Unit 4
Priority nursing intervention for a patient with an acute kidney injury due to dehydration.
Administer IV fluids as ordered. Watch for signs and symptoms of fluid overload, since some patients, especially older adults, may not tolerate rapid fluid replacement. Monitor serum electrolyte levels closely. Provide comfort measures and promote a restful environment.
Priority nursing intervention after bronchoscopy
After procedure, keep patient NPO until gag reflex returns. Monitor for recovery from sedation. Blood-tinged mucus is not abnormal. If biopsy was done, monitor for hemorrhage and pneumothorax.
RSV: The serious symptoms of RSV that you must take action for?
Answer is an expected finding that can affect gas exchange what were the exemplars Barking cough, which can be a sign of significant swelling in and around the vocal cords Fever, either low grade (less than 101 degrees F) or high (more than 103 degrees F) Difficulty breathing with one or more of the following: Abnormally fast breathing (tachypnea) "Caving-in" of the chest in between the ribs and under the ribs (chest wall retractions) "Spreading-out" of the nostrils with every breath (nasal flaring) Wheezing (a high-pitched whistling sound as the patient breathes out) Difficulty drinking Lethargy or irritability Bluish color around the mouth, lips, and fingernails (cyanosis) Apnea (stopping breathing) is a common symptom of RSV bronchiolitis among very young infants, especially those born prematurely
A diagnostic test finding of Hodgkin's lymphoma is the presence of: A. granulocytopenia. B. Reed-Sternberg cells. C. lymphoblasts. D. Howell-Jolly bodies.
B. Reed-Sternberg cells.
Factors that reduce resistance
Deficiencies of the immune system place the child at risk for infection. Other conditions that decrease resistance are malnutrition, anemia, fatigue, and chilling of the body. Conditions that weaken defenses of the respiratory tract and predispose children to infection also include allergies (e.g., allergic rhinitis), preterm birth, bronchopulmonary dysplasia (BPD), asthma, history of RSV infection, cardiac anomalies that cause pulmonary congestion, and cystic fibrosis (CF). Day care attendance and exposure to secondhand smoke increase the likelihood of infection.
What is an example of Eustress (good stress)
Examples of eustress are a much-needed vacation, playing a favorite sport, the birth of a baby, or the challenge of a new job. Since the same physiological responses are in play with stress and eustress, eustress can still tax the system, and down-time is important.
What's the priority with respiratory distress, Kid comes into ER with respiratory distress?
Focused respiratory assessment ABC
What's goal of treating skin infections Ultimate goal?
Heal. eliminate infection and prevent spread
Long term current smoker what's the priority for nurse?
Health promotion: Tell him to quit
What does impetigo look like? (honey colored lesions. Does it scar? Will it leave anything behind
Impetigo begins as a reddish macule that becomes vesicular and ruptures easily leaving superficial moist erosion. It tends to spread peripherally in sharply marginated irregular outlines, exudate dries to form heavy honey colored crusts. IF staph or streph enter any sub-layers of the skin infection ensues. Nonbullous impetigo: This is the more common form, caused by both staph and strep bacteria. This form initially presents as small red papules similar to insect bites. These lesions rapidly evolve to small blisters and then to pustules that finally scab over with a characteristic honey-colored crust. This entire process usually takes about one week. These lesions often start around the nose and on the face, but less frequently they may also affect the arms and legs. At times, there may be non-tender but swollen lymph nodes (glands) nearby. Bullous impetigo: This form of impetigo is caused only by staph bacteria. These bacteria produce a toxin that reduces cell-to-cell stickiness (adhesion) causing separation between the top skin layer (epidermis) and the lower layer (dermis). This leads to the formation of a blister. (The medical term for blister is bulla.) Bullae can appear in various skin areas, especially the buttocks and trunk. These blisters are fragile and contain a clear yellow-colored fluid. The bullae are delicate and often break and leave red, raw skin with a ragged edge. A dark crust will commonly develop during the final stages of development. With healing, this crust will resolve
Asthma: what are some red flags for children who have asthma when there is a change in the severity of their condition. Asthma is a chronic condition how do we know that its getting worse?
