Uworld NCLEX

Third degree heart block

Atrial and ventricular rhythms are regular but independent of each other. Involves complete inhibition of impulse conduction from the atria to the ventricles, usually at the AV node or bundle of His. The atrial and ventricular rhythms are regular but unrelated to each other. A complete heart block results in bradycardia, decreased CO, syncope, and possibly heart failure/shock. The client is typically symptomatic and requires immediate treatment with transcutaneous pacing until a permanent pacemaker can be inserted. Atropine, dopamine, and epinephrine can be used to increase heart rate and blood pressure until temporary pacing is available

Insulins

Basal long acting: Glargine, detemir (once a day) Intermediate-acting: NPH (twice a day) Postprandial short-acting: Regular (peak at 2-5 hours; best for IV use), lispro, aspart, glulisine (peak at 0.5-3 hours; best options for postmeal hyperglycemia)

Cisplatin

Antineoplastic medication that can cause renal toxicity. Dose should be adjusted or discontinued in those with decreased renal clearance.

Baclofen

Antispasmodic drug that promotes skeletal relaxation by interfering with the transmission of impulses that cause muscle spasticity. It is effective in decreasing pain and cramping associated with muscle tightness and spasticity in clients with MS and spinal cord injury. Orthostatic hypotension is an adverse effect

Colosotomy

Appliance and bag should be changed every 5-10 days. Clients with ascending colostomies need to prevent dehydration and drink lots of fluids. They also should refrain from eating food that is gas-forming and odorous such as beans, broccoli, cauliflower, onions, and asparagus. Empty when it is one-third full

Hypokalemia

Caused by furosemide or prolonged vomiting May manifest as muscle cramps, weakness, or paralysis and could cause arrhythmias. Especially dangerous in cardiac patients with hx of MI

Liver failure and hypokalemia

Clients with cirrhosis typically have hypokalemia due to hyperaldosteronism (aldosterone is not metabolized by the damaged liver). Hypokalemia can also result from diuretics used to treat the fluid retention and ascites.

Psychomotor retardation

Clinical symptom of major depressive disorder. Manifestations include slowed speech, decreased movement, and impaired cognitive function. The individual may not have the energy or ability to perform activities of daily living or to interact with others. Movement impairment - body immobility, slumping posture, slowed movement, delay in motor activity, slow gait Lack of facial expression Downcast gaze Speech impairment - reduced voice volume, slurring speech, delayed verbal responses, short responses Social interaction - reduced or non-interaction Psychogenic dystonia: psychogenic movement disorder characterized by involuntary muscle contractions that cause slow, repetitive movements such as twisting and abnormal postures Psychogenic gait: psychogenic movement disorder characterized by unusual standing postures and walking. May experience knee buckling and falling or may veer from side to side as if staggering Somatization: physical symptoms that cannot be explained by a medical condition or disease

Metal-containing transdermal patches

Clonidine Nicotine Scopolamine Testosterone Fentanyl Should remove the patch before MRI due to risk of burns and replace after testing

Anti-platelet agents

Clopidogrel Ticagrelor Prasugrel Aspirin

Avoiding heartburn

Common during pregnancy due to increase in progesterone and uterine enlargement that displaces the stomach. Progesterone relaxes smooth muscles and causes esophageal sphincter relaxation. Gastric contents are then regurgitated, usually causing a burning sensation behind the sternum. Lifestyle changes: Keeping the head elevated using pillows Sitting upright after meals Eating small, frequent meals Avoid tight-fitting clothing Eliminating common dietary triggers (fried/fatty foods, caffeine, citrus, chocolate, spicy foods, tomatoes, carbonated drinks, peppermint) Minimize gastric distension by drinking minimal amounts of fluid while eating and not overeating helps to reduce gastric acid production and subsequent reflux. Client should be instructed to cluster fluid intake between meals instead

Toxic megacolon

Common life-threatening complication of IBS and is seen more frequently in ulcerative colitis than in Chron disease. Toxic megacolon can also be associated with C-diff infection and other forms of infectious colitis. Symptoms include abdominal distension, bloody diarrhea, and fever Severe colonic inflammation causes release of inflammatory mediators and bacterial products which contribute to colonic smooth muscle paralysis. Rapid colonic distension ensures, thinning the intestinal wall and making it prone to perforation. Imaging confirms diagnosis

Cerebellum

Coordination of voluntary movements and maintenance of balance and posture Maintenance of balance is assessed with gait testing and includes watching the client's normal gait first and then the gait on heel-to-toe, on toes, and on heels Finger testing: ability to touch each finger of one hand to the hand's thumb Rapid alternating movements: rapid supination and pronation Finger-to-nose testing: clients touch finger to their own nose as the clinician's finger varies in location Heel-to-shin: client runs each heel down each shin while in a supine position

Dextromethorphan

Cough supressant

School-age development

Deal with conflict of industry vs inferiority. Attaining a sense of industry is the most significant developmental goal for children age 6-12. Parents should be encouraged to provide a hospitalized child with missed school work on a regular basis.

Warfarin

Do not eat foods high in vitamin K: leafy green veggies. Target INR is 2-3. Warfarin reduces clotting within 24 hours and takes 3-5 days for full effect. Warfarin is usually administered for 3-6 months following PE to prevent further thrombus formation. A longer duration (lifelong) is recommended in clients with recurrent PE. PT and INR must be monitored regularly

Oral potassium

Erosive substance that can cause pill-induced esophagitis. To prevent esophageal erosion, the client should take potassium tablets with plenty of water (at least 4 oz) and remain sitting upright for >30 min after ingestion. Should be taken during or immediately following meals to prevent gastric upset. This prevents the tablet from becoming lodged in the esophagus or refluxing from the stomach. Pill-induced esophagitis is also common with doxycycline and bisphosphonates ("dronates") so they should be given similar instructions

Bipolar acute manic episode

Excessive psychomotor activity, euphoric mood, poor impulse control, flight of ideas, non-stop talking, poor attention span, hallucinations and delusions, insomnia, wearing bizarre or inappropriate clothing, negelected hygeiene and inadequate nutritional intake Provide quiet calm environment, limit number of people they have contact with, one-on-one interactions rather than group activities, low lighting, structured schedule, physical activities, providing high protein high calorie meals and snacks, setting limits on behavior

Antihistamines

Fexofenadine, cetirizine, levocetirizine, loratidine' Used for hypersensitivity reactions

Sulfonylureas

Glyburide, Glipizide, Glimepiride Common adverse effects: hypoglycemia and weight gain Should use sunscreen as serious sunburns can occur Should avoid alcohol as it lowers blood glucose

Donning PPE

Gown Mask or respirator Goggles or face shield Gloves

Contact precautions

Gown and gloves Use when draining abscesses, C diff, head lice, scabies, viral conjunctivitis, diarrhea in a young child, herpes simplex (open lesions), impetigo, MRSA

GTPAL

Gravida: number of times the woman has been pregnant, regardless of pregnancy outcome Term: number of pregnancies delivered 37 weeks 0 days gestation and beyond Preterm: number of pregnancies delivered from 20 w 0 days gestation through 36 w 6 d gestation Abortion: number of pregnancies ending before 20 w 0 d gestation; these may be spontaneous or induced abortions Living: number of currently living children

Ketorolac

Highly potent NSAID often used for pain and available in IV form. However, NSAIDs (indomethacin, ibuprofen, naproxen, ketorolac) are nephrotoxic and should be avoided in clients with kidney disease. Also, the client should not be given two types of NSAIDs simultaneously as they can be toxic to the stomach and kidneys This drug is not used longer than 5 days due to risk of adverse effects (kidney injury, GI ulcers, bleeding)

Tricyclic antidepressants

Imipramine, amytryptiline, and nortryptiline must be tapered and have two weeks of discontinuation in order to leave the patient's system. Therefore, other antidepressants should not be started during this period Adverse reactions of having both: hypertensive crisis, discontinuation syndrome. ODs on TCAs can be especially dangerous (dysrhythmias and seizures) and these patients would be a priority These meds can also be used for bed wetting and neuropathic pain, but uncommon

Brachytherapy

Internal radiation involves direct application of a radioactive implant to the cancerous site or tumor for 24-72 hours. Used to treat cervical and endometrial cancer and delivers high dose to cancerous tissues with limited dose to adjacent tissues. Time spent in room should be restricted to 30 minutes per shift per staff member Wear a dosimeter film badge to monitor radiation exposure No pregnant or individals under 18 allowed in room All staff and visitors must stand 6 feet away Keep door closed Warning sign on door Instruct client to remain on bedrest to avoid dislodgement of the implant Must wear a lead apron when providing direct care and physical contact

Montelukast

Leukotriene receptor blocker with both bronchodilator and anti-inflammatory effects; used to prevent asthma attacks but is not recommended as an emergency rescue drug in asthma

Broborygmi sounds

Loud, gurgling sounds suggesting increased peristalsis. Potential disease processes resulting in borborygmi sounds include gastroenteritis, diarrhea, and the early phases of mechanical obstruction

Chest tubes in infants

May be placed during cardiac surgery to help drain fluid and air and to ensure room for lung expansion. Drainage >3 mL/kg/hr for 3 consecutive hours or >5-10 mL/kg in 1 hour

Discharge teaching for pacemakers

Report signs of infection Keep pacemaker ID card with you Microwave ovens are safe Learn to take your pulse and report it if is below predetermined rate Do not place a cell phone in a pocket located directly over the pacemaker MRI scans can affect or damage a pacemaker Avoid lifting your arm above the shoulder on the side that the pacemaker is implanted until approved by the HCP Air travel is not restriced but you may set off the metal detector and a screening wand should not be held directly over pacemaker Avoid standing near antitheft detectors in store entryways

Sprain

Rest - activity restriction for 24-48 hours Ice - applied 10-15 min every hour for first 24-48 hours Compression - ACE wrap Elevation - above heart Analgesia - NSAIDs taken every 6 hours Exercise rehab program - initiated as soon as possible after injury (when pain subsides) to restore ROM, flexibility, and strength

Eclampsia

Seizures are a potential complication of worsening preeclampsia, also known as eclampsia. Seizure precautions should be in place. During a seizure, the nurse should turn the client to the left side to prevent aspiration and promote uteroplacental blood flow. After the seizure subsides, the nurse should suction any oral secretions and apply oxygen 8-10 L Magnesium sulfate is a CNS depressant commonly prescribed to prevent seizures in clients with preeclampsia. Deep tendon reflexes should be assessed hourly. Hyperreflexia or clonus may indicate impending seizure activity, whereas hyporeflexia may indicate magnesium toxicity. Calcium gluconate is the reversal agent administered in the event of magnesium toxicity and should be readily available Environmental stimuli should be minimized to decrease risk for seizures. This may include limiting visitors

Duloxetine

Serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With the restoration of normal sleep patterns, faigue often improves as well.

Anencephaly

Severe neural tube defect resulting in little or no brain tissue or skull formation in utero. Many newborns with anencephaly are stillborn, and those born alive are incompatible with life. Comfort care for the newborn and emotional support for the family is priority at time o fbirth. Drying, bundling, and placing the newborn in skin-to-skin provides warmth, and administering oxygen may decrease discomfort to the newborn. Allowing the family to hold the newborn will assist with the grieving process

MDI use

Shake MDI and attach it to spacer Exhale completely to optimize inhalation of the medication Place lips tightly around the mouthpiece Deliver a single puff of medication into spacer Take a slow deep breath and hold it for 10 seconds to allow for effective med distribution After the dose, rinse mouth with water to remove any left-over med from oral mucous membranes. Spit out the water to ensure no med is swallowed

McRoberts maneuver

Sharply flexing the legs onto the maternal abdomen to straighten the sacrum. Suprapubic pressure is then applied to the fetal shoulder. Used for shoulder dystocia and will not take pressure off a prolapsed umbilical cord

Foods high in vitamin K

Should be avoided with warfarin use Leafy green vegetables Asparagus Broccoli Kale Brussels sprouts Spinach Other beverages may affect warfarin therapy and anticoagulant effects: Green tea Grapefruit juice Cranberry juice

Measuring JVD

Should be perfomed with the client sitting with the HOB at 30 to 45 degrees. Nurse will observe for distension and prominent pulsation of the neck veins

Post-op pneumonectomy

Should be placed on the affected side to promote adequate expansion and ventilation of the remaining lung

Decreasing ICP

Should not exceed 25 mmHg during procedures and should return to baseline within a few minutes. Pain, straining, agitation, shivering, fever, hypoxia increase brain blood supply and increase ICP. Keep HOB above 30 degrees with head in neutral position (midline) Stool softeners to reduce risk of straining Managing pain well Calm environment Managing fever and preventing shivering Adequate oxygenation Hyperventilating and preoxygenating the client before suctioning; reducing CO2 (potent cerebral vasodilator) by hyperventilation induces vasoconstriction and reduces ICP Limit performing interventions in clusters. Only suction for maximum of 10 seconds and only as necessary to remove secretions

Cardiac tamponade

Signs and symptoms: narrowed pulse pressure, hypotension, and JVD Life-threatening complication of pericardial effusion in which fluid builds up in the pericardial sac and compresses the heart. The heart is unable to contract effectively against the fluid and CO can drop drastically. Emergency pericardiocentesis is needed. Other manifestations include muffled or distant heart tones, pulsus paradoxus, dyspnea, tachypnea, and tachycardia

Sodium polystyrene sulfonate

Sodium polystyrene sulfonate (Kayexalate) can be used to treat hyperkalemia. It works in the GI tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing serum potassium level In clients without normal bowel function (post surgery, constipation, fecal impaction), there is a risk for intestinal necrosis. During therapy, severe hypokalemia (palpiations, lethargy, cramping) can develop. Frequent monitoring of electrolyte status is required. Because potassium exchanges with sodium content of the resin, excess sodium absorption could put clients at risk for developing volume overload and client should be monitored for signs and have daily weights and output assessment

Potassium sparing diuretics

Spironolactone, amiloride, triamterene, and eplerenone are potassium-sparing diuretics. In general, these are very weak diuretics and antihypertensives and are used mainly in combination with thiazide diuretics to reduce potassium loss

Heparin

Monitored using PTT Normal PTT: 25-35 Multiplied by 1.5-2 for patients on heparin

Aortic stenosis

Narrowing of the orifice between the left ventricle and the aorta. Usually asymptomatic. Symptoms usually develop with exertion as the left ventricle cannot pump enough blood due to aortic obstruction. These include dyspnea, angina, and in severe cases, syncope. Can have a soft or absent S2 sound

Carotid endarterectomy

Surgical procedure that removes atherosclerotic plaque from the carotid artery. Clients with CAD are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding. BP is closely monitored during the first 24 hours post surgery. HTN may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. SBP is maintained at 100-150 mmHg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain.

Transsphenoidal hypophysectomy

Surgical removal of the pituitary gland, an endocrine gland that produces, stores, and excretes hormones (ADH, growth hormone ACTH). Clients are at risk for neurogenic diabetes insipidus, a disorder with low ADH levels and massive diuresis.

Aspiration of foreign body

Occurs most often in toddler age group. Swallowing of objects such as buttons, small parts of toys, or food particles can be life threatening and result in airway obstruction due to the small diameter of the airway. Manifestations include choking, gagging, cyanosis, and inability to speak when the object is lodged in the larynx

Intususception

One part of intestine prolapses and then telescopes into another part. Initially, telescoping is intermittent, resulting periodic pain in abdomen with the legs drawn up. Pain is severe, progressive, and associated with inconsolable crying. Can compromise circulation, causing mucosal ischemia, occult bleeding, and if untreated, grossly bloody currant jelly stools Air enema is used for diagnostic purposes and often reduces intussusceptions. Air enema is considered safer than barium enema

Aspart

Onset is 15 minutes and peak is 0.5-3 hours Ensure that they eat within 15 minutes of administration

Codeine

Opioid prescribed as an analgesic to treat mild to moderate pain and as an antitussive to suppress the cough. Common adverse effects: constipation, nausea, vomiting, orthostatic hypotension, dizziness. Increase fluid intake and fiber in diet. Take medication with food to prevent Gi irritation.

Pelvic fractures

Pelvis contains significant large vascular structures and abdominal and pelvic organs. In addition to pain, the nurse should assess for internal hemorrhage (abdominal distension, BS, hematocrit, hemoglobin), paralytic ileus (bowel sounds), neurovascular deficits (extremity circulation, sensation, movement), and abdominal and genitourinary organ injuries (hematuria, urine output <0.5 mL/kg/hr).

Restraints

Perform hourly neurovascular checks (pulses, color, skin temp, sensation, movement) Briefly release restraints for skin integrity assessment and ROM exercises every 2 hours. Assess behavior and reaction to promote discontinuation as soon as possible Offer fluids, nutrition, and toileting every 2 hours and as needed Restraint straps should be attached to areas that move with the bed frame and not areas that do not move with the bed frame (side rails). Supine positioning increases aspiration risk, so side-lying or semi-Fowler should be used. Restraints should be tied in a quick release knot and never in a square knot, which is difficult to release quickly Assess continued need for restraints every hour Pad bony prominences with gauze under restraints if necessary to protect skin

Babinski reflex

Present in children up to 1 year. Beyond that can indicate neurologic disease

Lithium toxicity

Presents primarily with GI side effects such as nausea, vomiting, and diarrhea Neurologic symptoms typically occur later including tremor, confusion, and ataxia Late symptoms include seizures and encephalopathy Serum levels must be 1.0-1.5 for acute mania and 0.6-1.2 for maintenance therapy Dry mouth and thirst are common side effects and should resolve on their own

Infants and iron

Preterm infants and infants born in multiple exhaust their iron stores by 2-3 months (as opposed to 5-6 months in term infants). Iron must then be acquired through dietary sources (iron-fortified formula) or oral supplements. Exclusively breast-fed infants can receive supplements of oral iron drops as breast milk contains low levels of iron. After transitioning to solid foods, infants can obtain iron from fortified infant cereal and iron-rich foods

Herpes

Prevent transmission: wear gloves when touching lesions; avoid sex during outbreaks Pain control: analgesics, sitz baths, pouring water over genital area while urinating Genital hygiene: keeping area clean and dry and wearing loose-fitting, cotton undergarments

Addison disease

Primary adrenocortical insufficiency is also described as hypofunction of the adrenal cortex. The adrenal gland is responsible for secretion of glucocorticoids, androgens, and mineralocorticoids. Bronze hyperpigmentation of the skin in non-exposed areas is caused by an increase in ACTH by the pituitary in response to low cortisol Clients with Addison may also have vitiligo or patchy/blotchy skin, which is usually present when the etiology of the disease is an autoimmune problem. The immune cells are thought to destroy melanocytes which produce melanin, resulting in a patchy appearance. Other manifestations: Slow progressive onset of weakness and fatigue, anorexia or weight loss, orthostatic hypotension, hyponatremia and hyperkalemia, salt cravings, nausea and vomiting, depression and irritability

Scopes of practice

RN: clinical assessment, initial client education, discharge education, clinical judgement, initiating blood transfusion LPN/LVN: monitoring RN findings, reinforcing education, routine procedures (catheterization), most med administrations, ostomy care, tube patency and enteral feeding, specific assessments (limited - lung sounds, bowel sounds, neurovascular checks). May also monitor findings such as flow rate and drainage in continuous bladder irrigation. May measure peak expiratory rate. May take lung sounds, but may not evaluate a response to a medication such as albuterol (can collect data but cannot evaluate it). May perform higher-level skills in stable clients such as oral and injection medications, sterile procedures (dressing changes), suctioning and tube feeds UAP: ADLs, hygiene, linen change, routine stable vital signs, documenting I/O, positioning

Warfarin in pregnancy

Warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations. It results in fetal anticoagulation, dangerous fetal bleeding, including intracranial hemorrhage. Clients on warfarin are taught to use effective contraception

Oral contraceptives

ACHES Abdominal pain (ischemic bowel) Chest pain (PE or MI) Headaches (stroke) Eye problems (Retinal blood vessel ischemia) Severe leg pain (DVT) Do not smoke while on contraceptive because it increases risk for clotting

Glycoprotein IIb/IIIa receptor inhibitors

Abciximab, eptifibatide, tirofiban are used as platelet inhibitors to prevent the occlusion of treated coronary arteries during percutaneous coronary intervention procedures and prevent acute ischemic complications. They can cause serious bleeding from thrombocytopenia. Hypotension, tachycardia, changes in heart rhythm, blood in urine, abdominal/back pain, mental status changes, and black tarry stools may indicate internal bleedings and should be monitored carefully when GP IIb/IIIa receptor inhibitors are administered. During and after infusion, no traumatic procedures (initiation of IV sites, intramuscular injections) should be performed unless absolutely necessary

Oxybutynin

Anticholinergic medication that is frequently used to treat overactive bladder. Can also be used to treat bladder spasms related to the TURP procedure Common side effects: New onset constipation Dry mouth Flushing Heat intolerance Blurred vision Drowsiness Decreased sweat production may lead to hyperthermia. The nurse should instruct the client to be cautious in hot weather and during physical activity. Sedation is a common side effect of anticholinergic drugs. Clients should be taught not to drive or operate heavy machinery until they know how the drug affects them

Tolterodine

Anticholinergic medication used for overactive bladder and urge urinary incontinence. Decreases urinary frequency and urgency. Most common side effects are dry mouth, constipation, urinary retention, orthostatic hypotension, and cognitive dysfunction.

Emergency management of chest pain

Assess airway breathing, and circulation Position client upright unless contraindicated Apply oxygen if the client is hypoxic Obtain baseline vital signs Auscultate heart and lung sounds Obtains a 12 lead ECG Auscultate heart and lung sounds Insert 2-3 large bore IVs Assess pain using PQRST Medicate for pain as prescribed (nitroglycerine) Initiate continuous ECG monitoring Obtain baseline bloodwork Obtain portable chest x ray Assess for contraindications to antiplatelet and anticoagulant therapy Administer aspirin unless contraindicated

Ziprasidone hydrochloride

Atypical antipsychotic used for acute bipolar mania, acute psychosis, and agitation. Its use carries a risk for QT prolongation leading to torsades de pointes. A baseline ECG and potassium are usually checked. Client should be placed on a monitor. Should also be monitored for hypotension or seizures

Immune thrombocytopenic purpura

Autoimmune condition in which antibodies bind to and cause destruction of platelets. Patients are at increased risk of bleeding Should not use anti-inflammatory drugs (aspirin, ibuprofen, ketorolac) because they further impair platelet function

Sjogren's syndrome

Autoimmune condition that causes inflammation of the exocrine glands (lacrimal, salivary), resulting in decreased production of tears and saliva and leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Dryness in these areas can lead to corneal ulcerations, dental caries, and oral thrush. Symptoms: Skin - dry skin and rashes Throat and bronchi - chronic dry cough Vagina - vaginal dryness and painful intercourse Treatment with over-the-counter preservative-free artificial tears can relieve eye dryness, burning, itching, irritation, pain, and a gritty sensation in eyes. Some clients will use eye drops during the day and ophthalmic ointment at night. Wearing goggles can protect the eyes from outdoor wind and dust. Dry mouth is treated with artificial saliva. Using a room humidifier and not sitting in front of fans and air vents can also help Lubricants help to ease vaginal dryness. Use of lukewarm water and mild soap when showering can prevent dry skin Avoid decongestants as they can cause further dryness to the mouth and nasal mucosa. Should also avoid oral irritants (coffee, alcohol, nicotine) and acidic drinks (soda, juices) and instead sip water frequently

Magnesium sulfate

CNS depressant used to prevent/control seizure activity in preeclampsia/eclampsia clients. During administration, nurse should assess VS, I/O, and monitor for signs of Mg toxicity (decreased deep-tendon reflexes, respiratory depression, decrease UO). Therapeutic Mg level is 4-7 Can also be used to slow uterine contractions in preterm labor to administer corticosteroids to give the fetus more time to improve lung maturity

Cor pulmonale

Can happen with COPD. Right sided heart failure that occurs from vasoconstriction of pulmonary vessels. Cor pulmonale is treated with long term low flow oxygen, bronchodilators, and diuretics.

