivitis

pink eye *main concern= highly contagious!! (properly wash hands before/after eye drop instillation) -ensure children wash hands and keep from rubbing eyes

viral Conjunctivitis

pink eye highly contagious!! staff cannot work tell sx resolved (3-7 days), send home

IPV vaccine

polio vaccine *can give to HIV pos pt contraindicated in anaphylactic rx to neomycin, streptomycin, polymyxin B *if pt had seizure within 3 days of DTP vaccine, eval risks of giving IPV vs benefits standard precautions

AMRD--age related macular degeneration

portion of retina (macula) begins to deteriorate common s/sx= progressive BLURRING gradual loss of central vision (opp. glaucoma) (blurred/wavy visual disturbances) *blurry spots in vision *peripheral remains intact *is leading cause of irreversible vision loss risk factors- -advanced age -fam hx -HTN -smoking -long term poor intake of carotenoid containing frutis and veggies prevent= vit C, E, carotenoids -smoking cessation -laser therapy -antineoplastic meds goal= remain free from injury

Shock considerations

position: bedrest, extremities elevated 20 degrees, knees straight, HOB elevated slightly-->aids in blood flow to vital organs! hypovolemic shock: (most common) Sx= change in mental status (confusion), hypotension, tachycardia w/ thready pulse (compensatory) tachypnea decreased O2 sat dizziness, light-headedness COLD, CLAMMY SKIN--is priority finding! (indicates failing compensatory mechanisms) oliguria! <0.5/ml/hr rx= ASAP PRIORITY= IV FLUIDS/ vasopressors! IV epinephrine!! position= do NOT put the pt in HIGH FOWLERS think shock, ALWAYS start with fluids! isotonic or colloid (albumin, plasma) depend on need septic shock: infection priority= ABX!! do not delay--if pt has sepsis and needs abx, this is PRIORITY med to give! sx= hypotension, HYPOTHERMIA (<96.8F, 36C) or fever, leukocytosis or immature neutrophils (bands >10%), prolonged cap refill, tachycardia, decreased UO *warm, flushed skin (early sign) rx= move pulse oximeter to forehead (central) rather than finger Meds: ALWAYS before giving abx obtain culture and sensitivity, then NEVER DELAY GIVING ABX, after obtain give right away! dont wait for results distributive (vasodilatory) shock: types--> 1. neurogenic sx= massive vasodilation, bradycardia, hypotension (think like SCI), poikilothermia (inability to regulate body temp) *warm, flushed skin CARDIOGENIC SHOCK: Heart suddenly can't pump enough blood to meet body's needs rx= furosemide (decrease left ventricular preload) *sx= decreased CO, hypotension, narrow pulse pressure-->can lead to pulm edema! *do NOT give rapid IV fluid bolus here (even if hypotensive) as this can increase circulating blood volume, too much for poor heart to handle, and precipitate pulm edema

trach considerations Purpose of a cuffed tracheostomy

post op care: -priority= CHECK TRACH TIE TIGHTNESS (allow 1 finger fit under ties) -do not change inner cannula until 24 hrs post-op (can change dressing/suction however) -keep cuff inflated (cuffs NOT regularly inflated/ deflated) suction pressure 90-120 mmHg #12 or #14 french suction catheter hyperoxygenate with ambu bag attached to 100% ox before suction! FOR 30 SECONDS if secretions to thick to remove with just suction, increase hydration w/ aerosols of NS or mucolytics (acetylcysteine) admin by nebulizer to help, have humidification!! DO NOT USE WATER decreases chance of aspiration into trachea if tach tube gets dislodged: if mature trach (> 7 days after insertion) attempt to open airway using CURVED HEMOSTAT to maintain stoma patency, then IMMEDIATELY INSERT NEW TRACH TUBE w/ an OBTURATOR (to guide) (have two spare tubes on hand--one same size and one smaller) if new trach tube can't be inserted: cover stoma with sterile occlusive dressing (petroleum gauze, foam tape) to ensure seal so can manually ventilate with bag-valve mask over nose/mouth (dry gauze is porous and air will escape) *DO NOT INSTILL NS INTO TRACH BEFORE SUCTIONING--unsafe!!

phantom limb & residual limb

post-ambutation of limb; pt may still have pain (tingling) in phantom or "missing" limb --let pt be aware of this admin pain meds to help with this residual limb is the part on the amputated extremity that is still there --watch for infection! rx= wrapping extremity in heat/applying ice may help with phantom limb pain

Posterior and anterior fontanelle closing age

posterior: 2 mo (smaller)--triangle, back anterior: 9 to 18 mo (bigger)--diamond, frontal *norm for slight ant. fontanelle pulsations/bulging when infant crying, laying down, coughs

postpartum endometritis vs endometriosis

postpartum endometritis: inflamed uterine lining due to infection -->sx= uterine subinvolutation (does nto return to normal size) -foul smell lochia, fever, chills, tachy risk factor= C-section rx= abx (Clindamycin + gentamycin) vs endometriosis: lining of uterus grows outside of it sx= painful intercourse

cardiac catheterization

pre-op: (question surgery if pt... has hx of previous allergic rx with contrast recieved metformin today elevated Cr (contrast-induced nephropathy--can cause AKI) *site accessed= femoral or radial may feel *BURNING sensation when dye injected post op: -on bedrest 8-12 hrs after, pt supine with affected extremity flat 2-6 hrs post op -pressure dressing over cath insertion site -check peripheral pulses often -monitor for bleeding! q 15 min first hr after (reports of back/flank pain assess for retroperitoneal bleed), tachycardia, hypotension NPO at midnight FOR PROCEDURE!! (children NPO 4-6 hrs or more before) (infants shorter NPO, may be fed right up to time) *Check K+ level before procedure if bleeding: priority= CONTROl (apply direct manual pressure to puncture site--1 in above), then notify HCP position= flat or low fowlers (post op) with affected extrem straight for 4-6 hrs sexual counseling: teach= if pt can walk 1 block or climb 2 flights of stairs without sx, they are ready to resume safe sexual acitivity -encourage pt to discuss this with HCP and with approval of HCP after this acitivity can resume sex in general, ready to resume sex 7-10 days after uncomplicated MI

folic acid foods how much per day?

pregnancy= 400-800 mcg/day to prevent NTDs think "grains and greens" green leafy veggies cereals, breads, pasta, toast, rice also liver, peanut butter!

venipuncture

presence of pins and needles during may indicate nerve pain (if basilic vein used, close to brachial nerve and artery) sharp shooting pain, stop and reattempt with new needle dif location *if pt at high risk infections, best site for least infection risk= upper extremities, dorsal surface of hand (back) higher infection risk sites= lower extremities, wrist/upper arm

Purpose of cuffed trach? cuff pressure?

prevents aspiration of fluids! (inflated whenever client may aspirate-- during cont mechanical ventilation, during/after eating, during/ 1 hr after tube feed) check pressure q 8 hrs, maintain at less than 25 cm/H20 or 20 mmHg

PNA Sx

productive cough, fever, chills, fine/coarse crackles, pleuritic chest pain, increased tactile fremitis! dullness on percussion, unequal lung expansion, bronchial breath sounds

Birth control implants

progestin rods placed subdermally in upper arm provide contraception for up to 3 years ex: IMPLANON, NEXPLANON

Alzeimer's disease

progressive, irreversible, degenerative neuro disorder--loss in COGNITIVE AND BEHAVORIAL DISUTRBANCE sx= forgetful-->cant remember familiar paranoia, depression, combative, impulsive, short attention span night wandering cant perform ADLs deysphasia, incontinence (may develop) rx= calm environment regular routine clear simple explanations, repeat info display clock/calendar secure doors for night wantering gently distract/redirect avoid restraints (increase combativeness) simple activities (walk, exercise, socialize) easy to understand sentences write lists with simple instrctions organize activities into short, achievable steps discourage long naps during day cut food into small pieces *if caregiver displays signs of burnout: refer to social worker for long term assistance programs for pt

cystocele

prolapsed, herniated, dropped, or fallen bladder rx= PESSARY (vag device that supports the bladder, for pelvic organ prolapse) pelvic muscle exercises ERT teach= CAN remain sexually active while on surgery not required (pt can insert and remove themselves) can remove regularly (nightly or weekly for cleaning) *if pt cant remove on own, HCP is to do it q 2-3 mo expected SE= increased vag discharge

how do enemas work/action behind them? position? enema types oil or tap water first?

promote peristalsis; sims with right knee flexed oil before tap water enema (oil loosens hard stool, tap water helps evacuate) *if pt begins cramping during instillation: STOP INFUSING (CLAMP SOLUTION) FOR 30 SEC THEN RESUME AT A SLOWER RATE fleet enema: "bringing a fleet together" infuse hypertonic solution into bowel, pulls fluid into colon cause distention then defecation neomycin enema: medicated reduces # bacteria in intestine in prep for colon surgery

Urinary retention Meds other considerations

pseudoephedrine (nasal decongestant) antihistamines (diphenhydramine) opioids anticholinergics tricyclic antidepressants to assess for , priority action: PALPATE PT'S BLADDER if no urination return: (and pt male) initial action= HELP PT OUT OF BED (often positioning affects retention in older males--BPH) --if not this, then BLADDER SCAN (if sig. retention found (>300-400mL) then perform INTERMITTENT CATHETERIZATION acute urinary retention best treated with= rapid, complete bladder decompression (quickly release urine with cath--can do more than intermittent drainage which is max 500-1000mL at a time) however, watch for... AEs to watch for w/ this= hematuria, hypotension, postobstructive diuresis, bradycardia pain felt by distended bladder= constant, increased over suprapubic area, dull upon percussion

ostomy considerations

pt can resume all normal activities participated in previous life after healing of stoma/incisions abn findings: stoma appears tight; decreased amount of stool (obstruction/stoma stricture) -stoma abn color (not beefy red immediate post op expect): not gray tinged at edges, blueish, paleness, dusky, cyanotic ileostomies, ascending, or transverse ostomies: do NOT need to be irrigated (still liquid to semi liquid stools) IRRIGATE: may need to with descending or sigmoid ostomies since stool more formed change bags at least once a week--good time to closely inspect stoma size pouching system for stoma should be approx 0.1 in larger than stoma teach= drink LOTS of fluids!! 3000/day eliminate foods cause gasy and odor (broccoli, cauliflower, dried beans, brussel sprouts) *empthy pouch when becomes 1/3 FULL! (prevent leaks from increasing pouch weight) postop new stoma expected findings: -blood tinged mucus first few days -beefy red color fresh post op -stoma bleeds a small amount with manipulation (bag change) during postop period -by post op day 6, expect stool in ostomy (type depending on location) (stool appears when peristalsis returns--recall 5-7 days postop) -mild to moderate swelling for 2-3 weeks post op priority post op goal= PT WILL LOOK AND TOUCH STOMA (pt needs to be willing to do this to perform all other activities of self care)

enteral nutrition enteral medication (NG Tube)

pt unable to digest food but can still absorb nutrients through stomach purpose= maintain gut integrity, and help prevent stress ulcers (think, TPN doesn't do this--vascular) admin at room temp! watch for hyperglycemia complications: dehydration-- flush tube with water or give IV fluids flush tubing before, between, and after meds given through to avoid drug interactions cramp/ N/V--decrease feeding rate, change formula more isotonic if need aspiration--elevate HOB, check residual before feeding giving med: always crush each med separately before admin if not extended release BUT SEE IF MED AVALIABLE IN LIQUID FORM FIRST to help tube not clog, flush before and after each med *both TPN and enteral feeds have equally high risk of hyperglycemia *however, enteral is associated with lower risk of infectious complications, but mortality is the same

Diet to avoid with gout/ uric acid

purine: organ meats (red meat)/ seafood (shellfish/sardines), oily fish with bones

what are isometric exercises?

purpose= maintenance of muscle strength when joint immobilized JOINT REMAINS IMMOBILE Description= performed by client; alternate contraction and relaxation of muscle without moving joint (body stays in one position) examples= lifting weights

intermittent self cath teaching how often? how much should expect? how much liquid to consume?

q 4-6 hours, be consistent!! at times daily expect 350-400 mL each time should drink 250 mL at 2 hr intervals, or up to 2 L at reg intervals (help increase comfort)

Delirium tremens

rapid onset of confusion caused by alcohol withdrawal often occurs 3 days into withdrawal symptoms (48-96 hrs) sx= high BP, shaking, confusion, agitation, hallucinations, diaphoresis, tachycardia, fever Rx= with sedation (benzos), give to avoid alc withdrawal from developing into this *look out for increasing vital signs

Best indicator of hydration status best indicator of fluid status

rehydration= Urine output! fluid status= daily weights!

hypophysectomy

removal of the pituitary gland (acromegaly) post op care: observe for hypoglycemia elevate HOB observe hormonal deficiencies (glucocorticoid, thyroid)-->all made by pituitary! cortisone replacement before and after surgery avoid coughing avoid brushing teeth 2 weeks *pts with pituitary issues may have diabetic issues

renal transplant transplant considerations

renal transplant: pt needs to be in protective isolation post op for (for 72 hrs) consider: -post-transplant infection is most common cause of death (sx= (low grade even) fever, productive/dry cough, change in secretions) *however, if pt gets oral candiasis, this may not be priority pt as this is a common SE of immunospressant med pt is on

respiratory distress syndrome (RDS)

respiratory complication in the newborn, especially in premature infants *due to insufficient surfactant production (prematurity, genetic) sx= labored respirations, grunting, flaring, tachypnea, retractions, apneic epsidodes, unresponsive rx= maintain body temp TPN! *nipple/gavage feeds contraindicated IV fluids patent airway: suction, O2, mechanical, PEEP or CPAP (keep nasal prongs in place) position= side lying with head support by small folded blanket OR on back with neck slightly extended meds= abx, diuretics, vit E, surfactant

therapeutic response for pt with hallucinations/ delusions

responds to pt feeling, acknowledge client believes its true, but them represent reality in middle of hallucination: decrease environmental stimuli, place pt in quiet, darkened room

Rh incompatibility

rh neg mother, rh pos father-- baby is rh positive mother's antibodies will attack babies--breaking down fetus blood cells

Mitral valve stenosis. Association? Mitral valve prolapse (MVP) mitral valve regurgitation

rheumatic (fever)-->causes carditis, affects valve *diastolic murmur= auscultated at APEX OF HEART (5th ICS, midclavicular line) MVP (blood may leak back into atrium from ventricle)=regurgitation sx= palpitations, dizziness, lightheadedness, chest pain rx= beta blockers (for chest pain)--MVP pts dont respond to nitrates teach= -avoid caffeine, eat healthy, stay hydrated! -check OTC meds for stimulants (caffeine, ephedrine) -reduce stress -avoid alcohol use -aerobic exercise Mitral Valve Regurgitation *backflow of blood from left ventricle into left atrium-->can dilate left atrium-->reduce CO-->pulm edema can cause HF!! PRIORITY PT if observe sx of HF (fatigue, fluid overload, dyspnea, orthopnea, weight gain, cough)

Abdominal Aortic Aneurysm (AAA) where to auscultate bruit? thoracic aortic aneurysm

right above umbilicus (where abdominal aorta is) bruit indicates turbulent blood flow in aneurysm (swishing, humming, buzzing sounds) heard with BELL of stethoscope! weakening in vessel wall of abdominal aorta sx= acute onset abd pain radiating to low back w/ sx of hemorrhagic shock, hypotension, tachy, pallor THIS IS THE PRIORITY PT (even over potential sepsis/peritonits) as can cause life threatening MASSIVE hemorrhage! AAA> peritonitis!!!!!!! AORTIC ANEURYSM REPAIR: (W/ graft) *watch for decreased pedal pulses/mottled extremity as can indicate presence of ARTERIAL/GRAFT OCCLUSION -pre-op assess: peripheral pulses to get baseline for after surgery! -ENDOVASCULAR repair does NOT require abd incision, is a sutureless aortic graft, via femoral artery small incision in groin, minimally invasive procedure *OPEN REPAIR is standard procedure--does have large incision made in abd sx of graft leakage: pain in pelvis, back, groin (not relieved by meds) DECREASED UO distended firm abdomen decreased HCT/HbB, tachy, increased abd girth ECCHYMOSIS OF GROIN, PENIS, SCROTUM, PERINEUM *also watch RENAL PERFUSION-->risk w/ aneurysm repair is kidney injury (BUN, Cr, UO) expect sx post op: -abdominal tenderness, but abd soft, nondistended -pain -green bile drainage from NG tube (bloody would be concerning) monitor post op: -peripheral pulses, puncture sites for bleeding, UO and kidney func (graft occlusion can migrate to kidneys) THORACIC AORTIC ANEURYSM: *AEs= think pressure on esophagus= dysphagia (may mean aneurysm increased in size-check!)

Schizophrenia considerations catatonia

risk factors (exact cause unknown--combo) -twins (other twin has 50% chance develop) -genetic component -biochemical imbalance -structural brain abnormalities (reduce size certain areas) -prenatal development factors -birth trauma, epilepsy, maternal influenza during pregnancy sx= positive sx (hallucinations, delusions OR negative sx (regression, flat affect, emotional ambivalence, lack of energy, lack of interest in social, impaired ADLs) interventions for schiz pts: -if having hallucination, nurse should first assess what they are seeing/hearing etc, then can help pt deal with it -auditory hallucination: give pt headphones, DVD, to help tune sound out; voice dismissal (tell voices to go away), or CBT-assist pt in new ways to think and deal w/ sx catatonia= abnormality of movement and behavior from disturbed mental state (schizo) dx if pt has 2 or more of following features: -immobility -remaining mute bizarre postures (rigid in one position) extreme negativism (resist instructions or attempts to be moved) waxy flexibility (limbs stay in position placed by another person) staring stereotyped movements, prominent mannerism, grimacing AE= (unable to meet basic needs) at risk for DEHYDRATION/MALNUTRITION *social isolation and impaired social interaction are common neg. sx of schizo, nurse needs to accept behavior (let pt walk out of room and not say anything, and continue to attempt at brief contact until pt is comfortable to improve social interaction skills of pt: -make brief, frequent contacts -accept the pt unconditionally by minimizing expectations and demands -assess the pt's readiness for longer contact with the nurse or other pts -be with or close by the pt during group activities -offer positive reinforcement when the pt interacts with others

oral cancer

risk factors: -chronic tobacco/alcohol use (biggest) -excess UV light exposure (sunbathe/tanning bed)--oral cancer also is lips -hx HPV -poor oral hygiene -chronic irritation of oral mucosa (poorly fit dentures, broken teeth, tobacco pipe) sx= mucosal thickening or lump that does not go away -ulcer that does not heal -difficulty swallowing, chewing, speaking -unexplained mouth bleeds -persistant mouth/tongue pain -changes in salivation *precursor sign is erythroplakia (red, velvety patch lesion on oral mucosa) or leukoplakia (white velvet patch)--less common