Increased difficulty breathing. A drop in peak flow meter readings. Exercise limitations. Using a quick-relief inhaler more often. Waking up at night with coughing or wheezing. Having to disrupt your normal routine because of asthma.
Seasonal
Infection-related asthma occurs more frequently during cold weather, whereas winter and spring are typically the "RSV seasons."
Lab results for SIADH
Laboratory findings in diagnosis of SIADH include: Euvolemic hyponatremia <134 mEq/L, and POsm <275 mOsm/kg OR ( POsm - Serum [Urea]mmol/l < 280 mOsm/kg ) Urine osmolality >100mOsm/kg of water during hypotonicity[4] Urine sodium concentration >40 mEq/L with normal dietary salt intake Other findings: Clinical euvolemia without edema or ascites Low blood urea nitrogen (BUN) Normal serum creatinine[9] Low uric acid Normal Acid-Base, K+ balance Normal Adrenal, Thyroid function
What meds do you use to treat ringworm?
Oral griseofulvin Oral ketoconazole for difficult cases Selenium sulfide shampoos- 2% ketoconazole and 1% selenium sulfide shampoos may reduce colony counts of dermatophytes. These shampoos can be used in combination with oral therapy to reduce the transmission of disease to others. The shampoo should be applied to the scalp for 5 to 10 minutes at least 3 times per week. The child may return to school after the therapy is initiated. Topical antifungal agents (e.g., clotrimazole, haloprogin, miconazole) Griseofulvin- if the child is treated with the drug griseofulvin, the therapy frequently continues for weeks or months, and because subjective symptoms subside, children or parents may be tempted to decrease or discontinue the drug. The nurse should emphasize to family members the importance of maintaining the prescribed dosage schedule and of taking the medication with high-fat foods for best absorption. They are also instructed regarding possible drug side effects, such as headache, gastrointestinal upset, fatigue, insomnia, and photosensitivity. For children who take the drug over many months, periodic testing is required to monitor for leukopenia and assess liver and renal function. and the ones she mentioned Look at page Lamasil oles- antifungal medications such as terbinafine, itraconazole, and fluconazole *may be used when there are adverse reactions to griseofulvin.* These drugs are being studied to determine their efficacy and safety in treating tinea capitis in children but are *not approved by the U.S. Food and Drug Administration (FDA) for this indication.* Topical or systemic anti-fungal medications, (6 -8 weeks): • Terbinafine (LAMISIL) • Itraconazole (SPORANOX) • Griseofulvin (GRIFULVIN V) • Prednisone for Keryons • Ciclopirox (LOPROX, PENLAC) • Medicated shampoo, such as one that contains ketoconazole or selenium sulfide
The curb-65 score for RSV (SATA) what factors do you look at when looking at this score.
Page 523 Lewis Age Blood pressure Respiratory rate Presence of confusion Blood urea nitrogen (BUN) level
Priorities for caring for a child with impetigo (with impetigo its super contagious care takers must have good hygiene)
Primary prevention- good hygiene, trimmed nails, and hydration. Secondary prevention - isolation of the child from other children, immediate washing of fabric that comes in contact with contaminated skin and debris. Collaborative interventions: Skin care with warm soaks for debridement (loosen remove dried up secretions) Topical Antibiotic - Mupirocin, triple antibiotic ointment Oral Broad spectrum systemic antibiotics if improvement not achieved with local ie.- Vancomycin, Clindamycin. A major nursing consideration related to bacterial skin infections such as impetigo contagiosa is to prevent the spread of the infection and complications. This is done by thorough hand washing before and after contact with the affected child. Corticosteroids are not indicated in bacterial infections. Dressings are usually not indicated. The undermined skin, crusts, and debris are carefully removed after softening with moist compresses. A Wood's lamp is used to detect fluorescent materials in the skin and hair. It is used in certain disease states such as tinea capitis.