Addison's Disease

Chronic adrenal insufficiency. Symptoms include weight loss, muscle weakness, low BP, hypoglycemia, and hyperpigmented skin (skin folds, buccal area, palmar crease). Loss of libido and decreased axillary and pubic hair are common due to lower levels of androgens. Due to increased ACTH due to decreased cortisol negative feedback. Treatment consists of replacement therapy with oral mineralocorticoids and corticosteroids

MRSA

Clients at highest risk for MRSA are older adults and those with suppressed immunity, long history of antibiotic use, or invasive tubes or lines. Clients in the ICU are especially at risk for MRSA. COPD is a chronic illness that can affect immunity and clients experience exacerbations that may require frequent antibiotic and corticosteroid use.

Uterine rupture

Clients attempting VBAC have a slightly increased chance for uterine rupture due to previous surgical scarring of the uterus. Be vigilant for tachysystole, which increases the risk for uterine rupture First sign of uterine rupture is usually abnormal FHR (decelerations followed by fetal bradycardia). Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contraction. Hemorrhage, hypovolemic shock, and maternal tachycardia may occur if rupture goes unrecognized

Involuntary admission

Clients with a mental illness have the right to refuse admission and treatment. However, all states have laws for involuntary admission that require clients to receive inpatient treatment for psychiatric disorder against their will. Criteria include: Individual appears to be an imminent danger to self or others Individual has a grave disability (unable to adequately care for basic needs [food, clothing, shelter, medical care, personal safety]) as a result of mental illness

Decompressing the stomach

Connect main lumen of NG tube to suction apparatus The blue pigtail lumen is the air vent that facilitates removal of air and secretions from the stomach. The nurse should never connect the air vent to suction, use it for flushing, or clamp/plug it. If plugged, the tube may adhere to the side of the stomach or esophagus and cause tissue breakdown. Regular flushing of the NG tube with water prevents clogging and allows the suction a clear pathway to decompress the suction

Ileostomy

Connects to small intestine and bypasses the colon. In immediate post-op period, a low-residue diet is prescribed to prevent obstruction of the lumen. After it heals, they may introduce fibrous foods one at a time Foods to be avoided: High fiber: popcorn, coconut, brown rice, multigrain bread Stringy vegetables: celery, broccoli, asparagus Seeds or pits: strawberries, raspberries, olives Edible peels: apple slices, cucumber, dried fruit

Concussion

Considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration head injury. Typical signs include: A brief disruption in LOC Amnesia regarding the event Headache Should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days. Rest and light diet are encouraged during this time

Avoiding dumping syndrome

Consume small, frequent meals Eat slowly Avoid meals high in simple carbs (sugar, syrup) Consume meals high in protein, fat, and fiber - take longer to digest and stay in stomach longer than carbs Separate fluids from meals Avoid sitting up after a meal - gravity increases gastric emptying Dumping syndrome causes fluid shift into the small intestine that results in hypotension, abdominal pain, diarrhea, nausea, vomiting, dizziness, generalized sweating, and tachycardia

Fluticasone/salmeterol

Contains a corticosteroid and a bronchodilator. Salmeterol is a long-acting inhaled beta 2 adrenergic agonist that promotes relaxation of smooth muscles over 12 hours. Fluticasone decreases inflammation. Used as part of a treatment plan for prevention and long-term control of asthma Rinse mouth with water after without swallowing Avoid tobacco and smoking Receive the pneumococcal vaccine if there is risk for infection

TORCH infections

Dangerous for pregnant woman as they can cause fetal anomalies Toxoplasmosis Other: Parvo/B-19/varicella Rubella Cytomegalovirus Herpes simplex virus Also extreme caution while handling cytotoxic (chemotherapy) drugs

Mongolian spots

Congenital dermal melanocytosis is a benign discoloration fo the skin most often seen in newborns with darker skin tones. Mongolian spots are usually bluish gray and fade over the first 1-2 years of life. Because they are easily misidentified as bruises, it is important for the nurse to measure and document the area for reference during future health assessments

Bladder exstrophy

Congenital disorder in which the bladder was not developed in the abdominal cavity during fusion in the embryo and is exposed externally. The priority before surgical repair is to prevent injury. Placing a protective film of plastic (Saran wrap) over the exposed bladder will keep the tissue moist and help prevent infection This is not considered an emergent procedure

Oral surgery

Congenital heart disease and those with prosthetic valves are at risk for endocarditis with oral surgery and dental procedures. They should receive prophylactive antibiotic therapy prior to the procedure. Dentist should also be informed about heightened INR or inhibited clotting ability due to risk of excessive bleeding during procedures

Metformin

Decreases liver glucose production, lowering blood glucose. Also increases the sensitivity of insulin receptors in cells. These actions increase the efficacy of insulin secretion by the pancreas, and the risk for hypoglycemia is minimal. Although skipping meals would cause a drop in blood glucose, metformin would not cause further hypoglycemia. Side effect is lactic acidosis. If the client takes metformin before a iodinated contrast CT scan, the contrast may damage kidneys and worsen acidosis. Should not be used in patients with significant liver or kidney disease

Minimally invasive direct coronary artery bypass

Does not involve sternotomy incision or placement on cardiopulmonary bypass. Several small incisions are made between the ribs. A thoracotomy scope or robot is used to dissect the internal mammary artery that is used as a bypass graft. Radial artery or saphenous veins may be used if IMA is not available. Recover time is typically shorter with these procedures and clients are able to resume activities sooner than with traditional open chest coronary artery bypass graft surgery. However, clients may report higher levels of pain with MIDCAB due to the thoracotomy incisions made between the ribs.

Allen's Test

Drawing ABGs from the radial artery requires an Allen test beforehand to ensure the patency of the ulnar artery, which will ensure adequate blood flow to the hand during the blood draw. Instruct client to make a tight fist if possible Occlude the radial and ulnar arteries using firm pressure Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded. Release the pressure on the ulnar artery only. The palm should turn pink within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery (positive Allen test) If negative, an alternate site must be used for the ABG

Ethambutol

Drug used to treat TB Can cause optic neuritis - regular eye exams should occur Hepatoxicity can be common with other TB drugs such as isoniazid, pyrazinamide, rifampin. However, ethambutol does not normall have hepatoxicity effects Streptomycin, another antibiotic used for TB, is a second-line drug sometimes used to treat multi-drug resistant TB and can have ototoxic and nephrotoxic adverse effects

Signs of coping during labor

Effective: vocalization (moaning, counting, chanting), rhythmic breathing, inward focus on labor processes, ability to relax between contractions, rhythmic activity during contractions (rocking, swaying) Ineffective: crying, sweating, hyperventilating, tenseness, tremulous voice, thrashing, wincing, writhing, inability to focus/concentrate, clawing, biting, screaming, panicked activity with contractions

Risk factors for opioid induced respiratory depression

Elderly, those with underlying pulmonary disease, history of snoring, obesity, smoking, opiate naïve, and post surgery (24 hours)

Pulsus paradoxus

Exaggerated fall in systemic BP >10 mmHg during inspiration 1. Place client in semirecumbent position 2. Have client breathe normally 3. Determine the SBP using manual BP cuff 4. Inflate the cuff to at least 20 mmHg above previously measured SBP 5. Deflate cuff slowly, noting the first Korotkoff sound during expiration along with pressure 6. Continue to slowly deflate the cuff until you hear sounds through inspiration and expiration, also noting the pressure 7. Determine the difference between the 2 measurements in steps 5 and 6 8. The difference in normally <10 mmHg, but a difference >10 mmHg may indicate pulsus paradoxus

Failure to sense vs failure to capture

Failure to sense appears on an ECG as synchronous pacer spikes in inappropriate or random locations (pacer spike on T wave) Failure to capture is when pacer spikes are located appropriately but there is no electrical response elicited from the heart (no QRS complex after pacer spike)

Renal diet

Low in potassium, sodium, and phosphorous Dairy products and certain fruits (bananas, oranges, raw carrots and tomatoes, coconuts, watermelons, and avocados) have high potassium and phosphorous levels. Low protein diet helps prevent kidney disease progression. Those on dialysis should have a liberal protein intake to prevent malnutrition Fluid intake must also be restricted Examples of allowable foods for CKD: apples, pears, grapes, pineapple, blackberries, blueberries, and plums

A fib

If a client is in AF for more than 48 hours, anticoagulation therapy is needed for 3-4 weeks before cardioversion. Anticoagulation therapy is necessary as cardioversion may dislodge an atrial thrombus, putting the client at risk for a stroke other sequelae of thromboembolism. If 4 weeks of anticoagulation is not an option, TEE must be performed prior to cardioversion to assess for presence of clots

Bariatric surgery

Involves a surgical modification of the client's stomach to restrict the client's intake. Postop nursing care focuses on pain management and nausea and monitoring for complications. NG tubes are contraindicated after gastric surgery due to potential disruption of the surgical site, which can cause hemorrhage and anastomotic leak. Postop nausea would be controlled using IV antiemetics. Clients are placed on a clear liquid diet for the first 48-72 hours after bariatric surgery to promote healing. Low carb (sugar free) liquids decrease the risk of dumping syndrome. After bariatric surgery, low Fowler position is preferred during mealtimes as it slows gastric emptying, reducing risk of dumping syndrome.

Descending stairs with cane

Lead with cane Bring the weaker leg down next Then step down with the stronger leg Ascending stairs: Step up with stronger leg first Move the cane next while bearing weight on the stronger leg Move the weaker leg Mnemonic: UP with the GOOD and DOWN with the BAD. Cane always moves before the weaker leg Hold cane on stronger side

Fatty embolism

Leads to respiratory distress syndrome, altered mental status, and petechial hemorrhages in arms, chest, and neck

Phlebostatic axis

Level with the atria of the heart (fourth intercostal space at midclavicular line) or midway point of the anterior posterior diameter of the chest Used for arterial line pressure (where to place the transducer) Also used as a reference point for the upper arm when measuring BP indirectly using noninvasive BP device

Autonomic dysreflexia

Life-threatening Occurs with spinal cord injuries above T6 Classic signs include hypertension, bradycardia, diaphoresis above level of injury, goose bumps, flushing, piloerection, and nausea. Most common cause of AD is bladder irritation due to distention. Client should be catheterized. Bowel impaction can also be the cause, and digital rectal examination should be performed. Constrictive clothing should be removed to decrease skin stimulation. Should elevate bed 45 degrees or high fowlers

Hemolytic uremic syndrome

Life-threatening complication of E coli diarrhea and results in red cell hemolysis, low platelets, and AKI. Hemolysis results in anemia, and low platelets manifest as petechiae or purpura. Therefore, the presence of petechiae in this client could indicate HUS. Fruit juices are discouraged in acute diarrhea as they have high sugar (osmolality) and low electrolyte content. Continuing the client's normal diet is encouraged as it shortens the duration and severity of diarrhea

Death rattle

Loud rattling sound with breathing that occurs in a client who is actively dying. When the client cannot manage airway secretions, the movement of these secretions during breathing causes a noisy rattling sound. Death rattle can be treated using anticholinergic meds to dry the client's secretions. Medications include atropine drops administered sublingually or a transdermal scopolamine patch

Coronary arteriogram

Invasive diagnostic study of the coronary arteries, heart chambers, and function of heart. Instructions: Do not eat or drink anything 6-12 hours before procedure Client may feel warm or flushed while contrast dye is injected Most commonly done through femoral artery so they will need to lie flat for several hours to ensure hemostasis No anesthesia required If it is just a diagnostic study, the client should go home the same day

Normal LDL

<100

Normal brain natriuretic peptide

<100

Normal triglycerides

<150

Normal total cholesterol

<200

Excessive chest tube drainage

>100 mL/hr Collection chamber should be inspected every hour for the first 8 hours following surgery, then every 8 hours until it is removed.

Gastric residual volumes

>250. May indicate delayed stomach emptying and require adjustment to prevent nausea, vomiting, or abdominal distension.

Diabetic diet

Low-fat, low glycemic-index, high-fiber Method for meal planning: Monitor carb intake Manage caloric intake if weight loss is desired High-fiber foods including whole grains, legumes, fruits, vegetables, and low fat dairy Use monounsaturated fats, limit use of saturated fat, and eliminate trans fatty acids Choose foods with low glycemic index Consume total cholesterol <300/day Reduce sodium intake Limit intake of foods containing sucrose Limit intake of alcoholic beverages

Liver cirrhosis diet

Low-fat, low-sodium, high carb diet. Do not totally restrict protein Avoid hepatotoxic medications like acetaminophen and statins. Do not take NSAIDs as they may worsen bleeding

Cheyne-Stokes breathing

Metabolic brain dysfunction (hypoxemia, drugs) Cerebral hypoperfusion (stroke, increased ICP) End-of-life Characterized by repetitive, abnormal, irregular breathing pattern with gradual hyperpnea to gradual hypopnea and has long periods of apnea until the cycle starts again

External fixation

Metallic device composed of metal pins (screws) placed into the bone to stabilize it; these are positioned above and below the fracture through small incisions in the skin and muscle. After the pins are placed, they are attached to an adjustable external rod or frame outside the skin. Infection of the pin tract is a major complication associated with the device. Monitor for signs and prompt antibiotic treatment as it can progress to osteomyelitis and also cause the pins to loosen, leading to bone displacement. Nurse should perform meticulous sterile pin care with 1/2 strength hydrogen peroxide and normal saline or chlorhexidine solution. Regular neurovascular assessment is important to check for compromised integrity of nerves and vessels. Allows for early ambulation with the device in place

Supraglottic swallow

Technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration. 1. Inhale deeply 2. Hold breath tightly to close the vocal cords 3. Place food in mouth and swallow while continuing to hold breath 4. Cough to dispel remaining food from vocal cords 5. Swallow a second time before breathing

Cyanotic heart defects

Tetralogy of Fallot Infants can develop polycythemia (elevated Hgb) as a compensatory mechanism to prolonged tissue hypoxia. This will increase blood viscosity, placing an infant at risk for stroke or thromboembolism. Must stay hydrated. Clubbing is another manifestation of prolonged hypoxia. Clients with TOF will normally maintain oxygen saturation of 65-85% until the defect is surgically corrected.

Right-to-left cardiac defects

Tetralogy of Fallot, transposition of great vessels Cause cyanosis

Colles' fracture

Type of wrist fracture (distal radius) that causes a characteristic dinner fork deformity of the wrist. Occurs when someone lands on the heel of their hand. One of the most common fractures in women >50 and is related to osteopenia or osteoporosis. Perform neurovascular assessment Administer analgesia Apply an ice pack Elevate the extremity Instruct client to move the fingers to reduce edema, increase venous return, and help improve ROM

Corticosteroid therapy

Used to treat Addison's disease. They cause immunosuppression, so it is important to report any signs of infection immediately. The properties of the drug may also mask signs of infection. Infection can also trigger Addisonian crisis. Tachycardia, weight gain, and moon face are all side effects of corticosteroids

Ventriculoperitoneal shunt

Used to treat hydrocephalus and is usually placed at age 3-4 months. Blockage and infection are complications of shunt placement. Blockage results in signs of increased ICP. The normal pulse range for a 1 year old is 100-160. Cushing's triad includes bradycardia, slowed respirations, and widened pulse pressure.

Nystatin

Used to treat oral candidiasis. Available in the form of powders, suspensions, creams, ointments, and lozenges. Oral suspensions are the more common form of nystatin used for oral candidiasis. The client should be directed to swish the solution within the mouth, making contact with all mucous membranes, and then swallow the solution after several minutes. Swallowing will help to clear any unseen esophageal candiasis

Bronchoscopy

Uses mild sedation and topical anesthetic in nares and throat to suppress gag reflex. Blood-tinged sputum is common but hemoptysis of bright red blood can indicate hemorrhage Other complications include hypoxemia, hypercarbia, hypotension, laryngospasm, bradycardia, pneumothorax, and adverse effects from medications used before and after

Cranial nerves for eye movements

(III) - Oculomotor (IV) - Trochlear (VI) - Abducens

MAP calculation

(Systolic) + (Diastolic x 2) / 3 Normal MAP: 70-105

Normal serum creatinine

0.6-1.3

Triaging clients

1. ABCs plus vitals 2. Mental status changes, acute pain, unresolved medical issues, acute elimination problems, abnormal lab values, and risk 3. Longer term issues such as health education, rest, and coping

Normal urine specific gravity

1.003 - 1.030

Normal magnesium

1.5-2.5

Normal infant hemoglobin

12.5-20.5

Normal infant urinary output

2 mL/kg/hr

Normal CVP

2-8

Therapeutic INR for those taking Warfarin

2.0-3.0

Normal PTT

25-35 seconds 46-70 in patients on heparin

Normal infant respiratory rate

30-60 bpm

Normal newborn head circumfrence

32-37 cm 12.5-14.5 in

Calories to pounds

3500 calories in 1 pound

Normal infant temperature

36.5-37.6

Normal HDL

40-50 for men 50-59 for women

Therapeutic range for aPTT

46-70 seconds for clients on heparin

Normal range of wet diapers

6-10/day or approximately 1 every 4 hours

Normal MAP

70-105

Refusing treatments for children

A competent adult has the right to make any decision regarding the client's healthcare even if the provider does not believe it is in the child's best interest. However, parents do not have the right to place their minor child in a life-threatening position. Parents cannot refuse life-saving treatment. If they do, the hospital has to seek court-appointed custody to treat this child, so it would be appropriate to notify hospital administration in this situation.

Funic souffle

A murmur heard over the uterus upon auscultation caused by blood flowing through the umbilical cord

Cerebral palsy

Abnormal muscle tone and lack of coordination with spasticity. Treated with skeletal muscle relaxants like baclofen and benzodiazepines to control spasticity and seizures

Pica

Abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, dirt, clay, and paper. Many women only have pica when they are pregnant and it is often accompanied by iron deficiency anemia due to insufficient intake or impaired iron absorption.

Asthma attack symptoms

Accessory muscle use Chest tightness Cough Diminished breath sounds related to hyperinflation High pitched expiratory wheezing (may be heard on both inspiration and expiration as asthma worsens) Tachypnea Prolonged expiratory phase as a physiologic response to hyperinflation and trapped air

Donepezil

Acetylcholinesterase inhibitor used in Alzheimer's - no known increased adverse effects in the elderly

Guillain-Barre Syndrome

Acute immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep-tendon reflexes. Many clients have a history of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening condition. Early signs: Inability to cough Shallow respirations Dyspnea and hypoxia Inability to lift the head or eye brows Assessing the clients pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation

Bell Palsy

Acute onset of unilateral facial paralysis related to inflammation of the facial nerve (cranial nerve VII) that may be triggered by a viral illness (herpes). Standard treatment includes corticosteroids within 72 hours of symptom onset

Toxic epidermal necrolysis

Acute skin disorder most commonly associated with adverse medication reactions in adults with widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion. greatest risk posed is sepsis Wound care, infection, prevention, fluids, and nutrition. Must apply ointment to eyes. Keep room warm to avoid hypothermia

Risk for pressure injuries

Advanced age: decreased skin moisture, increased skin fragility, dementia Impaired sensation: diabetes, neurovascular impairment, spinal cord injuries, surgery Nutritional deficits: anemia, decreased albumin and prealbumin levels, decreased intake or weight loss Perfusion/oxygenation deficits: norepinephrine infusion, hypoxia, vascular disease, unstable hemodynamics Skin moisture: dry skin or excessive moisture, incontinence, edema, fever/infection

Proteinuria

Albumin is smaller than most other proteins and is typically the first protein that is seen in the urine when kidney dysfunction begins to develop. Proteinuria is characterized by elevated urine protein and can be an early sign of kidney disease. Occasional loss of 150 mg/day of protein in the urine, which may reflect as negative or trace protein on the dipstick, is typically considered normal and usually does not require further evaluation. Common benign causes include fever, strenuous exercise, and prolonged standing

Azithromycin

All macrolide antibiotics (erythromycin, clarithromycin) can cause prolonged QT intervals, which may lead to sudden cardiac death due to torsades de pointes. Therefore, an ECG should be monitored. Concurrent use of macrolide antibiotics with other drugs that prolong QT interval (amiodarone, sotalol, haloperidol, ziprasidone, azole antifungals) will further increase this risk. Macrolides can also cause hepatotoxicity when taken in high doses or in combination with other hepatotoxic drugs such as acetaminophen, phenothiazines, and sulfonamides. Elevation of AST and ALT may indicate hepatotoxicity is occurring, and the nurse should report these results to the HCP.

Drawing blood from CVC

All medications except vasopressors must be paused before drawing blood from a CVC to prevent false interpretation of the client's serum levels. Nurse should scrub the hub for 10-15 seconds before flushing, drawing blood, or administering medication

Pap testing

Allows early testing of cervical dysplasia that may indicate cervical cancer HPV is one of the most common STIs and causes almost all cases of cervical cancer Before age 30, HPV infections are transient and resolve spontaneously. Pap testing is generally started at age 21, regardless of sexual history. Women age 21-29 should be screened with a pap test every 3 years. At age 30, HPV and pap testing may be done together every 5 years. Discontinue pap testing at age 65-70

A1C

Also called glycosylated hemoglobin. Should be <7%

Zolpidem

Ambien - hypnotic

Tobramycin

Aminoglycoside antibiotic used in CF patients with Pseudomonas lung infection

Oligohydramnios

Amniotic fluid is produced by the fetal kidney and prevents cord compression and promotes lung development. Oligohydramnios is a low amniotic fluid volume. This can occur due to fetal kidney anomalies or fluid leaking through the vagina (undiagnosed ruptured membranes). Fluid volume also declines gradually after 41 weeks. Small uterine size for gestational age or a fetal outline that is easily palpated through the abdomen should raise suspicious for oligohydramnios. Major complications: Pulmonary hypoplasia: due to lack of normal alveolar distension by aspirated amniotic fluid. Therefore, additional neonatal personnel should attend the birth in anticipation of possible resuscitation. Umbilical cord compressions: continuous (not intermittent) fetal monitoring should be applied to monitor for variable decelerations

Closing fontanelles

Anterior closes around 12-18 months Posterior closes around 2-3 months

Tetracycline

Antibiotic used for acne and other skin conditions Take on empty stomach Do not take with antacids or dairy products Take with full glass of water - can cause esophagitis and gastritis Severe sunburn can occur with use of tetracyclic - use sunblock Decreases effectiveness of oral contraceptives - use other techniques when using this drug

Phentolamine

Antidote drug used to treat norepinephrine extravasation

Flumazenil

Antidote for benzodiazepine overdose

Pre-surgery medications

Antiplatelet medications should be discontinued 5-7 days before surgery to decrease the risk for excessive bleeding Should not smoke 24 hours before surgery to help prevent oxygenation problems Ginkgo bilboa should not be taken before surgery because it increases bleeding NSAIDs should not be taken before surgery because they can increase bleeding

Olanzapine

Antipsychotic

Oseltamivir

Antiviral given to clients who are within 48-72 hours of the onset of flu symptoms. These meds can shorten the duration of the illness by a few days. Zanamivir is also given.