Peptic Ulcer Disease (PUD)

risk factors: NSAIDs (chronic use) h. pylori infection! caffeine smoking alcohol meal timing= eating mult small per day or short before sleeping worsen! sx= burning pain located where ulcer is rx= meal timing--eating small frequent meals throughout the day or right before bedtime may actually worsen!! (increases stomach acid secretion) -reduce stress, sufficient rest -avoid (GERD) foods--spicy, acidic, black pepper, chocolate, tobacco -refrain from alc products -report black tarry stools, GI bleed (ortho hypo), perforation ASAP -take meds: amoxicillin, clarithromycin, omeprazole combo next 14 days (triple drug therapy of abx and PPI) to avoid relapse -avoid NSAIDs

pneumonia s/sx postoperative (aspiration) PNA HAP/CAP/VAP

risk factors: advanced age >65 (biggest! think vaccine!) -young age <2 -decreased LOC/ CNS depression (aspiration) -chronic cardo/pulmonary disease -immunosuppressed -inadequate nutrition -prolonged immobility -smoking/air pollution -URI -tracheal intubation expected findings PNA sx: rhonchi as condition resolves; crackles (fine or coarse) increased tactile fremitus (consolidated lung tissue increases) unequal chest expansion (decreased in affected lung) bronchial breath sounds at lung periphery (harsh/high pitched) fever, chills, productive cough, dyspnea, PLEURITIC CHEST PAIN dullness upon palpation *hemoptysis can be expected as long as not in abundance (if hemothorax) *subcutaneous emphysema!! (crackles under skin)-->observe resp distress--usually small and resolves on own LOBAR (unilateral) PNEUMONIA: -blood flow influenced by gravity -if pt has left lobar PNA, position in right lateral to have good lung on bottom, so blood will flow there and have most capable lung able to deliver O2 -right lobar PNA= left lateral position (left lung will transport O2) aspiration/ post op PNA: ambulate (w/in 8 hrs), incentive spirometer, cough with splinting, fowlers position SWAB MOUTH Q 12 HRS CHLORHEXIDINE SWABS (prevents VAP) HAP: hospital acquired *best indicator of abx therapeutic effect= DECREASED WBCS! (color of sputum could be due to dif types PNA) CAP (community acquired PNA): -avoid use of OTC cough suppressants (impairs ability to secrete excretions) -schedule follow up with HCP and CXR (2 weeks after abx completion) -use a COOL MIST HUMIDIFIER in bedroom at night (facilitate expectoration of mucus) -warm baths also good for this -cont. incentive spirometer -fluids!! -avoid tobacco, eat good diet, take rest but increase activity slow over 2 weeks -COMPLETE FULL COURSE OF ORAL ABX AFTER COMPLETING IV -need yearly pneumococcal vaccine even if get to facilitate secretion removal: -chest physiotherapy -huff coughing -fluids! -fowler position VAP: (to prevent) -elevate the HOB semi fowlers -oral care with antiseptics (chlorhexidine), oral suction -daily sedation vacations -strict hand hygiene -ONLY ET suction when need -ET tube cuff pressure >20 cm H20 -avoid PPIs and H2RAs if possible best indicator of VAP= purulent sputum, positive sputum culture, leukocytosis, elevated temp, new pulm infiltrates on cxr

skin cancer (types and sx) basal squamous melanoma

risk factors: sunlight, tanning beds, sunburns (UV radiation exposure) fam or personal hx light skin, red/blond hair, blue/green eyes, many freckles aging aytpical or high # moles immunospurresion/immunosuppressant meds!--lowers body ability to fight against cancer mutations outdoor occupation basal cell carcinoma: MOST COMMON red, waxy nodule, crusty on skin (sun exposed areas) wont norm metastasize, frequently occurs squamous cell carcinoma rough, thick, scaly tumor on arms/face malignant melanoma: MOST LETHAL changes color (brown, black, gray, white, blue, white, red)--all dif colors can occur in melanoma! irregular borders, circular lesions will metastasize to all areas of body remember dx= ABCDE~ w/ skin lesion biopsy! A= assymetrical B= border (edges notched or irregular) C= color (dark brown/black, tan/red) D= diameter (>/= 6mm--size of pencil eraser) E= evolving (change in size, shape, color, new lesion) *a pale or brown mole <5 mm is typically a normal finding! *purulent drainage is NOT an expected sx, this indicates infection not cancer! *NOT ALL NEW GROWTHS HAVE TO BE BIOPSIED

developmental dysplasia of the hip (DDH) s/sx RX

risk factors= LGA breech birth fam hx to reduce risk of DDH development: -proper swaddling= W/ HIPS BENT UP (FLEXION) AND OUT (ABDUCTION), allowing room for hip mvmnt -infant carriers/car seats with WIDE BASES (abducted manner) -avoid any device causing hip extension with knees straight and together (causes hip extension and adduction) -do not double/triple diaper sx=( <2-3 mo)--infancy -UNEVEN GLUTEAL AND THIGH FOLDS-->IS KEY FINDING ***extra fold on affected side!!!!!!! (should be symmetrical) -laxity of hip joint (seen with signs) ORTLANI'S SIGN: seen in infants less than 4 weeks= -->put infant on back and click sound is heard when abduct hip with anterior lifting BARLOW SIGN: -->adduction with posterior pressure on hip (hear click) *must successful nonsurgical rx when initiate first 6 mo of life sx= (after 3mo) -shorter limb on affected side (after 3 mo) *will see limited ABDUCTION of leg (cant turn out) w/ pain--after 3 mo (due to contractures) -may or may not see internal rotation (adduction of leg) if DDH not treated in infancy, sx= notable limp walking on toes positive trendelenberg sign (pelvic tilts down on unaffected side when stand on affected leg) waddling gait/severe lordosis (bilateral DDH) RX depends on age! new born to 6 mo: reduced by manipulation then PAVLIK HARNESS (less than 3 mo old), worn full time 3-5 mo or until hips stable! STRAPS ADJUSTED 1-2 WEEKS BY HCP -->harness keeps hips slightly flexed and abducted (legs bent, spread apart) teach: *stimulate infant with rattle, change environment AVOID LOTIONS/POWDERS under straps!! check skin 2-3x day *******HARNESS IS NOT TO BE REMOVED--except for sponge baths once a day--LEAVE ON AT ALL TIMES (not even for diaper changes) PARENTS DO NOT ALTER STRAPS AT HOME massage lightly skin under straps pad underneath straps dress child in shirt and knee socks under harness -regular skin assessment -only 1 diaper at a time, APPLY DIAPER UNDERNEATH STRAPS (keeps harness clean and dry) 6-18 mo bryants traction for gradual reduction cast for immobilize older child open reduction then in hip spica cast

colorectal cancer

risk fators: (often adults over age 50) first degree relative hx of cancer/polyps hx of IBD, crohns, ulcerative colitis hx of non-polyposis colorectal CA (lync syndrome) obesity diet high in red meat cigarette smoking alc consumption sx= fatigue weight loss (unexplained) ANEMIA -->Low hgb occult GI bleed, blood in stools abdominal PAIN and/or mass change in bowel habits (distention, N/V, diarrhea, constipation) *have regular screening colonoscopy starting at age 50 or earlier if have high risk (this is priority action if observe above sx), repeat q 10 years! *have occult blood test every year

colonoscopy--at risk for? expected v unexpected findings

risk for perforation! and rectal bleeding UNEXPECTED abd pain (with shoulder tip pain) positive rebound tenderness! guarding abd distention boardlike/rigid abd tenesmus (recurrent inclination to evacuate the bowels) EXPECTED abd cramping!! (inflation of bowel with air during procedure) frequent, watery stools recurring flatus prep for procedure: clear liquid diet day before NPO 8-12 hrs prior to polyethylene glycol day before (bowel cleansing agent--cathartic, enema) *healthy pts do NOT need abx prior to *smoking is NOT prohibited prior to

atypical antipsychotics!

risperidone, clozapine rx= schizophrenia/ schizoaffective AEs--no need to report to HCP weight gain hypersalivation ortho hypo sedative impairs body temp regulation photosensitivity AEs to REPORT! agranulocytosis (low WBC)-->infection risk--asap report to HCP if note sx (sore throat, fever, flu sx) *contraindication= never give respiridone/ clozapine to pt with dementia!

newborn reflexes

rooting and sucking: disappears 4-7 mo palmar grasp: fades 3-4 mo plantar grasp: lessen by 8 mo tonic neck (fencing): fades 3-4 mo moro (startle reflex): fades 3-6 mo babinkski: reverts to adult response by 1 yr *absent moro indicates underdeveloped/damage brain or spinal cord

radiofrequency catheter ablation

rx pts with recurrent episodes of SVT radiofrequency waves delivered through catheter in heart to inactivate tissue causing dysrythmia (same rules apply hear as after cardiac cath): -remain supine with HOB <30 -affected extremity straight to prevent bleeds -expect small amount of bleeds on gauze after cath remove, apply pressure above site -report any sort of chest pain (even mild)--may not be expected

social anxiety disorder

rx= SSRIs, benzos psychotherapy= cognitive behavioral systematic desensitization (gradually expose pt to trigger, thus decreasing anxiety)

Lactulose

rx= hepatic encephalopathy excretes ammonia (NORM LEVEL= 15-45) laxative effect! MOA= decrease intestinal absorption of ammonia route= PO with water, juice, or milk to improve flavor ENEMA --best on empty stomach admin -desired effect: 2-3 soft bm's per day (adjust dose to achieve this with no confusion or lethargy)--cont. to give med if reach this level! -keep admin dose until desired outcomes reached (decreased ammonia levels, improved mental status) AE= dehydration, hypernatremia, hypokalemia (laxative effect!)

sodium polystyrene sulfonate (Kayexalate)

rx= mild to moderate hyperkalemia risk= -INTESTINAL NECROSIS (in pts w abn bowel function) -severe hypokalemia (lethargy, palpitations, cramping) -fluid vol overload (sodium exchange) rx= daily weights/ I & Os -electrolyte frequent monitoring -ASSESS ABD AND REVIEW MED RECORD OF STOOL FREQUENCY BEFORE GIVE

Memantine

rx= moderate to severe sx of Alzheimer's improves quality of life (doesn't cure just makes delays progression of sx) improvement in cognitive, daily, functioning and behavioral problems (not rapid improvement takes a while to see changes come about)

Lithium toxicity

rx= mood stabilizer for bipolar dehydration/hyponatremia increase lithium toxicity risk (look out for factors that increase these)= sx... N/V, diarrhea (stomach flu)--early sx neuro sx: (later sx) ataxia, tremors, muscular excitability, confusion, agitation, myoclonic jerks also... polyuria, polydipsia! DI (diabetes insipidus) w/ chronic toxicity also *avoid sodium depletion LOW SODIUM PRECIPITATES LITHIUM TOXICITY *recall, LITHIUM DEPLETES SODIUM eat reg diet, adequate sodium intake, drink fluids (2-3 L/day)!! avoid diuretic substances (coffee, cola, tea, alc) *do not need to avoid potassium intake, eat! Conditions that cause lithium toxicity: think "4 D's" -->dehydration (signals renal reabsorption, lithium not excreted) -->decreased renal func (elderly)--lithium cleared renal -->diet low in sodium (hyponatremia, body holds onto sodium, reabsorp, lithium not excreted) -->drug-drug interactions= NSAIDS AND THIAZIDE DIURETICS CONTRAINIDICATED (use tylenol instead) therapeutic level= 0.6-1.2 >1.5= toxic >2.0= severe toxicity CONTRAINIDCATIONS to therapy if pt has: dehydration/hyponatremia (lithium depletes sodium), decreased GFR, severe renal dysfunction (kidneys will conserve sodium, less drug filtered out) rx= IV fluid bolus NS (for dehydration)

ECT (electroconvulsive therapy)

rx= severe depression, bipolar, schizophrenia, or suicidal and pt cant wait for med effects to kick in pts who have not responded to meds how it works: pulses of electrical energy through electrodes on scalp causes brief convulsion -course is 6-12 treatments performed 2-3x/week -can have maintenance therapy at 1-8 week intervals on long term basis to prevent relapses -often give meds in combo with ECT for therapy pre-op: general anesthesia (methohexital, propofol) and skeletal muscle (succinylcholine) relaxant admin to minimize seizure and injury, pt will feel no pain (unconscious) NPO at midnight! (6-8 hrs prior) except sips of water with meds *cannot eat or drink after! expected: (post-op) pt will feel nothing from procedure temporary memory loss confusion (postictal) teach: -driving is NOT permitted during course of treatment -D/C ANY PRESCRIBED ANTICONVULSANTS PRIOR TO ECT (valproic acid)

HIV considerations pregnancy?

safe sex practice--NO unprotected sex (even if both partners have)--HIV has mult strains, co-infection can result in HIV SUPERINFECTION (can hasten AIDS progression) use latex/synthetic condoms/ dental dams (for anal/oral/vag sex) *NO lambskin avoid raw/undercooked foods (eggs, meats, seafood) for foodborne illnesses do not share personal devices may have blood (toothbrush, razors) meds= ANTIRETROVIRAL THERAPY (ART) *decreases viral load, and increases CD4 helpter T cells teach= -treatment is LIFELONG, strict adherence *poor adherence= progression to AIDS! -reg testing for STIS >1 time annually recommend -use latex or polurethane barriers for sex (not natural skin condoms= lamb skin) Pregnancy consider: *perinatal transmission of HIV can occur anytime during preg/labor/postpartum *preg ladies should still recieve all inactivated vaccines as others would indicated for their age (just no live vaccines) *maternal ANTIRETROVIRAL THERAPY (ART) during preg is imperative! to decrease risk of transmission and viral load *breastfeeding is CONTRAINDICATED (in developed countries) *infants should recieve ART 4-6 weeks after birth *infants tested for HIV at birth and again age 1 mo 4 mo *for infant to be HIV neg, mut have 2 consecutive neg results and 1 and 4 mo

contact precautions

salmonella abscess draining with no dressing (cause infectious) MRSA *can hand hygiene c. diff *must use soap/water for hand hygiene scabies *must use soap/water for hand hygiene rotavirus s. aureus Vanco resistant Enterococcus (VRE) *can hand hygiene

Sumatriptan

selective serotonin agonist (5-HT1)-->constricts cranial blood vessels treat migraine HAs (due to dilated blood vessels) *migraine may be anticipated by an aura teach= take a dose at first site of migraine to relieve sx contraindications: (think vasoconstrictive) CAD uncontrolled HTN *watch for serotonin syndrome if take with SSRI/SNRI

histrionic personality disorder

self dramatizing, exaggerated, shallow emotional expression attention seeking--needs to be center -overly friendly and seductive--attempts to keep others engaged -demands immediate gratification and has little tolerance for frustration

Anencephaly

severe NTD little to no brain tissue or skull formation in utero -many are born stillborn, those born alive not compatable with life interventions: (allow fam to hold to assist with grieving process) -skin to skin with mom -bundling -admin Oxygen to decrease discomfort

hyperemesis gravidarum

severe and persistent N/V during pregnancy sx= (think dehydration) weight loss, >5% pre-pregnancy weight poor skin turgor, dry mucous membranes hypotension tachycardia labs: hypokalemia, hyponatremia (sodium leaves w/ H20) increased urine specific gravity (dehydrated) hemoconcentration (less fluid in body) metabolic alkalosis KETONURIA (starvation state, body breaks down fat since dehydrated) rx= IV fluid replacement antiemetic therapy

levothyroxine

should be taken in AM to prevent insomnia ON EMPTY STOMACH, separate from other meds (1 hr AC or 2 hrs PC) need to take daily! is lifelong therapy! once daily dose is all you need *therapeutic effects: increased everything (UO) *think cause want to increase metabolism *begin seeing relief of sx after 3-4 weeks, can take up to 8 weeks to reach full effect *check hormone levels q 4-6 weeks until normal thyroid hormone level reached *however, does NOT affect RR (increased RR is not effect of med) -do not take w/ antacids, calcium, iron preps! therapeutic response: increased HR, elevation of mood, improved energy levels teach= this is LIFELONG med -notify HCP if fluttering/rapid heartbeat for pregnant pts: SAFE TO GIVE -take levo on empty stomach at least 4 hrs prior to taking prenatal vitamin (which contains iron) -may need to increase med dose as preg. advances -levo should NOT be stopped even if sx resolve during pregnancy!!

Which medications for which dysrhythmias? do sinus atrial and ventricular dysrhythmias and blocks!

sinus tach: treat underlying cause, BBs (metoprolol), CCBs (diltiazem), cardioversion sinus brady: atropine! transcutaneous external pacing (symptomatic brady) *if neither of these work, consider dopamine or epinephrine infusion PAC: treat underlying cause atrial flutter: adenosine, cardioversion, or ablation, vagal maneuvers atrial fib: Bb's (metoprolol) , CCBs (diltiazem), digoxin, cardioversion, warfarin, procainamide *goal is to reduce/ obtain ventricular rate control PVCs: amiodarone, BBs (metoprolol), procainamide lidocaine is DOC for frequent recurring PVCs. -->occasional PVCs are not very concerning (esp if rhythm is regular) -->rx is based on underlying cause V tach (w/ pulse): HR 150-250, wide QRS! -->monomorphic: procainamide, sotalol, amiodarone -->polymorphic: magnesium, isoproterenol V tach (w/out pulse): CPR! defib, epinephrine (*to get pulse), amiodarone SVT (HR 150-220): QRS narrow! *first intervention= bear down (vasovagal maneuvers= coughing, carotid massage, valsalva), then, digoxin, CCBs, BBs, -------------->adenosine= DOC! admin rapidly over 1-2 sec IVP, follow by 20 ml NS bolus if meds unsuccessful can cardiovert *push adenosine closest to heart as possible (select proximal IV site) V fib: CPR! defib first degree AV block: treat underlying cause -->these are not the priority (only 2nd and 3rd degree should be treated as priority) Second degree AV Block: atropine, temp pacemaker also isoproterenol *treatment is ONLY indicated if pt is symptomatic (hypotensive, dizzy, SOB)--so TAKE VS FIRST IF PT IS SHOWING THIS ON EKG! Third degree AV block: atropine, epinephrine, pacemaker (temporary to permanent) Ventricular bigeminy: PVCs q other heartbeat (when in presence of MI) is serious as can increase risk for more serious arrythmia (vtach/vfib)

methods to decrease back pain

sit reclined with feet elevated squat to pick up something wide base support from feet aggravates pain: bend over legs crossed stands with feet close together

lung cancer

smoking is #1 cause (80-90% of all lung cancers!) *although risk> among smokers, teach nonsmokers can develop as well!! risk: -secondhand smoke -air pollution -genetic predisposition -exposure to radon, asbestos, chemicals in workplace rx= best is smoking cessation (nicotine patch)

external fixation

stabilizes broken bones with metal pins places through tissue to bone and connect to frame outside skin care: -assess pins regularly for circulation, purulent drainage -assess for compartment syndrome -perform pin site care with STERILE CLEAN SOLUTION (sterile NS, chlorhexidine, sterile water and gauze) -monitor for loose pins-->NOTIFY HCP IF LOOSE, cant move yourself! -PT CAN AMBULATE WITH DEVICE ON-->promote early ambulation! -keep vest liner clean and dry (change weekly or when soiled, using cool blow dryer to dry) -place FOAM INSERTS under pressure points -place SMALL PILLOW under pt's head when supine (reduce pressure on device) -keep correct size wrench available at all times at bedside in case of emergency -AVOID GRABBING DEVICE WHEN MOVING/REPOSITIONING/logrolling PT (may loosen screws) complication= infection (osteomyelitis)

pressure injuries

staged from 1-4 stage 1: erythema stage 2: partial thickness skin loss shallow, open wounds *wound bed red or pink, shiny or dry *may have fluid filled blisters stage 3: full thickness skin loss exposed SQ fat stage 4: full thickness skin loss exposed muscle and bone unstageable: full thickness skin loss with slough, eschar (yellow, tan stringy slough, dried black-brown eschar) *prevents visualization of wound base *wound must be debrided before it can be staged Deep tissue injury: pressure/shearing to underlying tissue purple or maroon discoloration Blood blisters intact skin care= -DO NOT MASSAGE -reposition q 2 hrs -use foam padding on seats under bony prominences -overlay mattress (cushioned one on top) is good -AVOID donut type devices and synthetic sheepskins -use emollients and barrier creams, hydration, moisturizer -high protein nutritional supplements, calorie counting, enteral nutrition if need

Botulism

standard precautions (not person to person) from contaminated food/aerosol inhalation -->is used for botox main source= IMPROPERLY CANNED/STORED FOOD -metal can swollen/bulging at end should be thrown out! sx= descending flaccid paralysis (weakness begins in face)--can relax muscles and cause: dysphagia constipation muscle paralysis resp paralysis! watch! *do not give honey (esp raw wild) less than 1yr old!-->cause INFANT BOTULISM --IS PRIORITY PT IF SEE =life threatening muscle paralysis= can cause resp failure! sx= constipation, difficulty feeding, decreased head control, diminished DTRs rx= botulism immune globulin (BIG-IV)

DVT Virchow's Triad

stasis hypercoagulable state endothelial damage these 3 factors lead to thrombosis! risk factors: prolonged immobilization (stroke, long travel) major surgery (hip fx) trauma pregnancy cancer birth control (oral contraceptives) smoking old age obesity myeloproliferative disorders (bone marrow abn develop) vericose veins >40 yrs sx= expect mild fever calf pain (localized) UNILATERAL leg edema lower leg warmth and redness tenderness to touch rx to prevent DVT: -limit alc/caffeine, adequate fluid intake (avoid dehydaration) -elevate legs, dorsiflex feet when sitting exercise program--early ambulation!! do NOT IMMBOLIZE smoking stop avoid restrictive clothing loose weight if obese DO NOT MASSAGE OR USE SCD'S ON AFFECTED EXTREMITY **do NOT need to stop traveling in cars/airplanes (but with extended travel >4 hrs, pts must use preventative measures--SCDs, exercise, walk q hr) **pt's with DVT can ambulate as long as not have severe edema or leg pain! (early ambulation is good)

status asthmaticus acute asthma attack

status asthmaticus: a severe, life-threatening, prolonged asthma attack that is refractory to usual treatment (bronchodilators) and places the patient at risk for developing respiratory failure can last minutes to several hours (24)! acute attack: sx= accessory muscle use chest tightness (air trapping of alevoli) high pitched expiratory wheeze tachypnea diminished breath sounds (hyperinflation) cough prolonged EXPIRATORY phase (air trapping) -maintain O2 sat >90% -fast acting ALBUTEROL/LEVOALBUTEROL and anticholinergic IPRATROPIUM nebulizer treatments q 20 min -systemic corticosteroids (methylprednisone SOLU-MEDROL) will take a bit more time to show effect (several hours to days!)--remember timelines when considering which med to give first! *NSAIDs/ASA contraindicated! long term asthma control: Montelukast (leukotriene modifier) w/ flucticasone, Budesonide (corticosteroids)

wet to dry dressing change considerations vs. dry dressing change

sterile! clean with clean cotton ball from center of wound to outer with sterile supplies do not overlap dressing onto skin (could cause skin breakdown) order: remove old dressing cleanse wound with sterile saline or prescribed cleanser (strokes from center out) *dry skin surrounding wound MOISTEN gauze with solution apply moist gauze as single layer cover with dry dressings DRY dressing changes: gauze applied must be DRY, not wet! dry gauze over wound and occlusive sterile dressing appied

Oxytocin

stimulates uterine contractions during childbirth and milk ejection during breastfeeding palpate the uterus frequently for contractions prolonged tetanic contractions can lead to uterine rupture! ***stop/decrease infusion if contractions less than 2 min apart and more than 90 sec long goal= contraction frequency q 2-3 min admin= -->large bore IV access (18G or more--for post partum admin) -->always given as secondary infusion (piggyback) controlled by IV infusion pump! -->begin at 0.5-1 milliU/min, increase 1-2 milliU/min at intervals 30-60 min, can go UP TO 30-60 mU/min until reach desired contractions -->(postpartum dosage) is higher!! 125-200milliU/min TITRATED BASED ON DESIRED CONTRACTIONS: 2-3 min apart lasting 80-90 seconds d/c if uterine tachysystole >5 contractions, in 10 minutes, persists or fetal distress occurs -->use 3mL syringe to prepare -->filter needle to withdrawal med from ampule (recall filter needles only used to withdrawal meds NOT inject as glass filtered out can go back in) -->19 G 1.5" filter to withdrawal, 20 G 1" to inject med into IV bag -->alcohol swab or gauze -->dont need gloves when prepping med, only when administering! -->hang on SECONDARY IV LINE, must be infusion pump d/c if: contractions=(they SHOULD BE LONGER THAN 2 MIN APART AND LESS THAN 90 SEC IN DURATION) -->stop if see this indication HYPERTONIC CONTRACTIONS (uterine hyperstimulation) or frequent variable/late decels observed in FHR Oxytocin puts pts at risk for: -abn or indeterminate fetal heart rate patterns -postpartum hemorrhage (from uterine atony) -uterine tachysystole -water intoxication (Antidiuretic effect) -placental abruption -uterine rupture