Short term physiological responses to stress
The well-known fight-or-flight response is the body's way of preparing for a situation an individual perceives as a threat to survival. This response results in increased blood pressure, heart rate, and cardiac output.
what vitamins we give kids with cystic fibrosis to help them
Vitamin A Vitamin A has many roles in health. It helps the immune system fight infections. It is needed for healthy skin, normal vision and healthy intestines. Low levels of vitamin A can cause night blindness and skin disorders, and raise your risk of infections. Low vitamin A also can be associated with zinc deficiency, which can impair growth. Vitamin A can be found in animal foods such as liver, eggs and milk, as well as in darkly colored fruits and vegetables including these: Carrots Sweet potatoes Cantaloupes Apricots Peaches Spinach Broccoli Vitamin D Vitamin D helps build and maintain strong bones and teeth by maintaining the right amount of the minerals calcium and phosphorus in your blood. Without enough vitamin D, bones can become thin and brittle. People with CF are at risk for osteoporosis and osteopenia. Vitamin D also helps keep the immune and nervous systems working well. Exposure to sunlight provides you with some, but often not enough, of the vitamin D you need. Many people with CF need to take extra vitamin D in addition to the amount provided in the CF-specific multivitamins. Other good food sources of vitamin D include these foods: Salmon Mackerel Canned sardines Tuna Milk Cereal Eggs Vitamin E Vitamin E is an antioxidant, which means that it protects compounds in the body from combining with oxygen. When compounds become oxidized, they become harmful to the body and can cause chronic diseases, such as cancer and heart disease. Vitamin E also helps make red blood cells and keeps the nervous and immune systems healthy. It is hard to get all the vitamin E you need from food alone. Some fruits and vegetables have small amounts. Most meat products do not have it at all. Vitamin supplements and the following foods can be good sources of vitamin E: Almonds Peanuts Mayonnaise Broccoli Margarine Bread (whole grain) and wheat germ Vitamin K Vitamin K is best known for its role in helping blood clot. Without it, a cut could bleed for a long time and a small bruise could turn into a big one. Vitamin K also helps keep bones healthy. Some of the vitamin K you need is made in the intestines, but the amount can be reduced in people who take antibiotics frequently. All forms of multivitamin supplements designed for people with CF include vitamin K, but not all over-the-counter multivitamins do. If you are not using multivitamin supplements designed specifically for people with CF, be sure to check the ingredient label and choose one that contains vitamin K. To make sure you get vitamin K in your diet, eat lots of dark green, leafy vegetables. Here are some good sources of vitamin K: Broccoli Spinach Leaf lettuce Peas Brussels sprouts Coleslaw Kale B-Vitamins Vitamin B1 helps change carbohydrates into energy that the body needs every day. It is also necessary for the maintenance of healthy skin, the heart and the nervous system. The foods in the following list can help you make vitamin B1 a part of your daily diet: Pork Long-grain rice Peas Pecans Bread Oranges Vitamin B2 (riboflavin) helps turn food into energy and repairs tissue. It also helps your body make healthy red blood cells. Low levels of vitamin B2 can lead to bad skin and itchy eyes. Here are some foods that are good sources of vitamin B2: Milk Yogurt Eggs Cereal Pasta Chicken Vitamin B3 (niacin) plays a role in metabolizing fats and is used to treat high levels of "bad" cholesterol. Vitamin B3 works with the other vitamins to keep your skin healthy and your nervous and digestive systems working right. Although vitamin B3 is found in many foods, it is really common in poultry and dairy products. Here are some foods you can eat to get this vitamin: Tuna Peanuts Chicken Lamb Beef Pork Vitamin B6 plays an important role in the metabolism of amino acids (the building blocks of protein). It is also needed for proper functioning of the nervous system and production of hemoglobin, the part of red blood cells that carries oxygen throughout the body. A deficiency of vitamin B6 can cause depression or anemia. If you don't like to eat vegetables, do not worry. A good way to get vitamin B6 is to eat chicken, pork, beef and fish. You also can find B6 in these foods: Eggs Baked potatoes Bananas Garbanzo beans (chickpeas) Oatmeal Vitamin B9 (folic acid) plays a role in the production of genetic material, in tissue growth and in the proper formation of red blood cells. It is important for healthy cell division and replication, which is essential for growth. A deficiency in vitamin B9 can cause anemia, abnormal tissue growth and birth defects. Folic acid is found in many vegetables and fruit juices, but if these foods are cooked