Sickle cell disease

Apparently immunosuppressed because their spleens have infarctions from the sickling episodes

Proper sterile glove application

Apply glove of dominant hand first, then use dominant hand to pull on the glove of the non-dominant hand

Hypothermia

As core temp decreases, the cold myocardium becomes extremely irritable and prone to dysrhythmias. The client should be handled gently as spontaneous ventricular fibrillation could develop when moved or touched. Therefore, placing the client on a cardiac monitor is a high priority the nurse should anticipate defibrillation in these clients.

Assault vs battery

Assault: an act that threatens the client to fear harm, but without client being touched Battery: making physical contact with the client without permission. This includes harmful acts or acts the client refuses (procedures).

Infants roll over

At 4 months - rolling off the diaper changing table would not be a plausible explanation for an infant younger than 4 months

Kidney disease

At risk for hyperkalemia and hyperphosphatemia due to lowered GFR.

ARBs and ACE inhibitors

Blackbox warning during pregnancy. pregnant women should take lebatalol or methyldopa instead

Cultures and antibiotics

Blood and urine cultures should be obtained prior to initiation of antibiotic therapy whenever possible to identify the causative microorganisms and determine the most effective antibiotics. Antibiotics should be given immediately after cultures are obtained

Jehovah's witness

Blood in any form is not acceptable - including whole blood, PRBCs, platelets, plasma, and white blood cells They can take albumin-free e-poietin alfa tho

Blood transfusion

Blood products should not be left at room temperature for more than 30 minutes before a transfusion is started. Leaving blood out at room temp for a prolonged period increases the likelihood of bacterial growth. If the start of the transfusion is delayed, the blood should be returned to the blood bank, where it can be refridgerated to the exact temperature

Albuterol

Bronchodilator beta adrenergic agonist. Expected side effects include tremor, tachycardia, and palpitation

Amlodipine

CCB

Sources of calcium and vitamin D

Calcium: milk, beans, dark green vegetables, and calcium-fortified cereals and juices Vitamin D: enhances absorption of calcium. Synthesized by skin with exposure to direct sunlight. Alternate sources include milk, fish oils, egg yolks, and vitamin D fortified foods

Cleft lip and palate

Can be caused by maternal anticonvulsant use (valproic acid)

MAOIs

Cannot be combined with SSRIs - may cause serotonin syndrome, neuroleptic malignant syndrome, or hypertensive crisis Examples of MAOIs: Selegiline

Caput succedaneum vs cephalhematoma

Caput is a soft spongy area on the scalp from prolonged pressure on the mother's cervix during labor. It crosses the suture line Cephalhematoma does not cross the suture line

CK-MB

Cardiospecific isoenzyme that is released in the presence of myocardial tissue injury. Elevations are highly indicative of an MI

Rheumatoid arthritis

Chronic, systemic, inflammatory, autoimmune condition of unknown origin that has periods of exacerbation and remission. The body's immune system attacks the lining of the joints, leading to bone erosion and joint deformity. Although there is no cure for the disease, early diagnosis and appropriate treatment can help limit localized joint destruction and systemic organ damage. Characteristics: Symmetrical pain and swelling that initially effects the small joints of hands and feet Morning joint stiffness that lasts from 60 minutes to several hours Elevated ESR and rheumatoid factor levels Asymmetrical pain in the weight bearing joints and crepitus is characteristic of osteoarthritis

Fluoroquinolones

Ciprofloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin Places patients at increases risk for tendinitis and tendon rupture that most often occur in the Achilles tendon. Cipro can cause photosensitivity

Loratadine

Claritin (Antihistamine) can help with allergies

Floppy muscle tone

Classic sign of Down syndrome

Meconium ileus

Classic sign of cystic fibrosis

Alzheimer Disease safety

Close supervisions Medical identification/location devices in case client wanders Keyed deadbolts Lowered water heater temperatures and cold and hot labels on faucets Safety hazards removed Grab bars in showers and tubs All meds should be out of the person's reach and locked away

Acceptable abbreviations

Cm (centimeters) II (stage 2) AC (before meals) PC (after meals) C/O (complaints of) QID (4 times a day) Do not use trailing zeroes after decimal points. The use of "u" for unit is not acceptable. 0 must precede a decimal point

Urinary retention

Considered >100 mL on residual bladder scan

Weight gain promotion

Diet high in protein and calories: Whole milk and dairy products, fruit smoothies Granola, muffins, biscuits Potatoes with sour cream and butter Meat, fish, eggs, dried beans, almond butter Pasta/rice dishes with cream sauce

Strabismus

Disorder involving misalignment of eyes caused by congenital defect or acquired weakness of an eye muscle. One eye may appear deviated inward or outward. When the visual axes are not in alignment, the brain perceives 2 images and suppresses the weaker image to compensate. If left untreated by age 4-6, permanent reduction or loss of visual acuity in the affected eye can occur. Initial treatments vary depending on the underlying cause. One common treatment is to strengthen the muscles of the weaker eye by wearing a patch over the stronger eye or using special corrective lenses. If nonsurgical methods are unsuccessful, surgical intervention to shorten or reposition the eye muscle for more effective movement may be required.

tPA

Dissolves clots and restores perfusion in clients with ischemic stroke. It must be administerd within a 3-4 1/2 hour window from onset of symptoms for full effectiveness. Contraindications: history of intracranial bleeding or actively bleeding. Surgery within last 2 weeks as tPA may disrupt surgical site. History of stroke or head trauma in last 3 months. Current anticoagulant use

Diplopia

Double vision

Medications contraindicated in pregnancy

Doxycycline - impairs bone mineralization in fetus Isotretinoin (Accutane) - severe birth defects ACE inhibitors - affect kidney development in fetus

Insulin rules

Draw up regular insulin first, then NPH in same syringe Do NOT mix glargine with any other insulin

Meningococcal meningitis

Droplet precautions continued for 24 hours after initiation of abx therapy NPO in somnolent clients to prevent aspiration Minimize stimuli Allow self position for comfort - most prefer to lie with head of bed slightly raised without a pillow or side-lying

Meds for diabetic neuropathy

Duloxetine, pregabalin, amitriptyline, gabapentin

Mucous plug

During pregnancy, a collection of secretions forms a mucous plug in the cervical canal, acting as a protective barrier. Although the client may notice expulsion of the mucous plug in the days preceding labor, it is not necessarily a sign of labor

Clinical features of hip fracture

Ecchymosis and tenderness over the thigh and hip - occur from bleeding into surrounding tissue as femur is very vascular Groin and hip pain with weight bearing Muscle spasm in the injured area - occurs as the muscles surrounding the fracture contract to try to protect and stabilize the injured area Shortening of the affected extremity - occurs because fracture can reduce the length of the bone and muscles above the fracture line and pull the extremity upward Abduction or adduction of the affected extremity depending on location and mechanism of injury Usually externally rotated

Microcephaly

Effect of fetal alcohol syndrome or cytomegalovirus

Colostomy

Ensure adequate fluid intake (3000 mL/day) to prevent dehydration; identify times to increased fluid requirements (hot weather, increased perspiration, diarrhea) Identify and eliminate foods that cause gas and odor (broccoli, cauliflower, dried beans, brussels sprouts) Empty the pouch when it becomes one-third full to prevent leaks due to increasing pouch weight Stool produced in the ascending and transverse colon is semiliquid, which eliminates the need for irrigation. Irrigation to promote a bowel regimen may be useful for descending or sigmoid colostomies as the stool is more formed

Ventricular bigeminy

Every other heartbeat has a PVC. In post-MI patients, this increases the risk for lethal dysrhythmias. This patient is a priority

Hearing impairment

Face client Get their attention first Post hearing impairment sign Speak in a normal volume into the least effected ear. Louder sounds create a higher pitch that is harder to understand

Contact HCP

Falls Deteriorates significantly or dies Has critical lab results Needs a prescription that requires clarification Leaves AMA or runs away Refuses key treatment in a relevant period Concerning assessment finding (significant change in vitals, unilateral drift, change in LOC, signs of trauma after fall)

Dependent personality disorder

Fear separation and tend to be indecisive and unable to take the initiative. Often preoccupied with the thought of being left to fend for themselves and want others to assume responsibility for all major decision making

Isoniazid

First-line antitubercualr drug prescribed as monotherapy to treat latent TB infection. Combined with other drugs, isoniazid is also used for active TB treatment. Two serious adverse effects of INH are hepatotoxicity and peripheral neuropathy Avoid intake of alcohol and limit use of hepatotoxic agents to reduce risk Take pyridoxine (vitamin B6) if prescribed to prevent neuropathy Avoid aluminum-containing antacids (aluminum hydroxide) within 1 hour of taking INH - decreases absorption Report changes in vision (blurred vision, vision loss) Report signs/symptoms of severe adverse effects such as scleral and skin jaundice, vomiting, dark urine, fatigue, numbness, tingling of extremities

Pregnancy diet

Foods containing folic acid, protein, whole grains, iron, and omega-3 fatty acidsa re important. Pregnant clients should avoid consuming unpasteurized milk produced, unwashed fruits and vegetables, deli meat and hot dogs (unless heated until steaming hot), and raw fish/meat. Should also avoid intake of fish high in mercury (shark, swordfish, king mackeral, tilefish). Liver should be avoided due to high intake of vitamin A that can be teratogenic.

Injection sites

For children <3 months use vastus lateralis

Foods rich in folic acid

Fortified grains (cereals, bread pasta) and green leafy vegetables

Rule of nines

Front torso: 18% Back torso: 18% Front leg: 9% Back leg: 9% Front arm: 4.5% Back arm: 4.5% Front head: 4.5% Back head: 4.5% Genitals: 1% Should go to burn center if partial-thickness burns >20% in adults and >10% in peds or older adults. Should go if full thickness burns >5%

Loop diuretics

Furosemide, torsemide, bumetanide Used to treat fluid retention, such as that found in clients with heart failure or cirrhosis. When administering loop diuretics, the nure can expect the client's kidneys to excrete a significant amount of water and potassium. When potassium is excreted at a fast rate, the client can develop hypokalemia resulting in arrhythmias, muscle cramps, and weakness Excess diuresis can cause hypotension and can affect the kidneys, causing BUN and creatinine levels to rise.

Neurological assessment

GCS Orientation Pupils Motor - strength and movement in all four extremities Vital signs - especially in signs of Cushing's triad - bradycardia, abnormal breathing, widening pulse pressure to assess for signs of increased ICP

Metabolic acidosis

GI bicarbonate losses (diarrhea) Ketoacidosis (diabetes, alcoholism, starvation) Lactic acidosis (sepsis, hypoperfusion) Renal failure (hemodialysis with inaccessible arteriovenous shunt) Salicylate toxicity. Acidosis damages cells causing them to release inctracellular contents. Hyperkalemia frequently occurs with acidosis Metabolic alkalosis: too much bicarbonate - may be due to vomiting and loss of stomach acid Respiratory alkalosis: too little CO2 - hyperventilation Respiratory acidosis: too much CO2 - hypoventilation

Opioid withdrawal

GI: nausea, vomiting, diarrhea, cramping, increased BS Cardiac: increased HR, BP, diaphoresis Psych: insomnia, yawning, dysphoric mood Other: myalgias, arthralgias, lacrimation, rhinorrhea, piloerection, mydriasis Management: methadone or buprenorphine. Non opioid: clonidine and antiemetics, antidiarrheals, benzos Symptoms are related to symphatetic activity as the depressant effect of the opioid wanes

Cholelithiasis

Gallstones. Priority with an actively vomiting client is to maintain NPO status and administer promethazine Other intervention include IV fluids and insertion of NG tube to low suction to decompress the stomach and alleviate nausea

Aminoglycoside antibiotics

Gentamicin, tobramycin, amikacin Cause ototoxicity and nephrotoxicity. Tinnitus and vertigo are early signs of ototoxicity. Nurse should assess for changes in client's hearing, balance, and urinary output

Herbal supplements that increase bleeding risk

Ginkgo biloba Garlic Ginseng Ginger Feverfew

Goodell, Chadwick, and Hegar signs

Goodell: Softening of cervix Chadwick: bluish discoloration of vaginal walls, cervix, and vulva Hegar: lower uterine segment Ballottement: sharp upward pushing against the uterine wall with a finger for diagnosing pregnancy by feeling the return impact of the displaced fetus

Antisocial personality disorder

Have a pattern of disregard and violation of the rights of others. They manipulate others for personal gain and lack empathy

Chronic kidney disease

Have high phosphorous levels as the kidney is unable to filter phosphate from the body; dialysis also does not filter it. Therefore, the client should take phosphate binders (calcium carbonate and calcium acetate) and non-calcium containing (sevelamer and lanthanum) to block absorption of ingested phosphate from the intestine and excrete it through the feces

Harsh systolic murmur

Heard in VSD

Thrombotic thrombocytopenic purpura

Hemolytic anemia with fragmentation of erythrocytes, signs of intravascular hemolysis, thrombocytopenia, decreased renal function, and fever. Regardless of the cause of low platelets, the concern is the critically low platelet count, which puts this client at risk for internal bleeding, especially within the brain. Change in LOC is the most clinically significant finding requiring an emergency response

Hepatitis transmission

Hep B and C can be transmitted through blood, semen, and vaginal secretions Hep A can be transmitted through the fecal-oral route via poor hand hygiene and improper food handling

Normal lab values for third trimester

Hgb: >11 HCT: >33% RBCs: 5.00-6.25 x 10^6 WBCs: 5000-15000 Platelets: 150,000-400,000

Salt substitutes

High in potassium. Should not be used by those on potassium-sparing diuretics or ACE inhibitors for risk of hyperkalemia

Antibiotic allergies

If a patient is allergic to penicillin, they are likely allergic to cephalosporins as well. You must find out more information about the specific reaction that the patient has to determine if you can safely administer an antibiotic.

Acute glomerulonephritis

Immune complex disease most commonly induced by prior group A beta-hemolytic streptococcal infection of the skin or throat. A latent period of 2-3 weeks occurs between the infection and the symptoms of AGN. They will have periorbital and facial/generalized edema, hypertension, and oliguria, primarily due to decreased kidney filtration. Urine is tea-colored and cloudy due to presence of protein and blood. Severe hypertension is anticipated and must be identified early. Can develop into kidney injury and development to hypertensive encephalopathy or pulmonary edema.

CD4 lymphocyte counts

Immunocompromised is considered: <750 in infants 12 months or younger <500 in children between 1-5 <200 in children >5 years and adults

Preventing UTIs

Increase fluid intake Wipe from front to back Avoid synthetic fabrics - use cotton Void after sex Avoid douching and using feminine perineal products Avoid spermicidal contraceptive jelly

Gastroduodenostomy

Involves removing the distal two-thirds of the stomach with anastomosis of the remaining stomach to the duodenum. Clients require education regarding dietary modifications to prevent complications. Small frequent meals consisting of low-carbohydrate, moderate protein and moderate-fat levels should be consumed without drinks to prevent occurrence of dumping syndrome. Clients may have an NG tube. Nurse should not attempt to manipulate or flush the device, as it may disrupt the surgical site causing hemorrhage or gastric perforation. Elevate HOB and encourage turn, cough, deep breathe

Phenelzine

MAOI - can cause hypertensive crisis

Creatinine clearance

Measure of glomerular function and a sensitive indicator of renal disease progression. Requires a 24-hour urine collection. Blood is drawn to measure serum creatinine level in addition to urine creatinine.

C diff

Metronidazole is first line drug for C diff. For severe C diff, oral vancomycin can be used, but IV is ineffective

Indicators of fluid loss or gain

Most accurate in the acutely ill is weight. I & O can be inaccurate because assessment of insensible losses is difficult. A 1 kg weight gain is equal to 1,000 mL of retained fluid

Guaifenesin

Mucinex. Helps thin mucus and facilitate mobilization

Guaifenesin

Mucinex. Increases respiratory fluids and thins secretions to facilitate mobilization and expectoration. Appropriate to prescribe to clients who have pneumonia with productive cough and low-pitched wheezing

Blood cultures

Must be taken before starting antibiotics. Drawing a culture from an IV site is not recommended

Potassium chloride infusions

No greater than 10 mEq/hr in PIV No greater than 40 mEq/hr in central IV

PAWP

Normal value6-12. If elevated, indicates pulmonary congestion and increased left ventricular preload

Colorectal cancer

Occurs most often in adults over age 50. Risk factors include history of colon polyps, family history of colon cancer, IBS (Chron disease, ulcerative colitis); and a history of other cancers (gastric, ovarian). Symptoms: Blood in stool from fragile, bleeding polyps or tumors Abdominal discomfort and/or mass (not common) Anemia due to intestinal bleeding, which may result in fatigue and dyspnea with exertion Change in bowel habits Unexplained weight loss due to impaired nutrition from altered intestinal absorption

Respiratory syncytial virus

Oxygen saturation of >90% is the goal for bronchioloitis caused by syncytial virus

Acute asthma attacks

Oxygen to maintain saturation >90% High dose short acting beta agonist (albuterol) AND anticholinergic agent (ipratropium) every 20 minutes Systemic corticosteroids (Solu-medrol)

Uterotonic medications

Oxytocin Methylergonovine Carboprost Misoprostol

Trisomy 13

Patau syndrome - also results in early death

Systolic ejection murmur

Pulmonic stenosis in children Aortic stenosis in adults

Suctioning airway

Should be set at medium pressure (100-120 mmHg and 50-75 mmHg for children)

Separation anxiety

Starts around 6 months, peaks at 10-18 months, and can least until 3 years

Silent chest

Sudden decrease in wheezing after an asthma attack that may be due to airflow being rapidly reduced due to increased bronchial constriction. This scenario can quickly progress to status asthmaticus, respiratory failure, unconsciousness, and death

MMR vaccine

Supposed to be administered between 12-15 months to ensure optimal vaccine response. However, vaccine is safe for children <12 months; it could provide some protection or modify the clinical course if administered within 72 hours of the child's measles exposure. Clinical indicators of measles would be seen after 7-21 days from exposure

Desmopressin

Synthetic ADH used during diabetes insipidus to lower urine output

Tocolytic drugs

Terbutaine, magnesium sulfate, indomethacin, nifedipine Given to slow contractions during PTL

Post op tracheostomy

The immediate priority goal for a client with a new tracheostomy is to prevent accidental dislodgement and loss of the airway. If dislodgement occurs during the first post-op week, reinsertion of the tube is difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical emergency. The priority nursing action is to ensure the tube is placed securely by checking the tightness of the ties and allowing for 1 finger to fit under these ties. Changing the inner cannula and ties is usually performed 24 hours after insertion due to the risk of dislodgement with an immature tract. However, the dressing can be changed if it becomes wet or soiled. Suctioning can be performed to remove mucus and maintain and airway

Tinnitus side effect

Tinnitus is commonly associated with toxicity related to salicylate-containing NSAIDs (aspirin) or aminoglycosides (gentamicin, neomycin, tobramycin). Onset should be reported and medication may need to be discontinued to prevent permanent hearing loss

True vs false labor

True: contractions at regular intervals; frequency, duration, and intensity increase over time. Discomfort begins in lower back, radiates to abdomen. Contractions increase despite comfort measures. Increase in cervical dilation and effacement False: contractions at irregular intervals, no increase in frequency, duration, or intensity; may dissipate over time. Discomfort is located in lower abdomen and groin. Contraction may lessen or dissipate with comfort measures. No cervical change. Braxton Hicks contractions are irregular contractions that occur throughout pregnancy and they do not result in cervical change. Although mild, they can be increasingly painful and regular for short periods during the last weeks before birth. They will typically lessen with comfort measures.

Leopold maneuvers

Used as a systematic approach to determining fetal position by palpating the abdomen

Hepatitis A, B, C

Vaccines for A and B Hep A is transmitted mostly through the fecal-oral route

Contraindication to venipuncture

Weakness Paralysis Infection AV fistula or graft Impaired lymphatic drainage (prior mastectomy)

Conscious sedation

When there is new onset of restlessness/agitation, the nurse should first think about oxygenation (or blood glucose). Change in LOC (restlessness/agitation or lethargy/sedation) can be an indication of excess medication and should be assessed before administering additional drugs. The desired level of sedation is level 3 on the Ramsay sedation scale, during which the client is drowsy but responds to a voice command.

Latex allergy

Will usually have a cross-allergy to bananas, kiwis, avocadoes, tomatoes, peaches, and grapes. Contact dermatitis and anaphylaxis are signs of allergic reaction

Normal calcium

8.5-10.5

Immunosuppressive meds

Cyclosporine Mycophenolate

Jaundice

Often causes intense itching that can be exacerbated by hot water and strong soaps. Should use cool water and mild soap

Potassium-sparing diuretics

Spironolactone Triamterine Amiloride

mL to ounces

1 oz = 30 mL

Ounces to pounds

1 pound = 16 ounces

Normal fetal heart tones

110-160 bpm

Developmental stages for preschool

3: walks upstairs with alternating feet, pedals a tricycle, jumps forward, draws a circle, feeds self without help, grips a crayon with fingers instead of fist, 3 or 4 word sentences, asks why questions, states own age, begins associative play, toilet trained except for wiping 4: walks down stairs with alternating feet, balances on 1 foot, catches a ball, draws a square, cuts with scissors, ties a simple knot, names 2+ colors, likes telling stories, begins imaginative/group play, recognizes analogies, often focused on self 5: skips, walks backward, uses a jump rope, draws a triangle, ties shoe laces, prints letters, numbers or words, counts to 10, speaks full sentences, names coins and days of week, independently dresses and bathes, identifies real from pretend

Normal serum calcium

8.6-10.2

Myasthenia gravis

Ai

Meds held prior to dialysis

Anithypertensives are held to prevent hypotension Some meds are dialyzed out of the client's system and should therefore be held until after dialysis. These include water-soluble vitamins (B and C), antibiotics, and digoxin

Signs of increased intracranial pressure

Change in LOC Projectile vomiting Ataxia Ipsilateral pupil dilation Seizures

Dextran in saline solution

Colloid used to expand intravascular volume in clients with hypovolemia

Circumcision care

Common complications include hemorrhage, infection, and voiding difficulty. Clean area with warm water (no soap) to remove urine and feces. Do not use alcohol wipes. Immediatley after, the glans penis will appear dark red and after 24 hours, will be covered with yellow exudate. Parents should not try to wipe or forcefully remove the exudate that will persist for 2-3 days. Diapers should be changed when soiled and at least every 4 hours to keep the area clean and assess for evidence of infection or bleeding. Petroleum gauze or ointment should be applied at every diaper change to prevent sticking. Diaper should be secured looseley

Signs of increased ICP

Cushing's triad: hypertension, bradycardia, irregular respirations Ipsilateral pupil dilation, headache, vomiting

Hydrochloroquine

DMARD that can cause retinal damage - eye exams required every 6 months

Diabetes insipidus

Damage to hypothalamus or pituitary gland leads to decreased ADH secretion, resulting in increased serum osmolality and decreased urine osmolality. Treatment is necessary, but polyuria and hypernatremia are expected manifestations

Common asthma triggers

Dander, dust mites, pollen, beta blockers, NSAIDs, aspirin, chemicals, sawdust, soaps/detergents, upper respiratory infections, emotional stress, GERD, perfumes, cigarette smoke, dry/polluted air. Activity does not need to be avoided all together. Athletes should take a bronchodilator 20 minutes before activity

GI bleed

Do not give red popsicles or anything red to clients with recent GI bleeding because if the patient vomits, the vomit may appear red and falsely lead the nurse to believe that the patient is bleeding

Organ donation

Does not leave obvious evidence on the client's body when the body is dressed. Special precautions and techniques are used to maintain integrity and outward appearance of the body. Consent is not needed from the family if the client is already a registered organ donor

Eosinophils

Elevated with allergies

Serotonin syndrome

Excessive serotonin. May cause anxiety, agitation, disorientation, shivering, diarrhea, muscle rigidity, fever, seizures, mydriasis (dilated pupils), autonomic instability and hypertension, clonus, tremor, hyperreflexia, tachycardia, agitation, diaphoresis, warm moist skin, and fever Can be triggerd by SSRIs, MAOIs, dextromorphan, ondansetron, St. John's Wort, and tramadol

Trousseau's sign

Indicates hypocalcemia. Carpal flexion during blood pressure inflation. Can occur after thyroidectomy as the parathyroid can be inadvertently removed during the surgery. Hypocalcemia can cause tetany, seizures, laryngeal stridor, and cardiac dysrhythmias.