Nitroglycerin

store tabs in dark bottle (away from light and heat sources) discard opened bottle after 6 mo keep tabs in original container take 3 pills up to 15 min-->should relieve pain in 3 min and lasts up to 30-40 min always SUBLINGUAL! (should cause SLIGHT TINGLING SENSATION under tongue if potent--if it doesn't, med is outdated! if spray route: spray onto/under tongue *NOT INHALED *teach to call EMS if pain doesn't improve 5 MIN AFTER 1 DOSE (1 pill or 1 spray) or chest pain worsens -avoid vasodilators (sidenafil, tadalafil, terazosin, tamsulosin) SEs= HA/flushing (cont taking med if occur), nervousness may be felt during infusion cause of this (expected) -->TAKE DRUG WHILE LYING DOWN, to prevent fall risk PRIORITY FINDING= LIGHTHEADED/DIZZINESS AE= while dizzy, lightheaded expect, if pt reports CAN CAUSE SEVERE HYPOTENSION--PRIORITY INSPECTION!--may need to decrease/stop NTG dose IV Nitro: -usually is titrated based on pain level and BP q 3-5 min until pain is relieved and BP is stable -if sys BP falls <90 or >30 below pt's baseline should decrease or STOP infusion NTG transdermal patches: -takes 40-60 min for onset of action *used to prevent angina in pts with CAD -apply once a day -wear 12-14 hrs, then remove-->dont immediately replace (can develop tolerance) -no more than 1 patch at a time should be worn -**choose dif. location each day -location= upper body or upper arms -clean, dry, hairless skin not irritated, scarred, burn, broken. calloused is used -CAN WEAR IN THE SHOWER *if patch is accidentally removed and pt having chest pain, do NOT just reapply another one first--first action is to admin dose up to x3 of SL nitro for quick acting angina relief (then can reapply another patch), then can get 12-lead EKG if pain not relieved by med

endocarditis

streptococcal infective endocarditis (IE) sx= (expected) think "FAME"= FEVER, ANEMIA, MUMUR (circulation prob!) fever many days during initial stages abx, need to cont to monitor fever at home chills malaise, weakness, fatigue heart murmur arthralgias anemia *high risk for re-occurrence: give PROPHYLACTIC ABX PRIOR TO DENTAL PROCEDURES risk= EMBOLISM (due to vegetation on valves)-->watch for sx embolism to organs= ... sx= stroke (paralysis on one side) -spinal cord ischemia --paralysis of both legs -ischemia to extremities (pain, pallor, cold foot/arm) -intestinal infarction (abd pain) -splenic infarction (left upper quadrant pain) -kidney infarction (hematuria) *also splinter hemorrhages (on nail beds)--not as priority of finding tho rx= abx up to 4-6 weeks (give through PICC line at home after stable) -->if pt still febrile consistently after 1-2 weeks, need to report to HCP, can indicate INEFFECTIVE ABX THERAPY

Position for suctioning/ trach care suctioning/ET tube considerations

suctioning/ trach care positions= semi-fowlers ORAL suction consider: -oral suction q 2 hrs with oral care is appropriate (prevents VAP) ET suction consider: *ET TUBES ARE IN MOUTH -ONLY ET suction when need to, never on a q hr basis (increase risk for tracheal trauma, bleed, hypoxia) -CAN auscultate the neck to monitor for ET tube cuff leak Indications for suctioning: -audible gurgling -increased irritability -decreasing O2 sat -increased RR/HR --*pay attention to VS based on age! Steps for Suctioning ET tube: 1. don clean gloves 2. suction oropharynx and perform oral care (ensure system connect to wall suction <120) 3. hyperoxygenate the lungs 4. advance cath into trachea 5. gently rotate cath while suctioning (can repeat 1 or 2 times if need) 6. eval pt tolerance and document

myasthenia crisis

sudden inability to swallow, speak, maintain patent airway (rapid weak fatigue in voluntary muscles due to lack of med, surgery, stress) -->imp of taking med on time! factors that cause: "mycins" strepto & neomycin surgery, infections, emotional upset undermedication (of pyridostigmine)--which rx MG

amniotic fluid embolism

sudden onset of dyspnea and hypotension

SIDS (sudden infant death syndrome)

sudden unexplained death of infant <1 yr occurs most frequently age 6 mo or less during naps/sleeps recommend: infant sleep on back (avoid prone, side lying) sleep surface firm in crib--> AVOID BUMPER PADS no loose, soft items in it (blankets, toys, pillows) smoke-free environment breastfeeding updated vaccinations no more than one layer of clothing than an adult requires--> use sleep sack (onesie) for clothing do not co sleep with infant and parents OKAY TO USE A PACIFIER DURING SLEEP avoid overheating CRIB SLATS NO MORE THAN 2 1/4 INCHES APART

Trimethoprim/Sulfamethoxazole

sulfonamide abx-->sulfa drug! SE= -crystaluria (drink fluids!!) - cross sensitvity rx: glyburide diuretics (thiazides, furosemides) *if pt on one of these and able, have HCP switch to dif. abx preferably contraindications= hypersensitivity to sulfas pregnancy breastfeeding

intracranial tumors supra vs infratentorial sx

supra= cerebral hemisphere (comrpises all lobes) upper half position post op= HOB elevated semi fowlers infra= brainstem + cerebellum= lower half surgery= position post op flat or lateral on either side sx= neuro changes think depending on location of tumor see sx of this lobe *pts may be organ donors for brain tumors! any other malignancy cant be do NOT use narcotics (decreases LOC) and will mask changes in LOC *brain tumor (can cause increased ICP), morning HA, N/V--grows more slowly than hematoma, not priority assessment compared to this

Abdominal exploratory surgery post op assessment order considerations (think priority)

surgical exploration of the abdominal cavity assess RR assess pulse check dressing for bleeding turn pt to left side check surgical notes monitor for purulent drainage (recall infection not seen until 3 days after)

episiotomy

surgical incision of the perineum to enlarge the vagina and so facilitate delivery during childbirth rx after= use warm soapy water/ provide ice packs asap after to decrease edema

hemorrhoidectomy

surgical removal of hemorrhoids (distended, inflamed veins in lower rectum) caused by increased pressure (defecate, constipation) sx= rectal bleed, pain, pruitis, prolapse post-op: PAIN MGMNT PRIORITY (pain associated with removal is severe!--must be controlled to prevent further constipation as pts dread first bm after removal -NSAIDs/tylenol (initially) -1-2 days post op warm sitz baths (2-3x daily 15-20 min each for 7-10 days to help cleanse/relieve pain) -prevent constipation! (oil retention enema if persists 2-3 days) *do not remove gauze at site to assess for bleeding until 1-2 days post-op! unless dressing soaked before

hydraulic lift considerations

suspend (dangle) pt lifted over bed for a few seconds (increases their comfort) leave sling under pt to move back and forth from chair to bed set base at widest position flex knees when lowering client into chair to match positioning

hemianopsia

sx in stroke loss of half of visual field homonymous hemianopsia-- loss of half of vision field in both eyes on the same side (both Left side lost in right and left eye) teach pts: -turn head and scan to the side with the visual field deficit to reduce injury and self neglect risk -keep food and fluids within client's vision field

glaucoma

sx of glaucoma= TUNNEL VISION (poor peripheral vision) blurred vision reduced visual fields fixed and mid-dilated pupil cornea edema/cloudiness conjunctival redness TYPES open angle (primary)= (POAG) TUNNEL VISION (impair peripheral, normal central)--so slow pt doesnt usually notice slow. gradual onset of condition development, asymptomatic initially painless difficult vision with dim lighting increased glare sensitivity halos observed around bright lights *visual loss caused by glaucoma is NOT reversible even if treatment started early! (have routine ocular exams to start meds early cause can slow disease progression) risk factors= black race advancing age fam hx diabetes, HTN, corneal thinning (acute angle closure)= emergency!! --can lead to permanent blindness! sudden severe onset eye pain reduced central vision blurred vision halos around lights ocular redness rx= eye drops monitor IOP!

basilar skull fracture

sx= halos ring CSF fluid battles sign (ecchymosis behind ear) racoon eyes (ecchymosis around eyes) HA (can be 10/10 expected)--concern if unrelieved by analgesics, signs of increased ICP suspect basilar fx when have CSF leak. to test= CSF rhinorrhea/otorrhea (nose/ear) drainage -->if clear, dextrose test will determine if CSF -->if blood present, makes test unrelaible as blood contains glucose -->so then do HALO/RING test (add few drops of blood tinged fluid to gauze and assess for pattern of COAGULATED BLOOD SURROUNDED BY CSF)--looks like halo ring (clear fluid surrounding blood) *CSF places at risk for infection *if basilar skull fx suspected, NO NG/ORO GASTRIC TUBES inserted blind by RN--must be guided by flouroscopy

septic arthritis

sx= pain limited ROM fever *watch for septic hip-->medical emergency! hip joint prone to avascular necrosis->permanent joint destruction, sepsis, death rx= culture synovial fluid and blood, abx, debriding infected joint

stroke considerations

sx= "FAST" F- Facial drooping A- Arm weakness (or drifting) S- Speech Difficulties T- Time (time of onset) single most modifiable factor to prevent stroke= controlling HTN--> BP control! *pt not considered stable until about 48 hrs have passed with no changes (do not delegate care within this time period--until pt is stable) position= HOB elevate 15-30 (low fowlers) to prevent increased ICP facilitate swallowing post-stroke by sit up with head flexed slightly *avoid milk (food in unaffected side, move with unaffected side) maintain upright position 30-45 min after eating encourage use of affected side stroke protocol--initiate in first hr: draw labs for CBC & plts NPO diet!! CT scan (detects ischemic vs hemorrhagic) lumbar puncture--detects blood in CSF IV started (in case give meds)--fluids at SLOW rate (50/hr) to not overload care post stroke: -teach pt to dress first the affected side

scoliosis considerations

sx= KYPHOSIS, uneven hips/scapulae/waistline dx= VISUALIZATION OF DEFORMITY BY BENDING AT WAIST 90 degrees! (if goes away when bends, it is functional=reversible; if doesn't go away when bends, it is structural=irreversible) types: functional: can be corrected (reversible) structural: cant be corrected (irreversible) to help: ISOMETRIC ABDOMINAL EXERCISES (supports spine) for functional scoliosis = sit ups, pelvic tilt, push ups with pelvic tilt surgery if all else fails brace is most common treatment! teach= they *do not cure but prevent further weakening: TSLO (boston brase)--> most common TLSO (milwaukee) --less common, more severe (includes neck ring) TEACH CARE; -->wear cotton shirt underneath prevent skin breakdown AT ALL TIMES -compliance is imp, esp adolescence w/ body image issues discuss -meet other individuals their age that wear braces do NOT: use powder/lotion (can irritate skin) continue exercises involving spinal muscle (allow brace removal for such exercises) -wear brace 18-23 hrs/day and remove during bathing/exercise *NEVER SHOWER while wearing hard brace braces made of hard plastic and mold to body to correct and hold deformity (from pts arm/neck to pelvis) brace care: WEAR 23 HRS OF THE DAY (take off 1 hr for personal hygiene/physical activity) isometric exercises!! abd strength skin care, wear tshirts under

bulimia nervosa

sx= NORMAL WEIGHT or above norm range! uncontrolled binge eating followed by laxative/diuretic use, self induced vomiting, excess exercise 1-2 hrs after binging, fasting -scars/calluses on hand -enlarged parotid glands -erosion of tooth enamel -dental caries -preoccupation with body weight, image, food, dieting most imp to monitor pt 1-2 hours after meal! (may have to restrict to dayroom or specified area with no BRP) also supervise during every meal *ALLOW to have food diary during hospitalization assess for electrolyte disturbances (hypokalemia) be alert to hidden or discarded food wrappers d/c laxative use!

MDD (major depressive disorder)

sx= SIGECAPS S- sleep (increased or decreased) I- interest deficit (anhedonia) G- guilt (worthless, hopeless) E- energy deficit C- concentration deficit Appetite (increased or decreased) P- psychomotor retardation/agitation S- Suicidiality *to dx MDD, must have at least 5 or more of above sx and 1 symptom must be either DEPRESSED MOOD OR LOSS OF INTEREST OR PLEASURE also can see: psychomotor retardation catatonia (immobility and speechlessness) *may also show psychomotor agitation (pacing, hand wringing, muscle tension, erratic eye mvmnt) if pt doesnt want to eat: state "I will help you get ready, We will walk to the dining room together" sleep hygiene tips: -avoid naps in day -physical activity at least 5 hrs before bedtime -20 min of natural sunlight each day (morning best) -avoid caffeinated beveraginos afternoon -decrease environment stimuli -drink warm milk, eat small amount carbs, take warm bath, read before bedtime

urinary tract infection (UTI)

sx= dysuria, urinary frequency, suprapubic discomfort, back pain, lethargy confirmed by bacterial colony >100,000 mL in clean catch specimen *pos nitrates in urinalysis indicate UTI urine culture >10,000 organsims/mL keep urine acidic to prevent avoid alkaline products: milk, fruit citrus juices!! lemonade/OJ makes urine alkaline DO consume: cranberry, blueberry, plum juice drink LOTS of fluids!! flush bad urine out med: phenazopyridine hydrochloride (pyridium)-->will discolor urine bright red-orange! rx= sulfa based meds/ ampicillin *may need repeat urinalysis is pt is symptomatic but results not matching up (should show Increased WBCs/RBCs) to prevent recurrent UTIs: -drink lots of fluids!! -void immediately after intercourse -wear COTTON UNDERWEAR (avoid nylon, spandex, lycra)--think tighter, seal in moisture -take all abx as prescribed full course -wipe from front to back -avoid douching/ PERINEAL PRODUCTS (deodorants, powders, sprays) -take showers instead of baths, NO BATHS -avoid spermicidal contraceptive jelly (d/c diaphragm use until ABX done and sx subsite) -AVOID ANTIBACTERIAL SOAP -only fill bathtub with water and hair should be washed last

fetal alcohol syndrome (FAS)

sx= epicanthal folds (inner eye) smooth philtrum (area above lip) thin upper lip maxillary hypoplasia microcephaly (SGA) flat midface short palpebral fissures (eyelids) intellectual/hearing disorders irritability during infancy, hyperactivity during childhood IS THE LEADING CAUSE OF INTELLECTUAL DISABILITY/DEVELOPMENTAL DELAY *teach: STOP DRINKING ALCOHOL 3 MO before conception!! *no safe level of alcohol consumption during preg!!!!!!! *at birth, think infant will go through alc withdrawal (see excitability sx) so... decrease environmental stimuli!! swaddle infant-->do nOT decrease touch!! replace vitamins from often poor maternal diet (vit B for CNS function)

Hepatitis Considerations and types

sx= fatigue, jaundice, RUQ pain, clay color stools, tea color urine, pruitis, LFT elevated, prolonged PT, anorexia HEP B: transmitted through parenteral and sexual contact *unprotected sex! mother to fetus think "B for body fluids" :) (blood, semen, vag secretions, IV drug use, vertical transmit from born from moms) *not breastfeeding HBIG (is post-exposure prophylaxis for those exposed) HBV vaccine may also be necessary if exposed vaccine: given 3 series (day 0, 1 mo, 6 mo)-->no revaccination required! teach= -promote rest periods between activity -do not share razors or toothbrushes -oral care if pregnant: *infected pt CAN breastfeed baby as long as-- -->nipples intact, -->immunoprophylaxis (HBIG, hep B vaccine is adminstered)--give both to infant WITHIN 12 HRS OF BIRTH HEP A: (fecal oral) *also through water, food! if pt is diapered or incontinent, CONTACT PRECAUTIONS are required on top of standard precautions (this is same for rotavirus, cause both transmitted fecal oral route!) *treat both Hep A/B with immune globulin early postexposure -vaccine is recommended for all children age 1 for adults at risk of contracting virus diet hepatitis= high protein, high carbs, high cal, low fat (well-balanced diet) no alcohol *avoid hepatotoxic meds (aspirin, tylenol, sedatives) -->small frequent meals to prevent nausea! -->eat a larger breakfast (anorexia) -->fluids!! -->avoid extremes in food temp *type A infectious 2-3 weeks before onset of jaundice and about 1 week or so after onset of *hepatitis will cause itching due to accumulation of bile salts under skin (rx calamine lotion, antihistamines) meds= interferon, lamivudine HEP C: Blood/bodily fluids greater potential for chronicity think, C, chronic HEP D: drugs (needles) "d" HEP E: oral-fecal (like A)

MRSA (methicillin-resistant Staphylococcus aureus)

sx= fever, wound drainage, purulent mucus--can be transmitted through body secretions/excretions (so if have PNA or comorbidity this is major contact precaution!) contact precautions who is at risk: indwelling urinary catheters chemo meds immunocompromised pts (CDT) count 200 *low grade fevers are NOT at risk Bathing pts w/ MRSA or other drug resistant organisms: -use pre moistened cloths OR warm water containing CHLORHEXIDINE solution

narcissistic personality disorder

sx= grandiosity, need for admiration, lack of empathy project superiority, uniqueness, independence REAL MEANING BEHIND IT IS THEY HAVE LOW SELF ESTEEM AND FEELING OF EMPTINESS INSIDE

Anaphylaxis

sx= itching, flushing, hives (skin rash) wheezing, bronchospasm, stridor swelling of oral mucosa, hypotension dyspnea lightheadedness hypotension chest tightness 1. first swelling of facial area, then wheezing and SOB, then cardio sx (hypotension, flushing, lightheaded, LOC) *FEVER IS NOT Associated w/ anaphylaxis if pt reports "throat tightness" (and this is unexpected with their condition)-->this is PRIORITY PT, AIRWAY ISSUE! COULD BE ALLERGIC RX!

miscarriage/ spontaneous abortion Stillbirth

sx= persistent uterine bleeding; cramp-like pain before 20 W! "light vaginal spotting" stillbirth= infant born not alive -assist parents with bereavement process -hold infant, provide privacy -help bathe/dress infant -encourage to view body before d/c to funeral home -offer and obtain handprints/footprints/ lock of hair, photograph -encourage to name infant and identify this name during care

purpose of OCD rituals

sx= self willed, obstinate, PUNCTUAL, follow rules and regulations, need control of internal and external experiences, rigidity and inflexibility PURPOSE OF RITUALS: to AVOID anxiety!! or alleviate increasing to extreme levels of anxiety to control/relieve the level of tension and anxiety the pt is experiencing rx= if pt new admit performing rituals, let them do to avoid panic anxiety, DO NOT INTERRUPT (will increase anxiety) instead, provide feedback about behavior (how long they've been at it) since they often don't realize how long its been, and that it's time to take a break --> then rx focuses on assisting pt to develop better coping behaviors and gradually reducing time spent on ritualistic behavior, involve other activities/problem-solving skills ------------------------------------------------------------------------------nursing care= assist pt in identify circumstances increase anxiety, --offer positive feedback when pt engage in non-ritualistic behavior, -remain non-judgemental and empathetic, ---------------use reflective communication, CBT (thought stopping)

Vaginal hematoma cervical lacerations uterine inversion uterine atony

sx= severe vaginal pain feeling of fullness (uterus firm/midline, and lochia is normal) *likely to occur with forceps/vacuum assisted birth/episiotomy cervical lacerations= uterus firm, midline despite continued vag bleeding uterine inversion= large, red mass protruding outside of pt (w/ placenta, is uterus) -->hemorrhage, pain, hypovolemic shock *do NOT admin oxytocin until inverted uterus is corrected! -serial BP monitoring q 3-5 min -IV lines for fluids!! rx= manual replacement of uterus through vag canal by HCP with hands! (uterus must be soft uncontracted to do this)--may need tocolytics to help with this uterine atony: boggy uterus, increased vag bleeding

gout considerations

sx= tolphi (uric acid buildup in joints), exacerbations (acute gout attacks)--can cause -kidney stones to form also -pain, swelling, redness of one or more extremity joints (typically great toe) those at risk: obesity, HTN, dyslipidemia, insulin resistance poor diet, alcohol consume, sedentary lifestyle improvements in uric acid control: WEIGHT LOSS + DIETARY MODIFICATIONS -->increase fluid intake (2L/day)-eliminate excess uric acid -->low purine diet, low fat diet, limit alc--esp beer encourage partial weight bearing activity when ambulating (helps with pain, relieves pressure) do not perform passive ROM, immobilize, or limit ambulation periods (aggravates pain/inflammation)

C diff --can cause? meds to treat

sx= watery diarrhea, nausea, fever, abd pain hypovolemia causes= hyponatremia, hypokalemia, elevated BUN (poor renal perfusion) meds= PO vanco metronidazole (abx)