too long, they lose a lot of B9. That is why you may need a vitamin supplement plus a healthy diet with the following foods: Lentils Asparagus Spinach Cereal Peanuts Orange juice You need only a small amount of vitamin B12 in your diet, but that small amount protects your nerve cells. It is also needed to form red blood cells. Vitamin B12 deficiency can cause a type of anemia known as pernicious anemia, which is commonly found in the elderly and in strict vegetarians. If you like beef and seafood, you are lucky. These foods are good sources of B12. But if you do not eat animal products, you may not get enough B12 and should take vitamin supplements. Here are some food sources of B12: Salmon Beef Tuna Milk Pork Chicken Vitamin C Vitamin C does hundreds of jobs in the body. It works hard to fight free radicals that can hurt your cells. Vitamin C also helps make collagen, a sticky substance that keeps your bones and muscles together, and helps blood vessels stay strong. It also can help heal a wound and shorten the length and severity of a cold. Our bodies need a diet rich in vitamin C foods to stay healthy. The good news is that vitamin C is found in many fruits and vegetables such as the ones listed below: Broccoli Grapefruit Oranges Strawberries Cantaloupes Mangoes Pantothenic Acid The enzyme maker, pantothenic acid, helps metabolize fats, carbohydrates and proteins. It also helps make red blood cells and control the body's hormones. Low levels of pantothenic acid can lead to stomach cramps, vomiting and tingling in the hands and feet. It is easy to get the right amounts of pantothenic acid because it is found in many foods that are a part of a daily diet. Here are some ideas: Avocados Mushrooms Chicken Lentils Potatoes Eggs Biotin Some bacteria that live inside the body help you stay healthy. In fact, these "good" bacteria make a vitamin called biotin. Biotin helps metabolize fats, carbohydrates and proteins. You need biotin to keep your hair healthy. There are lots of ways to get the biotin you need every day. In addition to the biotin that your body makes, vitamin supplements have good amounts. There are many common foods that have it as well, such as these: Milk Chocolate Eggs Cheese Bacon Chicken
know what to do for reverse isolation for neutropenic precautions
Wash your hands often. Dry your hands completely. Bathe daily Brush your teeth 2 times each day Do not share personal items with anyone Avoid fresh flowers, live plants, and standing water. Keep cooked and raw foods separate Cook your food all the way through.
Teaching about the spread and reoccurrence of tinea capitis (esp. about spread spreading) (will be SATA answer)
When teaching families how to care for ringworm, the nurse should emphasize good health and hygiene. Because of the infectious nature of the disease, affected children should not exchange grooming items, headgear, scarves, or other articles of apparel that have been in proximity to the infected area with other children. Affected children are provided with their own towels wash towel in warm soapy water and dry each time an infected person uses it, and direct to wear a protective cap at night to avoid transmitting the fungus to bedding, especially if they sleep with another person. Soak combs and brushes for 1 hour in a day in a mixture one part bleach 10 parts water- 3 days in a row. Other children in home may want to be prophylactically treated with the shampoo 2-3 times a week for about 6 weeks Because the infection can be acquired by animal-to-human transmission, all household pets should be examined for the disorder. Other sources of infection are seats with headrests (theater seats), seats in public transportation vehicles, helmets, and gymnasium mats. *Contact Isolation may be key*
early detection for breast cancer. What can we teach about early detection for breast cancer
Yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. A controversial recommended change is that women at normal risk for breast cancer should begin annual screening at age 50 and stop screening at age 75. Clinical breast examination (CBE) preferably at least every 3 years for women in their 20s and 30s, and every year for women beginning at age 40.7 •Women should report any breast changes promptly to their health care provider. Breast self-examination (BSE) is an option for women starting at age 20. •Women at increased risk (family history, genetic link, past breast cancer) should talk with their health care provider about the benefits and limitations of starting mammography screening earlier, having additional tests (e.g., breast ultrasound or magnetic resonance imaging [MRI]), or having more frequent examinations. Self Exam: Lie down and place your left arm behind your head. Lying down spreads breast tissue evenly and thinly over the chest wall, making it easier to feel the tissue. 