Neonatal resuscitation interventions

Initiated in 30-second intervals. Begins with clearing airway, stimulating the newborn, and placing them in sniffing position. If HR remains below 100, begin positive pressure ventilation. If HR remains below 60 after 30 seconds of PPV, begin chest compressions and medication interventions (epinephrine)

Emergency contraception

Levonorgestrel (Plan B) should be taken within 5 days of intercourse, but efficacy is reduced after 3 days Copper IUD can be inserted for up to 5 days after intercourse as another form of EC P.S. Backup contraception is required for 7 days after starting oral contraceptives unless the pill pack is started on the first day of menses

Labs in liver dysfunction

Low serum albumin - normal 3.5-5.0 High serum ammonia - normal 15-45 Elevated INR/prolonged PT - normal INR 0.75-1.25; normal PT 11-16 sec Increased bilirubin level - normal 0.2-1.2 Low platelets - normal 100,000-400,000

COPD

May develop polycythemia due to chronic alveolar hypoxia which stimulates erythropoiesis. HCT >53% in males, >46% in females; hemoglobin >17.5 in males and >16 in females

Celecoxib

NSAID - COX-2 inhibitor Clients are directed to stop taking NSAIDs 7 days before surgery to decrease the risk for intra- and postoperative bleeding

Autism spectrum disorder

Need a calming environment with minimal stimulation. A private room away from the nurses station would be best. Use quiet voice, use eye contact and gestures carefully, move slowly, limit visual clutter, maintain minimal lighting, provide child with a single object to focus on

New grad RN assignment

New grad RN should be given RN-level responsibilities caring for stable clients who do not require specialized knowledge and performing skills taught in nursing school Providing teaching for common medications is within the skill and knowledge set of a new grad RN Appropriate clients include those being discharged or requiring new teaching

Isosorbide

Nitrate commonly used with hydralazine in African American clients with heart failure - decreases cardiac workload by reducing preload and afterload

Hypomagnesemia

Normal: 1.5-2.5 Assocaited with alcohl abuse due to poor absorption, inadequate nutritional intake, and increased losses via the GI and renal systems. Associated with: Ventricular arrhythmias (Torsades de pointes) Neuromuscular excitability: similar to those found in hypocalcemia include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures

AED

One pad below right collarbone and one pad a few inches below the left armpit. Move clients out of large bodies of water Dry the chest area Remove transdermal patches and wipe the chest of medication residue before applying AED pads Small puddles are OK and the whole body does not need to be completely dry (just under the pads and on the chest) and AED should never be placed over a medication patch

Riluzole

Only medication approved for ALS treatment Glutamate antagonist that may slow neuron degeneration by decreasing the production and activity of glutamate in the brain and spinal cord. May slow disease progression and prolong survival 3-6 months.

5 P's of neurovascular assessment

Paresthesia (pins and needles), pain, pallor, paralysis, and pulselessness

BNP

Peptide that causes natriuresis. BNPs are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles due to increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure. Elevation of BNP >100 helps to distinguish cardiac from respiratory causes of dyspnea

Radiofrequency ablation

Performed through transvenous cardiac catheterization to ablate (burn) electrical pathways causing supraventricular or ventricular tachydysrhythmias. Ablation performed near the AV node can damage conduction, causing varying degrees of AV block

Contraindications to thrombolytics

Prior intracranial hemorrhage Structural cerebrovascular lesion Ischemic stroke within 3 months Suspected aortic dissection Active bleeding or bleeding diathesis Significant head trauma

Insulin peaks

Regular: 2-5 hours Rapid-acting: 30 min-3 hours NPH: 4 hours Detemir: 4-9 hours Glargine: no peak - constant

Ovarian cancer

Results in more deaths than any other gynecological cancer. Symptoms are often subtle and may include abdominal bloating, pelvic pain or pressure, abdominal girth increase, early satiety, abdominal, back or leg pain, urinary frequency, and GI disturbances

Pasero opioid induced sedation scale

S - sleeping, easy to arouse: no action necessary 1 - awake and alert: no action necessary, may increase sedation 2 - slightly drowsy but easy to arouse: acceptable, no action necessary 3 - falls asleep during conversation: unacceptable, monitor respiratory status, notify HCP to decrease sedation by 25-50% 4 - somnolent, minimal or no response to verbal and physical stimuli: stop sedation, consider using naloxone, notify HCP, monitor respiratory status

Chlorpheniramine

Sedating antihistamine used to treat allergy symptoms. Increased CNS effects (drowsiness, dizziness) may occur due to reduced clearance in elderly

Carbamazepine

Seizure medication highly effective for neuropathic pain. Associated with agranulocytosis and infection risk

Lithium interactions

Several medications may increase lithium levels These include thiazide diuretics, NSAIDs, and antidepressants Thiazide diuretics have the greatest potential

Narrow pulse pressure

Sign of hypovolemia. Means that the systolic and diastolic are too close together. Usually caused by low stroke volume of left ventricle, aortic valve stenosis, or cardiac tamponade.

Acanthosis nigricans

Skin condition that occurs with obesity and diabetes - appears as velvet-like patches of darkened, thick skin around the back of neck and in the groin and armpits

Epstein pearls

Small, white cysts found on the hard palate of newborns. Considered a common finding and disappear after a few weeks

Schizoid personality disorder

Social detachment and an inability to express emotion. They do not enjoy close relationships and prefer to be aloof and isolated

Shock continuum

Staged in severity from initial to irreversible. During the initial stage, there is inadequate oxygen to supply the demand at the cellular level and anaerobic metabolism develops. At this point, there may be no recognizable signs or symptoms. As shock progresses to the compensatory stage, sympathetic compensatory mechanisms are activated to maintain homeostasis (oxygenation, cardiac output) Cold, clammy skin indicates failing compensatory mechanisms (progressive stage) and immediate intervention is necessary to prevent irreversible shock and death

Meds that affect liver enzymes

Statins and isoniazid for TB

Naegele's rule

Subtract 3 months and then add 7 days to the first day of the woman's last menstrual period

Otitis externa

Swimmers ear Damage from foreign body may also cause OE. NOT the same as OM, which risk factors for are tobacco smoke, regular pacifier use, drinking from a bottle while laying down, and lack of immunizations (pneumococcal)

Puberty in boys

Testicular enlargement including scrotal changes is the first manifestation of puberty and sexual maturation. This typically occurs age 9 1/2 to 14. It is followed by the appearance of pubic, axillary, facial, and body hair. The penis increases in size and the voice changes. Some boys also experience increase in breast size. Growth spurt changes of increased height and weight may not be apparent until mid-puberty

Discontinuing CVC

To prevent air embolism, instruct patient to lie in supine position. Instruct them to bear down or exhale. Apply an air-occlusive dressing to prevent delayed air embolism.

Tooth avulsion

Tooth falling out. There is limited time (<1 hour, longer if placed in cold milk) until death of the tooth.

Causes of low pressure ventilator alarm

Tubing disconnect or leak ET or tracheostomy tube cuff link Loss of airway (total or partial extubation or decannulation)

Splinter in eye

Use an eye shield on the injured eye and patch the un-injured eye to be sure that the eyes do not move. Flushing the eye is contraindicated as it may cause further damage by moving the splinter and/or introducing potential wound pathogens

Rolling over

Usually occurs at 4 months

Signs of SBS

Vomiting, irritability, lethargy, inability to suck or eat, seizures and inconsolable crying. Usually not external signs of trauma except occasional small bruises on chest and arms

Acute pancreatitis

Acute inflammation of the pancreas with associated escape of pancreatic enzymes into surrounding tissues. Maintain NPO status and maintain hydration with IV fluids Administer parenteral nutrition for severe nutritional depletion Maintain NG tube to decrease gastric distension and suppress pancreatic secretion Administer opiates for pain Administer antacids as prescribed to neutralize gastric secretions Anticholinergics can decrease vagal stimulation, decrease GI motility, and inhibit pancreatic enzyme secretion Avoid alcohol Maintain positions that flex the trunk and draw knees up to the abdomen to decrease tension in the abdomen Side-lying position with HOB 45 degrees Can develop respiratory complications including pleural effusions, atelectasis, and acute ARDS. These complications are due to activated pancreatic enzymes and cytokines that are released from the pancreas into the circulation and cause focal or systemic inflammation. ARDS is the most severe form of these complications can rapidly progress to respiratory failure within a few hours. Can also develop hypovolemia from third spacing and hypocalcemia from necrosed fat binding to calcium

Normal albumin

3.5 - 5.0

Short acting beta 2 agonists

Albuterol. Causes immediate bronchodilation. Adverse effects: tremor, tachycardia, palpitations, restlessness, hypokalemia. These side effects can be reduced with a spacer or chamber device because they are mostly derived by oral deposition of the medications

Biphosphonates

Alendronate, risendronate, ibandronate, zoledronic Used for treatment in osteoporosis by decreasing bone resorption so loss of bone density is minimized. Medication should be taken on an empty stomach with a full glass of water, with at least 30 min before other drugs. Client must remain upright for at least 30 min to aid absorption and prevent esophageal irritation Can cause jaw necrosis

Rifapentine

Anti-tubercular agent used with other drugs as a combination therapy in active and latent TB infections. It reduces the efficacy of oral contraceptives. Should be taken with meals for best absorption and to prevent stomach upset. Hepatotoxicity may occur; therefore, liver function tests are required at least every month. Signs and symptoms of hepatitis include jaundice of the eyes and skin, fatigue, weakness, nausea, and anorexia. May cause red-orange-colored body secretions, which is an expected finding. Dentures and contact lenses may be permanently stained

Ear irrigation

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

If a client falls

Assess for pulse Check for injuries Get help and move client to bed Notify HCP Incident report

Bupropion

Atypical antidepressant used to treat depressive disorder, including major depressive disorder, seasonal affective disorder, and persistent depressive disorder. Preparations of bupropion include immediate release, sustained release, and extended release. Seizures are of particular concern if a client takes a high or toxic dose of bupropion. Limit alcohol; inform HCP if you are used to consuming large amounts of alcohol Do not double up on medication if a scheduled dose is missed Take the med at the same time each day It may take several weeks to feel the effects of bupropion Weight loss may occur when taking this medication Also used for smoking cessation. Can cause serious neuropsychiatric effects like depression and suicide

Aripiprazole

Atypical antipsychotic that can be used in dementia patients experiencing agitation and hallcucinations

Beta blockers

Can cause bronchoconstriction and may be contraindicated in those with respiratory diseases

Kussmaul respirations

Characterized by regular but rapid deep respirations and is associated with conditions that cause metabolic acidosis Ketones Uremia Sepsis Salicylates Methanol Aldehydes (U) Lactic acidosis

Hypertensive encephalopathy

Characterized by severe HTN and symptoms of increased ICP (nausea, vomiting, headache), visual disturbances, altered mental status, and seizures. When BP is increased significantly, blood vessels are injuried, resulting in increased capillary permeability and intracranial HTN. Untreated carries a high mortality due to risk of acute MI, stroke, and kidney injury

1 hour oral glucose screen

Considered abnormal if >140

Group A streptococcus

Contagious bacterial throat infection that can lead to renal (glomerulonephritis) or cardiac complications (rheumatic fever) if not treated. Children may refuse to eat due to pain. A soft diet and cool liquids should be offered rather than solid foods. It is important to complete the full course of antibiotics. Toothbrushes should be replaced 24 hours after starting antibiotics. Children can return to school after 24 hours as well. Acetaminophen or ibuprofen should be given for pain

Parkland Formula

First 24 hours of fluid = 4 mL x %BSA x weight (kg) Give half of this number in first 8 hours and the other half in the next 16 hours Crystalloid solution (LR) commonly used

Possible C-spine injury

First assess client for adequate breathing and the presence of a pulse. Using a rigid cervical collar, C-spine immobilization must be maintained throughout the client assessment to minimize further injury. Client should be removed and placed on a backboard after the C spine has been stabilized. Nurse should also perform GCS scoring to determine the level of neurological impairment. Use the jaw thrust technique to open the airway, not the head-tilt/chin lift maneuver.

Unclogging an NG tube

First attempt to unclog by using a large-barrel syringe to flush and aspirate warm water in a back and forth motion. If this does not work, you can attempt to use a digestive enzyme solution that must dwell in the tube for 30 min to an hour before flushing and aspiration are attempted again.

Normal HCT

Hemoglobin x 3 39.6-51.9% in males 35.1-46.5% in females

Pyelonephritis

Inflammation of the kidney parenchyma causes flank pain that is experienced in the back and may spread to the umbilicus. Presence of nausea, vomiting, chills, fever, and lower UTI symptoms (dysuria, frequency, urgency) indicate pyelonephritis Renal colic pain is different, and it is excruciating, sharp, and stabbing. It will radiate to the groin area as the stone travels down the ureter

Prostatitis

Inflammation of the prostate gland, usually caused by bacterial infection. Symptoms include rectogenital pain, burning, urinary hesitancy, and/or urinary urgency. Management of prostatitis includes antimicrobial and anti-inflammatory medciations (ibuprofen). Alpha-adrenergic blockers (tamsulosin, alfuzosin) halp relax the bladder and prostate. Suprapubic catheterization may be necessary for urinary retention in severe cases of acute prostatitis. Urethral catheterization is contraindicated due to the risk of exacerbating pain and urethral inflammation Hydrate with clear liquids. Avoid coffee, tea, and other caffeinated beverages due to diuretic and stimulant properties, which may worsen symptoms Complete the full course of antibiotics Engage in sex or masturbation to reduce discomfort related to retained prostatic fluid. Use condoms so you do not transmit the causative organism Take stool softeners as prescribed to reduce straining during defecation - tension of the pubic muscles presses against the prostate, causing pain Take sitz baths, in which the hips and buttocks are immersed in warm water to relieve symptoms

Oral mucositis

Inflammation or ulceration of the oral mucosa, results from chemotherapy or radiation therapy. Oral hygiene practices that minimize oral mucositis and promote comfort include the following: Cleansing the mouth with normal saline after meals and at bedtime to promote oral health Use of a soft bristle toothbrush to decrease gum irritation Application of prescribed viscous lidocaine to alleviate oral pain Use of water soluble lubricating agents to moisten mouth tissues Avoidance of hot liquids and spicy/acidic foods Should avoid antiseptic mouthwashes with alcohol Administration of palifermin prevents oral mucositis clients diagnosed with hematoligic malignancies

Tracheostomy

Inflated cuff is used in clients who are at risk for aspiration (unconscious or mechanical ventilation). However, an inflated cuff is uncomfortable for clients who are awake because it is difficult to swallow or talk. The cuff is deflated when the client is improving, is determined to not be at risk for aspiration, and is awake. Before the cuff is deflated, the client is asked to cough to expectorate the oropharyngeal secretions that have built up above the inflated cuff. In addition, suction is applied through the tracheostomy tube and then the mouth; the cuff is then deflated. Additional interventions to decrease the risk of aspiration include the following: Having the client sit upright with the chin flexed slightly toward the chest Monitoring for wet or garbled-sounding voice Monitoring for signs of fever

TNF inhibitors

Infliximab, adalimumab, etanercept Suppress the inflammatory response in autoimmune diseases such as RA, Chron's and psoriasis. A client with current, recent, or chronic infection should not take a TNF inhibitor. Immunosuppresive action of TNF inhibitors can activate latent TB. Clients with RA can use NSAIDs in conjunction with TNF therapy to effectively treat pain and minimize inflammation

Cholestyramine

May be prescribed to increase the excretion of bile salts in feces, thereby decreasing pruritus. It is packaged in powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be given 1 hour after all meds

Hypovolemic shock

May occur after abdominal trauma or surgery as mesenteric edema resolves and previously compressed sites of bleeding reopen

Hydatiform mole

Molar pregnancy. The fetus is replaced by edematous, cystic chorionic villi. Clients experiencing molar pregnancy should anticipate intermittent, dark brown vaginal discharge until the pregnancy is evacuated

Pregnancy and NSAIDs

NSAIDs are category C in first and second trimesters and category D in third trimester. They must be avoided in the third trimester because they risk causing premature closure of the ductus arteriosus in the fetus. In first and second trimester, NSAIDs should only be taken if benefits outweigh the risks. Acetaminophen is a category B and a better alternative. However, intake should not exceed 4 grams a day.

Reye syndrome

Occurs when children take aspirin. They can get encephalopathy/cerebral edema and acute fatty liver failure. Manifests as lethargy, fever, acute encephalopathy and altered hepatic function. Elevated serum levels of ammonia are an expected lab finding. Encephalopathy manifests with vomiting and a severely altered LOC; it can rapidly progress to seizures and coma. The risk of developing Reye syndrome is higher if aspirin therapy is used to treat fever associated with varicella or influenza

Nitroprusside

Potent vasodilator used for hypertensive emergencies (aortic dissection, acute hypertensive heart failure). Causes both venous and arterial dilation, which reduces preload and afterload. Begins to act within 1 minute and can produce a sudden or drastic drop in blood pressure if not monitored properly. Should be monitored every 5-10 minutes. Metabolizes to cyanide, and clients with renal disease can occasionally develop cyanide toxicity.

Sumatriptan

Prescribed for moderate to severe, acute migraine headaches that are characterized by severe, pulsatile, throbbing unilateral head pain with or without auras, phototobia, nausea, and vomiting

Metoclopramide

Prescribed for treatment of delayed gastric emptying, GERD, and an antiemetic. It is associated with extrapyramidal effects, including tardive dyskinesia. This is especially common in older adults with long-term use. Symptoms of TD: Protruding, twisting of tongue Lip smacking Chewing movements Frowning or blinking eyes Twisting fingers Twisted or rotated neck (torticollis) Other side effects: sedation, fatigue, restlessness, headache, sleeplessness, dry mouth, constipation, and diarrhea

PICCcare

Prior to central line dressing change, the nurse performs hand hygiene. Central line dressing change is performed using sterile technique with th enurse wearing a mask to prevent contamination of the site with microorganisms or respiratory secretions. During injection cap and tubing changes, the client is instructed to hold the breath to prevent air from entering the line, traveling to the heart, and forming an air embolism. Client should turn head away from the site during dressing change to prevent potential contamination.

Mitral valve regurgitation

Result of disrupted papillary muscles or ruptured chordae tendinae, allowing a backflow of blood from the left ventricle through the mitral valve into the left atrium. This backflow can lead to dilation of the left atrium, reduced cardiac output, and pulmonary edema. Clients are instructed to report any new symptoms inidicative of heart failure (dyspnea, orthopnea, weight gain, fatigue).

Peritonsillar abscess

Serious complication that can result from tonsillitis or pharyngitis. Presenting features include fever, hot potato (muffled) voice, trismus (inability to open mouth), and deviation of uvula to one side. The abscess can progress to life-threatening airway obstruction and this client should be a priority

Cardioversion

Used in clients with tachydysrhythmias (ventricular tachycardia with a pulse, SVT, or atrial fibrillation with a rapid ventricular response) who have been unresponsive to medications or are hemodynamically unstable

Normal creatinine level

0.6-1.3 Elevated creatinine increases risk for intra- and post-operative complications. NPO status, dehydration, intraoperative fluid therapy, and advanced age affect renal function and increase the risk for post-op exacerbation of the kidney

Normal FHR

120-160

Skin cancer

ABCDE Asymmetry Border irregularity (edges are notched) Color changes and variation (different brown or black pigmentation) Diameter of 6 mm or larger (pencil eraser) Evolving (appearance is changing in shape, size, color) Will not blanch

Signs of lithium toxicity

Acute: GI - nausea, vomiting, diarrhea, neurological findings occur later Chronic: neurologic - ataxia, sluggishness, confusion, agitation, neuromuscular excitability (coarse tremor), and diabetes insipidus

Protamine sulfate

Antidote for heparin - usually not used because heparin has a short half-life and the dose can usually just be adjusted or held instead of administering an antidote when aPTT is too high

RA treatment

Apply moist heat to stiff joints and ice packs to painful joints Daily ROM exercises Sleep in flat, neutral position Frequent rest periods between activity

Clinical features of PAD

Atherosclerosis risk factors (diabetes, hyperlipidemia, hypertension, smoking, age >70) Asymptomatic in 50% Weak or absent peripheral pulses Bruits on auscultation Poor wound healing from impaired perfusion Cool, pallid skin; prolonged capillary refill Shiny atrophied skin with missing hair, ungual dystrophy Common clinical patterns: ischemic muscle pain with activity, alleviated with rest and erectile dysfunction Failure of pinprick testing indicated peripheral neuropathy likely from undiagnosed diabetes, which can lead to PAD

Clozapine

Atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis and is therefore only used in clients with treatment-resistant schizophrenia. Clients must have a WBC count of >3500 before starting clozapine Other potential adverse effects: weight gain, hyperglycemia, and dyslipidemia

African American skin assessment

Best places to look for Petechiae: buccal mucosa and conjunctivae of the eyes Cyanosis: nail beds of fingers and toes Jaundice: palms of hands and soles of feet

Diltiazem

Calcium channel blocker Unlikely to convert a fib to sinus rhythm, but will lower the rate

Foods rich in vitamin C

Citrus fruits, potatoes, tomatoes, green vegetables

Rotavirus

Contagious virus and the leading cause of diarrhea in children less than 5 years old. It is also the cause of many nosocomial infections each year. Rotavirus is spread via the fecal-oral route. Transmission can occur through contact with food, toys, diapers, and hands. Meticulous hand washing and proper diaper disposal prevent the spread of the virus. Symptoms include foul-smelling watery diarrhea that lasts 5-7 days and is often accompanied by fever and vomiting. Vaccine is available, but vaccinated children can still acquire strains not covered by the vaccine. Antibiotics are not effective against this viral agent. Because the virus can easily lead to dehydration, parents should be taught the symptoms (lack of tears when crying, extremely fussy or sleepy, decreased urination, dry mucous membranes. Oral rehydration solutions should be used to combat dehydration Breastfeeding and normal diet should be maintained Parents should change the child's diapers more frequently and wash the perianal area with mild soap and water. Commerical baby wipes containing alcohol should not be used as they are irritating. Protective zinc oxide can be applied instead

Ptosis in newborns

Drooping of the eyelid below the level of the pupil could indicate paralysis of the oculomotor nerve.