STIs (sexually transmitted infections)

syphyllis (copper colored rash, painless genital ulcer) (diffuse rash, lymphadenopathy, oral lesions, hepatitis) -->can lead to CNS/cardiac dysfunction -->treat with IM Penicillin G benzathine--ONLY adequate prenatal rx! (if preg, can give and will cross placenta and treat fetus as well! all preg clients screened on first prenatal visit) treponemun pallidium test! (VDRI) *if preg: (and untreated)-->may cause fetal harm or death, teratogenic effects, preterm labor *if preg pt has penicillin allergy, expect PENICILLIN DESENSITIZATION for adequate rx to be provided *if not preg and allergy to penicillin, can use doxycycline gonorrhea--> "silent infections" monitor for PID (pelvic inflammatory disease) (painful, purulent discharge) -->also infertility! GENITAL HERPES (HSV)-->painful genital sores (pain, burning, tingling) can cause newborn blindness/mortality!-->instill prophylactic med into baby's eyes after delivery *also increased cervical cancer risk, sterility admin ABX as ordered *no cure, highly contagious when lesions active (recurrences/flare ups common) *if pt has active lesions or symptoms during pregnancy close to labor (not rx w/ acyclovir)-->REQUIRES CESAREAN BIRTH to prevent transmission rx= acyclovir -->use gloves when applying topical meds *prescribed at 36W G to prevent outbreaks prior to labor (for pts w/ hx of HSV) -keep lesions clean/dry (no bandages) -cleanse with soap, warm water (no perfumed soaps/bubble baths) -during periods of active lesions, abstinence is indicated!! -use condoms during periods of dormancy -use sitz/oatmeal baths to comfort and relieve itching/burning -avoid touching lesions to prevent spread -use hair drying cool setting to dry lesions after shower If preg and have active lesions: vag birth not recommend (to c section) -start acyclovir ASAP to rx active infection HPV (most common STI, often asymptomatic)-->cervical cancer! *monitor PAP smears regularly *get HPV vaccine 11-12 yrs old (9-26 yrs) chlamydia--> "silent infections" most common STI complication= sterility (untreated) (asymptomatic often in females-->leads to no abx rx-->causes PID/infertility!) sx= spotting after sex, dysuria, abd vag discharge -can still spread even if dont have sx -have yearly screening for it even if no sx (<25 yrs/ >25 and at risk--new/mult sex partners) -ensure partner gets checked and treated -if start on abx (azithromycin), must abstain from sex for until 7 days after initiation!! condylomata acuminata (genital warts)-->also increased cancer risk! *rx= most common treated with abx (bacterial STIs) axithromycin, doxycyclin, erythromycin

Kawasaki disease

systemic vasculitis; mucocutaneous lymph node syndrome (lips, oral mucosa) unknown etiology; not contagious sx= >5 days fever, bilateral nonexudative conjunctivitis, cervical lymphadenopathy, rash, extremity swelling, splenomegaly, skin peeling, swollen lips/strawberry tongue, irritability expected findings: irritability (hallmark, can last up to 2 mo), arthritis, desquamation (skin rash) *complications= most common: CORONARY ARTERY ANEURYSMS-->MI-->Death! so.. PRIORITY INTERVENTION= MONITOR FOR HF (gallop heart sound, decreased UO, tachy, dif breathing) rx= IVIG (iv immunoglobulin) w/ ASA to prevent aneurysms and occlusion *one of few peds conditions ASA is OKAY with IVIG therapy, delay live vaccines for 11 MO after admin as this therapy decreases childs antibodies to defend live vacc (MMR, varicella) rash= cool compresses, unscented lotions, loose fit clothing, ROM d/c home: monitor for FEVER by check PO or rectal temp q 6 hr for first 48 hrs following last fever *if develops fever, notify HCP as can develop acute phase KD occurrence -teach irritability after KD episode may last up to 2 months -f/u app for cardiac eval so imp!!

fetal FHR monitoring (dif types of rhythms)

tachycardia >160 more than 10 min bradycardia <110 more than 10 min variability: GOOD! 6-25 bpm-- indicates fetal well being absent: 0-2 bpm (or decreased) 3-5 bpm if persists more than 30 min may indicate fetal distress increased: >25 bpm accelerations: GOOD --fetal well being (15 bpm above baseline, followed by return to baseline) decelerations: fall below baseline lasting 15 sec or more, followed by return to baseline sinusoidal pattern (absent variability, repetitive, wave like fluctuations, no response to contractions)= OMINOUS FINDING indicates severe fetal anemia (hemorrhage or infection)-->NEED EMERGENT INTERVENTION expedited birth expected, intrauterine resuscitation (Category III tracing) *think, if see this pattern, THIS IS PRIORITY FHR PATTERN PATIENT THINK VEAL CHOP eary decels: onset close to beginning or before peak of contraction (looks even with contraction)-->head compression (*if occurs in second stage of labor with pushing, this is a REASSURING pattern) rx= no intervention needed late decels: BAD onset after contraction, usually begins at peak of contraction -->fetal hypoxia due to deficient placental perfusion rx= think "LIONS" (late, lions) left side, IV fluids, oxygen, notify HCP, stop oxytocin (position= left side first (if no change), trandelenberg, knee to chest, or hands and knees, right side)--to take pressure off placenta prep for C section!! variable decels: UV shape, can occur at any time, decrease more than 15 bpm, last 15 sec, return to baseline less than 2 min from onset (cord compression) rx= turn mother on left side (if repetitive/prolonged)--to relieve cord compression: admin O2 & d/c oxytocin -prepare for AMNIOINFUSION IF NEED (variable decels caused by cord compress 2/2 loss of amniotic infusion)= isotonic fluid instilled into uterine cavity

Alendronate Sodium --special considerations

take 30 min before other meds/foods/liquids in AM-->must be consumed in AM on empty stomach! *if miss in AM, skip dose for day and resume next morning sit up 30 min after taking (reduce esophageal irritation) AE= photosensitivity, jaw necrosis (seen with biphosphonates)

Histamine 2 Receptor Antagonists "idines"

take before meals (or during) or at bedtime (best to reduce stomach acidity) *AEs= CNS effects (esp in elderly)= confusion dizziness, memory probs SE= constipation, diarrhea, HA, acne like rash

prenatal vitamins--how to take?

take with orange juice at bedtime (acidic increases iron absorption), take with food at bedtime decreases nausea likelihood

Chvostek's sign

tap facial nerve anterior to earlobe and twitching of facial muscles indicates tetany= hypocalcemia

MRI considerations (what is contraindicated?)

tattoos esp. red! (nail polish NOT AFFECTED) transdermal patches with metal backing or NOT CONTRAINDICATED: clonidine, nicotine, scopolamine, testerosterone, fentanyl -->contain heat conducting aluminized layer and can cause burning of skin (Nitroglycerin, etc)--may be?? foil backing? anything medal! body piercings (permanent), dentures, ICDs, pacemakers, hearing aids (cochlear implant), shrapnel, retained metallic foreign body, heart valves, metal plate, pin, brain aneurysm clip, joint prosthesis, implant device: insulin pump, medication port teach= MRIs are safe during pregnancy -may cause claustrophobia (inside closed chamber)--also have open chambers, however -will make loud tapping noises while inside -is painless -given gadolinium contrast!! Does not need to be NPO!

Sexual Activity after childbirth

teach to pt: ovulation may occur again as early as 4 weeks after birth, before resumption of menses so USE CONDOMS/CONTRACEPTIVES to prevent pregnancy through first postpartum checkup (4-6 weeks) when another bc method can be prescribed -feed newborn BEFORE sexual activity (limit interruptions) -need vaginal lubrication (expect dryness) -can resume sex after no vag bleed/lacerations healed (>2 weeks postpartum for pts with normal birth)

obesity considerations

teach= -create reward system -develop health goals UNRELATED TO WEIGHT (climb stairs) -adopt anxiety reducing diversional activities -place visual motivational cues throughout environment

Acute stage of HIV findings precautions?

temporary decrease in CD4+ T cells Symptoms take 2-3 weeks after initial infection to occur standard!! prevent infections! -avoid undercooked meats -avoid contact with cat feces -remain up to date on vaccines (includes flu) -drink water bottled/purified when in developing countries -always use condoms

Contusions, Strains, and Sprains

think RICE for sprains 1. Rest= stop activity, limit movement for 24-28 hrs (may be no weight bearing and crutches) *not even dorsiflexing feet is allowed--NO MVMNT 2. Ice= ice pack 10-15 min q hr for 24-28 hrs (reduce pain/inflammation) *do NOT apply ice directly to skin 3. Compression= Ace wrap or splint (prevent edema and promote fluid return) 4. Elevate= above heart on pillows for 24-28 hrs (reduce swelling, fluid return) *Analgesia= NSAIDs q 6 hrs PRN for pain, swelling *Exercise Rehabilitation Program-- begin ASAP AFTER INJURY (WHEN PAIN SUBSIDES) restore ROM rx= first cold! (inflammation) for 24 hrs then can apply moist heat 20-30 min (after 24 hrs)! (aid with mvmnt, reduce swelling) Dislocations= immobilize *keep in mind for inflammation issues, always use REST FROM PAIN AGGRAVATING ACTIVITIES (dont use heat= vasodilation=worsens)

Frostbite

tissue freezing, reduce blood flow, vasoconstriction, stasis, cell damage sx= mottled blue, waxy yellow skin, while hard to touch rx= -remove clothing to prevent constriction DO NOT MASSAGE, rub, squuze area involved -immerse affected area in heated water (whirpool)--98.6-102.2F -avoid heavy blankets or clothing -provide analgesia as rewarming is extreme painful -as thawing occurs, injured area becomes EDEMATOUS (ELEVATE INJURED AREA AFTER REWARMING) -keep wounds open, then allow to dry after whirpool in loose, nonadherent, sterile dressings -monitor compartment syndrome

Incentive Spirometry steps?

to prevent atelectasis r/t incisional pain *give adequate pain meds before use spirometer *5-10 breaths/hr while awake high fowlers position! exhale normally place mouthpiece in mouth seal lips tightly around piece inhale deeply, until piston is elevated to predeteremined level (set on device, is goal marker) hold breath at least 2-3 sec exhale slowly around mouthpiece *breathe normally several breaths before repeat cough at end of session to help expectorate

dental caries

to prevent: chew sugar free gum include MILK, YOGURT, CHEESE IN DIET minimize sweet/sticky food consumption rinse mouth with water after meals when brushing not possible brushing after meals, floss twice a day rinse mouth after meals/snacks DRINK TAP RATHER THAN BOTTLED WATER (flouride source) finish meals with high protein food! *increase intake cariostatic foods (inhibit progression of caries)= DAIRY, whole grains, furits veggies, sugar free gum

What to do to If suspect Central line air embolism?

to prevent: pt perform valsalva maneuver upon insertion, withdraw, AND every time tubing is changed! if air embolism occurs: clamp cath, put pt in TRANDELENBERG ON LEFT SIDE, admin O2 if need (air rises, so inverting pt upside down will keep air rise to right atrium and avoid from entering pulm circulation), apply occlusive dressing over dislodged cath site (if applicable), notify HCP, stay w/ pt and provide reassurance *NEVER PUT IN HIGH FOWLERS--trapped air could travel to pulm circulation

ear irrigation

to remove impacted/excess cerumen contrainidcations= FEVER, EAR INFECTION -->use otoscope to assess ear canal, ensure tympanic membrane intact, no foreign bodies steps: (after assess) 1. explain procedure/ sensations: vertigo, fullness, warmth 2. sitting/sidelying position with head tilted toward affected ear 3. towel/emesis basin under ear 4. verify irrigation solution at body temp (98.6F) 5. straighten canal= pull pinna up and back adults (down and back children </= 3 yrs) 6. irrigate solution with syringe tip toward TOP of ear *stop asap if pt in pain/nausea/dizziness 7. repeat as tolerated until prescribed amount instilled

toddler vs preschool and school age nutrition adolescent nutrition

toddler: *need fewer calories than infant, but more protein and calcium (500 mg/day) picky eaters/schedules!--allow choices of food to prevent struggle over eating *whole fruit chopped is good *provide water between meals *space intro of new foods by about a week to monitor for reaction, expose repeatedly to new foods -set and enforce schedule for meals/snacks -offer 2-3 choices for foods -DO NOT FORCE CHILD TO EAT -keep portions small -avoid TV/games during meals/snacks PHYSIOLOGIC ANOREXIA CAN OCCUR (high metabolic demands slow down as toddler, may appear child not consuming enough calories, they ARE getting enough) *DO NOT PUT TO BED WITH BABY BOTTLE MILK/FRUIT JUICE-->TOOTH DECAY 6-8 teeth erupt 1-3 years, begin to eat solid food preschool/school age: growth rate slowed less caloric needs, protein calcium still high adolescent: RAPID GROWTH SPURTS caloric, calcium, and protein needs all high high iron intake females due to menstruation high vitamins/minerals for rapid tissue growth cal= 2000-2400/day iron= 15mg/day

growth and development appropriate considerations by age (surgery prep, etc) (child) injections

toddler: simple explanations (fear separation, egocentric approach for autonomy, emotional displays--temper tantrums) -prep child for surgery only a few hrs before (no concept of time) *hospitals may cause regressive behavior to help: (home routines) -integrate preferred snacks into days routine -plan quiet play prior to usual nap time -provide 1 or 2 options when choosing toys (always give options rather than yes/no!) -encourage participation/parental presence when possible preschool: allow play with equipment (fear mutilation), dolls/puppets, do mock run-through of procedure *clarify procedures are not punishment for misbehavior, encourage to ask questions school age: allow questions/choices when possible, simple explanations, handle equipment, explain why (fear loss of control), draw pictures, read illustrated book (*videos or pamphlets not as good of method for school age) -use correct anatomical terminology -post a daily schedule by the child's bed -can prep child day before surgery adolescent: provide privacy, explain POC (expect resistance; fear loss of independence), peer support with other pts undergoing same thing, involve in care planning, discuss fears of body image, interact with peers INJECTIONS: toddler: keep needle out of view school age child: offer specific coping technique (count aloud, deep breathing) -explain in simple terms "medicine under the skin" instead of needle -tell truth about pain accompany injection "the skin may hurt for a minute" *can have caregiver hold child while injection being done (on lap etc)

polycythemia vera

too many RBCs (and often WBCs and plts too!) increase blood viscosity-->*increased thrombus risk sx (expected)= ruddy skin (red) due to venous stasis from viscous blood HA, blurred vision can occur (take ASA) Pruitis after bathing (bathe with cool water and pat dry w towel)--antihistamine relief rx= phlebotomy (periodic) *removal of 300-500mL of blood through venipuncture to reduce RBC count and achieve HCT <45% *initially pts may require daily rxs until goal HCT reached, then monitor monthly and additional blood draws PRN care= think, prevent thrombus formation--viscous blood so promote circulation ELEVATE LEGS WHEN SITTING (increase venous return) -stockings, hydration monitor for sx of dvt! -drink fluids! (reduce blood viscosity)--esp hot weather -avoid dehydration -report swelling/tenderness in legs -for pruitis: reduce water temp, use starch baths, pat skin dry (dont rub vigorously)

Capsaicin

topical OTC Analgesic Cream rx= minor pain relief in osteoarthritis, neuralgia *wat at least 30 min after massaging into hands before washing to ensure adequate absorption *avoid contact with mucuous membranes/skin not intact *wear gloves when applying to other areas of body/immediately wash hands after *do not apply heat to med *may feel burning, stinging, erythema when apply--should norm subside first week of use -use 3-4x daily for long periods (weeks to months) to achieve desired effecct -often used with NSAIDs/ASA

rotavirus

transmitted fecal oral route--can occur through contact with food, toys, diapers, and hands most common cause of diarrheal disease among infants/young children (less than 5) sx= fever, vomiting, abd pain, watery, foul smelling DIARRHEA (lasts 5-7 days), -->(at risk) DEHYDRATION: lack of tears when crying, extreme fussy or sleepy, decreased UO, dry mucous membranes if pt is incontinent/diapered, need contact precautions (requires private room) VERY CONTAGIOUS!! care= -frequent hand washing -proper diaper disposal -can still breastfeed, cont normal diet -wash perineal area with mild soap/water (no alc--commercial baby wipes) -can apply protective zinc oxide *vaccine available, must give before 8 mo--but can still acquire even with vacc as many dif. strains *no abx, is a virus!

ureterosigmoidostomy

transplantation of the ureters into the sigmoid colon, allowing urine to flow through the colon voiding out of the anus encourage void q 2-4 hrs NO enemas or cathartics!!

-TURP -prostatectomy

transurethral resection of the prostate (helps with BPH, urinary probs), to trim away excess prostate that is blocking urine flow red UO expected for first 12 hrs after surgery (may be bright red) -during first 24 hrs, urine changes color from reddish pink to pink -small clots expected up to 36 hrs post op prostatectomy: *EXPECT bladder spasms in pt with indwelling urinary cath following prostatectomy (clean cath with warm water/soap) -before 36 hrs post-op, may see some blood clots, but should NOT impair urine stream med for spasms= oxybutynin or belladonna opium suppositories *teach pt not to urinate around catheter--increase bladder pressure UNEXPECTED: (after 36 hrs post-op!) blood clots & decreased urinary stream, urinary retention, fever, dysuria *pts may have CBI after: -if distention and bladder pain, can indicate cath obstruction, assess to ensure no blockage from clots)--if there is, manually irrigate with NS sterile until no clots/urine is clear/pink -adjust CBI rate w/ findings so that urine remains light pink without clots teach= -MUST AVOID RECTAL INTERVENTIONS (suppositories, enemas) -do not strain when having bm -prevent constipation!! fluid intake!!

Pheochromocytoma

tumor in adrenal medulla causes hypersecretion of catecholamines (epi and norepi) dx= 24 hr urine collection test for VMA norm results= 1-5 (elevated= + catecholamines) S/Sx= everything increased metabolism!! tachycardia, hyperglycemia, N/V, weight loss, headache, diaphoresis, pain, HTN *key to remember is INTERMITTENT HTN (pt BP is very unstable, can shoot up and cause HTN episodes, can also drop and cause ortho hypotension) PAROXYSMAL HTN CRISIS -->nursing care centered around monitoring this! take bp in sitting and lying positions rx= Nitroprusside infusion -avoid activities precipitating HTN crisis (valsalva maneuver, bending, lifting) -avoid abd palpation--manipulates adrenal gland (located in top of kidneys)

function of cerebellum

two functions: 1. coordination of voluntary movements 2. maintenance of balance and posture (affects equilibrium) location= behind brainstem underneath occipital lobe) balance= heel to toe gait coordination= finger tapping, rapid alternating movements, finger to nose test, heel to shin

congenital heart disease considerations types feeding implications

two types: cyanotic: decreased pulmonary blood flow Sx= (cyanosis, clubbing, hypoxia, difficulty eating cause hard to breathe at same time, FTT, small stature, murmur, severe resp infections), SQUATS!! (position eases breathing) compensatory= tachycardia, polycythemia (to try to increase O2 perfusion), posturing (squatting to help with dyspnea) acyanotic= obstruction of blood flow from ventricles Sx=(weight loss/gain, FTT, small stature, murmur, increased resp infection) can be caused by maternal alcohol/drug intake meds: digoxin, iron preps, diuretics, potassium *change infant feeding pattern! goal= want to term-195avoid energy expenditure -->small amounts every 2 hrs -->feed infant right after waking up (well rested) -->enlarge nipple hole (easier to suck); or use preemie nipple -->low sodium, high potassium ventricular septa defect: acyanotic; MORE SERIOUS left to right shunt (opening between ventricles)-->can progress to CHF/pulm HTN--MONITOR! for sx= diaphoresis, tachypnea, dyspnea, HARSH SYSTOLIC MURMUR--expect abn= increased RR exertion (GRUNTING)--need further assess for CHF! atrial septal defect: acyanotic; left to right shunt abn opening between right and left atria (blood flows back to low pressure right atria) *hear SYSTOLIC MURMUR with FIXED SPLIT SECOND HEART SOUND coartactation of the aorta (COA): abn aortic narrowing-->decreased CO sx= elevated pulse pressure upper extrem, diminished pulse pressure in lower patent ductus arteriosis (PDA): acyanotic; left to right shunt aorta attached to pulm artery sx= poor feeding, LOUD systolic murmur w/ machine sound & diastolic murmur *commonly resolves w/in 48 hrs and requires no intervention! tetralogy of fallot (TOF): cyanotic--right to left defect 4 abns= pulm stenosis, right ventricular hypertrophy, ventricular septal defect, overriding aorta sx= irritability, clubbing of fingers, POLYCYTHEMIA (*report if >22 Hgb or HCT >65%--increase thrombus risk!), poor weight gain due to fatigue and poor feeding when have hyper cyanotic episode "tet spell" (exacerbation when child cries, upset, or feeding) first= rx= place in KNEE TO CHEST POSITION!, supplemental O2, avoid irritating stimuli, morphine (if knee to chest don't help) transposition of the great vessels: cyanotic; right to left defect LEFT TO RIGHT SHUNTS (PDA, ASD, VSD) sx= acyanotic; excess blood flow to lungs (think left to right) -tachypnea, tachycardia (even at rest) -diaphoresis during feed/exertion -heart murmur/extra sounds -CHF -poor weight gain w/ increase metabolic rate RIGHT TO LEFT DEFECTS (fallot, transposition) sx= cyanotic and impede blood flow to vasculature -cyanosis -chronic hypoxia -clubbing of fingers

Influenza vaccination

two types: live virus= nasal spray injection= not live need to get annually, ALL PTS >/=6 months to recieve UNLESS pt has life threatening allergy to one of ingredients (egg) *make sure to vaccinate high risk individuals: -chronic conditions -immunocompromised (HIV) -HCPs -healthy children 6-23 mo and >65 yrs -pregnant pts expect after= minor AEs such as flulike sx, rx with ibuprofen/acetaminophen

diabetes mellitus sx hgb a1c

type I: 3 p's weight loss acanthosis nigricans (velvety light brown to black skin thickening on axilla, neck, or flexures indicative of insulin resistance), with skin tags hcb a1c level for diabetics: goal= keep <7% normal is 4-6% w/out DM *target BM goal for diabetic pt= <140/90 RELIGIOUS CONSIDER: *if pt islamic and diabetic, wants to fast during ramadan -->FIRST ASSESS PTS CLINICAL STABILITY AND GLYCEMIC CONTROL (if low risk, may be able to adjust their meal plan, exercise, insulin therapy to still fast) higher risk pts may be discouraged from fasting diabetic diet: -LOW FAT, LOW GLYCEMIC INDEX (low carb foods affecting blood glucose levels), HIGH FIBER -low cholesterol, reduce sodium intake -limit sucrose foods, alcoholic beverages -manage calories if weight loss desired DM mangmnt for school aged children: -choose and clean finger for bg test (parent performs puncture) -select site for insulin injection (w/ parent approving appropriate site/rotation) -pushing syringe plunger to admin insulin after a parent/caregiver inserts/stabilizes needle -identify s/sx of hypo/hyper glycemia at 14 yrs: can begin to analyze test results and adjust insulin doses based on sliding scale and readings *diabetic retinopathy= treat with retinal photocoagulation!