2, Use finger pads of three middle fingers on your right hand to feel for lumps in left breast. Use overlapping dime-sized circular motions to feel the breast tissue. Use three different levels of pressure to feel the breast tissue. Light pressure to feel tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel tissue closest to the chest and ribs. A firm ridge in the lower curve of each breast is normal. 3, The up-and-down (vertical) pattern is recommended for examining the entire breast. Move around the breast in an up-and-down pattern starting at an imaginary line straight down your side from the underarm (including the tail of Spence, which is the triangular breast tissue projecting into the axilla), and moving across the breast to the middle of the sternum. Examine the entire breast going down until you feel only ribs and up to the neck or clavicle. Repeat procedure while examining your right breast. 4, Stand in front of a mirror. Place your hands firmly on your hips, which will tighten the pectoralis muscles. Look at your breasts for size, shape, redness, scaliness, or dimpling of the breast skin or nipple. 5, Examine each underarm while standing or sitting with arm slightly raised. Check for any lump, hard knot, or thickening of tissue. *Teaching* When teaching the woman about BSE, include information related to potential benefits, limitations, and harm (chance of a false-positive test result). Allow time for questions about the procedure and a return demonstration. At every periodic health examination, ask the woman who is performing BSE to demonstrate her technique.BSE is recommended on a monthly schedule. For women who are having regular menstrual periods, this would be right after menstruation when breasts are less lumpy and tender. If menses are irregular or a woman is postmenopausal, advise choosing the same day each month. For women taking oral contraceptives, the first day of a new package may be a helpful reminder.
During admission of a patient diagnosed with non-small cell lung carcinoma, the nurse questions the patient related to a history of which risk factors for this type of cancer (select all that apply)? a. Asbestos exposure b. Exposure to uranium c. Chronic interstitial fibrosis d. History of cigarette smoking e. history of asthma and bronchitis
a. Asbestos exposure b. Exposure to uranium d. History of cigarette smoking
A 65 year old client Dx with Pulmonary embolism has been admitted. Nursing management should focus on which of the following actions a. Assess oxygenation status b. Monitor the oxygen delivery device c. Monitor for other sources of clots d. Determine whether the client requires another ventilation perfusion scan
a. Assess oxygenation status
signs of hypotension during hemodialysis (side effects during hemodialysis to watch out for)
abdominal discomfort, yawning, sighing, nausea, vomiting, muscle cramps, restlessness, dizziness or fainting, and anxiety
What is it called when a bone transplant compatible donor is an immediate family member
allogeneic transplantation
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure? a. Start a peripheral IV line to administer the necessary sedative drugs. b. Position the patient sitting upright on the edge of the bed and leaning forward. c. Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. d. Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.
b. Position the patient sitting upright on the edge of the bed and leaning forward. Rationale: When the patient is sitting up, fluid accumulates in the pleural space at the lung bases and can more easily be located and removed. The patient does not usually require sedation for the procedure, and there are no restrictions on oral intake because the patient is not sedated or unconscious. Usually only 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or pulmonary edema.
An infant is hospitalized with RSV bronchiolitis. The priority nursing diagnosis is: a. fatigue related to increased work of breathing. b. ineffective airway clearance related to copious mucous seceretions c. risk for fluid volume deficit related to tachypnea and decreased oral intake. d. fear and/or anxiety related to dyspnea and hospitalization.
b. ineffective airway clearance related to copious mucous secretions Rationale: An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection.
The patient is being treated for non-Hodgkin's lymphoma (NHL). What should the nurse first teach the patient about the treatment? a. Skin care that will be needed b. Method of obtaining the treatment C. Gastrointestinal tract effects of treatment d. Treatment type and expected side effects
d. Treatment type and expected side effects The patient should first be taught about the type of treatment and the expected and potential side effects. Nursing care is related to the area affected by the disease and treatment. Skin care will be affected if radiation is used. Not all patients will have gastrointestinal tract effects of NHL or treatment. The method of obtaining treatment will be included in the teaching about the type of treatment.