Trisomy 18

Edward's Syndrome. Chromosome anomaly characterized by severe cardiac defects and multiple musculoskeletal deformities. Life expentancy is typically a few weeks. A discussion of end-of-life choices would be appropriate in this situation as the neonate is already experiencing respiratory difficulty. A palliative care team will be an asset to the discussion. There is not cure or treatment.

Lymphocytes

Elevated with viral infections and hematologic malignancies

Circumstances in which minors can provide their own consent

Emancipated minor: homeless, parent, married, military service, financially independent, high school graduate Medically emancipated minor: emergency care, STI, substance abuse, pregnancy care, contraception

Normal infant HR and RR

HR: 100-160 RR: 30-60

Thumb sucking and teeth

If thumb sucking stops before the permanent teeth begin to erupt, misalignment of the teeth and malocclusion can be avoided.

Percutaneous coronary intervention

Improves coronary artery patency and increases cardiac perfusion Potential complications: thrombosis, stent occlusion, bleeding/hematoma, and limb ischemia. Nurse should immediately identify the HCP of post-procedure angina, which indicates possible thrombosis or stent occlusion, necessary prescriptions (NTG, second PCI) should be obtained and promptly intiated

Risk factors for cervical cancer

Infection with HPV History of STIs Early onset of sexual activity Multiple or high-risk sexual partners Immunosuppression (corticosteroids) Oral contraceptive use Low socioeconomic status Tobacco use Cervical cancer is usually asymptomatic in the early stages, but can present as irregular, painless vaginal bleeding

INR and antibiotics

Intestinal bacteria produce vitamin K; most antibiotics kill these bacteria, leading to vitamin K deficiency. Warfarin is a vitamin K antagonist; therefore, INR would overshoot in the setting of vitamin K deficiency, placing the client at risk for bleeding

Trismus

Lockjaw May indicate a more serious complication of tonsillitis, a peritonsillar abscess or retropharyngeal abscess. Other features of these include hot potato muffled voice, pooling of saliva, and deviation of the uvula to one side. Abscesses can occlude the airway, making it a medical emergency. Surgical intervention is often required

Salmeterol

Long-acting beta agonist administered with inhaled corticosteroid for long-term control of moderate to severe asthma; not used as a rescue drug

Bladder cancer risk factors

Main symptom is painless hematuria. Primary cause of bladder cancer is tobacco use. Carcinogen exposure is the second most common risk factor. Also high-fat diet and use of artificial sweeteners

Foods high in iron

Meats Shellfish Eggs Green leafy vegetables Broccoli Dried fruits Dried beans Brown rice Oatmeal

Non-selective beta blockers

Propanolol, nadolol Can have beta 2 blocking effect so they should not be used in clients with asthma

COPD with hypercapneic

Put on BiPAP machine and administer nebulizer treatment. Do not raise oxygen because they will retain more CO2.

Ankle-brachial index

Ratio of the blood pressure in the upper arm. Lower blood pressure in the leg suggests blocked arteries due to PAD

Nonstress test

Reactive: baseline of 110-160/min with moderate variability and >2 accelerations in 20 minutes, each peaking >15/min above baseline and lasting >15 seconds Nonreactive: does not meet criteria for reactivity

Flu vaccine

Recommended for all individuals age >6 months unless the client has a life-threatening allergy to the vaccine or one of its ingredients High risk individuals: chronic conditions, immunocompromised, healthcare workers, pregnant clients, healthy children 6-23 months and those >65

New onset agitation and confusion in dementia

Requires priority assessment because delirium is a sign of a different issue, such as worsening infection/condition, fluid and electrolyte imbalance, or drug-drug interaction

Water intoxication

Results in hyponatremia and may occur in infants when formula is diluted to stretch the feeding to save money. Hyponatremia may also result from ingestion of plain water (caregiver attempting to rehydrate an infant who has been ill. Infants have immature renal systems with a low GFR, which decreases their ability to excrete excess water and makes them susceptible to water intoxication. Symptoms include irritability, lethargy, and in severe cases, hypothermia, and seizure activity.

Methylphenidate

Ritalin, Concerta Classified as a stimulant, but in children with ADHD, it improves attention, decreases distractibility, helps maintain focus on an activity, and improves listening skills. Significantly increases levels of dopamine in the CNS that leads to stimulation of the inhibitory system of the CNS. It works quickly, and symptom relief is often seen after the first dose Side effects: Decreased appetite and weight loss leading to growth delays Hypertension and tachycardia (in adults) Appearance of new or exacerbation of vocal/motor tics Excess brain stimulation - restlessness, insomnia Abuse potential - misuse, diversion, addiction

Thiazolidinediones

Rosiglitazone and pioglitazone are used to treat type 2 diabetes. They increase insulin sensitivity but do not release excess insulin, leading to low risk for hypoglycemia. These drugs can worsen heart failure by causing fluid retention and an increased risk for bladder cancer. Heart failure is a contraindication for these drugs. They also increase risk for cardiovascular events

SIRS

SIRS occurs due to trauma, ischemia, infection, or other distributive shock processes that trigger systemic inflammation remote from the primary source. This overwhelming inflammatory response can rapidly progress to hemodynamic instability, respiratory failure and end organ dysfunction This client has fever and decreased arterial pCO2/ Early therapy wit aggressive fluid resuscitation and other indicated treatments based on cause is crucial. SIRS includes 2 of the following: Temperature >100.4 or <96.8 Heart rate >90/min Respiratory rate >20/min or pCO2 <32 WBCs >12,000

Sertraline

SSRI commonly used to treat major depression and anxiety disorders. Generally well tolerated except sexual dysfunction (over 50%) - decrease in sexual desire, arousal, or orgasm. Side effect may decrease or cease after a 2-to-4 week waiting period or the client may switch to a different antidepressant med

Aldosterone

Saves Sodium and Pushes Potassium out of the body. lack of aldosterone from ACE inhibitors causes hyperkalemia

Decerebrate posture

Sign of severe brain damage. Arms and legs straight out, toes pointed down, and the head/neck arched back

Normal lymph nodes

Small, mobile, firm, and non-tender are normal findings Tender, hard, or fixed nodes could indicate malignancy Infected nodes would be tender and have a red streak or skin lesions present

Liver biopsy

The liver is a highly vascular organ and bleeding is a major complication. Tachycardia is an early sign of internal hemorrhage and this patient would be a priority

Urine cultures

UAPs can do clean-catch or midstream urine specimen, but cannot collect from Foley catheters as this is a sterile procedure

VT with pulse

Unstable client in VT (hypotension, altered mental status, signs of shock, chest pain, and acute heart failure) with a pulse is treated with synchronized cardioversion. The stable client in VT with a pulse is treated with antiarrhythmic medications (amiodarione, procainamide, sotalol) VT without a pulse should be treated with CPR and defibrillation

Phalen's maneuver

Used to recognize carpal tunnel syndrome Ask client to place back of hands against each other to provide hyperflexion of the wrist while the elbows remain flexed

Iodine

Used to treat thyrotoxicosis or to prepare the client for a thyroidectomy. In large doses, iodine quickly blocks the release of T4 and T3 from the gland within hours. In addition, iodine decreases thyroid gland vascularity and is helpful when preparing the client for a thyroidectomy.

Anaphylaxis

Vasodilation -> hypotension and tissue edema Tachycardia Upper airway edema -> stridor and hoarseness Swelling of mouth, tongue, lips, and upper airway Bronchospasm -> wheezing Lightheadedness LOC Urticarial rash, pruritus, flushing Nausea, vomiting, abdominal pain Treatment: IM epinephrine, airway management and volume resuscitation, adjunctive therapy (antihistamines, glucocorticoids)

Sildenafil

Viagra. Phosphodiesterase inhibitor used to treat erectile dysfunction. This drug is contraindicated with the use of nitrates commonly used to treat unstable angina because it can cause life-threatening hypotension. Half-life is about 4 hours.

Cyanocobalamin

Vitamin B12 administered every 4 weeks for deficiency

Home oxygen therapy

For clients with COPD, they should only use the precscribed amount of oxygen and refrain from turning it up when they feel SOB. This is because higher levels of O2 will lower their drive to breathe. They should avoid wool or nylon fabrics, as these can cause friction and be flammable. They should not paint their nails or use nail polish remover because acetone is combustible. They should be 5-10 feet away from gas stoves or any other flames. Should not use Vaseline. Should use a water-soluble lubricant No smoking, electrical devices in good condition and plugs grounded, having fire extinguishers readily available and testing smoke detectors

DASH diet

For hypertension Emphasizes intake of vegetables, fruit, fat-free or low-fat dairy products Whole grains, fish, poultry, seeds, nuts, and vegetable oils Limits ingestion of sodium, sweets, sugary beverages, and red meat DASH diet is low in saturated and trans fats and rich in potassium, calcium, magnesium, fiber, and protein

Acute open angle glaucoma

Form of glaucoma that requires immediate medical attention. Increased intra ocular pressure due to decreased outflow of aqueous humor, resulting in compression of optic nerve that can lead to permanent blindness. Sudden onset of severe eye pain Reduced central vision Blurred vision Ocular redness Report of seeing halos around lights

Normal SVR

800-1200 dynes/sec/cm

Calcium acetate

Used for hyperphosphatemia. Normal phosphate: 2.4-4.4

Cup to mL

1 cup = 240 mL 1 cup = 8 oz

Renal assessment

1. Empty bladder to avoid discomfort during percussion and palpation 2. Inspect the abdomen and lower back for color, contour, symmetry, distension, and movements. 3. Auscultate immediately after inspection as percussion or palpation may stimulate the bowels and interfere with sound transmission. Listen for renal artery bruits in the right and left lower abdominal quadrants 4. Percuss for kidney borders, CVA tenderness, and bladder distension. A dull percussion sound indicated solid structure or fluid filled cavities. Palpate for bladder distension, masses, and tenderness. A normal kidney is usually not palpable; if it is, may indicate polycystic kidney disease or hydronephrosis 5. Document all renal findings immediately

Catheter size for blood products

20 gauge is acceptable, but 18 is preferred

Growth hormone replacement

A child who demonstrates a slow growth pattern will undergo diagnostic evaluation to determine the cause. If the cause is found to be GH deficiency, they may undergo GH replacement therapy. Despite therapy, the child may still havea final height less than "normal"/ Treatment is successful when diagnosis and replacement therapy begin early in a child's life. When to stop therapy is decided by the client, family, and provider. However, growth less than 1 inch per year and a bone age of 14 years in girls and 16 years in boys are the criteria often used to stop therapy

Pheochromocytoma

A condition caused by a tumor in the adrenal medulla. This results in excess release of catecholamine such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis Hypertension will often be difficult to treat and resistant to multiple drugs Client should avoid activities that can precipitate a hypertensive crisis (bending, lifting, Valsalva) Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate a hypertensive crisis Puts client at risk for stroke. Nitroprusside, phentolamine, and nicardipine are vasodilators given via infusion and can be titrated to keep the BP within a desired parameter

Cystic fibrosis

A defective protein responsible for transporting sodium and chloride causes exocrine gland secretions to be thicker and stickier than normal. Sticky respiratory secretions accumulate, resulting in an inability to clear the airway and a chronic cough. Clients eventually develop chronic lung disease, which predisposes them to recurrent infections. Chest physiotherapy helps open airways and break up secretions. Should be performed after administration of bronchodilators. Physical exercise enhances clearance of mucous and improves cardiovascular and muscular function. Pancreatic enzymes should be given with all meals and snacks, as well as supplementation of multiple vitamins (A, D, E, K) Some clients may not experience typical symptoms of lung infection (fever, chest pain). The presence of anorexia, weight loss, and decreased activity levels may indicate infection and should be reported to the healthcare provide for management A diet high in calories, fat, and protein is required to meet growth needs CF causes congenital absence of vas deferens in male clients, resulting in low sperm levels and infertility. Female clients have thick cervical secretions that can obstruct sperm entru

Placenta previa

Abnormal implantation of the placenta resulting in partial or complete covering of the cervical os. Condition is diagnosed by ultrasound. In clients reporting painless vaginal bleeding after 20 weeks gestation, placenta previa should be suspected. Placenta previa found early in pregnancy may resolve by the third trimester, but women with persistent placenta previa or hemorrhage require cesarean birth. A type and screen to determine Rh status is appropriate. Fetal well-being is assessed via continuous electronic fetal monitoring to help determine appropriate timing for birth. Large bore IV access is established in anticipation of fluid resuscitation and administration of blood products. Client should also be monitored frequently for any changes in bleeding via pad counts. Do NOT perform digital vaginal exams if the origin of bleeding is unknown. If placenta previa is present, manual manipulation of the cervix can damage placental blood vessels, causing subsequent bleeding that can progress to hemorrhage. Clients with placenta previa are on pelvic rest (no intercourse, nothing per vagina)

Placenta accreta

Abnormal placentation that involves implantation in the myometrium (normal implantation is in the endometrium). A placenta accreta adheres very strongly to the myocardium, and attempted separation results in life-threatening hemorrhage. These clients should have a type and cross-match on the chart in case an immediate blood transfusion is needed. They also require an IV site in addition to the one used for anesthesia in case blood transfusion is necessary. Transfusion requires a large-bore IV (18) that is patent.

Epidural hematoma

Accumulation of blood between the skull bone and dura mater. The majority of epidural hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle meningeal artery. This bleed is arterial, so hematoma develops quickly. Clinical presentation of epidural hematoma is characteristic. The client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that can progress to coma and death.

Lymphedema

Accumulation of lymph fluid in soft tissue. It can occur as a result of lymph node removal or radiation treatment. When the axillary nodes cannot return lymph fluid to central circulation, the fluid can accumulate in the arm, hand, or breast. The client's arm may feel heavy or painful, and motor function may be impaired. Increases risk for infection or injury of the affected limb Interventions: Decongestive therapy - massage technique to mobilize fluid Compression sleevs or intermittent pneumatic compression sleeve (increased distal pressure and less proximal pressure). Clothing should be less constrictive at the proximal arm and over chest Elevation of arm above the heart Isometric exercises Avoidance of venipunctures, blood pressure measurements, and injections on the affected limb Injury prevention - limb less sensitive to temperature changes Infection prevention

Isotretinoin

Accutane. Decreases sebum secretion and is prescribed for severe, disfiguring nodular acne that is unresponsive to other therapies. It is a pregnancy category X drug - causes birth defects. Females must have 2 negative pregnancy tests before taking this medication. 2 forms of contraception should be used for at least 1 month prior to starting this drug and must be continued throughout treatment and at least 1 month after treatment is discontinued. Blood donation is also discouraged wile on therapy to ensure that pregnant women do not receive any donated blood. Side effects include suicide risk, increased ICP, and Steven-Johnson syndrome. This medication is derived from vitamin A, so vitamin A supplements should not be taken as they may get viramin A toxicity. This can cause increased ICP, GI upset, liver damage, and changes in skin and nails. Should not taken with tetracycline (antibiotic used for acne) because the latter also increases the risk for increased ICP Dryness of the eyes, mouth, and skin are common. Capsules should be swallowed whole with water - opened capsules can irritate the esophagus. Client must use sunscreen regularly as it causes photosensitivity

Rheumatic fever

Acute inflammatory disease of the heart. It is a complication that occurs 2-3 weeks after a streptococcal pharyngitis. RF is caused by a delayed onset autoimmune reaction involving anti-streptococcal antibodies that cross-react with the antigens in the heart and other organs. Recurrent, untreated streptococcal pharyngitis will lead to faster onset and increased severity of rheumatic heart disease due to increased autoimmune activity Presence of 2 major criteria or 1 major and 2 minor criteria and evidence of a preceding strep infection indicate high probability of RF. Major clinical features: Joints (migratory arthritis) Endocarditis Nodules (subcutaneous) Erythema marginatum (pink rings on torso and inner surfaces of limbs) Sydenham chorea (involuntary movements of arms, legs, trunk, and face) Minor: Fever Arthralgias Elevated erythrocyte sedimentation rate/C-reactive protein Prolonged PR interval Late sequelae: mitral regurgitation/stenosis

Kawasaki disease

Acute systemic inflammatory illness and vasculitis. Cause is unknown, but may be associated with an infection and organism or toxin. Cardiac involvement is most serious complication; aneurysms can develop Assessment: Acute stage: fever, red throat, swollen hands, rash, enlargement of cervical lymph nodes. Sub-acute stage: cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, thrombocytosis Convalescent stage: child appears normal, but signs of inflammation may be present If the child develops a fever, the parents need to notify the HCP immediately because this may indicate recurrence of the acute stage. They may need additional treatment with IVIG to prevent cardiac issues. Treated with aspirin and IVIG to prevent coronary artery aneurysms. Antibodies acquired from the IVIG therapy will remain in the body for up to 11 months and may interfere with the desired immune response to live vaccines. Therefore live vaccines (MMR, Varicella) should be delayed for 11 months after the IVIG administration as this therapy may decrease the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity.

Emergent catheterization

Acute urinary retention is best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis. With sudden release of bladder obstruction, cardiovascular autonomic activity occurs and the blood pressure and heart rate are reduced due to excitation of the parasympathetic system. However, these are rarely clinically significant if appropriate supportive care is administered, whereas inability to relieve the obstruction can be associated with infection and kidney injury.

Guillan-Barre syndrome

Acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes. Lower extremity weakness progresses over hours to days to involve the thorax, arms and cranial nerves. Neuromuscular respiratory failure is the most life-threating complication. The rate and depth of the respirations should be monitored. Measurement of the serial bedside forced vital capacity (spirometry) is the gold standard for assessing early ventilation status Autonomic dysfunction is common in GBS and usually results in orthostatic hypotension, paralytic ileus, urinary retention, and diaphoresis. These complications need to be assessed but are not priority. Absence of knee reflexes are expected early in the course of GBS due to ascending nature of the disease. Absence of gag reflex indicates GBS progression. PERRLA evaluation assesses CNs II, III, IV, and VI. CN abnormalities are expected after the thoracic muscles (respiratory) are involved due to ascending nature of GBS.

Patent ductus arteriosus

Acyanotic congenital defect more common in premature infants. When fetal circulation changes to pulmonary circulation outside the womb, the ductus arteriosus should close spontaneously. This closure is caused by increased oxygenation after birth. If a PDA is present, blood will shunt from the aorta back to the pulmonary arteries via the opened ductus arteriosus. Many newborns are asymptomatic except for a loud, machine-like systolic and diastolic murmur. The PDA will be treated with surgical ligation or IV indomethacin to stimulat duct closure.

Bradycardia vs tachycardia

Adenosine: tachy Atropine: brady and heart block Dopamine: brady Epinephrine: brady

Best indicator of fluid resuscitation

Adequate urine output depends on adequate renal perfusion and is the greatest indicator that fluid resuscitation therapy has effectively restored tissue perfusion

Iron supplements in children

Administer between meals Give with citrus juice because vitamin C aids in abruption Place medicine at back of the mouth Avoid giving with milk - calcium can reduce absorption Keep no more than 1-month supply on hand - extreme quanitites can be lethal Black tarry stools are expected

Addisonian crisis

Adrenocortical insufficiency or hypofunction of the adrenal cortex. Addisonian crisis is a potentially life-threatening complications and can lead to shock. It is triggered by stress and manifestations include: Hypotension and tachycardia Dehydration Hyperkalemia and hyponatremia Hypoglycemia Fever Weakness and confusion

Nephrotic syndrome

Affects children 2-7 and is characterized by increased permeability of the glomerulus to proteins (albumin, immunoglobulins, natural anticoagulants). Loss of albumin in the urine leads to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows fluid to leak out of the vascular spaces. Low albumin levels will also trigger increased liver proteins and increase lipid synthesis, leading to hyperlipidemia. Reduced plasma volume (hypovolemia) activates kidneys to retain salt and water (RAAS). Decreased bloodflow to the kidneys will also cause an increase in renin, which will cause vasoconstriction and increased hydrostatic pressure, leading to edema. They will have generalized edema, weight gain, loss of appetite, and decreased urine output. Loss of immunoglobulins results in infection susceptibility. Clinical manifestations: massive proteinuria, hypoalbuminemia, edema, hyperlipidemia Causes: minimal change nephrotic syndrome which is often idiopathic. Less common secondary causes may be related to systemic disease or infection, such as glomerulonephritis, drug toxicity, or AIDS Treatment: corticosteroids and other immunosuppressants, loss of appetite management, and infection prevention. Will need fluid restriction, less salt in their diet, and should not be around other children. Caregiver should test for proteinuria, weigh the child weekly, and keep a diary of results If genitals are very edematous, the nurse can place cotton balls in the child's diaper and squeeze urine onto the dipstick to determine presence of proteinuria. Do not use a collection bag because it could cause skin breakdown. Do not catheterize because they are at increased risk for infection

Diabetic ketoacidosis

All clients with DKA experience osmotic diuresis from high levels of sugar in the blood. This causes increased urination and cause additional water to come into the urine, increasing its amount. Prompt and adequate fluid therapy restores tissue perfusion and suppresses the elevated levels of stress hormones. The initial hydrating solution is normal saline.; Insulin therapy should be started after the initial rehydration bolus as serum glucose levels fall rapidly after volume expansion. Potassium should never be given until the serum potassium level is known to be normal or low and urinary voiding is observed. Peaked T waves indicate hyperkalemia is present. Clients with insulin deficiency frequently have increased serum potassium levels due to extracellular shift despite having total body potassium deficit from urinary losses. Once insulin is given, serum potassium levels drop rapidly, often requiring potassium replacement. Potassium is never given as a rapid IV bolus, as cardiac arrest may result

Terazosin

Alpha-adrenergic blocker that can relive urinary retention in clients with BPH. Relaxes smooth muscle in the bladder neck and prostate gland; however, it also relaxes smooth muscle in the peripheral vasculature, which can cause orthostatic hypotension, syncope, and falls. Particualrly common when drug is first started or when dosage is increased. Take medication at bedtime, change positions slowly, and avoid any meds that also increase smooth muscle relaxation (sildenafil). Some cleints may experience ejaculatory dysfunction

TB skin test

Also called the purified protein derivative (Mantoux) test Site must be evaluated 48-72 hours after the test is administered Induration means a positive test Induration >15 mm in health individuals >5 mm in high-risk populations >10 mm in clients with potential risk of immunosuppression Redness without induration is a negative reaction The immigrant client has a positive derivative test (>10 mm). The bacilli Calmette-Guerin vaccine improves TB resistance in high-risk countries but produces false positive TB skin test results. Knowing this info for documentation is important Positive results warrant further testing. CXR helps identify clients who do not have symptoms but still have active disease. Sputum cultures can be used for diagnosis if the client is asymptomatic. Clients with active TB are placed under airborne isolation. If the client has no symptoms and unless CXR and sputum culture are positive, the client has only latent TB and isolation precautions are not needed

Thrombolytic agents

Alteplase, tenecteplase, reteplase Often prescribed to resolve acute thrombotic events like ischemic stroke, MI, massive PE. They are recombinant plasminogen activators that activate the blood fibrinolytic system and dissolve thrombi. Contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled HTN (BP >180/110). Administering in the presence of these complications can cause hemorrhage, including intracerebral hemorrhage

Scopolamine

Anticholinergic medication used to prevent nausea and vomiting in motion sickness and as an adjunct for anesthesia to control secretions. Transdermal scopolamine is placed on a clean, dry hairless area behind the ear for proper absorption. Clients should be instructed to Replace the patch every 72 hours as prescribed to guarantee ongoing medication absorption Remove and discard old patch before placing a new one behind the opposite ear to prevent overdosing Dispose of the patch out of reach of children and pets to avoid accidental toxicity Wash hands with soap and water after handling the patch to avoid inadvertent drug absorption and contact with the eyes

Dicyclomine

Anticholinergic/antispasmodic drug prescribed to manage symptoms of intestinal hypermotility in clients with IBS. Dicyclomine is contraindicated in clients with paralytic ileus as it decreases intestinal motility and would exacerbate the condition.