IUDs (intrauterine devices)

types: (can be used as emergency contraception) COPPER= last 10 yrs *immediate contraceptive effect--no backup needed *HEAVIER MENSES and more menstrual cramping is expected *may have cramping and vag spotting for short time after insertion *ovulation/menses STILL OCCURS (device does not have hormones)--if period missed, preg test needed levonorgesterel-releasing: skyla=(3 yrs), Mirena (5 yrs) *backup contraception required at first *can be emergency contraceptive w/ in first 72 hrs Mirena= 5 yrs PAINS acronym for complications (see Uworld flashcards!) assess string position daily first 4 weeks, then after each menses--monthly (if shorter, longer, or not there notify HCP asap!) could indicate no longer in uterus -abstain from intercourse or use barrier device until placement verified if occurs

ileal conduit

urinary diversion in which the ureters are connected to the ileum with a stoma created on the abdominal wall, brought to skin surface *postop mucus threads normal, watch for obstruction at anastomosis

Menopause considerations

use ERT only if severe hot flashes: contraindicated if fam fx breast/uterine cancer, thrombophlebitis, HTN supplemental calcium to slow osteoporosis

obtaining ABG sample considerations

use allen's test to assess (perfusion should return less than 15 sec--assess for patency of ulnar artery= positive test if good perfusion) & ASEPTIC TECHNIQUE FOR PROCEDURE apply pressure to puncture site 5 minutes (15 min if pt is on anticoagulants) have ice bag ready to put sample in at bedside apply sterile dressing after holding pressure at site *most imp to doc on lab slip is the use of supplemental oxygen (NC) if pt had any time of blood draw

PICC line considerations care dressing change

use for= PARENTERAL NUTRITION! chemo, long term IV therapy, pts w/ poor venous access dressing change: (always sterile technique) -q 48 hrs w/ a gauze dressing OR -7 days with a transparent semipermeable dressing OR -immediately if dressing loose/torn/soiled, damp -nurse wears mask -pt turns head to opp side -have pt hold breath during injection cap and tube changes position= SUPINE! *only put pt in TRANDELENBERGS on left side if air embolism suspected!! *Flush line before and after med admin *do not perform BP/venipuncture on arm *all infusing meds/TPN (except vasopressors) MUST BE PAUSED BEFORE DRAWING BLOOD (to prevent false interpretation of serum levels) *scrub the hub w/ alc or chlorhexidine alc for 10-15 seconds!

hormonal contraception

use of hormones to suppress ovulation and prevent conception -estrogen with or without progestin (oral contraceptives) Biggest complication= BLOOD CLOTS risks: "ACHES"-->think anything to do w/ clot! A- abdominal pain -->ischemic bowel C- chest pain -->PE or MI H- headaches -->Stroke E- eye problems -->retinal vessel ischemia S- severe leg pain --DVT *do not smoke while on pill expected SEs: -irregular bleeding/spotting between menses -breast tenderness *backup protection required up to 7 days after starting oral contraceptives (but not required if the pill pack is started on the first day of menses)

tPA (tissue plasminogen activator)

used for ischemic strokes *must do CT before to ensure not hemorrhagic! onset of sx= <4.5 hrs (last well time)

Sengstaken-Blakemore tube esophageal varices--sx?

used for tx of esophageal varices sx= upper GI bleed (coffee ground emesis) *recall coffee ground emesis means older blood (not new, so need to look but not always priority) however, LIFE-THREATENING EVENT= variceal rupture!! massive GI bleed, shock, death so avoid things that cause (increase in portal venous pressure)= coughing, straining, vomiting or mechanical injury (chest trauma, sharp/hard foods) *NGT= question prescription if pt has varices cause can cause rupture! NGT is given for Upper GI bleed (but varices question) SENGSTAKEN-BLAKEMORE/MINNESOTA TUBE: 2 balloons and 3 lumens to control bleeding varices (compresses bleed) --> **keep scissors at bedside! if pt shows sx of resp distress/airway obstruction (due to upward displacement of esophageal balloon), cut balloon ports and remove tube *stops slow bleeding (hemorrhage), so not a stable pt! pressure 25 mmHg in balloon

Misoprostol

used to prevent GI ulcers in pts taking long term NSAIDS (is designed to reduce effects SEs of NSAIDs); also for labor induction in pregnant women--cervical ripening agent (best before onset of labor) *teach pt to use Birth control while on med, if think preg must stop immediately, can cause uterine contraction *has GI AEs, take with food (diarrhea, dehydration) in pregnancy, contraindicated if: -pt recieving another uterotonic (oxytocin)--oxytocin must be given at least 4 hrs after last dose of miso -hx of uterine surgery (c section)--increased rupture risk at site -has abn FHR/uterine tachysystole -route= PO or Vaginally!

Circumcision

uses a clamp (gomco) or plastic ring (plastibell) *typically performed near d/c to ensure newborn stable wrap newborns upper body in blanket restraint (prevent injury) *swaddling, non-nutritive sucking with pacifier dipped in sucrose help with pain sterile technique! diaper changes: -wash hands prior -perform at least q 4 hrs or when soiled, assess for bleeding/infection **apply petroleum gauze/ointment at every diaper change to prevent sticking --> (unless Plastibell is used) for 3-7 days to prevent adherence of glans to diaper until site heals (heals in 7-10 days) -wear LOOSE fitting diaper after apply sterile gauze dressing with petroleum jelly/ A&D ointment to the site *except! when plastibell used if plastibell used: report to HCP if has not fallen off in about 8 days post-op care: -monitor for bleeding and voiding/infection (odor, discharge, redness, swelling) *bleeding no larger than a quarter (if excessive, report!) -clean with warm water *NO soap, squeezed over penis and dry gently, NO ALCOHOL (until healed 5-6 days) at least twice a day to remove feces in diaper *notify HCP if NO VOIDING WITHIN 6-8 HRS OF procedure immediate post-op -will be dark red (expected) *24 hrs after: whitish-yellow exudate is NORMAL (2-3 days), DO NOT REMOVE if UNCIRCUMSIZED: do not force foreskin retraction (takes 3-5 years to completely separate) gently test for retraction occasionally during bath, and when has occurred, gently clean glans with soap and water

Intravenous pyelogram considerations

uses contrast dye--check allergies to shellfish (oysters), iodine, chocolate, eggs, milk (remember IV contrast can be nephrotoxic!!) position= supine on table do need bowel prep night before and NPO midnight

influenza considerations vaccine reccomendations to get

vaccine recc's over 65 exposed to general public have young children/come into contact have chronic resp/cardio condition not risk if have animals if live with 1 person in apt CDC recommendation: ALL PEOPLE AGE >/= 6 MONTHS RECIEVE INFLUENZA VACCINE ANUALLY contraindications to live vaccine: (safe 2-49 yrs) less than 2 years, greater than 50 pregnant children on long term ASA health conditions (chronic), immunosuppressed INFLUENZA CONSIDERATIONS: -incubation period 1-4 days -peak transmission= 1 day before sx appear to 5-7 days after illness stage begins -teach= avoid close contact (since droplet) with person infected for about a week to avoid infection spread -antiviral meds (zanamivir, oseltamivir) give to pts w/ sx onset w/in 48-72 hrs

Nitrazine test

vaginal exams to assess for ROM should always be using STERILE GLOVE TECHNIQUE tests vaginal secretions to differentiate amniotic fluid (alkaline) and normal vag fluids (urine=acidic) *ROM= blue-ish color amniotic membranes are intact= yellowish, olive, green color (think acidic) false positives= may be generated due to blood/semen presence *if pt reports sexual activity, notify HCP as could be false pos!

Labor considerations (at dif. stages)

vaginal exams to assess for ROM should always be using STERILE GLOVE TECHNIQUE SECOND STAGE: Full dilation Intense contractions BIRTH!! *imp to observe the perineum at this point for crowning of infant head FIRST STAGE: latent: time of onset until 3 cm active: 3cm-7cm transition: 7cm-10cm *phase will be painful!! tell pt to pant with pursed lips (breathing technique increases urge to push) *pt should NOT push until fully dilated! (second stage of labor) THIRD STAGE: after expulsion of fetus, to expulsion of placenta FOURTH STAGE: first 2-3 hrs after birth until fundus has fully contracted?? FIRST POSTPARTUM PERIOD AFTER VAG DELIVERY-->need to check lochial flow before palpating fundus!! (assess hemorrhage) -have pt change positions frequently during labor to promote fetal rotation/descent and increase maternal comfort (q 30-60 min) -don't have pt remain in bed early in labor--get them up!! helps labor progress

Meds with nephrotoxicity AEs

vancomycin aminoglycosides NSAIDs

Milirinone

vasodilator (inotropic agent) *give to HF pts unresponsive to other med therapies infuse over 48-72 hrs hopsital or PICC line home infusion *need IV infusion pump

types of diets what are vegans at risk for?

vegan= no animal products (no dairy, no meat) *risk vit B12 deficiency= MACROLYTIC/MEGALOBLASTIC ANEMIA (cause only found in animal products dairy/meat); risk toxic Vit A levels *emphasize consuming marcobiotics *vegan diet unable to sustain growth needs to children TEACH: -->need vit b12 sources: fortified grains or supplements (prevent pernicious anemia) -->may require calcium/vit D supplementation since like dairy -->poor iron intake (feed fortified breads/cereals), foods high in Vit C to increase absorption) lacto-vegetarian= no meat, no eggs, yes dairy (milk, cheese, yogurt) ovo-vegetarian= no meat, no dairy, yes egg lacto-ovo-vegetarian= no meat, yes dairy, yes egg red meat abstainers= vegetarian except yes to red meat *vegetarian diet can cause weight loss (no meat which is major fat source)

Candida vaginitis

yeast infection sx= itching, irritation of vagina white cheesy vaginal discharge low vag pH stable pt, can wait up to 2 hrs for treatment rx= fluconazole (antifungal) ANTIBIOTICS CAN CAUSE CANDIDA INFECTIONS (thrush, vaginitis)

Hypercalcemia

"BACK ME" -->Is a CNS depressant; see these effects Bone pain Arrhythmias cardiac arrest kidney stones muscle weakness (depressed/absent DTRs) excessive urination (Ca has a diuretic effect!) also: constipation, abd distention/pain, confusion SHORTENING OF QT AND ST SEGMENT Rx= restrict dietary intake (limit intake calcium carb antacids) CALCITONIN= decreases Ca+ level IV admin 0.45 NaCl or 0.9 NaCl (hypo or iso) furosemide to: maintain acidic urine (prevent renal calculi) *hypercalcemia can impair bone growth (leading to osteoporosis) so reduce dietary intake in immobility if find

Hypernatremia S/S

"Fried salt" -->think w/ sodium, CNS changes F- flushed skin and fever--low grade R--restless, irritable, anxious, confused (delusions/hallucinations) I-increased BP and fluid retention (tachycardia) E-edema (peripheral and pitting) D- decreased urine output/dry mouth OR (shorter) S- skin flushed A- agitation L- low grade fever T- thirst Rx= restrict Na+ foods IV admin= hypotonic fluids (0.45 NaCl, 0.3% NaCl, 5DW) *pull back into cells

what can child do at 8 mo?

sit up unsupported say a few words (mama, dada) play peek a boo

Hypermagnesemia S/Sx and Rx

"LETHARGIC" -->Think "Mag is Drag"= CNS Depressant L- lethargy E- EKG Changes T- deep tendon reflexes absent/grossly diminished H- hypotension A- arrhythmias (Bradycardia/heart blocks) R- Resp. arrest G- GI issues (N/V) I- Impaired breathing C- cardiac arrest Rx= antidote= CALCIUM GLUCONATE!! for mag toxicity decrease diet intake d/c mag meds

benzodiazepines

"Lams and pams" -->anxiolytics, seizures, sedatives, alcohol withdrawal avoid kava, valerian root tea, melatonin with as all can exacerbate cns depressant effects (lavendar oil is safe) SE= sedation (make everything low and slow), sleepiness, supression of ABCs TAKE AT BEDTIME (sedative effect) DO NOT SKIP DOSES (even when pt feeling okay -stop drinking alc -dont operate machinery do NOT abruptly withdraw!!--highly addictive *not safe for long term use ANTIDOTE= FLUMAZENIL!! *in elderly, can cause a paradoxical worsening agitation effect

Oxygen portable tank considerations (take home)

*is combustible! home safe measures: -avoid vaseline (use water-soluble lubricant) -keep O2 canisters at least 5-10 feet away from gas stoves, lighted fireplaces, wood stoves, candles, sources of open flames -avoid nail polish/remover -avoid synthetic and wool fabrics (use cotton instead) -in COPD pts, oxygen should be prescribed to achieve: O2 sats of 90-93% and PaO2= 60-70 -flow rate of 2L/min, AVOID 6L/min --> *recall too high saturation decrease pts drive in COPD to breathe!

water-soluble vitamins and their function

"take your birth control with water"= B/C B1- thiamine--normal growth/carb metabolism deficient= beriberi. wernicke/korsakoff syndrome B2- riboflavin--protein/energy metabolism deficient= ariboflavis B3- niacin (nicotinic acid)--normal growth deficient= pellagra B6- pyroxidine--amino acid metabolism deficient= anemia, CNS change, PERIPHERAL NEUROPATHY isoniazid= increase B6 intake (give together to help with peripheral neuropathy) levodopa= decrease B6 intake B12-cyanocobalamin- nerve func, RBC formation deficiency= pernicious anemia folic acid- RBC formation (prevent NTD in maternity!=spina bifida/ancephaly) deficient= anemia C- ascorbic acid collagen synthesis (think vit C serum on skin!)

how many cm in an inch?

1 inch= 2.54 cm

How long do you hyperoxygenate someone?

1-5 minutes before, after each suction pass, and after can do with 100% O2 or pt takes 3 deep breaths

Irrigation procedure (for colostomy)

1. fill irrigation container w 500-1000mL lukewarm water, flush irrigation tubing, and reclamp, hang on hook or IV pole 2. place irrigation sleeve over stoma, extend sleeve into toilet 3. place irrigation container about 19-24 in above stoma 4. lubricate cone-tipped irrigator, insert cone/cath gently into stoma, hold in place 5. slowly open roller clamp, allow irrigate 5-10 min flow 6. clamp tubing if cramp occurs, until subsides 7. after solution instilled, cone remove and feces drained through sleeve into toilet *NEVER USE ENEMA SET TO IRRIGATE ALWAYS CONE-TIPPED APPLICATOR: made specifically for colostomy openings

CVP pressure--how to take

1. zero manometer to phlebostatic axis (4th ICS and midway line even to sternum and midway between AP diameter) (midaxillary line) then level zero reference stopcock of transducer with level of atrium use ruler or carpenter's level (think that yellow thing i used during OSCE) 2. turn stopcock to fill manometer with fluid (18-20 cm) 3. turn stopcock to allow fluid to flow from manometer into pt -->level of fluid fluctuates with respirations, after level stabilizes--take HIGHEST READING 4. return stopcock to proper position to adjust IV flow rate

Blood transfusion administration & steps

20-micron-in line filter (filtered piggyback tubing) secondary solution=NS 18-20 G cannula for adults, elders consider 20-22G, and slower blood admin bp cuff and thermometer for frequent VS *HAVE PT VOID/empty urine cath BEFORE ADMIN so can get fresh clean catch urine sample if need if rx! STEPS (to admin): verify informed consent signed make sure patent IV access double verify compatibility of blood with pts blood type identify client (right before begin admin) initiate transfusion eval for transfusion rx (most likely first 15 min, first 50 mL of blood) STEPS (if rx occurs): stop transfusion infuse NS w/ new tubing notify HCP (to order meds) & blood bank admin any prescribed meds (vasopressors, antihistamines, fluids, steroids) collect urine sample (eval for hematuria-->hemolytic) return blood and tubing to blood bank document

ADHD (Attention-Deficit Hyperactivity Disorder)

3 core sx of ADHD: hyperactivity (may be aggressive, dif. control anger) impulsiveness inattention low self-esteem impaired social skills risk for learning disability risk for depression/anxiety/substance abuse emotional immaturity rx= stimulants (methylphenidate, dextroamphetamine) methyl--admin 2-3 divided doses daily 30-45 min before meals How to know meds therapeutic? =child should be able to more easily complete school assignments and other tasks teach= -offer two choices between things (avoid overstimulation) -advocate for individualized educational plan SEs= insomnia, irritability, diminished appetite, WEIGHT LOSS, HA's -give last dose no later than 6pm! -MONITOR BP (for htn) teach= sx cont into adulthood (children do NOT outgrow condition)--will learn to cope and manage tho -dietary modifications (less sugar/additives) will NOT improve symptoms in hospital: priority= give pt a written schedule of daily activities (inattentive so have trouble holding attention to tasks, easily distract) -calm, structured, organized, consistent environment -have visitors to work on social skills, but not too much to where overly distracting environment if child has difficulty controlling anger: action= deep breathing ask child to blow up balloon *discuss disruptive behavior ONLY after child is calm

Medical Asepsis in newborn nursery (medical asepsis= clean technique) surgical asepsis= sterile technique

3 minute had scrub before entering the nursery hand hygiene with sanitizer consistently between care of dif newborns change linen of crib at least once a day non-sterile gloves *surgical asepsis is useing povidone-iodine cleaner (prior to circumcision)-->sterile procedure!

preschool growth and development

3 years: WALK UP STAIRS WITH ALTERNATING FEET decreased tantrums than toddler undresses without help rides tricycle 900 WORD VOCAB, USES SENTENCES increased attention span jumps off bottom step/forward copies/draws a circle builds bridge with 3 cubes grips crayons with fingers not fist FEEDS SELF WITHOUT HELP 3-4 word sentences, asks why states own age draw/copy square 4 years: 1500 WORD VOCAB skips and HOPS ON ONE FOOT laces shoes brushed teeth climbs/jumps well throws overhead may have imaginary friend! catches a ball 50% of time copy or draw a square 5 years: -->11 hrs sleep daily runs well jumps rope dressing without help 2100 WORD VOCAB tolerates increasing periods of separation begin cooperative play ties shoes (think kindergarten tie shoe) gender specific behavior skips on alternative feet copy shapes other than circle (and square) HOSPITAL CARE: teach child they did not cause the illness -physical assessment: as young as 3 yrs can show examiner where hurts/what they feel in their own terms *in children under 6, the diaphragm is major resp. muscle (display abd breathing pattern)

hyperbilirubinemia (types in infants)

4 types: *recall, byproduct of HgB breakdown= bilirubin, infant needs to be able to excrete! Pathological jaundice (HEMOLYTIC ANEMIA) BAD -->seen in FIRST 24 hrs -->rx= phototherapy exchange transfusions (removes bili and maternal hemolytic antibodies) -->sx= jaundice, decreased HCT (RBCs breakdown), anemia -->Coomb's test (antibodies--from mother--acting on baby's Rh antigens-- causing destruction of RBCs, hemolysis and anemia) physiologic jaundice: OKAY -->causes= immature hepatic func, resolving cephalohematoma -->seen AFTER FIRST 24 hrs, will resolve on own, no rx needed (lasts 5-7 days) breast feeding jaundice: -->caused by poor milk intake, baby cant poop out excess bili -->onset 2-3 days -->rx= frequent breastfeeding, caloric supplements breast milk jaundice: -->factor in milk impairing newborn from excreting bili -->obset 4-5 days -->rx= d/c breastfeeding for 24 hrs

average daily sodium intake

6-15 mg *HF pt: diet of 2 g Na+ is considered low sodium diet?? check on this

Hypothermia treatment

<95F cold myocardium-->at risk for DYSRYTHMIAS-->handle pt gently, spon v fib could occur when moved/touch *anticipate defibrillation *priority action= apply cardiac monitor on pt! keep warming pt (blankets, IV fluids) need TWO large bore needles preferred

bladder scan

>100 mL -->report to HCP! indicates urinary retention and abnormal!