Adrenalectomy highest priority post op. What's the highest priority after ABC?
electrolytes, risk for dehydration, I/O, F/E
What type of microorganism is ringworm
filamentous fungi, that invade primarily the stratum corneum, hair, and nails. These are superficial infections that live on, not in, the skin. They are confined to the dead keratin layers and are unable to survive in the deeper layers. Trichophyton tonsurans, Microsporum audouinii, Microsporum canis, Microsporum canis, the "kitten" or "puppy" fungus
Where do you get ring worm? Where do you get it from?
gyms, pools, locker rooms, sandboxes
what are modifiable risk factors for breast cancer (Things we can change)
hormone use, alcohol consumption, physical inactivity Maintain a healthy weight. Being overweight or obese increases the risk of breast cancer, especially after menopause. Exercise regularly. Physical activity can help you maintain a healthy weight which, in turn, helps prevent breast cancer. Limit alcohol. Try to limit your alcohol consumption. Don't smoke. Evidence suggests a link between smoking and breast cancer risk, particularly for premenopausal women. Stopping smoking is one of the best decisions you can make for your overall health. Breastfeed. There may be a link between breastfeeding and breast cancer prevention. The longer you breastfeed, the greater the protective effect. Limit hormone therapy. Ask your doctor about managing the symptoms of menopause with exercise, dietary changes or other non-hormonal therapies. Or if you must use hormone therapy, do it on a temporary basis at the lowest dose possible.
Risk factors that decrease the incidence of lung cancer
smoking cessation
Postop renal resection priority nursing actions
urine output- In the immediate postoperative period, measure and record the urine output at least every 1 or 2 hours. Measure drainage from the various catheters and record it separately. Do not clamp or irrigate the catheter or tube without a specific order. The total urine output should be at least 0.5 mL/kg/hr. It is important to assess for urine drainage on the dressing and to estimate this amount. Observe and monitor the color and consistency of urine. Urine with increased amounts of mucus, blood, or sediment may occlude the drainage tubing or catheter. Weigh the patient daily using the same scale, and have the patient wear similar clothing and dressings each time. A significant change in daily weight can indicate retention of fluids, which places the patient at cardiovascular risk for developing heart failure. Retention of fluids can increase the work required of the remaining kidney to perform its functions. respiratory status- important to ensure adequate ventilation. The patient is often reluctant to turn, cough, and deep breathe because of the incisional pain. Give adequate pain medication to ensure the patient's comfort and ability to perform coughing and deep-breathing exercises. Frequently, additional respiratory devices such as an incentive spirometer are used every 2 hours while the patient is awake. In addition, early and frequent ambulation assists in maintaining adequate respiratory function. abdominal distention- most commonly due to paralytic ileus caused by manipulation and compression of the bowel during surgery. Oral intake is restricted until bowel sounds are present (usually 24 to 48 hours after surgery). IV fluids are given until the patient can take oral fluids. Progression to a regular diet follows.
How do you prevent the spread of impetigo to other areas of skin (self inoculation)
wash hands, staph can peacefully live on our skin protecting us from invasion of other microorganisms they must be kept in check from overgrowth with good hygiene. self inoculation happens when scratching from contaminated areas to intact areas, as small abrasions are created and contaminated.
Post-thyroidectomy assessment what do we look at first
•Assess the patient every 2 hours for 24 hours for signs of hemorrhage or tracheal compression such as irregular breathing, neck swelling, frequent swallowing, sensations of fullness at the incision site, choking, and blood on the anterior or posterior dressings. •Place the patient in a semi-Fowler's position and support the patient's head with pillows. Avoid flexion of the neck and any tension on the suture lines. •Monitor vital signs and calcium levels. Complete the initial assessment by checking for signs of tetany secondary to hypoparathyroidism (e.g., tingling in toes, fingers, around the mouth; muscular twitching; apprehension) and by evaluating difficulty in speaking and hoarseness. Monitor Trousseau's sign and Chvostek's sign. Expect some hoarseness for 3 or 4 days after surgery because of edema. •Control postoperative pain by giving medication. If postoperative recovery is uneventful, the patient ambulates within hours after surgery, is permitted to take fluid as soon as tolerated, and eats a soft diet the day after surgery. The appearance of the incision may be distressing to the patient. Reassure the patient that the scar will fade in color and eventually look like a normal neck wrinkle. A scarf, jewelry, a high collar, or other covering can effectively camouflage the scar. Although not common, airway obstruction after thyroid surgery is an emergency situation. • Oxygen, suction equipment, and a tracheostomy tray should be readily available in the patient's room.