Levetiracetam

Anticonvulsant prescribed for seizure disorders. Has a depressing effect on the CNS, which may cause drowsiness, somnolence, and fatigue as clients adjust to the medication. Clients should be assured that this is common and typically improves within 4-6 weeks. However, the CNS depressing effects ma be enhanced if taken with other CNS depressing substances (alcohol) or medications. New or increased agitation, anxiety, and depression or mood changes should be reported immediately as this medication is associated with suicidal ideation This drug can trigger Steven-Johnson syndrome that is life-threatening and causes rash, blistering, muscle/joint pain, or conjunctivitis Clients with seizure disorders should avoid driving or operating heavy machinery until they have permission from their healthcare provider and have met the requirements of their department of transportation.

Miconazole

Antifungal cream used to treat vaginal candidiasis. It is inserted high into the vagina using an applicator. It is best applied at bedtime so that it will remain in the vagina for an extended period. Sexual intercourse is avoided until the inflammation is resolves, typically for the duration of infection or reinfection of candida, and partner evaluation is not needed.

Amphotericin B

Antifungal medication used to treat systemic fungal infections. It is commonly associated with severe adverse effects, including hypotension, fever, chills, and nephrotoxicity. Due to the similarity between the adverse effects of this med and the symptoms of a blood transfusion reaction, the nurse's best action is to complete the blood transfusion and allow one hour of observation before initiating amphotericin.

Promethazine

Antihistamine that can control nausea and vomiting in patients with cholelithiasis

Hydroxychloroquine

Antimalarial drug commonly prescribed to reduce fatigue and treat the skin and arthritic manifestations of SLE. Can also reduce exacerbations in clients with inactive to mild disease, but several months can pass before its therapeutic effects become apparent Although rare, serious adverse drug reactions such as retinal toxicity and visual disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo regular ophthalmologic examination every 6-12 months Should be taken with food to decrease GI upset

Croup

Any inflammation of the larynx and trachea in children, associated with infection and breathing difficulties. Clinical manifestations: brassy (barking) cough, fever, runny nose, retractions, sore throat, drooling, agitation, inspiratory stridor, tripod positioning Maintain patent airway Do not measure oral temperature Prepare for possible intubation Administer IV fluids IV antibiotics Corticosteroids Nebulized epinephrine Cool mist oxygen therapy

Apgar score

Appearance: 0 - completely blue/pale 1 - body pink, extremities blue 2 - completely pink Pulse: 0 - absent 1 - <100/min 2 - >100/min Grimace: 0 - absent 2- grimace/whimper 3 - cough/sneeze/cry Activity: 0 - limp 1 - some flexion 2 - active/spontaneous Respiratory effort: 0 -absent 1 - slow, weak cry 2 - regular, good cry Scored at 1 minute and 5 minutes. If the score is less than 7 at 5 minutes, the Apgar assessment should be repeated every 5 minutes for a max of 20 minutes Scores below 7 indicate that resuscitation efforts may be necessary in addition to routine postpartum care

Pacemaker failure to capture

Appears on the cardiac monitor as pacemaker spikes that are not followed by QRS complexes. Pacemaker malfunction may be caused by a failing battery, malpositioned lead wires, or fibrosis at the tip of the lead wire preventing adequate voltage for depolarization This client is symptomatic from insufficient perfusion. The nurse's priority is to use a transcutaneous pacemaker to normalize the heart rate, stabilize blood pressure and adequately perfuse organs until the permanent pacemaker can be repaired or replaced. Administer analgesia or sedation as transcutaneous pacing is very uncomfortable for the patient

Skeletal traction

Applied directly to the bone with a metal wire or pin and is used to immobilize, position, or align a fracture when continuous traction is needed and skin traction is not possible. Removing the weights can cause injury to the client and should never be removed unless there is a life-threatening situation

Breast self exams

Appropriate timing Women with regular menstrual periods should perform BSE 5-7 days after menstruation Women with irregular menses should perform BSE on the same day each month Women taking oral contraceptives should perform BSE when a new package is initiated Women who are post-menopausal should perform BSE on the same day each month

Pre-dialysis prep

Assess client's fluid status (weight, BP, peripheral edema, lung and heart sounds), vascular access (fistula, graft), and vital signs. The amount of fluid removed (ultrafiltration) is determined by calculating the difference between the last post-dialysis weight and the client's current pre-dialysis weight. After the client is connected to the machine, IV heparin is added to the blood from the client to prevent clotting that can occur when the blood contacts foreign substance. Giving subq heparin prior to initiation is not necessary Do not give HTN meds prior to dialysis because dialysis potentiates hypotension. Also, many meds are removed from the blood during hemodialysis, making them ineffective. Meds that are taken once daily should be held until after dialysis treatment to prevent their removal.

Romberg test

Assesses clients' perceptions of their head in space (vestibular function) and body in space (proprioception). It is used to determine the reason for loss of coordination (ataxia). Clients are asked to stand with the feet together and hands at the sides of body. They are then asked to close their eyes while ability to maintain balance is assessed. A loss of balance is considered to be a positive Romberg sign and indicates that ataxia is sensory in nature rather than cerebellar. Clients demonstrating a positive Romberg test are likely to have ataxia, or be prone to lose balance, and would require assistance with ambulation

Bronchiolitis

Associated with RSV. Cell debris clumps and clogs the airways. Air can get in but has difficulty getting out. Mild symptoms include low grade fever, wheezing, tachypnea, and poor feeding; severe infections have more serious distress, including signs of hypoxia. Treatment is supportive. Child should be isolated and will receive support care.

Alcoholic cirrhosis

Associated with gastritis, clotting abnormalities (thrombocytopenia, coagulation disorders), and esophageal varices that increase the risk for hemorrhage (coffee ground emesis from oxidized blood). Hypotension and tachycardia in the presence of blood loss can indicate hypovolemia. The nurse should monitor for signs of hemodynamic instability (hypotension, decreased urine output, peripheral vasoconstriction, pallor) and notify the HCP of any significant changes from baseline as immediate esophagogastroduodenoscopy is necessary to determine bleeding site. Treatment to stop the bleeding (heat probe, sclerotherapy) may be indicated.

Cleft palate

At risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies can increase oral intake and decrease aspiration risk: Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases aspiration Tilt the bottle so the nipple is always filled with formula. Point down and away from the cleft Use special bottles and nipples, including cross cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation. Feeding slowly over 20-30 min reduces the risk of aspiration and promotes adequate intake of formula Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula

Eczema

Atopic dermatitis. Chronic skin disorder characterized by pruritus, erythema, and dry skin. In infants, red, crusted, scaly lesions may also be present. Commonly diagnosed before age 1. Associated with impaired skin barrier that allows penetration of allergens, causing an immune response. Goals are to alleviate pruritus and keep the skin hydrated to prevent scratching because it leads to formation of new lesions and predisposes to secondary infections. Cut and file nails short, place gloves or cotton stockings over the hands, do not wear rough fabrics or woolen clothing, and apply moisturizer.

Systemic lupus erythematosus

Autoimmune disorder in which an abnormal immune response leads to chronic inflammation of different parts of the body. SLE ranges in severity from mild (affecting skin, muscles, joints) to severe (affecting kidneys, heart, lung, blood vessles, CNS) disease Increased creatinine, BUN, and abnormal urinalysis (protein, RBCs, cellular casts) can indicate the presence of lupus nephritis, a potentially serious complication of SLE. Early recognition and aggressive immunosuppressive treatment are necessary to preserve renal function and prevent irreversible kidney damage Clinical manifestations: butterfly rash across the cheeks and bridge of the nose, elevated erythrocyte sedimentation rate indicating an inflammatory process, positive antinuclear antibody titer, anemia, mild leukopenia, and thrombocytopenia are often present in SLE. Both physical and emotional distress can exacerbate SLE. Therefore, clients should follow a healthy lifestyle. Balanced exercise with alternating periods of rest is recommended. Sunlight is known to worsen the rash of SLE and should be avoided when possible (especially between 10 AM-4 PM); protective clothing and sunscreen application are recommended during periods of sun exposure. Rashes should be cleansed with mild soap only

Marfan syndrome

Autosomal dominant disorder affecting the connective tissues of the body. Abnormalities are mainly seen in the CV, musculoskeletal, and ocular systems. Clients with Marfan syndrome are very tall and thin, with disproportionately long arms, legs, and fingers. Their breast bone may dip inward or protrude outward. They may have joint hypermobility and flat feet CV manifestations of Marfan syndrome include abnormalities of the aorta and cardiac valves, including aneurysms, tears (dissection), and leaky heart valves that may require replacement or repair. Therefore, competitive or contact sports are discouraged due to the risk of cardiac injury and sudden death. These clients are at risk for scoliosis so they should be monitored. They are also at risk for ocular problems (lens dislocation, retinal detachment, cataracts, glaucoma). May have overcrowding of teeth from very high-arched palate and preventive antibiotics may be needed prior to dental work to prevent endocarditis.

Total knee arthroplasty

Average hospital length of stay is 3-5 days. After the surgery, immediate initiation of physical therapy is a priority. An isometric quadriceps setting is initiated on the 1st post-op day. The client should be fully weight beraring by discharge. Clients use an assistive device (walker, cane, crutches, grab bar, hand rails) to help them sit, rise safely from sitting to standing, and to negotiate steps. A knee immobilizer is used to maintain extension during ambulation and at rest for about 4 weeks

Laxatives

Avoid laxatives and enemas with constipation as overuse can cause dependency and the bowel may lose its ability to contract. Also may lead to fluid and electrolyte imbalances

Burn rehab phase

Begins after patient's wounds have fully healed and lasts about 12 months. Interventions are aimed at improving mobility and independence and minimizing the potential for long-term complications. These interventions include: Counseling or other psychosocial support Gentle massage with water-based lotion to alleviate and minimize scarring Planning for reconstructive surgery Pressure garments to prevent hypertrophic scars and promote circulation Range of motion exercises to prevent contractures Sunscreen and protective clothing to prevent sunburns and hyperpigmentation Dily application of water-based lotion is necessary to minimize scar formation and alleviate itching. Infection is not likely as the rehabilitiation phase begins after the wounds are fully healed

Anticholinergic medications

Benztropine and trihexyphenidyl Used to treat tremor in PD patients. Can precipitate urinary retention and an acute glaucoma episode, so they are contraindicated in these patients (glaucoma and BPH). Constipation is a common side effect

Malnutrition

Best way to measure if they are responding to treatment is weight gain. Serum albumin is not an accurate measure because it has a long half-life and can change during inflammatory responses. Serum prealbumin is more reliable in indicating acute nutritional status because it has a shorter half-life.

Clinical features of Hirschsprung disease

Bilious vomiting Extensive crying Abdominal distention Failure to pass meconium Failure of internal anal sphincter relaxation (tight anal sphincter) Characterized by enlarged colon and aganglionic segment that lacks nerve cells and causes distal intestinal obstruction Potential fatal complications is Hirschsprung enterocolitis - inflammation of the colon that can lead to sepsis and death. Will present with fever, lethargy, explosive foul-smelling diarrhea, and rapidly worsening abdominal distention

Uterine atony

Bladder distension prevents the uterus from contracting sufficiently to control bleeding at the previous placental site. The client's uterus will be deviated to the right. Client should be assisted to void to correct the distension. Nurse should then perform fundal massage

Hypoglycemic reaction

Blood sugar <70. If the client is alert enough to ingest food/liquids orally, they should be given 15 grams of a simple carbohydrate such as orange juice or low-fat milk. The fat in milk slows the absorption process and will not treat hypoglycemia quickly enough. FSBS should be checked 10-15 minutes after this. If the client shows no improvement, the simple carbohydrate can be re-administered orally Dextrose IV and glucagon are administered to hypoglycemic clients who are unable to ingest a simple oral carbohydrate. The can cause rebound hypoglycemia by stimulating additional insulin release from the body in response to increased serum glucose levels

Ischemic stroke

Body senses the need for increased pressure to perfuse the penumbra (area of swollen and vulnerable but salvageable brain tissue) to keep the stroke from extending. This phenomenon IV antihypertensives are often used if medication is required for acute stroke treatment. However, rapid blood pressure reduction may prolong the stroke. BP should be lowered cautiously by about 15% within the first 24 hours Thrombolytics (tPA) would be used if the stroke symptoms started in the previous 3-4.5 hours and within hours for intra-arterial tPA. Also BP must be <185/110 prior to administering tPA and must be maintained at <180/105 for >24 hours after starting fibrinolytic therapy

Scoliosis brace

Boston brace, Wilmington brace, thoracolumbosacral orthosis brace, and Milwaukee brace are used to diminish progression of deformed spinal curves in scoliosis. Braces do not cure the existing spinal deformities but do prevent further worsening. Braces are molded plastic shells worn around the trunk of the body under the client's outer clothing. Due to risk of skin breakdown, clients should wear a cotton t-shirt under the brace to decrease skin irritation and absorb sweat. Compliance is a major problem in most adolescents as they are preoccupied with body image. Psychosocial issues are very important to discuss Do not use lotion or powder under the brace. Perform spinal muscle exercises by removing the brace. Should be worn 18-23 hours a day and should be removed for showering

Aphasia

Broca: expressive. Spontaneous speech is sparse and nonfluent. Comprehension is relatively preserved. Nurse should listen without interrupting and give the client time to form words. A client may have one type of aphasia or combination of both and severity varies with the individual Wernicke: receptive. Spontaneous speech is fluent and voluminous but comprehension is greatly diminished. Nurse should speak clearly, ask simple yes or no questions and use gestures and pictures to increase understanding Dysarthria is weakness of the muscles used for speech. Pronunciation and articulation are affected. Comprehension and the meaning of words are intact, but speech is difficult to understand

Theophylline

Bronchodilator with a low therapeutic index and narrow therapeutic range. Serum level should be monitored frequently to avoid severe adverse effects. Theophylline can cause seizures and life-threatening arrhythmias. Toxicity is usually due to unintentional overdose or concurrent intake of medications that increase serum theophylline levels. Cimetidine and ciprofloxacin can dramatically increase serum theophylline levels. Caffeinated products should be avoided as they would intensify adverse effects Signs of toxicity: anorexia, nausea, vomiting, restlessness, insomnia >20 mcg/mL is associated with toxicity

Lung contusion

Bruised lung. Injury is potentially life threatening because bleeding into the lung and alveolar collapse can lead to ARDS. Clients should be monitored 24-48 hours as symptoms (dyspnea, tachypnea, tachycardia) are usually absent initially but develop as the bruise worsens. Inspiratory chest pain leads to hypoventilation and hypoxemia. Interventions include supplemental oxygen, medications, ventilator support

Fetal sex

By the end of 12 weeks gestation, fetal sex can often be determined by the appearance of external genitalia depending on the quality of the image. Fetal movements are typically felt around 16-20 weeks gestation

Large anterior wall MI

Can affect the pumping ability of the left ventricle, putting the client at risk for developing heart failure and cardiogenic shock. The new development of pulmonary congestion on x-ray, auscultation of a new S3 heart sound, crackles on auscultation of breath sounds, or JVD can signal heart failure and should be reported immediately to the HCP. Dysrythmias are a common complication after MI. Occasional PVCs are not significant, but the nurse should further assess the client's potassium level and assess the apical-radial pulse for the presence of the a pulse deficit.

Catatonia

Can be a symptom of schizophrenia. Has at least 2 of the following additional features: Immobility: client remains in a fixed stupor or position for long periods. Refuses to move about or engage in ADLs. May have brief spurts of excitement or hyperactivity. Remaining mute Bizarre postures: the client holds the body rigidly in one position Extreme negativism: the client resists instructions or attempts to be moved Waxy flexibility: the client's limbs stay in the same position in which they are placed by another person Staring Stereotyped movement, prominent mannerisms, or grimacing Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at high risk for dehydration and malnutrition. The priority nursing action is to anticipate the client's needs, and to ensure that the client is well hydrated and has adequate nourishment. Some clients will need total care

Iron deficiency anemia in toddlers

Can be caused by insufficient dietary intake, premature birth, delayed introduction of solid food, and consumption of cow's milk before age 1. One common cause in toddlers is excessive milk intake over 24 oz/day

Renal calculi

Can be due to many factors (family history, dietary imbalances, immobilization, dehydration). Manifestations include sudden, severe abdominal or flank pain and nausea/vomiting. Client management focuses on analgesics administered at regularly scheduled intervals, rehydration of up to 3 L/day unless contraindicated by other comorbidities, and ambulation to facilitate the passage of calculi. Should strain all urine obtained. The collected stones are analyzed to determine their composition (calcium oxalate, calcium phosphate, struvite, uric acid, cysteine), which can then direct preventive measures, such as dietary and lifestyle changes, after discharge

Cognitive behavioral therapy

Can be effective in treating anxiety disorders, eating disorders, depressive disorders, and conditions such as insomnia and smoking. 5 components: self-observation and monitoring Physical control strategies Cognitive restructuring: new ways to reframe thinking patterns Behavioral strategies: focusing on situations that cause anxiety and practicing new coping behaviors Desensitization to anxiety-provoking situations or events

Neonatal HSV

Can be passed to the infant in utero, perinatally, or postnatally as a result of direct contact with virus particles shed from the infected vulva, vagina, cervix, or perineum. Neonatal HSV has serious morbidity (permanent neurologic sequelae) and mortality. Immediate antiviral therapy (acyclovir) should be initiated to treat the active infection. Vaginal birth is not recommended in the presence of active lesions. Cesarean birth helps reduce the risk of transmission to the newborn.

Heimlich maneuver

Can be performed in children greater than 1 year old. Do NOT blind sweep a child's mouth as it can force a loosely obstructing object to fully block the airway or cause the object to fall farther into the airway, requiring surgical removal. If the child is conscious and able to cough or make sounds, the nurse should encourage the child to try to cough it out before intervening

NSAIDs

Can cause CV side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention. They also decrease the effects of diuretics and other BP meds. Risks are even higher in clients with CV disease that has taken NSAIDs for a long time.

Dumping Syndrome

Can cause a fluid shift from the intravascular space to the small intestine, leading to hypotension and activation of the sympathetic nervous system. Symptoms include abdominal pain, diarrhea, nausea, vomiting, dizziness, sweating, and palpitations (tachycardia). Symptoms usually diminish over time and dietary changes are helpful in controlling symptoms.

Poison ivy

Can cause contact dermatitis rash in those who are sensitive to the oily resin found on the leaves, stems, and roots of the plant. About 50% of people who come in contact with the plant develop a rash. It is often linear in appearance where the plant brushed against the skin. The rash develops 12-48 hours after exposure and can last for several weeks. The severity of the rash depends of the amount of resin on the skin. It is most important to first thoroughly wash the area to remove the resin and prevent its spread to other areas of the body. If a rash does develop, applying cool compresses, applying topical cortisone, and discouraging the child from scratching are all appropriate after the rash has developed

Infective endocarditis vegetations

Can cause: Stroke Spinal cord ischemia - paralysis of both legs Septic pulmonary emboli Kidney infarction Ischemia to the extremities - pain, pallor, and cold foot or arm Intestinal infarction - abdominal pain Splenic infarction - left upper quadrant pain IE commonly presents with fever, arthralgias (multiple joints pains), weakness, and fatigue. Splinter hemorrhages can occur with infection of the heart valves. They may be caused by vessel damage from swelling of blood vessels or tiny clots that damage the small capillaries. The presence of splinter hemorrhages is not as critical as the the macroemboli causing a stroke or painful cold leg.

Radiation therapy to head and neck

Can decrease a client's oral intake due to development of oral mucositis (inflammation of the mouth, esophagus, and oropharynx) and xerstomia (dry mouth). These adverse effects affect speech, taste, and ability to swallow, and can have a significant impact on the client's nutritional status Avoid irritants such as spicy, acidic, dry, or crumbly foods; coffee and alcohol Consume supplemental nutritional drinks, which are often easier to swallow Use artificial saliva to manage xerostomia and the production of thick saliva due to altered salivary gland function. Sipping water throughout the day is equally effective and less expensive Topical anesthetics can increase comfort Must maintain more frequent oral hygiene due to drying effects of mucositis

Small bowel obstruction

Can have mechanical or non-mechanical causes. Mechanical obstruction is commonly caused by obstruction of the bowel resulting from surgical adhesions, hernias, intussusception, or tumors. Paralytic ileus, a non-mechanical obstruction, may occur after abdominal surgery or narcotic use. When a small bowel obstruction develops, fluid and gas collect proximal to the obstruction, producing rapid onset of nausea and vomiting, colicky intermittent abdominal pain, and abdominal distension. The nurse should recognize symptoms of bowel obstruction quickly as delay could lead to vascular compromise. bowel ischemia, or perforation. Nursing management of an obstruction includes placing the client on NPO status, inserting an NG tube, administering IV fluids, and instituting pain control measures Symptoms of large bowel obstruction differ slightly and include gradual onset of symptoms, cramping abdominal pain, abdominal distension, absolute constipation, and lack of flatus. Constipation and decreased flatus resulting from small-bowel obstruction would occur later, as the stool and gas in the large colon would be expelled for a few days

Varicella immunization

Can have redness, discomfort, and a few vesicles at the injection site. Cover the vesicles with clothing or a small bandage to reduce the risk of transmission from any exudate. Once the vesicles have crusted, a dressing is no longer necessary

Thoracic aortic aneurysm

Can put pressure on the esophagus and cause dysphagia. May indicate that the aneurysm has increased in size.