LGA newborn care risk factors for LGA

>8 lbs 13 oz risk factors to produce a LGA infant: gestational DM excessive gestational weight gain elevated pre-pregnancy BMI hx of prior newborn LGA postterm gestation genetics (male sex, maternal birth weight, ethnicity) care for LGA newborn: AT RISK FOR HYPOGLYCEMIA -assess birth related injuries -discuss need for possible feeding supplementation if newborn is hypoglycemic (breastmilk, formula) -asssit mom feed newborn q 2-3 hrs -obtain cap BG before feeding to assess for hypoglycemia (notify HCP BG read <40-45)

Clubfoot (Talipes Equinovarus)

A birth defect in which one or both feet is turned inward rx= manipulate deformity soon after birth by stretching affected foot and placing in long leg cast -need weekly recasting over 5-8 weeks (ponseti method) to gradually reposition -then custom shoes secured to a bar brace -long term follow up until child attains skeletal maturity teach parents= -monitor circulation -keep cast dry during diaper/bathing -continue to cradle/hold infants!! (bonding) -sleep in supine position

Allergy Immunotherapy Injections (allergy shots) Allergy Skin Testing

ALLERGY SHOTS: reduce body's allergy sx when exposed to specific antigens small dose injected SQ on pt-specific schedule -must remain at facility for 30 min after an injection so nurse can monitor severe anaphylactic rx -first few months, give every week -then maintenance dose given every few weeks for 3-5 years expect: localized rx (redness/swelling) at site after shot unexpect: mild systemic allergic rx (hives, itching, facial swelling, mild asthma) up to 24 hrs after shot-->need to notify HCP to adjust next dose/delay SKIN TESTING: introduce common allergens into skin surface and observe site for rx (wheal, erythema), test several at same time teach before procedure: -AVOID ANTIHISTAMINES (diphenhydramine, loratadine, promethazine) for up to 2 weeks prior to test -avoid systemic corticosteroids possible--have HCP determine *albuterol is okay before!

Priority nursing action when patient has SOB, resp. distress?

ALWAYS FIRST RAISE HOB before anything else!! positions= (high fowlers) or fowlers orthopneic --sit in chair/bed w/ head all the way raised and leaning over bedside table with pillows under arms for support tripod - sitting in chair upright leaning forward with hands/elbows resting on knees

antisocial personality disorder (APD) Borderline personality disorder (BPD)

APD: when one consistently disregards and violates the rights of others around them -pt has problem with authority figures BPD: live in fear of rejection and abandonment -patter of instability in relationships, intensive emotions, poor self image, impulsive -goes to great lengths to avoid being abandoned (suicidal attempts, inappropriate anger, make one feel guilty for leaving) -known to go years with suicide threats before completing a suicide (always assess pt if any attempt made no matter what!) rx= **assign different staff members to care for pt each day seen in APD/BPD: manipulative behaviors (aimed at gaining control/power of situation/person for gratification) --flattery, pitting staff members against each other rx for manipulative behaviors: MOST IMP= assign different staff members to care for the pt each day! interventions: -set limits that are realistic, non-punitive, enforceable -use nonthreatening, matter of fact tone when discuss limits/consequences of unacceptable behaviors -enforce all unit, hospital, center rules -ensure consistency from staff in enforcing set limits

ARF (Acute Respiratory Failure) vs. ARDS (Acute respiratory distress syndrome)

ARF= broad term comprising many lung conditions that cause resp failure (COPD, etc) PaO2 <60 or PaCO2 >45, pH <7.30 (acidotic!) hypoventilation respiratory acidosis! type I= hypoxemic type II= hypercapnic sx= ALTERED MENTAL STATUS HUGE!! (confusion, agitation, somnolence) paresthesias, dyspnea, tachypnea hypoxemia hypercapnia PARADOXICAL BREATHING absence of wheezing and silent chest (no air movement) single word dyspnea ARDS= damage to alveolar capillary membrane fluid leaks into space impairs gas exchange-->priority ND!

DIC (disseminated intravascular coagulation)

Acquired coagulation disorder, causing simultaneous thrombosis and hemorrhage high mortality! first sx often prolonged oozing from sites of minor trauma signs of external/internal bleeding (petechiae, ecchymosis), organ damage from blood clots (resp distress/renal failure)

Loperamide

Antidiarrheal should not be used more than 2 days or if fever is present (dont want retention of bacteria)

Methotrexate

Antimetabolite, antineoplastic, immunosuppressant, anti-rheumatic AE= bone marrow suppression (leukemia, anemia, thrombocytopenia)--PRIORITY IF FIND SX r/t this! hepatotoxic, teratogenic! GI irritation (N/V) at risk for infection! *get routine inactivated vaccines, avoid large crowds at risk for bleeding! *= purpura (larger, red, non-blanching lesions) petechiae (smaller pinpoint, red/purple typically raised lesions) *avoid alcohol *do not become preg at least 1 ovulatory cycle (for women) and 3 mo after stop taking (for men) *avoid caffeine/ folic acid with med (decrease effectiveness)

chlorpromazine hydrochloride

Antipsychotic/Antiemetic phenothiazine ae= daytime sedation

Sucralfate (Carafate)

Antiulcer Agent provides PHYSICAL BARRIER against stomach acids admin 1 hr BEFORE MEALS (AC) AND AT BEDTIME to coat and prevent irritation during *take on empty stomach with glass of water *avoid antacids, PPIs, H2RAs within 30 min of taking, take other meds 1-2 hrs after or before (give at least 2 hrs before or after taking other meds in general) SE= constipation

Growth and Development Children Beliefs about death based on age

Birth--2 no understanding of death, sensative to separation/loss react anxiously to altered daily routines 3--5 believes death is reversible (magical thinking/fantasty) may wish a person would die; may feel guilty/responsible for death due to their wishes react axiously to altered daily routines **talk about the death in simple terms as often as needed for child to process loss, do not avoid it *infants/toddlers react more to separation from caregivers, affects daily routines 6--9 understands death is final; difficulty perceiving their own death; preoccupied with medical/physical aspects of dying (curious about death!) 10--12 understands death is final, affects everyone--thinks about how will personally affect them may perceive it as evil adolescence: views death on adult level difficult concept for them to percieve thinks about spritual/religious aspects of death

Black Cohosh Hawthorne

Black Cohosh used for menopausal hot flashes think cohosh, "im hot" SE= uterine lining thickening, liver toxicity *check to see if have any adverse rx with other meds pt is taking Hawthorne: extract to treat HF (in germany is approved for this)

Warning signs of cancer (CAUTION)

C- change in bowel/bladder habits (dif color stool/urine) A- A sore that does not heal U- unusual bleeding or discharge from body orifice T- thickening or lump in breast or elsewhere (hard and fixed mass) I- indigestion or difficulty swallowing (chronic, not occasional) O- obvious change in wart or mole N-nagging cough or hoarseness (persistent, not seasonal) *unintentional weight loss >10% (in non obese pts) *Nausea, anorexia, dysgeusia (altered taste)

SQ injections IM ID

CAN be either 90 or 45 degree angle how do you know? -->if can grab 2 in...90 degrees -->if can only grab 1 in...45 degrees 3/8-5/8 in (1/2 in) size 25-27 G BUT do 45 degree angle for pts who have insufficient adipose tissue (cachexic, malnourished)--as 90 may go into muscle! ID (intradermal)= 15 degree angle 1/4 in-5/8 in 25-27G IM 90 degree angle 1-1 1/2 in 18-25G *IM for infants: use vastus lateralis site 1 in length! (not 1 1/2 too long) (not ventrogluteal until at least age 3)

Cervical cap vs. diaphragm

CERVICAL CAP barrier contraceptive method used with spermicide placed over cervix before intercourse *cap should REMAIN IN PLACE >/= 6 HRS to allow for sperm to die, but NO MORE THAN 48 HRS *cap can remain in place for multiple intercourses, but pt should verify correct placement and ADD ADDITIONAL SPERMICIDE EACH TIME *use alternative method during menses (increases TSS) when have cap during menses-->avoid! DIAPHRAGM: -contraindicated in TSS! increase risk for this and UTI -do not insert more than 6 hrs prior to coitus! -use spermicidal gel -remove at least once q 24 hrs

cranial nerves

CN I- olfactory (smell/hearing) -->have pt smell, each nostril individually CN II-optic (sense of vision) -->snellen chart (begin at age 6 and older) CN III-oculomotor (pupil constriction, raise eyelids) -->PERRLA, symmetry of eye CN IV-->Trochlear (eyes look down and inward) -->inferior adduction CN V-->Trigeminal (Jaw mvmnt/ facial sensation) -->open jaw, bite down (clench teeth) -->pin and wasp of cotton over cheeks (light touch) CN VI-->Abducens (lateral eye movement) -->lateral abduction (*nerves CN III, IV, and VI GO TOGETHER TO TEST THE "H" SHAPE) CN VII-->Facial (movement of face, taste) -->facial symmetry test -->substance on tongue to taste CN VIII--> Acoustic/Vestibulochochlear (sense of hearing/balance) -->Romberg's test -->Rinne/ Weber (hearing) tests -->Caloric test! (water trickling into ear)--expect vertigo/dizziness (N/V) --watch for dizziness/vertigo in pts w deficit CN IX-->Glossopharyngeal (gag reflex, able to swallow/taste) -->taste test, elicit GAG REFLEX, swallow ability -dysphagia in pts with deficit CN X-->Vagus (swallow and speaking) -->say "ahh" (think, ahhh vegas) -->observe uvula midline, rate quality of voice -->uvular and palate movement CN XI--> Spinal Accessory (rotation of head, shrugging of shoulders) -->turn head and lift shoulders to resistance CN XII--> Hypoglossal (movemnt of tongue) -->stick out tongue

African American diseases at risk for

Cervical Cancer Hypertension (women over AA men too!) Ischemic Stroke

Infection control procedures in home care setting

Change a dressing: wash hands before after gloving open sterile supplies carefully PLACE OLD DRESSING (SOILED) INSIDE GLOVE OR PLASTIC BAG BEFORE DISPOSAL INTO HOUSEHOLD TRASH *is NOT okay to wrap soiled dressing in paper towels--can seep through to other items in trash

fat soluble vitamins and their functions

DAKE A- visual acuity D- calcification of bones, absorption of ca/phos K- blood clotting E- antioxidant, growth

what are patients with sepsis at risk for developing?

DIC! *emergent situation!

what is the best indicator of pain relief?

DONT SAY pt says they feel relief (they could be lying) look for objective indicators: improvements in breathing, physical comfort through body language etc

Failure to Thrive (FTT)

DX= <80% of ideal weight OR below 3rd-5th percentile on growth charts OR persistent decrease in growth over time on growth charts poor growth due to: risk factors= -preterm birth -breastfeeding difficulties -GERD -cleft palate -inadequate caloric intake -inadquate food absorption -excess caloric expenditure -domestic voilence -hx of child neglect/abuse -negative attitudes of either caregiver/child towards food (anorexia, fear obesity, food restrict) -poverty or food insecurity -disordered feeding behaviors (unstructured mealtimes) -social or emotional isolation of parents -lack of parental nutritional education -parent has cognitive disability or mental health disorder -one parent, unemployed

supine hypotensive syndrome

Dizziness and a drop in blood pressure caused when the mother is in a supine position and the weight of the uterus, infant, placenta, and amniotic fluid compress the inferior vena cava, reducing return of blood to the heart and cardiac output. sx= low CO, reflex tachycardia pallor, cold, clammy skin rx= wedge under pts hip while supine turn pt left lateral position!! (can be right also)

Donning and Doffing PPE

Donning: (CDC) 1. Gown 2. Mask/Respirator 3. Goggles/Face Shield 4. Gloves Doffing: (most to least contaminated) normal: 1. gloves 2. goggles 3. gown 4. face mask For (airborne/contact) precautions: 1. Gloves 2. Gown (discard and perform hand hygiene), exit neg. pressure room and immediate close door 3. Face shield/Mask and perform hand hygiene Droplet precautions?

hypoxia S/Sx

EARLY SIGNS: restlessness/agitation= always first indicator!! increasing BP/HR nasal flaring LATE SIGNS: cyanosis circumoral cyanosis (bluish discoloration of mouth)

retinal detachment

EMERGENCY!! sx= painless, CURTAIN BLOCKING OF part of visual field HAIRNET/gnat/cobweb-LIKE EFFECT ACROSS VISION (can be gradual or emergent depending how detachment occurs) floaters sudden flashes of light (lightning flashes) cloudy vision causes= blunt force trauma to head *unrepaired can cause blindness! ocular EMERGENCY! rx= EMERGENCY SURGERY to attempt to restore vision teach post op: *think, avoid increase intraocular pressure -avoid rub/scratch affected eye -avoid straining with bm -report any sudden pain to hcp -rest eyes by refraining from reading/writing/sewing! -report any signs of pain, flashes of light, vision loss, bleeding -wear an eye patch/shield! to prevent rub eye -ensure pt in appropriate position

Dawn phenomenon

Early morning glucose elevation; abnormal early-morning increase in blood sugar — usually between 2 a.m. and 8 a.m. — in people with diabetes, due to declining insulin levels and increase growth hormone release. Rx: Avoid carbohydrates at bedtime. *DO NOT eliminate bedtime snack, just adjust it *Adjust your dose of medication or insulin. -->if taking Isophane (NPH), increase dose at bedtime to prevent early morning hyperglycemia

Preconception Pregnancy Counseling

Encourage pt: achieve normal BMI: 18.5-24.9 abstain from alcohol smoking cessation folic acid at least 400 mcg/day check rubella immunity dental wellness exam: prevent peridontal disease *rubella: should be given vaccine to pt if nonimmune avoid pregnancy for until 4 weeks after

Assisting patient to stand

Face the pt with hands grasping each side of rib cage; push nurse's knees against 1 of the pt's; rock pt forward to standing; pivot to sit in a chair (have chair on pts strong side)

Growth Hormone Replacement Therapy

GH deficiency--may undergo therapy *despite therapy, child still may have final height less than "normal" SQ daily injection *treatment most successful when dx and replacement begins early in life stop therapy: decide by pt and fam, however, when growth less than 1 in per year and bones of 14yr girls /16 yrs old boys is criteria to usually stop (when bone growth ceases)

What is the hands down most imp factor in preventing infection transmission?

HAND HYGIENE

gestational HTN/ HTN Ecclampsia sx preeclampsia sx

HTN: dx before 20W G and treated gestational HTN: dx after 20W G, Sys >140, Diastolic >90 withOUT proteinuria resolves after 12W postpartum risk factors for: eclampsia african american primigravida >35 yrs or younger 17 yrs multiple fetuses + large fetus after 20W hx renal disease fam hx HTN previous pregnancy PREECLAMPSIA: (two types) MILD= BP: >140/90 proteinuria: 300mg/24 hrs, > 1+ random sample no seizures no hyperreflexia mild FACIAL EDEMA weight gain > 4.5 lb/week *have seizure precautions in place! (for all pts with preeclampsia) rx= bed rest, left lateral position (ensure perfusion to fetus) monitor BP 6-8 oz drinks/day SEVERE= BP >160/110 proteinura: >500mg/24 hrs/ >+3 random sample No seizures YES hyperreflexia FACIAL EDEMA All the sx: HA, Oliguria, Blurred vision, RUQ pain, thrombocytopenia, HELLP syndrome rx= delivery of fetus! (only cure), but depends on fetal age control BP with: HYDRALAZINE, hydrochloride, diazepam, nifedipine prevent seizures with: MAG SULFATE ECCLAMPSIA BP >160/110 marked proteinuria YES SEIZURES (tonic clonic, 3-4 min)-->hallmark difference! NO hyperreflexia All the sx: severe HA, Oliguria, Blurred vision, RUQ pain, thrombocytopenia, edema, HELLP syndrome, renal failure, cerebral hemorrhage *may collapse into coma rx= seizure precautions! airway, DIC mangemnt delivery of fetus same meds as above for preeclampsia turn pt to left side during seizure! convulsions may occur in severe HTN postpartum up to 24-48 hrs after, so monitor (give mag sulfate/hydralazine cont) *large bore IV proteinuria, epigastric pain (often indicates impending convulsion), pitting edema, HTN *keep in mind ecclampsia can happen postpartum, look out for sx after too!

ACE inhibitors contraindications ARBS contraindications

HYPERKALEMIA, ortho hypotension *watch renal function WATCH FOR ANGIOEDEMA--MAJOR AE of ACE-Is--incidence not as high in ARBS *if experience sx (teach= immediately d/c drug and notify HCP) SE= dry cough (switch to arbs if cant tolerate) ace inhibitors are good FOR PTS WITH DIABETES/KIDNEY DYSFUNC: meds to reduce destruction on kidneys (dilates arterioles) DOC for patients with HTN or proteinuria and diabetic! ACE & ARBS= DO NOT GIVE IN PREGNANCY! teratogenic! teach pts: rise slowly and sit on side of bed for several minutes *contraindicated during pregnancy (teratogenic) *given to pts after MI to prevent ventricular remodeling *if pt cannot tolerate ACE-Is, next drug to give is ARBS (if have dry cough, episode of angioedema)

Potassium chloride IV considerations PO?

IV: *can only admin max 10 mEq/hr to minimize phlebitis, given OVER 1 HOUR MINIMUM! may be discomfort during infusion MUST be given via INFUSION PUMP should be DILUTED, never give in concentrated amount -if pt has burning/discomfort at IV site--SLOW DOWN INFUSION RATE (do not stop!) -stop infusion is sx of extravasation/infiltration observed (swell, red, pain, phlebitis, thrombosis) PO: *is available extended release, oral liquid, capsules, tabs *is erosive & can cause pill-induced esophagitis (this also occurs with tetracyclines and dronates so also perform below: ***take with plenty of water and remain sitting upright >30 min after *take during, or immediately following meals (prevent GI upset) PICC/CVC -can deliver concentrations 20-40mEq/100mL at max rate of 40mEq

Fall Considerations

If pt falls, steps to take are: 1. assess for presence of adequate pulse 2. inspect for injuries 3. get help and move pt to bed, VS 4. notify HCP 5. complete incident report

infant---> 12 months growth and development

INFANCY TO 2 YEARS: separation anxiety (protest, despair, denial) *infants at risk for DEHYDRATION -->watch for decreased LOC, priority! *norm for infants to cry 1-3 hrs for first 3-4 mo of life, in response to hunger, tired, lonely--but need to assess to make sure not anything abn going on first before assume! 1 month: (everything head) head sags turns head side to side when prone lifts head momentarily from bed 2 month: *posterior fontanelle closes able to turn from side to back diminished tonic neck and moro reflex eyes begin to follow moving object social smile first appears 3 month: CAN HOLD RATTLE (smaller) head held erect, steady follows objects to 180 degrees smiles in mother's presence (recognize familiar faces) laughs audibly 4 month: ROLLS SIDE TO SIDE (abdomen to back) brings objects to mouth evidence of pleasure in social contact drooling *moro reflex absent at 3-6 mo sits straight up when propped 5 month: BIRTH WEIGHT DOUBLED teething may begin takes objects presented to him smiles at mirror image 6 month: average weight gain 3-5 oz per week during second 6 mo CAN TURN from BACK TO STOMACH CAN HOLD BOTTLE (bigger) early ability to distinguish and recognize parents and strangers can CHEW AND BITE (think 6 mo when start introducing food on top of breastfeed) head lag (falls behind shoulders when lifted) ends here (normal 4-6 mo) 7 month: sits for short periods using hands for support transfers toys hand to hand fear of strangers begins lability of mood responds to name (by turn toward sound when spoken) SAY MAMA/DADA 8 month: stranger anxiety SITS UNSUPPORTED regular patterns elimination begin PINCER GRASP (so good time to offer finger foods starting now) makes consonant sounds responds to word "no" 9 month: elevate self to sitting position creeps on hands/knees develops dominant hand preference respond to parenteral anger, imitative expression 10 month: CRAWLS WELL pulls self to standing position without support brings hands together vocalizes one or two words -->MAMA, DADA grasps a small doll by the arm 11 month: walks holding onto furniture erect standing posture with support PLAYS PEEK-A-BOO drops objects and expects to be picked up shakes head for no *REFERAL made if child can't well form syllables (mama, dada) neat pincer grasp (thumb and index finger) 12 month: BIRTH WEIGHT TRIPLED NEEDS HELP WALKING/walks first steps independently sits from standing position without assistance eats with fingers (2 finger pincher grasp) SAYS 3-5 WORDS +mama/dada may need security blanket, or fave toy Hospital appropriate care: -adhere to home routine -encourage fam to bring child's fave toy -promote quiet sleep environment/reduce stimuli -provide parent's shirt for child to hold during procedures (offer a familiar object) Growth: -first 6 mo: grow 5-7 oz per week 6-12 mo: grow 3-5 oz per week AAP recommends ban on mobile walkers as high injury incidence (use stationary walkers instead)

Dehydration S/sx

Infants: (much more prone to dehydration, high percent of body made of water) sx= lethargy sunken fontanel increased cap refill tachycardia tachypnea rx= IV isotonic fluid bolus for rehydration--priority!!