Epiglottitis

Can result in life-threatening airway obstruction. Symptoms begin with onset of high-grade fever and severe sore throat, followed by the 4 Ds: drooling, dysphonia, dysphagia, and distressed airway (inspiratory stridor). Children are typically toxic-appearing and may be tripoding. Child may need emergency intubation. However, intubation of such clients can be difficult and preparation for tracheostomy is standard

Troponin

Cardiac specific serum marker that is a highly specific indicator of MI and has greater sensitivity and specificity for myocardial injury than CK. Serum levels of troponin increased 4-6 hours after the onset of MI, peak at 10-24 hours, and return to baseline within 10-14 days. Troponin I should be <0.5 and troponin T should be <0.1. However, MI is not diagnosed alone by serum cardiac markers. ECG and client health history along with risk factors also help make the diagnosis. D-dimer is a lab test that measures the amount of cross-linked fibrin fragments resulting from clot degradation. It is ordered in clients with suspected PE Myoglobin is released into circulation within 2 hours after an MI. Although it may be the first serum cardiac marker to appear after MI, it lacks cardiac specificity and its role in diagnosing MI is limited.

Acute cholecystitis

Cardinal symptoms include pain in RUQ with referred pain to the right shoulder and scapula. Clients often report fatty food ingestion 1-3 hours before the initial onset of pain. Associated symptoms include low-grade fever, child, nausea, and vomiting and anorexia During an attack, inflammation of the mucous lining and wall of the gallbladder occurs as a result of gallstone obstruction of the cystic bile duct. The inflammation and increased pressure in the gallbladder from the blocked bile duct results in Murphy's sign - palpation over the RUQ causes pain and inability to take a deep breath. Lab results will show leukocytosis Pancreatitis has pain radiating from below the sternal area to the upper back Neprholithiasis has pain radiating from the flank to the groin Appendicitis may start as pain in the umbilicus

Left-to-right heart defects

Cause blood to shunt from higher pressure left side to lower pressure right side. Examples: ductus arteriosus, atrial septal defect, ventricular septal defect. These increase pulmonary bloodflow and cause pulmonary congestion, causing increased work of breathing and decreased lung compliance. COmpensatory mechanisms (tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects include: Tachypnea, tachycardia at rest, diaphoresis during feeding and exertion, heart murmur, extra sounds, signs of CHF, increased metabolic rate with poor weight gain

Megaloblastic anemia

Caused by B12 deficiency or folic acid deficiency. Vitamin B12 deficiency can also cause peripheral neuropathy (tingling and numbness), spinal cord involvement (gait problems) and cognitive impairment (memory loss/dementia). Vitamin B12 is formed in microorganisms only found in animal foods; some plant foods may contain minimal amounts only if they accidentally contain animal particles. Natural sources include meat, fish, poultry, eggs, and milk. Some breads and cereals may be fortified with B12 as well as some nutritional yeasts Vegans are highest risk for developing macrocytic anemia

Varenicline

Chantix. Used for smoking cessation. Risk for depression and suicide

Mononucleosis

Caused by Epstein-Barr virus. It is typically seen in adolescence from the sharing of drinks, kissing, or other direct exposure to saliva. Symptoms may include fatigue, fever, sore throat, splenomegaly, hepatomegaly, and swollen lymph nodes. Abx treatment would not be effective and could actualy cause rash if ingested. Treatment is management of symptoms and includes hydration, rest, control of pain, and reducing fever if necessary. Sore throat is treated with saline gargles or anesthetic troches. Complications include airway obstruction (stridor, difficult breathing) from swollen lymph nodes around the neck and severe abdominal pain. (splenic rupture). These should be reported to HCP immediately. Contact sports should be avoided due to splenomegaly and hepatomegaly

Botulism

Caused by GI absorption of neurotoxin produced by Clostridium botulinum. The neurotoxin blocks Ach at the neuromuscular junction, resulting in muscle paralysis. The organism is found in the soil and can grow in any food contaminated with spores. Manifestations include descending flaccid paralysis (starting form the face), dysphagia, and constipation (smooth muscle paralysis) Main source is improperly or canned or stored food. A metal can's swollen/bulging end can be caused by the gases from C botulinum and should be discarded. The infant form of botulism can occur in children under age 1 year if they eat honey, particularly raw honey. The immature gut system in these children makes them more susceptible Can also be acquired from Botox injections, which block neuromuscular transmission by inhibiting ACh release from nerve endings. Complications are uncommon but the toxin can relax thr muscles used for swallowing and breathing, resulting in dysphagia and respiratory paralysis

Emphysema

Caused by alveolar wall destruction. Lung tissues lose elasticity due to permanently enlarged, floppy alveoli. This causes hyperinflation of the lungs, manifested by hyperresonance on percussion and prolonged expiration. Hyperinflation of the lungs causes the client to develop a barrel-shaped chest. Hyperinflated lungs also prevent the client from meeting oxygen demands during increased activity, leading to activity intolerance and anxiety. Pursed lip breathing, accessory muscle use, and the tripod position (leaning forward with hands on the knees) are seen during exertion and as the disease progresses.

Carpal tunnel syndrome

Caused by compression of a median nerve within the carpal tunnel at the wrist. Any swelling in the canal puts pressure on the nerve and produces pain and paresthesia in the median nerve distribution (first 3 1/2 digits). These symptoms are often worse at night when the wrists are flexed during sleep. The most commonly used conservative treatment is wrist splinting, particularly at nighttime. Splinting prevents excessive flexion of extension, which could narrow the carpal tunnel.

Scarlet fever

Caused by group A strep and results in a sand paper like skin rash and fever

Torsades de Pointes

Caused by hypomagnesemia, which causes a prolonged QT interval that increases the client's risk for V-tach. Torsades is a polymorphic V-tach that is lethal and leads to decreased cardiac output and can develop quickly into V-fib.

Hepatitis

Caused by infection, toxins, or trauma (drug use, viral hepatitis, acute poisoning) resulting in impairment of liver function (bile production, detoxification of blood, metabolism). Nursing interventions for clients with acute viral hepatitis include: Alternate periods of rest and activity to reduce metabolic demands and avoid fatigue Avoid hepatotoxins (alcohol, acetaminophen) as they worsen injury to liver cells Medications (appetite stimulants, antipruritics, analgesics, sedatives) metabolized in the liver should be used cautiously to allow hepatocytes to heal Encourage low fat, small frequent meals to decrease nausea and promote intake in clients with anorexia. Promote eating a large breakfast since anorexia is lowest in the morning. Provide oral care and avoid extremes in food temperature to increase appetite Promote water consumption and diets adequate in carbs and calories Hepatitis B is transmitted through sexual contact and infected blood. Clients should not share razors and toothbrushes and should use condoms

SVT

Caused by stimulants - cocaine, caffeine, nicotine Absent or short P wave with narrow QRS complex (HR typically 150-220) Treatment is vagal stimulation and drug therapy. IV adenosine is drug of choice to convert SVT to a sinus rhythm. If these do not work, cardioversion is used

Late decelerations

Caused by uteroplacental insufficiency. The lowest point of late deceleration occurs near the end of the uterine contraction and may occur with marked hypertonia and increased uterine tone. Patient should be given oxygen, repositioned to right or left side (promotes uterine perfusion), oxytocin stopped, and IV fluid bolus given

Tension pneumothorax

Causes marked compression and shifting of mediastinal structures (tracheal deviation) including the heart and great vessels, resulting in reduced CO and hypotension. This is a life-threatening emergency and will need large-bore needle decompression followed by chest tube placement to relive the compression on the mediastinal structures.

Hypocalcemia

Causes sustained muscle contraction (tetany, tingling of hands and feet and around the mouth) and decreased cardiac contractility Laryngeal spasm may occur and hypoxia would be evident

Medications commonly used for open fracture

Cefazolin: bone penetrating cephalosporin antibiotic that is active against skin flora; it is given prophylactically before and after surgery to prevent infection Cyclobenzaprine: central and peripheral muscle relaxant given to treat pain associated with muscle spasm. Carisoprodol or methocarbamol can also be prescribed Tdap toxoid: given prophylactically to prevent infection if immunizations are not up to date Ketorolac: NSAID given to decrease inflammation and pain Opioids: given for analgesia

Emergent dialysis

Central venous catheter will be used until a graft or fistula can be placed and is ready for use. Catheter should always be the last option for long-term dialysis due to risk of infection and mechanical malfunction Excess fluid and solutes are removed at a more gradual rate with peritoneal dialysis. This slower rate of metabolite removal is a disadvantage in sudden kidney failure. It is more helpful for clients who want dialysis at home or in an ambulatory setting as it requires multiple exchanges per day

Atrial fibrillation

Characterized by disorganized electrical activity in the atria due to multiple ectopic foci. It leads to loss of effective atrial contraction and places the client at risk for embolic stroke as a result of thrombi formed in the atria. During a fib, the atrial rate may be increased to 350-600/min. The ventricular response can vary. The higher the ventricular rate, the more likely the client will have symptoms of decreased CO (hypotension). Treatment goals are to reduce the ventricular rate to <100/min and prevent stroke. Ventricular rate control is the priority. Medciations used for rate control include CCBs, beta blockers, and digoxin.

Erythema toxicum neonatarum

Characterized by firm, white, or yellow papules or pustules surrounded by erythema. This idiopathic rash, which closely resembles flea bites, appears in the first few days after birth and resolves within 5-7 days

Second degree type 2 AV block

Characterized by more P waves than QRS complexes. The PR intervals are consistent or constant, reflecting regular conduction of electrical impulses through the AV node, but dropped QRS beats randomly occur as ventricular conduction is blocked. A second degree AV bloc can rapidly deteriorate to complete heart block, which is life threatening. The nurse should quickly obtain a transcutaneous pacemaker, assess the client for symptoms (bradycardia, hypotension, and syncome) and be prepared to apce the client if symptoms occur. If the client is asymptomatic, the pacemaker is kept nearby in case rhythm deteriorates, and the HCP is alerted.

Amyotrophic lateral sclerosis

Characterized by progressive loss of motor neurons in the brainstem and spinal cord. Clients have spasticity, muscle weakness, and atrophy. Neurons involves in swallowing and respiratory function are impaired, leading to aspiration, respiratory failure, and death. Care of clients with ALS focuses on respiratory function, adequate nutrition, and quality of life. There is no cure, and death usually occurs within 5 years of diagnosis Medications can be used to decrease symptoms (spasms, uncontrolled secretions, dyspnea) Use of mobility assistive devices (walker and wheelchair) Communication assistive devices (alphabet boards, specialized computers)

Pleurisy

Characterized by stabbing chest pain that usually increases on inspiration or with cough. It is caused by inflammation of the visceral pleura (over the lung) and the parietal pleura (over the chest cavity). The pleural space (between the 2 layers) normally contains 10 mL of fluid to help the layers glide easily with respiration. When inflamed, they rub together, causing pleuritic pain A pleural friction rub is auscultated in lateral lung fields over the area of inflammation. The sound is produced by the 2 layers rubbing together and can indicate pleurisy, a complication of pneumonia. It is characterized by squeaking, crackling, or the sound heard when the palm is placed over the ear and the back of the hand is rubbed with the fingers. Complications of pneumonia are more prevalent in elderly clients with underlying chronic disease

Paralytic ileus

Characterized by temporary paralysis of a portion of the bowel, which affects peristalsis and bowel motility. Signs and symptoms include abdominal discomfort, distension, and nausea, vomiting. Risk factors for paralytic ileus include abdominal surgery, perioperative meds (anesthesia, analgesics), and immobility (stroke) To prevent further abdominal distension, the client should remain NPO. NG tube to wall suction may be necessary to decompress the stomach. IV fluid and electrolyte replacement may be necessary to correct losses that occur from NG suction. Nausea can be treated with prescribed antiemetics. The client should not take meds by mouth and opioid medications should be avoided as they prolong paralytic ileus. Instead, non-opioid analgesics (ketorolac, ibuprofen, acetaminophen) should be administered as prescribed for pain

Associated symptoms of MI

Chest pain radiating to back and jaw Described as pressure, heaviness, tightness Lasts more than 30 min Not improved with rest or position change Worsens with exertion *Atypical symptoms*: more common in women, elderly, and diabetics: SOB, nausea, vomiting, sweating, anxiety, indigestion, dizziness, fatigue, weakness

Solifenacin

Cholinergic antagonist prescribed to treat symptoms associated with overactive bladder (urge incontinence, frequency). Common expected adverse effects include dry mouth and constipation. The nurse should caution the client about safety when performing activities until the response to the medication is determined, as it can cause dizziness and blurred vision.

Psoriasis

Chronic autoimmune disease that causes a rapid turnover of epidermal cells. Characteristic of silver plaques on reddened skin may be found bilaterally on the elbows, knees, scalp, lower back, or buttocks. The goal of therapy is to slow epidermal turnover, heal lesions, and control exacerbations. There is no cure, but disease management includes avoidance of triggers (stress, trauma, infection), topical therapy ( corticosteroids, moisturizers), phototherapy (UV light), and systemic medications, including cytotoxic (methotrexate) and biologic (infliximab) agents. The client should avoid alcohol as it can worsen psoriasis. In addition, liver kidneys, and bone marrow are specifically affected by the systemic medications commonly used to control psoriasis

Polycythemia vera

Chronic disorder of the bone marrow in which excessive amounts of red blood cells, white blood cells, and platelets are produced. A secondary form of polycythemia can occur as physiologic response to hypoxemia. Clients with PV are at risk for developing blood clots due to increased volume, viscosity, and stasis of their blood. Clients should be taught to monitor for warning signs of thrombus formation; these include redness, tenderness, and swelling in legs or symptoms of stroke. In addition, they should be taught preventive measures such as using support stockings, elevating the legs when sitting, and hydrating properly. The venous stasis in PV causes the face, hands, and feet to become a ruddy red color, especially during a hot bath or shower. These are expected findings with PV. Clients can develop headache or blurred vision due to venous stasis in the brain. Low-dose aspirin is often indicated in these clients to prevent blood clotting and alleviate headaches.

Hypertensive disorders of pregnancy

Chronic hypertension: systolic pressure >140 mmHg and or diastolic pressure >90 mmHg prior to conception or 20 weeks gestation Gestational HTN: new-onset elevated blood pressure at >20 weeks gestation. No proteinuria or end-organ damage Preeclampsia: new onset elevated blood pressure at>20 weeks gestation and proteinuria or signs of end organ damage. May manifest with symptoms such as headache, visual disturbances, and facial swelling. Complications include thrombocytopenia, liver dysfunction, and renal insufficiency. (HELLP): hemolysis, elevated liver enzymes, and low platelets Eclampsia: pre-eclampsia and new onset of grand mal seizures

Parkinson Disease

Chronic progressive neurodegeneration of the dopamine-producing neurons. Damage to the dopamine neurons makes it difficult to control muscles through smooth movement. PD is characterized by a delay in initiation of movement (bradykinesia), increased muscle tone (rigidity), resting tremor, and shuffling gait. They will have a mask-like appearance, flexed elbows and wrists, forward tilt of the trunk, reduced arm swinging, and slightly flexed hips and knees. Caused by low levels of dopamine in the brain. Levodopa is converted to dopamine in the brain and carbidopa helps prevent the breakdown of levodopa before it reaches the brain. This medication is particularly effective in treating bradykinesia (slowed movements), tremor, and rigidity. This drug should never be stopped suddenly as it can lead to akinetic crisis (complete loss of movement). Prolonged use can lead to dyskinesias (spontaneous involuntary movements) Adverse effects of this drug are orthostatic hypotension and neuropsychiatric disturbances such as confusion, hallucinations, delusions, agitation, and psychosis.

Myasthenia gravis

Chronic, neurologic autoimmune disorder that involves damage to ACh receptors at the neuromuscular junctions, which results in skeletal muscle weakness. The ocular (ptosis) and facial muscles, along with those responsible for chewing and swallowing, are affected initially; however, weakness can progress to respiratory muscles (intercostal, diaphragm). Semi-solid foods preferred over solid foods (to avoid stressing muscles involved in chewing and swallowing) or liquids (aspiration risk) Skeletal muscles are involved in myasthenia gravis so they will not have impaired reflexes or impaired bladder or bowel control commonly seen in CNS disorders like MS. Pyridostigmine is a first-line drug that inhibits Ach uptake and is prescribed to temporarily increase muscle strength in clients with MG. It is a priority medication as difficulty swallowing indicates weakness of the muscles involved and aspiration risk Infection, undermedication, and stress can precipitate a life-threatening myasthenic crisis, which is characterized by oropharyngeal and respiratory muscle weakness and respiratory failure.

SSRIs

Citalopram, escitalopram, sertraline, fluoxetine, paroxetine. Weight gain or weight loss and loss of appetite is a common side effect with long-term SSRI use. Should eat a healthy diet and exercise to combat weight gain. Other major side effects include *increased suicide risk* (at the beginning of therapy), sexual dysfunction, headaches, dizziness, drowsiness, insomnia, nausea, vomiting, diarrhea, and serotonin syndrome. Should not be stopped abruptly and need to be gradually tapered to avoid withdrawal symptoms. Most clients will start to see improvement in 1-2 weeks. However, some may take several weeks and require dose adjustments.

Beers criteria

Classifies potentially harmful drugs to avoid in the eldery due to high incidence of drug-induced toxicity, cognitive dysfunction, and falls Antipsychotics Anticholinergics Antihistamines Antihypertensives Benzodiazepines Diuretics Opioids Sliding insulin scales

Mixing insulins

Clean both vial tops with alcohol swabs Inject air into NPH without touching needle to solution Withdraw needle from NPH insulin and inject air into regular Withdraw regular into syringe Insert the needle into the NPH insulin and withdraw Use mnemonic RN: regular before NPH

Cataract surgery

Client will be instructed that for several days, activities that may increase intraocular pressure should be avoided to decrease the risk for damage to sutures. These include bending, lifting more than 5 pounds, sneezing, coughing, rubbing, or placing pressure on the eye, or straining during BM. Should sleep with 2 pillows to elevate the head and decrease intraocular pressure May take 1-2 weeks before visual acuity is improved and it is common that they will have itching in the eye, phototobia, and mild pain for several days following the surgery

Anemia in pregnancy

Clients are diagnosed with anemia when hemoglobin is <11 in the first and third trimesters, or <10.5 in the second trimester. Iron deficiency is a common cause

TB precautions

Clients with airborne infections such as TB, measles, or chickenpox are confined to negative-pressure rooms except when travelling to various departments for essential diagnostic procedures or surgery. While being transported, they must wear a surgical mask to protect HCWs and other clients from respiratory secretions. HCWs transporting the client should wear N95 respirator masks as protection against exposure to airborne droplets by removing particles from inhaled air. The client is already infected and does not require protection from inhaled air

Pneumonia

Clients with consolidative lung processes may have bronchial breaths ounds due to over transmission of sound over the chest wall Fremitus is palpable vibration felt on the chest wall - sound travels faster in solids (consolidation) than in an aerated lung, resulting in increased fremitus in pneumonia. Low-pitched wheezing (rhonchi) is heard over the large airways, usually during expiration. It indicates the presence of secretions in larger airways and is an expected finding as pneumonia resolves

Testicular self examination

Clients with hx of undescended testes have a high risk of developing a tumor. All men age 15-35 should perform monthly TSEs Perform monthly on same day Perform while taking a warm shower or bath as temperature will relax the scrotal tissue and make the testes hang lower in the scrotum Use both hands to feel each teste separately Palpate each testicle gently using thumb and first two fingers Check that the testicle is normally egg-shaped and movable with a smooth surface Report: Painless, hardened lump on testes Scrotal swelling or heaviness Dull ache in pelvis or scrotum

Walking with a cane

Clients with one-sided weakness or injury, increased joint pressure, or poor balance can use a cane to provide support and stability when walking. Cane length should equal the distance from the client's greater trochanter to the floor as incorrect cane length can cause back injury. A can measured from the waist would be too long to provide optimal support. Teaching points: Hold the cane on the stronger side to provide maximum support and body alignment, keeping the elbow slightly flexed (20-30 degrees) Place the cane 6-10 inches in front of and to the side of the foot to keep the body weight on both legs to provide balance. For max stability, move the weaker leg forward to the level of the cane, so that the body weight is divided between the cane and the stronger leg. If minimal support is needed, the cane and weaker leg are advanced forward at the same time. Move the stronger leg forward past the cane and the weaker leg, so the weight is divided between the cane and weaker leg Always keep at least 2 points of support on the floor at all times

Hypothyroidism

Clinical manifestations: Bradycardia Weight gain, constipation Fatigue, muscle aches, joint pains Lethargy, apathy, forgetfulness, depression Menstrual irregularities, infertility, decreased libido Cold intolerance, dry and thick skin, brittle nails and hair, hair loss, facial and generalized interstitial edema Anemia

Central acting alpha-2 agonists

Clonidine, methyldopa Decrease the sympathetic response from the brain stem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation Side effects include dizziness, drowsiness, and dry mouth (3 D's) Clonidine is a highly potent antihypertensive. Abrupt discontinuation can result in serious rebound hypertension due to rapid surge of chatecholamine secretion that was suppressed during therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction, or sudden death

Codependence

Codependent behaviors are those that allow the codependent person to maintain control by fulfilling the needs of the addict first. Behaviors such as keeping the addiction a secret, suffering physical or psychological abuse from the addict, not allowing the addict to suffer the consequences of actions, and making excuses for the addict's habit are hallmarks of codependency. If the addict is not happy, the codependent person will try to make the addict happy. Codependent persons will focus all their attention on others at the expense of their own sense of self. Codependent friends, family, and spouses keep the client from focusing on treatment; this behavior is counter productive to both themselves and the client

Benztropine

Cogentin Anticholinergic medication used to treat extrapyramidal symptoms, which are side effects of some antipsychotic medications. These side effects include: Pseudoparkinsonism: symptoms that resemble parkinsonism (masklike face, shuffling gait, rigidity, resting tremor, psychomotor retardation) Dystonia: abnormal muscle movements of the face, neck, and trunk caused by sustained muscular contractions (torticollis, oculogyric crisis, opisthotonos)

Fibrocystic breast changes

Common benign breast disorder. They correlate with the estrogen/progresterone hormone fluctuations during the menstrual cycle. Clients may report cysts, nodules, or lumps that are more tender, swollen, and/or noticeable prior to menses. Typically resolves after menopause. Noncyclic breast changes may indicate malignancy and should be immediately reported. Pain may be reduced by decreasing caffeine and sodium intake, taking vitamins E, A, and B complex, wearing a support bra, utilizing cold compresses, and taking NSAIDs They do not increase risk of breast cancer

Cyclobenzaprine

Common centrally acting skeletal muscle reactant prescribed for muscle spasticity, muscle rigidity, and acute or chronic muscle pain/injury. Interferes with reflexes of the CNS. Like many meds, muscle relaxants are metabolized by the liver. The presence of liver disease decreases hepatic metabolism and can cause a buildup of the med, leading to toxicity and increased CNS depression.