Acute Epiglottitis

Inflammation of the epiglottis; H influenzae type b is the most common cause, especially in non-immunized children can prevent with vaccinations! (2 mo/ 4 mo) sx= classic= 4 "ds" drooling, dysphagia dysphonia (muffled voice) distressed resp effort sore throat, fever, restless, stridor high-grade fever, tachycardia PUT PT IN: tripod position (leaning forward, sitting up) *throat inspection should not be done until emergency intubation is readily avaliable is EMERGENCY--AIRWAY! keep pt sitting up to breathe and transfer to ED (because epiglottis is blocking tracheal airway) PRIORITY ACTION= *prep for endotracheal intubation in OR w/ prepared trach kit standing by do not look in back of throat NO VISUAL INSPECTION as touching can cause spasms, occlude airway, until airway is secure

Enoxaparin (Lovenox) Dalteparin (Fragmin) Fondaparinux (Arixtra)

LMWH --enoxaparin and dalteparin routine dose less than 1 mL, admin from 1mL syringe (often in pre-filled syringe) 28 gauge needle (SQ) best in love handles of abd (right or left lateral abd. wall, at least 2 in away from umbilicus--parallel level with umbilicus and laterally is good location!) DO NOT EXPEL AIR BUBBLE PRIOR TO ADMIN (could result in incomplete dose) alcohol swabs medication label for vial--esp if med is reconstituted after injection: -do not rub injection site Fondaparinux-- unfractioned heparin *do not admin until at least 6 hrs after surgery DO NOT GIVE ANTICOAGS WHILE EPIDURAL IS IN PLACE (bleeding-->hematoma-->Spinal cord compression)

diuretics AEs examples of

LOOP DIURETICS: furosemide, torsemide, bumetanide -->loop diuretics work best for dilutional hyponatremia THIAZIDE: hydrochlorthiazide spironolactone (K+ sparing) AEs furosemide= ototoxic! (slow infusion to prevent AE)--slowing infusion will not prevent hypokalemia *check BUN, cr, BP, K+ before admin these meds!

Maneuvers in pregnancy (shoulder dystocia) Leopolds McRoberts

Leopold's: 4 dif hand mvmnts to identify fetal presentation on abd Occiput Posterior/Transverse position= if fetus remains, may attempt to manually rotate (most rotate on own to preferred Occiput anterior, however) McRobert's: sharply flex pts thigh onto maternal abd, apply suprapubic pressure with other hand to straighten the sacrum--used for shoulder dystocia in fetus *SHOULDER DYSTOCIA after deliver of head, baby's anterior shoulder gets caught above the mom's pubic bone (lasting >5 min can result in fetal asphyxia)-->time is of the essence! sx= fetal head retracting back toward maternal perineum after birth of head (turtle sign) -common with macrosomia rx= McRobert's Maneuver (press downward on the symphysis pubis), suprapubic pressure -request help from other's asap! -document time fetal head was born, shoulder dystocia maneuvers -verbalize passing time for HCP "2 min have passed" Occiput Posterior position= cause increased back pain "back labor" rx= apply counterpressure to pt's sacrum during contractions!!--this is good! -position woman on her hands and knees counterpressure= firm cont. pressure applied with a closed fist heel of the hand or firm object (tennis ball, back massager)

Arterial line considerations

Low pressure alarm: could indicate hypotension (check pt for evidence, bleeding, cause) fast flush of arterial line system: verifies if arterial line functioning accurately transducer: measured to phlebostatic axis (4th ICS, Mid-axillary line) to measure arterial pressure accurately zeroing of monitor: *done if measurement accuracy questioned

Hyperkalemia S/S

M-U-R-D-E-R Muscle weakness/cramps Urine abnormalities (oliguria or anuria) Respiratory Distress Decreased cardiac contractility EKG changes (peaked T waves or small P waves) Reflexes (hyper or hypo) P WAVE FLATTENING, QRS COMPLEX WIDENING, PEAKED T WAVES Rx= restrict diet K+/meds *sodium polystyrene sulfonate (think Na/K inverse) *in emergency= calcium gluconate, sodium bicarb, regular insulin and dextrose IV given *in cases of SEVERE HYPERKALEMIA >7: rx= IV dextrose 50% with 10 U Regular Insulin! (quicker acting insulin shift K+ intracellularly) dextrose prevents hypoglycemia associated with insulin *if pt has ECG changes with hyperkalemia, give CALCIUM GLUCONATE IV before insulin

MMRV vaccine considerations

MMR +varicella combo vacc! may have mild rx within 5-12 days after first dose (low grade fever, mild rash, swelling, erythema at site, irritability, restlessness) rash should disappear within 2-3 days *rare but fever after vaccine can lead to FEBRILE SEIZURES (imp to assess fever) give tylenol if have *children with hx seizures should be vaccinated with separate MMR and varicella vaccine than MMRV vaccien *if pregnant pt rubella titer shows nonimmune (since live vaccine), administer first thing postpartum (is safe to give during breastfeeding) *avoid preg 1-3 mo after vaccine given

contraindications for live vaccines which are...? exceptions?

MMR, varicella immunosuppression less than 1 year old *HOWEVER, MMR may be admin to children <12 mo if infant is exposed because could provide some protection/modify disease course when admin within 72 hrs of child's exposure *can also admin immunoglobulin within 6 days of exposure as prophylaxis *if receive before first bday, revaccinate at 12-15 mo and again age 4-6 yrs *after receiving vaccine, children CAN be around other children

Abnormal vs normal heart sounds (S1/S2/S3/S4) what are murmurs? pericardial friction rub?

Murmurs= turbulent blood flow across diseased/ malformed cardiac VALVES (musical, blowing, swooshing, rasping) *erb's point counts as a point where murmur can be auscultated! pericardial friction rub: high pitched, scratchy sound during s1 or s2 at the apex of the heart (when inflamed surfaces rub together) *best heard when pt sitting and leaning forward at end of expiration s1= "lub"= systole (mitral/tricuspid valves closed) *hear aortic/pulmonic stenosis murmur during sys when working s2= "dub"= diastole (aortic/pulmonic valves closed) think d for diastole *hear mitral/tricuspid stenosis murmur hear when working to refill during diastole (aka murmurs--low-pitched)--> so heard with BELL of stethoscope S3- made when blood from atrium is pumped into noncompliant ventricle *may be norm in young adults *in older adults, ABNORMAL-->indicate volume overload/HF!

restraint considerations

NOT influenced by someone's hold status (voluntary vs involuntary)-->this will NOT matter must get written permission from patient for restraints (informed consent!!) if pt is judged incompetent, get permission from pt's legal guardian dont need a prescription: if restraints are TEMPORARY or side rails fully padded during seizure/ immobilization devices for therapetuic effect cannot have restraints ordered PRN *HCP order is required (24 hrs, q 4 hrs, 6x) for adult 2 hrs for children 9-17 1 hr for children <9 yrs *order must be re-written q 24 hrs and say restraints are "on" remove restraints q hr to check skin!! -->MUST BE ABLE TO INSERT 2 FINGERS UNDERNEATH SKIN position= keep pt semi fowler/side lying (NOT SUPINE) --increase aspiration risk quick release knot (not square)

PCI (percutaneous coronary intervention)

NPO 6-12 hrs not under general anesthesia after procedure: lie flat 8-12 hrs encourage drinking to dilute contrast dye expect pt to have NO CHEST PAIN AT REST (if have, indicates Myocardial ischemia)

Professional Boundaries

OKAY: make a visit to hospital/nursing home after a previous pt has surgery to check up (considered caring) -offer to pray together if pt wishes -send sympathy card to fam after pt dies UNACCEPTABLE: socialize with pt after hours accept a valuable gift

Hypertension

OTC meds contraindicated w/ HTN: cold and sinus meds (contain pseudoephedrine) appetite supressants high-sodium antacids DASH diet: eliminate foods high in sodium, cholesterol, trans and saturated fats limit red meats

urinary incontinence types

OVERFLOW: bladder doesn't completely empty when urinate; small remaining amounts leak out occurs due to urethral compression (BPH, uterine prolapse, impaired bladder muscle--SCI, diabetic neuropathy, anticholinergics) sx= incomplete bladder emptying, urinary retention, dribbling of urine involuntarily rx= *interventions to prevent overfilling fixed void schedule -valsalva meneuver/crede to facilitate bladder empty -assess skin breakdown r/t incontinence -measure postvoid residual volumes have pt wait 20-30 sec after void and then attempt to void again to help empty *do NOT FLUID RESTRICT STRESS INCONTINENCE: unintentional, when physical mvmnt puts pressure on bladder and causes release rx= -pelvic exercises--kegels (takes 6 wks to improve) -HIGHEST PRIORITY= bladder train-EMPTY Q 2 HRS WHEN AWAKE, and Q 4 HRS AT NIGHT -incontinence products (pessaries)--when other measures fail -prevent skin breakdown/UTIs -avoid smoking, alcohol, caffeine URGE INCONTINENCE (aka overactive bladder) -when bladder randomly contracts stroke, sudden urge to urinate followed by urine leakage rx= reduce excess weight -anticholinergics (oxybutynin, tolterodine, solifenacin) decrease spasms--watch for urinary retention AE -avoid bladder irritants (artificial sweeteners, caffeine, citrus juices, alcohol, carb drinks, nicotine) -pelvic floor exercises -bladder training (void q 2 hrs while awake), gradually increase intervals between voids

bismuth subsalicylate

Pepto Bismol (anti diarrheal) *absorbs PO meds, separate admin from others (like antacids!) wait 1 hr before taking other meds if take bismuth

Correct medication administration

Prepare meds for only one client at a time, uninterrupted environment questions HCP if med dose seems off verifies med label with MAR 3x two client identifiers asked of client (name and DOB)-->ALSO CAN COMPARE PT TO THEIR PHOTO IN MED RECORD document AFTER complete med admin *only double verify for certain meds (insulin, narcotics) and some dosage calculations (peds), not all *if a competent pt questions a med admin (i haven't seen this before), always check the MAR and prescription before teaching to them--if find its correct, then go ahead and teach! when admin 2 meds concurrently: most imp action is COMPARE DRUG COMPATIBILITY *if 2 drugs aren't compatible and given, will see either a color change, clouding of solution, or presence of particles in IV line *do NOT give another dose of med to child if child vomits after taking the med (can still cause OD) *encourage preschool age child to participate in med prep!

Types of Defense Mechanisms

Projection: feeling uncomfortable with a feeling and easing its anxiety by assigning it to another person ex: husband with thoughts of infidelity who then accuses his wife of being unfaithful "BLAMING your bad thoughts on someone else" Displacement: person shifts uncomfortable feelings about one's own situation or person to a substitute situation or person deemed acceptable to receive these uncomfortable feelings ex: "client leaves a stressful family meeting and immediately begins to verbally abuse a roommate" "TAKING FEELS OUT on someone else"

Neurological Assessment Abn findings

Pupil dilation: (mydriasis) Normal= 3-5 mm diameter fixed and dilated= brain herniation unilateral dilation= CN III compression Oculocephalic Reflex= Dolls Eyes *normal= when rotate head and eyes move simultaneously in opposite direction abnormal= no eye movement or assymetrical (1 eye moves) Positive Babinksi: only norm up to age 1 after, may indicate brain or spinal cord lesion Nuchal rigidity: cant flex neck towards chest

blood transfusion rx S/Sx (For each) and considerations How long remain with pt after begin? How big cath gage? steps in rx

RANKED IN ORDER FROM MOST TO LEAST DANGEROUS: 1. hemolytic-->the most dangerous kind!! (N/V, pain in lower back, hematuria) Rx= stop blood, OBTAIN A URINE SPECIMEN (for Hgb determination), maintain kidney perfusion (treat sx as needed, oxygen, benadryl, manage airway) *blood container should be returned to lab NOT discarded in biohazard 2. fluid vol overload rx= adjust infusion rate, position upright, admin oxygen and possible diuretics 3. anaphylactic (itching, urticaria, pruitis, fever) rx=stoop blood, give antihistimine, restart transfusion slowly 4. febrile (fever, chills, nausea, headache) rx=stop blood, admin antipyretics stay with pt for first 15 minutes at least to monitor for Sx of reaction! *hypotension also sign of rx -->infuse over 2-4 hrs -->clamp NS after prime tubing, and only after to flush tubing use again cath gage 14-22 (uworld); 20-24 (kaplan) admin max over 4 hrs STEPS WHEN TRANSFUSION RX OCCURS: 1. stop immediately and d/c tubing at cath hub 2. MAINTAIN IV ACCESS WITH NS, USE NEW TUBE (prevent hypotension)--NEXT STEP! 3. notify HCP and blood bank 4. monitor vital signs 5. re-check labels, numbers, pts blood type 6. rx sx according to hcp prescription 7. collect blood/urine specimens to eval hemolysis 9. return blood and tubing set to blood bank 9. complete paperwork/document

bowel obstruction (small v large)

SBO: RAPID ONSET, N/V, intermittent/colicky abd pain, abd distention (rx quick or else can lead to ischemia/perforation) expected: bile-colored (green, brown) drainage *watch for electrolyte imbalances (hypokalemia, met acidosis, dehydration) LBO: absolute constipation, lack of flatus (think further in bowel), abd distention, colicky pain, GRADUAL ONSET rx= NPO, NGT, IV Fluids, pain control (SBO)

UAP tasks that can be delegated

SUP= standard unchanging procedures under stable clients!! CAN: -empty, measure, and record output from a surgical drain (just like foley!)--can recompress hemovac drain as well (SUP!) -can ASSIST pts in using incentive spirometer (but cannot teach!) -can courrier blood products to and from blood bank -can reposition pt unmedicated in active labor (can turn/reposition stable pts) -perform oral (nonsterile) suctioning for pts during oral care (even with dentures) -collect and doc VS (but if new admin RN should take first VS??) -can ambulate/promote mobility stable pts -assist with ADLs (feeding, bathing, dressing, hygiene) UAP CANNOT: perform assessments, monitor for assessment changes, or provide education (telling someone to do spirometer, reinforce infection control is not providing education just basic reminders) -take VS on newborn in first several hours after birth (RN must do this!)

Clomiphene

Selective Estrogen Receptor Modulator (SERM) first line treatment for infertility--stimulates ovulation! how it works: take med PO for 5 days early in menstrual cycle (days 3-5 of menses); ovulation occurs 5-9 days after complete med teach= HAVE FREQUENT SEXUAL INTERCOURSE (every other day for 1 week) 5 DAYS AFTER COMPLETING MED AEs= increase odds of having multiple gestation (twins, triplets) mood swings, hot flashes, nausea, HAs

Tamoxifen

Selective Estrogen Receptor Modulator (SERM) block estrogen rx= breast cancer, inhibit cells expected sx= that of menopause (blocks estrogen) hot flashes, vag dryness, decreased libido AE= endometrial hyperplasia (stimulates estrogen activity in the uterus)-->endometrial cancer ... (sx of this= excess menstrual bleeding in pre-menopause women or any bleeding in post-menopause women)--PRIORITY ASSESSMENT *also increased THROMBOTIC RISK think estrogen-->thrombosis

nitrates= vasodilators examples

Sodium Nitroprusside: potent acute vasodilator *withold if pts BP <90-->PRIORITY ACTION IS MONITOR BP *in pts with renal failure, this med may cause cyanide toxicity used in emergent situations--rapid acting begins in 1 min of admin *measure pts BP for severe decrease q 5-10 min other nitrates= NTG, isosorbide, hydralazine

Newborn stool and urinary findings

Stool: Meconium (black tarry): passed in 12-24 hrs green-brown: third day yellowish with feeding *delayed meconium passage may indicate CF or Hirschsprung disease formula: firm, pale, light brown stool breast: loose, golden, seedy yellow paste genitourinary: *may not void until 12-24 hrs after birth brick red spots on daiper (reddish yellow) pale yellow urine by 6-10 days *females may have white discharge/blood tinge out of vagina, males testes can feel in scrotum

Engorgement

Swelling of the breasts resulting from increased blood flow, edema, and the presence of milk. avoid by: nurse frequently (q 30 min to 3 hrs) and long enough to empty breasts completely -->see this by INFANT SUCKING BUT NOT SWALLOWING ANYMORE alternate starting breasts at each feeding -WARM shower/compresses (stimulate milk production) -massage before feedings (for plugged ducts) -CHILLED, CABBAGE LEAVES ON BREASTS Throughout the day (cool temp helps discomfort) -mild analgesic 20 min prior to feeding (ibuprofen) -ice packs both breasts 15-20 min q 3-4 hrs between feedings for pronounced discomfort -supportive bra, breast binder

STD screening in Pregnancy

Syphillis: universal screening first prenatal visit then third trimester & delivery (if high risk)

Normal Lab Values Based on Pregnancy /Trimester

THIRD TRIMESTER HgB >11 HCT >33% RBCs 5.00-6.25 WBCs 5,000-15,000 Plts 150,000-450,000 *increased blood volume expected to meet O2 demands of fetus, but this causes a hemodiluted physiologic anemia of pregnancy *prescribe iron if HgB/HCT less than above

Third degree AV block (complete heart block)

THIS IS AN EMERGENCY PRIORITY! causes decreases CO (severe bradycardia) can decompensate into cardiogenic shock and even periods of asystole, syncope sx- dizziness, syncope, mental status changes, HF, hypotension, bradycardia give atropine/ *requires temporary or permanent pacemaker eventually (given temporary until can be placed) to restore conduction activity--priority action!

End of life/ Comfort Care considerations *recall, end of life means goal is comfort and quality of pt's life Palliative Care vs. Hospice Care

Therapeutic communication= be factual, open, and honest about process pt is going through (anticipate what to expect) while conveying empathy (offer self) "your spouse's body is shutting down and the time is near; I will stay hear with you." Refusing food: -fam members often get upset when pt does this feeling personally rejected, like loved one is "giving up" -may think pt will get stronger by eating -NURSING ACTION= EXPLORE FAM'S THOUGHTS/CONCERNS ABOUT PT'S REFUSAL OF FOOD (to help them identify other ways to express care) Palliative Care -not limited to 6 months -can begin immediately after diagnosis of terminal disease (ex: cancer, advanced HF) -can still receive CURATIVE RX -focuses on quality of life and sx management -provided by a multidisciplinary team w/ focus on pts and their families (psychosocial support) Hospice care -begins when pt has 6 months or less to live -only started once pt DECIDES TO FOREGO CURATIVE rx

CMV (cytomegalovirus)

Type of herpes virus found in human milk, genital tract, urine, and pharynx. Transmitted by bodily fluids-->standard precautions! Avoid pumping or breastfeeding in premature infants if mom has acute infection. for healthy humans, doesn't really affect or show sx for weakened immune systems, this is when lookout for sx (sore throat, fatigue, aches) and can be fatal

How to walk with cane up and down stairs? other cane considerations

Up with the good, down with the bad! -->up w/ strong leg, followed by cane, then weak leg -->down w/ cane, weak leg, then strong leg hold cane with GOOD HAND, STRONG SIDE (opp of affected leg), lean on cane when moving good leg when walking: (maximum stability) move cane forward FIRST then weak leg then strong leg--move stronger leg forward past the cane and the weaker leg, so weight is divided between cane and weak leg minimal support needed? move cane and weaker leg forward at same time -keep 2 points of support on floor at all times do not advance cane too far in front of feet (tip of can should be 6-10 in. (15-25 cm) in front and to the side-lateral of foot) -cane should be at level of greater trochanter (BELOW the waist, by hip bone) flex elbow no more than 20-30 degrees Nurse: walk slightly behind pt on STRONG side

pernicious anemia (macrolytic anemia) who is at risk?

Vitamin B12 (cobalamin) deficiency foods= (think animal products) --the anti vegan way meat, poultry, fish, dairy, eggs dx= schilling test (fast 12 hrs, give vit B12 dose, 24 hr urine collection test for radioactivity of vit) sx= red sore beefy tongue (chronic deficiency= -peripheral neuropathy (tingling/numbness) -neuromuscular impairment (gait, poor balance) -memory loss/dementia vegetarians/vegans who consume no meat products at risk!! (teach take vitamins/fortified soy milk) *Vit B12 deficiency may cause megaloblastic anemia (RBCs too large)--so too narrow to go into bloodstream and deliver O2 (so see above sx) rx= initial IM admin vit B12 -followed by every 1-2 mo injections or cyanocobalamin nasal spray *also incorporate Vit B12 fortified foods: -cereal, gains, soy and nut milks, meat substitutes

Informed consent may a HCP provide emergency surgery if no consent is signed?

Yes! if it is a child, the next of kin may be contacted. if cant get a hold, still can perform because could be life saving nurse responsibilities for inform consent: - be a witness (not obtain consent) of signatures after HCP explained the procedure -verify pt is competent to provide informed consent -document in med record the date and time consent signature obtained *if pt has question about procedure-->HCP must explain *if pt has question about other details regarding general care/health care teaching (post procedure etc), nurse can teach this! *HCP must explain right to refuse procedure *recall, inform consent cannot be signed if pt is not competent (drinking alcohol, premedicated) *if pt already unconcious, in surgery, unable to give consent, and dr. finds another med prob during surgery pt did not consent to, doc can CONTACT PT'S MEDICAL POA, LEGAL GUARDIAN, NEXT OF KIN to obtain their consent!

Apgar scale

a standard measurement system that looks for a variety of indications of good health in newborns scored at 1 min and 5 min of life--assess transition to extrauterine life, then stop if >/=7 0-2 points each for: cardiac rate Respirations muscle tone reflexes color 0-3=poor --needs resuscitative measures 4-6=fair --may need resuscitative measures 7-10= excellent *repat scoring q 5 min for up to 20 min if apgar score <7!

delusion of reference

a tendency to take all sorts of messages personally (song, show, letter) everything is personal to them "that song is a message sent to me in a secret code"

terbutaline MOA (two things)

bronchodilator and tocolytic (suppress premature labor) helps in asthma, bronchitis, emphysema helps to slow down labor (prevent and slow contractons of uterus) major SE is maternal tachycardia!! palpitations, hypotension, withhold if observe fetal effects= tachycardia/hypoglycemia TOCOLYTICS: (contraindications)= maternal cardiac disease >37W G, used for <37W G

rheumatoid arthritis

a chronic autoimmune disorder in which the joint lining are attacked; remission and exacerbations--becomes worse overtime contracture of ligaments and joint remodeling may occur, resulting in weakness and deformity *however, deformities CAN be prevented with appropriate rx sx= nodules over bony prominences salmon pink macular rash contractures ****joint stiffness upon waking up (and about an hour to several hours after), and during periods of immobility ****symmetrical pain and swelling in small joints of hands elevated ESR/rheumatoid factor levels JOINT DEFORMITIES OVER TIME (decrease ROM, loss of function over time) unexpect= infection sx (leukocytosis)--may be due to immunosuppressive meds and take seriouslY! Rx= apply (moist) HEAT to STIFF JOINTS (mvmnt) apply ICE (packs) to PAINFUL JOINTS (aid pain) perform ROM-->ENCOURAGE to promote mobility of joints! (do not immobilize) -frequent rest periods (esp during pain episodes--but keep performing ROM to prevent func loss) -good nutrition -for prolonged morning stiffness: TAKE WARM SHOWER/BATH first thing upon wakening! (decreases stiffness) *do NOT support joints with pillows, (soft mattress), can do splints (prolonged flexion increases contracture risk) *when resting, USE BODY IMMOBILIZERS to KEEP EXTREMITIES STRAIGHT, prevent contratures *do not massage on joints, exacerbates inflammation *weight REDUCTION! (removes joint stress) goals= MANAGE PAIN (PRIORITY!) w/out this, cant complete ADLs -joint mobility -maximize self care, self esteem, pos body image meds= METHOTREXATE (Dmard) take as prescribed regardless of sx

Physical assessment considerations Normal Vital signs based on age proper order (abd vs other areas)

abd: inspection, auscultation, percussion, palpation (*palpate last!) *have knees flexed to relax muscles *RENAL/URINARY SYSTEM EXAM REQUIRE ABD ASSESSMENT ORDER! (auscultate first!) other: inspection, palpation, percussion, auscultation *think auscultation and palpation switch *percussion is always third BP: newborn 65/41 toddler= 90/60 school age= 100/60 adult 120/80 HR: newborn 110-160 toddler: 70-110 school age= 60-95 adult= 60-100 RR: newborn: 30-60 toddler: 20-40 school age: 16-22 adult: 12-20 temp: (for all ages) oral= 98.6F (37C) rectal= 99.6F axillary= 97.6 *perform temp axillary in newborns! *auscultate murmurs/ renal, aortic, iliac, femoral arteries with BELL OF STETHOSCOPE

Nurse communication with Interpreter/ considerations

address pt directly in first person speak short sentences, pausing to allow interpreter to speak ask only 1 q at a time avoid complex issues, jokes, med jargon *do not ask pt to nod to confirm understanding, have pt repeat back verbally and interpreter will interpret hold pre conference with interpreter to review interview goals use qualified professional interpreter (not fam) when possible identify any of pt's gender, age preferences of interpreter -->pts are more responsive often if same gender interpreter used (esp if condition is highly personal)--use same sex interpreter if can!! -speak in sequence of order actual events will be performed (surgery, and then follow up with HCP) when selecting an interpreter: -must have training in med terminology -must be fluent in langugae -must understand cultural beliefs -must have ability to protect pt's rights in med setting *only use fam member as interpreter when in emergency situation and access to med one is not avaliable

Trisomy 18 (Edwards Syndrome)

affects multiple organ systems *many fetuses affected die in utero *of those who are born, half die in first week, and most do not make it to first birthday teach= palliative care team and collaborative meeting between HCP and fam is appropriate intervention

phobic disorder

best intervention= systemic desensitization

Cholestyramine

bile acid sequestrant--for pruitis in cirrhosis Lipid lowering agent AE= constipation (diet high in fiber and fluids) sprinkle powder on liquid (packaged in powdered form) -must be mixed with food (applesauce) or juice (apple juice) take other meds 1 hr before or 4-6 hrs after give this med 1 hour AFTER ALL OTHER MEDS med depletes fat soluble vitamins so increase in diet D + A= milk E + K= green leafy veggies

Alzheimer's disease

cause= combo of genetic, lifestyle, environmental factors dx at age >/= 65 *have fam hx w/ early onset AD (before age 60) increases chances of developing by 50%! late onset AD--strongest known risk factor is advancing age first degree relative with late onset increases development risk -->brain trauma can also increase risk to reduce risk: healthy lifestyle choices! -exercise regularly -avoid excess alc, smoking cessation -participate in mentally challenging activities meds should be out of reach and locked away for pts safety if get confused PRIORITY ACTION= encourage pt to make advance directive before condition worsens! home safety: -close supervision -ALL MEDS STORED AWAY FROM PT/locked -grab bars installed showers/tubs -place locks (keyed deadbolts) above/below eye level on doors leading outside (pts loose peripheral vision) -disguise door with curtain/wallhanging -place black mat/strip at exit -arrange furniture to allow for free movement -keep frequently used items in reach -label common doors/places in environment -night light in sleeping room -put med identifier bracelet/location device in shoe etc in case pt wanders -decrease water heater temp, put hot/cold labels on faucets -remove hazards: gas appliance, rugs, toxic chemicals *pts often become agitated, aggressive, restless when can't identify a stressor (if see this assess for physical sx first!) rx= ACKNOWLEDGE EMOTIONS, REASSURE SAFETY, DISTRACT, AND REDIRECT (fold napkins/towels, stack plates) eating: give pts something to eat when they say they are hungry (because they often forget) *dont agitate them by restricting food -->give half meal now and half later smaller meals throughout day, low cal snacks strategies for care for caregivers: -simple yes or no questions, simple instructions for activities (no open ended statements) -limit # of choices (decreases anxiety) -dont try to rationalize -use visual cues with directions -respect dignity, call pt by adult name, not honey -distraction and redirection (go for a walk) to manage agitation -allow PLENTY OF TIME for task completion

Postpartum urinary retention

common r/t decreased bladder sensation from labor if bladder displaced (uterus boggy, above umbilicus and to right of midline), have pt ambulate and void to BR if can *if pt can't , In-n-out catheterization is indicated: esp if pt... -is unable to ambulate -not voided within 6-8 hrs after delivery -has difficulty emptying bladder

adult and elderly nutrition requirements

decreased calorie due to decrease activity high vitamin/minerals good calcium to prevent osteoporosis --> 1000-1500/day + vita D (limited exposure to sun) good protein/energy supplements complex carbs: 5 servings of fruits & veggies. 6 servings of whole grains daily

dorsal recumbent vs lithotomy

dorsal= trunk flat, knees up, feet on bed lithotomy= (going to gyno), feet in stirrups

Bromocriptine

ergot alkaloid used in the treatment of pituitary tumors, Parkinson's disease (PD), hyperprolactinaemia, neuroleptic malignant syndrome, and type 2 diabetes.\ take with meals to decrease GI upset take twice a day for 2-3 weeks

TNF (tumor necrosis factor)

ex: etanercept, adalimumab, infliximab block TNF action, block immune system inflam. response rx= rheumatoid arthritis *before initiate therapy= baseline TST level, then yearly skin tests thereafter *NEED TO HAVE TB SKIN TEST (TST) before start med, as positive TB skin test and taking this med can cause reactivation of latent TB *watch for infection since immunosuppressed-->priority finding if observe!

CCBs

ex: nifedipine, amlodipine, felodipine, nicardipine, diltiazem, verapamil (can lower HR) VASODILATE rx= HTN, chronic stable angina AEs= dizziness, flushing, HA, peripheral edema, constipation ortho hypo when used with other anti-HTN, can cause hypotension and HF--due to MOA of decreasing myocardial contractibility *decreases HR *withhold in pts with low HR! (MOA= decreases HR and BP) teach= change positions slowly leg elevation/compression (edema) mgmnt of constipation

puberty first sign?

first sign in boys= testicular enlargement (9 1/2-14 yrs)

pH of GI contents

gastric: 1-4 intestinal: greater than 5 respiratory: greater than 5.5

Danger signs of pregnancy

gush of fluid/bleeding from vagina regular uterine contractions severe HA, visual disturbances, abd pain, persistent vomiting fever or chills SWELLING OF FACE/FINGERS-->unexpected decrease in fetal movement

Naloxone (Narcan)

has short half life --wears off 1-2 hrs, may need to prepare another dose if pt becomes sedative again *priority nursing action when admin= FOLLOW UP PT'S RESP STATUS IN 60 MIN (if pt was on hydromorphone--has duration of 3-4 hrs, naloxone effects can wear off and pt can go back to resp depression) give oxygen! *no drug to drug interactions with naloxone

Graves disease thyroid storm/tyroidtoxicosis thyroidectomy considerations

hyperthyroidism sx= everything increased metabolism potential for resp difficulty frequent mood swings, fine soft hair, weight loss, exopthalmus (can be irreversible)!! IRREGULAR, TACHYCARDIC RYTHMS ARE EXPECTED rx= antithyroids (methimazole, propylthiuracil, potassium iodide), irradiation (radioactive iodine), thyroidectomy teach= -diet= high protein, high calorie!! (4,000-5,000) -avoid caffeine products -6 full meals/snacks per day (protein, carbs, vitamins, minerals) -avoid high fiber foods (hyperstimulated GI) -avoid spicy foods *methimazole can cause neutropenia AE exopthalmus rx= (risk for dryness, injury, infection) -maintain HOB raised to facilitate periorbital drainage offer artificial tears maintain HOB raised, facilitates drainage lightly tape shut eyelids if don't close during sleep teach about smoking cessation (increases graves) restrict salt intake (decreases edema) recommend use dark glasses to prevent irritation reg eye exams intraocular muscle exercises: turn eyes using ROM DO NOT LIMIT EYE MOVEMENT limit to quiet activities (read, knitting) frequent rest periods, restrict visitors (anything avoid stimulating) keep room cool diet= high protein, high calorie post thyroid: low, semi fowlers position, HOB 30, PREVENT NECK FLEXION/HYPEREXTENSION have trach/suction at bedside -watch laryngeal injury (detect by hoarse voice) thyroid storm= (thyroidtoxicosis) sudden dramatic thyroid hormone increase (hypermetabolic state) caused by trauma, illness, med stop, stress-> ANY PT W/ HYPERTHYROID REPORTING ONE OF SX IS PRIORITY ASSESSMENT AS THIS IS EMERGENT CONDITION (dont think "oh fever is expected, no! can develop into thyroid storm) sx= all VS increase, alter clotting, abrupt CHF, afib, severe N/V, HTN, Tachyseizures, FEVER, ANXIETY/RESTLESSNESS DELIRIUM (agitation/ confusion) EMERGENT RX NEEDED= hypothermia blanket, o2, meds (propanolol, potas iodide, antithyroids) *can lead to Hypertermia, V tach if untreated! THYROIDECTOMY: tetany can occur after thyroidectomy (decrease PTH and thus calcium) have IV cal gluconate/ calc chloride available (assess hypocalcemia signs!) -admin iodine pre-op to prep pt (decreases thyroid gland vascularity) expected post op findings: -pain, small incisional bleeding (sanguineous is okay) as long as not in excess -sore throat, burning while swallowing unexpected: SX of THRYOID STORM (INCREASED TEMP, chills, tachycardia, ETC)--REPORT ASAP!!--can occur even after thyroidectomy! -hoarseness, noisy breathing= laryngeal stridor/airway compromise! -sx of hypocalcemia (tetany, tingling, spasms, cramps) -neck swelling/increased pain (may be hematoma forming)--priority due to airway!! care post-op: -avoid neck flexion/extension (maintain neutral head position/neck alignment)-prevent hemorrhage -ensure trach kit, oxygen, suction at bedside -HOB semi fowlers -monitor voice (stridor) strength and quality -assess frequently facial numbing/tingling -monitor resp distress as swelling can occur q 1hr -->PRIORITY TO REPORT= NOISY BREATHING (stridor, dyspnea) (o2 sats not as reliable since pt post op and can have lowered from surgery meds) diet= non-iodized salt, high cal?? new metabolic needs *frequent complication of surgery= persistent hoarseness (if unable to raise voice after 24 hrs postop)--damaged laryngeal nerve HYPOCALCEMIA can also occur w/ thyroid removal! have calcium gluconate readily avaliable!

Incorrect documentation

if error made in charting, use single line through the error and doc your initials, date, and time--do NOT erase, white out, or scratch out an error or use correction fluid and write a new note explaining what occurred *do not chart for anyone else *do not just put "will continue to monitor" (this is expected)

Trousseau's sign

inflate BP cuff upper arm above SBP 20 mmHg and see carpal spasms within 2 min= tetany= hypocalcemia

oliguria

less than 20 mL/hr or 400 mL/day

what must occur for internal fetal electronic monitoring?

membranes must be ruptured, cervix sufficiently dilated, and presenting part low

Assist patient out of bed

move pt to stronger side if has weaker side (easier for pt to pull the weak side)

pupil changes from dif causes

narcotics: constrict pupils (cociane is not a narcotic!)

How much fluid max should be removed from straight cath?

no more than 1,000mL

Normal Urine outputs based on age

norm UO infant= 2mL/kg/hr todder= 1.5mL/kg/hr adolescent= 1mL/kg/hr adult= >0.5/kg/hr

tonsillectomy--method to watch for post op hemorrhage?

observe for frequent swallowing

Potassium rich foods

orange juice green leafy veggies bananas oranges lentils raisins

Angina Pectoris

pain may radiate down left arm, arm pain (stress, exertion) pain feels like SQUEEZING or VISE like (holding/squeezing very tightly) causes= exertion, emotion, extreme temps-->anything that INCREASES o2 demand and DECREASES o2 supply angina WILL be relived AT REST or by use of: nitro 3 tabs x 5 min each to relieve, if not go to ED= MI! diet= limit sodium/fat intake goal= decrease BP/HR upon exertion Rx= PTCA/CABG after CABG hooked to mechanical vent 6-24 hrs, as well as chest tubes meds= long acting nitrates are used to reduce anginal attack incidence -->effective if pt able to do activities without chest pain occurrence -->contraindicated to take "fils" (sildenafil, etc) w/ nitrates as cause life threatening vasodilation -->if pt has taken, must determine when last (half life about 4 hrs)

relaxed/boggy uterus interventions how to palpate fundus?

palpate fundus by placing one hand on abd over fundus and press gently down with FINGERTIPS massage fundus until firm assess bladder for fullness put infant on breast (stimulates oxytocin release) FUNDAL MASSAGE IS ONLY PERFORMED AFTER PLACENTA IS EXPELLED

Common med abbreviations that should not be used

per os (per mouth or left eye) (od= right eye) (ou both eyes) --these are okay qhs (every hour, at bedtime) qd (four times daily instead every day) q1d *no trailing zeroes (4.0) if decimal must have zero in front not: .5 no "u" for unit OKAY THINGS: ac, pc (after meals), c/o Mg for milligram

Spironolactone

potassium sparing *will save potassium, but excrete sodium (recall inverse) *so watch for hyponatremia, hyperkalemia

macrolide abx AE

prolonged QT interval-->can cause torsades de pointes may develop Cdiff (common comp of many abx) (erythromycin, azithromycin, clarithromycin)

breath sounds

rhonchi: heard on expiration, indicate presence of secretions in larger airways

stress test

start an IV infusion line to give oxytocin

Nursemaid's elbow

subluxation of the radial head (due to swinging of arms) child suddenly stops using arm, but is not emergent just needs reduction of elbow

liver biopsy positioning

supine position or lateral with upper arms elevated can be at bedside after procedure position on right side 2-3 hrs with pillow under costal margin to splint

carotid endarterectomy

surgical procedure to remove atherosclerotic plaque from carotid artery to improve cerebral perfusion surgical risks= increased risk for TIA and stroke! cerebral ischemia and infarction, bleeding monitor neuro status post-op for alterations (stroke, TIA, etc) *monitor BP first 24 hrs post-op (HTN may strain surgical site, cause hematoma formation, hemorrhage/airway obstruction) *sys at 100-150= goal

Sodium Dietary Sources

table salt, processed foods, condiments, sauces, soups, chips beef broth, tomato soup, INSTANT OATMEAL, quick breads *eggs NOT high in sodium!

Shock S/S

tachycardia, tachypnea (shallow, rapid RR), hypotension, met acidosis (increased lactate level), oliguria, cool, clammy skin cause no circulating O2! *maintain systolic BP >90

Diuretic special considerations

take in AM, not at night! with food/meal avoid herbals "ALG" algee when diuresing aloe, licorice, gingko -->increase hypokalemia

testicular self-examination TSE testicular cancer

testicular cancer is most common form in men age 15-35 dx early is highly curable--importance of TSE! at risk= hx of undescended testis, hx of testicular cancer--encouraged to perform monthly TSE once a month on the same day support testes in palm of hand, palpate between thumb and forefinger -USE BOTH HANDS TO FEEL EACH TESTIS SEPARATELY -palpate with thumb and first 2 fingers gently *best performed in warm bath or shower! when muscles relaxed, hanging loosely expect: each testicle is egg shaped and movable with smooth surface -normal for one testicle to be slightly larger or hang lower than the other -the epididymis (small coiled tube)--they may confused as a small lump= teach does not need to be reported unexpected: *report if hard mass over testis *painless, hardened lump on testis *dull ache in pelvis or scrotum *scrotal swelling or heaviness

Meds with photosensitvity AE

tetracyclines thiazide diuretics sulfonamides; antipsychotics; antidepressants

Advance directives vs POAs

there are dif types of POAs! so need to clarify (medical/financial)

Airborne precautions

think "MTV, on Air" varicella, TB, measles (rubeola) (and disseminated herpes zoster--shingles) *should be placed in private rooms (sep from each other), unless emergency and need more rooms in facility, NEGATIVE AIRFLOW ROOM REQUIRED; HEPA AIR FILTERS *when pts being tranferred out of room, they only need to wear surgical mask (staff who is transporting wear N95 mask) *airborne precautions are the priority pt to put in isolation rooms over others first!--most contagious *for varicella= only when uncrusted lesions are present, contact precautions (gown, gloves) also required; *for shingles= only in disseminated disease or immunocompromised pts, contact precautions also required

Codependent Behaviors

those that allow the codependent person to maintain control by fulfilling the needs of the addict first THEY WILL FOCUS THEIR ATTENTION ON OTHERS AT THE EXPENSE OF THEIR OWN SELF ex: keeping addiction a secret suffer physical/psycho abuse from addict not allow addict to suffer consequences of actions make excuses for addict will try everything to make addict happy if isnt keep pt from focusing on rx *codependency is counterproductive and not therapeutic in helping pt recovery from condition!

Inferior Vena Cava (IVC) Filter

traps blood clots from lower extremities teach: notify HCP if getting MRI promote physical activity avoid crossing legs to promote venous return *report sx of PE (chest/back discomfort, SOB) ASAP--unexpected

migraine

triggers= chocolate, oranges, tomatos, onions, cheese aspartame alcohol monosodium glutamate (MSG)--flavor used to enhance chinese food meals fatigue!! fluctuating estrogen levels (menstruation) rx= go to bed same time every night

Amnioinfusion

used to relieve cord compression and recurrent variable decels in pts with ROM/oligohydramnios complication= uterine overdistention (too much fluid infusing) -use infusion pump to control rate -eval for fluid return frequently -monitor uterine resting tone *if resting tone elevated >20 mmHg, and minimal to absent fluid return-->PAUSE THE INFUSION AND NOTIFY HCP ASAP

postpartum blues

usually occurs days 3-7 postpartum (is normal) and resolves with support, rest, and sleep *report if prolonged or later onset

Newborn prophylactic meds

vit K: IM! routine give in first hours of life for first 3-4 days of life newborn cant synthesize vit K for clotting -can result if not give in hemorrhagic disease of newborn eye prophylaxis: erythromycin eye ointment (prevent pinkeye in first month)--from chlamydia (STI in moms vag canal) (includes c section infants) hep B: give first dose in hospital within 24 hrs of birth

acetaminophen poisoning?

watch LFTs!! can cause liver damage *OKAY to give to children, want to avoid salicylates in children due to reye's syndrome risk sx poisoning= (think antipyretic) N/V, sweating, pallor, hypothermia, slow weak pulse then latent period sx subside then if no treatment hepatic involvement! see sx liver probs (recall major AE tylenol is hepatic toxicity) *okay to give in pregnancy (do not exceed 4g/day)

Elder abuse or neglect

water, food, medication, hygiene, clothing unsafe living conditions sx weight loss, dehdyration, malnutrition poor hygiene, soiled bedding/clothing, pressure ulcers missing/broken assistive devices (eyeglasses), meds withheld or expired how to assess: -pt breaks eye contact when discussing caregiver -or underexagerates abuse for fear of embarrassment

phrase to remember for whether to raise HOB vs trandelenberg

when face is red, raise the head -->breathing issues when face is pale, raise the tail -->from blood loss, (feeling dizzy) restores perfusion to brain, hypotension

Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)

when the trachea and esophagus do not properly separate or develop!! most common= upper esophagus ends in a blind pouch and lower esophagous connects to trachea through small fistula sx= frothy saliva, coughing, choking, drooling apnea, cyanosis during feeding distended abdomen (buildup of air in stomach) FIRST ACTION when pt has excess oral secretions/cyanosis= SUCTION MOUTH COMPLICATION= ASPIRATION! so if newborn has sx of EA/TEF, immediately placed on NPO rx= surgery NGT cont suction until surgical repair position= keep supine with HOB at least 30 (prevent aspiration)

Paraphimosis

when uncircumcised male foreskin cannot be return to original position (such as being inappropriately retracted back with condom cath insertion) causes swelling of foreskin, impaired blood flow, pain-->can have permanent damage! urologic emergency!!

Heparin MOA thrombolytic MOA

will keep the current clot from getting bigger and prevent new clots from forming thrombo: used to break clots

Can patients with trachs eat?

yes