IBS

Common chronic bowel condition caused by altered intestinal motility. Peristaltic action is affected, causing diarrhea, constipation, or combo of both. Management focused on reducing diarrhea or constipation, abdominal pain, and stress. Clients can manage their symptoms with diet, meds, exercise and stress management. Cleints should restrict gas-producing foods (bananas, cabbage, onions, beans), caffeine, alcohol, honey, high fructose corn syrup, wheat, and GI irritants (spices, hot/cold food or drink, dairy products, fatty foods). Clients should gradually increase fiber intake (whole grains, legumes, nuts, fruits, vegetables) as tolerated. Foods that are generally well tolerated include proteins, breads, and bland foods

Constipation

Common discomfort of pregnancy due to increase in progesterone. Can also occur with ferrous sulfate use. Interventions to prevent or treat constipation: High-fiber diet: high amounts of fruits, vegetables, breakfast cereals, whole-grain bread, prunes High fluid intake: 10-12 cups of fluid daily Regular exercise Bulk-forming fiber substances: psyllium, methylcellulose, wheat dextrin Dairy should be consumed by pregnant women because it is a good source of calcium. However, dairy products should be taken 2 hours before or 1 hour after ferrous sulfate as it can affect absorption

Cooperative play

Common in school-age children (6-12). These children play with one another with a specific goal (building a castle with blocks), often within a rigid set of rules.

Mastitis

Common infection in postpartum women due to multiple risk factors leading to inadequate milk duct drainage. Bacteria are transmitted from the infant's nasopharynx or the mother's skin through the nipple and multiply in stagnant milk. Symptoms include fever, breast pain, and focal inflammation. Mother should take antistaph antibiotics and analgesics (ibuprofen) and treatment required effective and frequent milk drainage. Milk ducts are most efficiently drained by direct breastfeeding. Breastfeeding should be continued every 2-3 hours to relieve milk duct obstruction. Mother should be reassured that the infant can safely feed from the infected breast as the newborn is already colonized. Abx, breast support, adequate hydration, and frequent continued breastfeeding

Lead poisoning

Common source of exposure is lead-based paints found in houses built before 1978, when such paint was banned. Blood lead level screenings are recommended at ages 1 and 2, and up to age 6 if not previously tested. Because lead poisoning particularly affects the neurological system, elevated BLLs are dangerous in young children due to immature development of the brain and nervous system. A mild to moderate increase in BLL can manifest with hyperactivity and impulsiveness; prolonged low-level exposure can cause developmental delays, reading difficulties, and visual-motor issues. Extremely elevated BLLs can lead to permanent cognitive impairment, seizures, blindness, or even death. Also damaging to the kidneys

GERD

Common symptoms are heartburn, regurgitation, persistent sore throat, painful swallowing, and chronic cough. Can be treated with acid suppression using antacids (calcium carbonate, magnesium hydroxide) PPIs (omeprazole), and H2 antagonists (ranitidine) Lifestyle and dietary modifications: Decrease caffeine, alcohol, fatty foods, large meals, tight clothing Weight loss Small, frequent meals with sips of water or fluids Abdominal breathing exercises to strengthen sphincter Avoid nicotine, chocolate, spicy foods, peppermint, and carbonated beverages Chew gum to promote salivation which may help neutralize and clear acid from the esophagus Elevate HOB Refrain from eating at bedtime and/or lying down immediately after eating

Opioid agonist-antagonist

Commonly used in labor Butorphanol tartrate and Nalbuphine IV push is the preferred route and is given over the peak of 2 contraction to decrease the bolus of medication to the fetus. During contractions, the uterine muscle is very tense and blood flow to the fetus is slowed. Therefore, medication reaches the fetus at a slower rate This class of meds has a ceiling effect - after a certain dosage, subsequent or higher doses will not be effective or produce pain relief. Therefore, usually no more than 3 doses will be prescribed. The meds can precipitate withdrawal in opioid-dependent clients and should not be used. Alternatively, epidurals or nonpharm pain methods should be used in opioid dependent clients

Myxedema coma

Complication associated with progression of symptoms of hypothyroidism from lethargy and mental sluggishness to a coma state. This client has hypothermia, bradycardia, hypotension, and depressed mental status. Hypothyroidism can also cause hypoventilation due to central depression of respiratory drive, respiratory muscle fatigue, and mechanical obstruction by a large tongue. This client exhibits signs of acute respiratory distress (increased respirations, low O2 sat). Therefore, life-saving measures to facilitate respiratory support, such as mechanical ventilation, must be implemented first. Other treatments include thyroid hormone replacement with levothyroxine IV push, heating warming the client with a blanket, and frequent diagnostics of the thyroid, including serum thyroid panel

Exophthalmos

Complication of hyperthyroidism. Defined as protrusion of the eyeballs caused by increased orbital tissue (connective, adipose, muscular) expansion and can be irreversible. The exposed cornea is at risk for dryness, injury, and infection Nursing care: Maintain the head of bed in a raised position to facilitate fluid drainage form the periorbital area Use artificial tears to moisten eyes and prevent corneal drying Tape client's eyelids shut during sleep if they do not close on their own Teach: Regular visits to ophthalmologist Anti-thyroid drugs to prevent further exacerbation Smoking cessation as smoking increases risk of Grave's and associated eye problems Use dark glasses to decrease glare and prevent external irritants and infection Perform intraocular exercises (turning eyes) to maintain flexibility

Infiltration

Complication that occurs when solution infuses into the surrounding tissues of the infusion site Interventions: Discontinuing the IV line immediately and starting a new IV, preferably on the opposite extremity Continuing to monitor the infiltration site for swelling or other abnormalities (redness, warmth, coolness) Elevating the affected extremity to decrease swelling Notifying the HCP if severe complications (cellulitis, tissue necrosis, nerve damage) develop Applying a cold or warm, moist compress based on the solution infiltrated. Heat is avoided when extravasation of a vesicant (drug capable of causing tissue necrosis) occurs

Dietary fiber benefits

Composed of indigestible complex carbs that absorb and retain water, which increases stool bulk and makes stool softer and easier to pass. Consuming a diet high in fiber-rich foods improves stool elimination, which helps prevent constipation and decreases the risk for colorectal cancer. Fiber-rich foods tend to have low glycemic load and are nutrient dense, yet have lower caloric density. Clients may experience increased satiety as fiber absorbs water and produces fullness. This may help reduce caloric intake, improve blood glucose control, and promote weight loss. Fiber binds to cholesterol in the intestines, which reduces serum cholesterol levels by decreasing the amount of dietary cholesterol that enters the bloodstream. Decreasing serum cholesterol levels helps reduce vascular plaque buildup and atherosclerosis. A high intake of fiber rich foods directly correlates with a reduced risk of vascular diseases, including coronary artery disease and stroke.

Chronic venous insufficiency

Compression is essential for the treatment of chronic venous insufficiency, venous ulcer healing, and prevention of ulcer recurrence. The client will need individual evaluation to determine what level of compression is needed. Assessment of the ankle-brachial index should be performed as well. An ABI <0.9 suggests concurrent PAD and the need for lower levels of compression therapy. There are several options that the nurse can explore with the client to decide which compression device will work best in the situation (custom fitted elastic compression stockings, elastic tubular support bandages, Velcro wrap, paste bandage with elastic wrap, or multilayer bandage system). PS it is ok for clients to hang legs over the bed while sleeping with PAD because gravity will help arterial bloodflow

Dissociative identity disorder

Condition in which 2 or more identities alternately control the client's behavior. The alternate identities likely develop as a response to abuse or traumatic events and serve to protect the client from stressful memories. The client may not be aware of the alternate identities and may be confused by "lost time" and gaps in memory. Switching between identities occurs as a reaction to stress and individual triggers. The goal of treatment is to integrate into one personality while maintaining safety. Client should journal about triggers and use a grounding technique (deep breathing, rubbing stone) to counter dissociative episodes. Monitor personalities for indications of harm to self or others. Nurse should attempt to form trusting, therapeutic relationships with each identity to explore feelings and facilitate identity integration. Allow clients to remember the memory gaps at their own pace.

Red Man Syndrome

Condition that can occur with rapid IV vancomycin administration. It is characterized by flushing, erythema, and pruritus, typically in the face, neck, and chest. Muscle pain, spasms, dyspnea, and hypotension may also occur. RMS is usually a rate-related infusion reaction and not an allergic reaction. It can be reduced by infusing vancomycin over a minimum of 60 min. It can be difficult to differentiate severe RMS from anaphylaxis as flushing and hypotension can occur in both conditions. However, hives, angioedema (lip swelling), wheezing, and respiratory distress are more suggestive of anaphylaxis

DIC

Condition that initially causes clotting within the microvessels. Platelets and clotting factors are consumed in clotting and become unavailable for body use, leading to bleeding complications. The initial clotting also disrupts blood flow to extremities and organs. Signs of DIC include frank external bleeding, signs of internal bleeding (petachiae, ecchymosis, hematuria, hematemesis, bloody stools) and respiratory distress (bleeding/clotting into lungs). Signs of DIC need immediate assessment and emergency intervention. Rapid replacement of clotting factors (FFP), platelets, and blood is needed to save the client from death.

Hiatal hernia

Conditions that increase intraabdominal pressure (pregnancy, obesity, ascites, tumors, heavy lifting) and weaken the muscles of the diaphragm may allow a portion of the stomach to herniate through an opening in the diaphragm causing a hiatal hernia. A sliding hiatal hernia occurs when a portion of the upper stomach squeezes through the hiatal opening in the diaphragm. A paraesophageal hernia (rolling hernia) occurs when the gastroesophageal junction remains in place but a portion of the upper stomach folds up along the esophagus and forms a pocket. These are a medical emergency Symptoms of hiatal hernias commonly associated with GERD symptoms including heartburn, dysphagia, and pain caused by intraabdominal pressure or supine positioning Interventions to reduce herniation: Diet - avoid high-fat foods and those that decrease lower esophageal pressure (chocolate, peppermint, tomatoes, caffeine). Eat small, frequent meals and decrease fluid intake during meals to prevent gastric distension. Avoid consumption of meals close to bedtime and nocturnal eating Lifestyle changes: smoking cessation and weight loss Avoid lifting or straining Elevate head of bed to approximately 30 degrees - this can be done at home with 4-6 inch blocks under the bed

Salem sump tube

Continuous suction can be applied to decompress the stomach if a double lumen Salem sump tube is in place. The larger lumen is attached to suction and the smaller lumen (within the larger one) is open to the atmosphere. Checking for residual volume is not an appropriate intervention because the Salem sump is attached to continuous suction for decompression and is not being used to administer enteral feeding. The air vent (blue pigtail) must remain open as it provides a continuous flow of atmospheric air through the drainage tube at its distial end. This prevents damage to the gastric mucosa. If gastric content refluxes, 10-20 mL of air can be injected into the air vent. However, the air vent is kept above the level fo the client's stomach to prevent reflux. Turn off suction during auscultation Inspect drainage system for patency Provide mouthcare every 4 hours Place client in Semi-Fowlers

NSAIDs in heart failure

Contraindicated as they contribute to sodium and fluid retention

Foods high in potassium

Cruciferous vegetables, legumes, potatoes, green leafy vegetable, tomatoes, raw carrots Dried fruits, melons, avocadoes, oranges, mangos, nectarines, strawberries, bananas Milk and milk products Most fish and shellfish, most beef products, pork Whole grains, granola, bran

Statin drugs

Cuts LDL and raises HDL Most of the cholesterol in the body is synthesized by the liver during the fasting state at night. Should be taken in the evening or at bedtime. Can cause rhabdomyolysis, so client should report any signs of muscle weakness or aches to the HCP Other side effects include abdominal discomfort, insomnia, and morning headache

Tetralogy of Fallot

Cyanotic congenital heart defect that has 4 characteristics: Pulmonary stenosis Right ventricular hypertrophy Overriding aorta Ventricular septal defect If they experience a hypercyanotic episode or "tet spell", which can happen when the child cries, becomes upset, or is feeding, place them in the knee-chest position. Flexion of the legs provides relief of dyspnea as the angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the VSD.

Osteoarthritis

Degenerative disorder of the synovial joints (knee, hip, fingers) that causes progressive erosion of the articular cartilage and bone beneath the cartilage. As the degenerative process continues, bone spurs (osteophytes), calcifications, and ulcerations develop within the joint space, and the cushion between the ends of the bones breaks down Manifestations: Pain exacerbated by weight-bearing activities: results from synovial inflammation, muscle spasm, and nerve irritation Crepitus, a grating noise of sensation with movement that can be heard or palpated: results from the presence of bone and cartilage fragments in the bone space Morning stiffness that subsides within 30 min of arising Decreased joint mobility and ROM Atrophy of muscles that support the joint (quadriceps, hamstring) due to disuse

Positive pressure ventilation

Delivers positive pressure to the lungs using a mechanical ventilator, either invasively through a tracheostomy or ET tube or noninvasively through a nasal/facemask, nasal prongs, or a mouthpiece. The most common type used in the acute care setting for clients with ARDS is the volume cycled positive pressure MV, which delivers a preset volume and concentration of oxygen (21-100%) with varying pressure. Positive pressure applied to the lungs compresses the thoracic vessels and increases intrathoracic pressure during inspiration. This leads to reduced venous return, ventricular preload, and cardiac output, which results in hypotension. The hypotensive effect of PPV is even greater in the presence of hypovolemia (hemorrhage, hypovolemic shock) and decreased venous tone (septic shock, neurogenic shock) Fluid and/or sodium retention usualy occurs about 48-72 hours after initiation of PPV due to increased intrathoracic pressure and decreased CO that stimulate the kidneys to release renin; as well as physiologic stress that leads to the release of ADH and cortisol; as well as breathing through the ventilator's closed circuitry which decreases insensible loss associated with respiration.

Nocturnal enuresis

Desmopressin may be useful in treating nocturnal enuresis; however, nonpharm strategies should be attempted first. Encourage fluids during the day, but restrict to small sips after the evening meal Have child void before going to bed Use positive reinforcement and motivation Avoid punishing, scolding, or ridiculing the child Avoid the use of disposable training pants and diapers at bedtime, as these discourage the motivation to get up and void Have the child assist with wet linen changes but reassure that this is not a punishment Use an enuresis alarm

Fine motor skills in infants

Develop around the ability to grasp and pick up objects. By 3 months, infants will reflexively grasp a rattle placed in their hand. At 5 months, they are able to voluntarily clasp it with their palm. Around 7 months, infants are able to transfer an object from one hand to another. By 8-10 months, infacnts have replaced the palmar grasp with a crude pincer grasp to pick up round cereal and other finger foods. By 11 months, this develops into a neat pincer grasp (thumb and index finger). By 12 months, infants may attempt to turn multiple book pages at once, and they also begin attempts to stack 2 blocks.

Lyme Disease

Develops after a bite from a tick infected with Borrelia burgdorferi. Initial symptoms are flu-like (headache, fever, myalgia, fatigue). Many clients develop bulls-eye rash; however, it is not always present. Any of these symptoms should e reported immediately. The client will likely be prescrined doxycycline, amoxicillin to treat Lyme disease and prevent it from spreading to other organs (heart, brain, joints). Clients are taught to prevent tick bites by avoiding tall grass and wooded areas and to hike in the center of the trail only. Clients should use insect repellent and wear long pants tucked into boots or closed toed shoes. Do NOT cover ticks with petroleum jelly as this increases risk for infection by keeping the tick on the skin. Promptly remove the tick using tweezers, being careful to grasp the tick close to the attachment site and not to crush it during removal

IVC filter

Device inserted percutaneously usually via the femoral vein. Filter traps blood clots from lower extremity vessels and prevents them from migrating to the lungs and causing a PE. It is prescribed with clients who have recurrent emboli or anticoagulation is contraindicated. Clients should be questioned and should report metallic implants prior to radiologic imaging, specifically MRI. Physical activity should be promoted and clients should avoid crossing legs to promote venous return. Leg pain, numbness, or swelling indicate impaired neurovascular status distal to the insertion site and should be reported immediately

Diabetic autonomic neuropathy

Diabetic neuropathy is caused by nerve damage as a result of metabolic disturbances associated with diabetes. Autonomic neuropathy is nerve damage to the ANS, the system responsible for involuntary body functions, such as blood pressure, heart rate, perspiration, sexual function, and digestion. Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension, tachycardia, painless MI, bowel incontinence, diarrhea, urinary retention, and hypoglycemic unawareness. Clients with suspected DAN should have their BP checked sitting and standing

Digoxin

Digoxin is a cardiac glycoside that increases cardiac contractility but slows the heart rate and conduction. It is used in heart failure (to increase CO) and atrial fibrillation (to reduce HR). The drug is excreted almost exclusively by the kidney. BUN and creatinine levels are measurements of kidney function. Elderly clients tend to develop age-related decrease in GFR. These clients and those with obvious kidney injury (possibly due to diabetes) can accumulate digoxin. Early symptoms of toxicity are nausea and vomiting. My also have lethargy, fatigue, weakness, confusion. Visual symptoms can include alterations in color vision, blind spots, or blindness. Later signs of toxicity are arrhythmias, including heart blocks. Therefore, clients at risk for digoxin toxicity require regular drug level monitoring and dose adjustment Safe to administer drug when HR >60 Digoxin levels need to be monitored in these patients as well as potassium due to risk for hypokalemia potentiating digoxin toxicity. However, client does not need to increase potassium intake just because they are on digoxin. If they take some other potassium-depleting meds (diuretics), supplemental potassium may be needed. Digoxin therapeutic range: 0.5-2.0

Cauda equina syndrome

Disorder that results from injury to the lumbosacral nerve roots (L4-L5) causing motor and sensory deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia (motor weakness/loss of sensation in inner thighs and buttocks), and bowel and bladder incontinence. Cause equina syndrome is a medical emergency and requires urgent reduction of pressure on the spinal nerves to prevent permanent damage. This client displays characteristic late signs of cauda equina syndrome, therefore the nurse should assess them first.

Neurogenic shock

Disruption of sympathetic nervous system -> loss of sympathetic tone -> venous and arterial dilation -> decreased venous return -> decreased stroke volume ->decreased CO -> decreased cellular oxygen supply -> impaired perfusion -> impaired cellular metabolism The imbalance of activity between the SNS and PNS results in massive vasodilation and pooling of blood in the venous circulation, causing hypotension and bradycardia, the characteristic manifestations of neurogenic shock

Chicken pox

Do NOT use aspirin. Supportive treatment includes antihistamines and acetaminophen

Long term corticosteroid replacement

Do not DC glucocorticoid therapy abruptly - can lead to Addisonian crisis Report any signs and symptoms of infection to HCP immediately. Corticosteroids cause immunosuppression and can mask signs of infection Increase dose of corticosteroid during times of stress - stress response can cause a sudden decrease in cortisol levels, triggering Addisonian crisis Side effect is hyperglycemia Corticosteroids are catabolic to bone (osteoporosis) and muscle (muscle weakness). A diet high in calcium and protein but low in fat and simple carbs is recommended. Cataracts are a side effects of corticosteroids. Make an optometrist appointment yearly Can cause gastric irritation and should not be taken on an empty stomach Develop a regular HCP-approved exercise program

Cirrhosis pruritus

Due to buildup of bile salts beneath the skin. Clients with cirrhosis are at increased risk for skin breakdown due to the development of edema, which increases skin fragility and impedes wound healing, and the loss of muscle and fat tissue from pressure points (heels, sacrum) Cut nails short and wear cotton gloves or long-sleeved shirts to avoid injury to the skin from scratching. Other comfort measures include baking soda baths, calamine lotion, and cool, wet cloths, which cool and soothe the irritated skin

Inflammatory bowel disease

Due to inflammatory nature of the disease, erythrocyte sedimentation rate, C-reactive protein, and white blood cells can be elevated. Mild to moderate anemia is also expected. Client may take sulfasalazine to relieve symptoms, which carries a risk of dehydration and the formation of crystals in the kidney.

Rh alloimmunization

During pregnancy, the mother and fetus have separate blood supply mechanisms. However, disruption of this separation can occur at delivery or when trauma results in fetomaternal hemorrhage (placental abruption after a motor vehicle collision. If an Rh negative mother is exposed to Rh positive blood, the pregnant client can develop antibodies to the Rh antigen, placing the current fetus and all future pregnancies at risk for serious complications (hemolytic anemia). An indirect Coombs test is performed to screen for Rh sensitization any time hemorrhage secondary to placental abruption is suspected RhoGAM is administered to all Rh-negative pregnant clients at 28 weeks gestation and within 72 hours postpartum as well as after any maternal trauma, to prevent the development of permanent Rh antibodies. Not effective once sensitization occurs

Testicular torsion

Emergency condition in which blood flow to the testes has stopped. The testicle rotates and twists the spermatic cord, initially causing venous drainage obstruction that leads to swelling and severe pain. Arterial blood supply is subsequently interrupted, resuling in testicular ischemia and necrosis, which require surgical removal of the testis. The condition can be diagnosed with ultrasound. There is a short time frame in which testicular torsion can be treated (to untwist the rotation), generally 4-6 hours, making this condition a priority

Lumbar puncture

Empty bladder before procedure Patient placed in lateral recumbent position or sitting upright. Help widen the space between vertebrae Needle will be inserted between L3/L4 or L4/L5 May have pain radiating down leg, but it should be temprorary After the procedure: lie flat with no pillow for at least 4 hours to reduce chance of spinal fluid leak and resultant headache. Increase fluid intake for at least 24 hours to prevent dehydration If increased ICP is expected, must perform a CT scan before the lumbar puncture because the puncture could cause brain herniation with increased ICP or mass lesions

Mental status changes

Encompasses a sudden onset of new behaviors such as restlessness and confusion. Clients with dementia are expected to be in an alert but disoriented state. However, restlessness and confusion are changes in mental status that deviate from the normal presentation in this client. Such changes are often the only symptoms of illness in an elderly client with dementia who also has conditions such as pneumonia or UTI. Other considerations for a sudden change in mental status include hypoxia, hypoglycemia, and stroke

SIADH

Endocrine condition in which ADH hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia. Hyponatremia can cause seizures, confusion, or other neurologic conditioning. Important to institute seizure precautions. Treatment: Fluid restriction to <1000 mL/day Salt tablets to increase serum sodium Hypertonic saline during first few hours for clients with markedly decreased sodium and severe neurologic manifestations Vasopressin (ADH) receptor antagonists so they will release more water Strict I&O

Anaphylactic shock

Ensure patent airway, administer oxygen Remove insect stinger IM epinephrine stimulates both beta and alpha adrenergic receptors and dilates bronchial smooth muscle and provides vasoconstriction. The IM route is better than subq. Repeat every 5-15 minutes. Place in recumbent position and elevate legs Maintain blood pressure with IV fluids, volume expanders, or vasopressors Bronchodilator such as albuterol is administered to dilate the small airways and reverse bronchoconstriction Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus Corticosteroids administered to decrease airway inflammation and swelling associated with the allergic reaction Anticipate cricothryotomy or tracheostomy with severe laryngeal edema

Tripod position

Epiglottis is caused by Hib and inflames the tissues surrounding the epiglottis - edema can develop in as quickly as a few minutes and obstruct the airway. The tripod position (sit with trunk leaning forward, mouth open, and neck and chin extended) will help to open the airway

Signs of hypoglycemia

Epinephrine is released during hypoglycemic reaction and may cause early symptoms such as trembling, palpitations, anxiety/arousal, and restlessness. Diaphoresis and pallor are present upon examination. When the brain is deprived of glucose due to prolonged and severe hypoglycemia, neuroglycopenis symptoms (confusion, seizures, coma) develop

TNF inhibitor drugs

Etanercept, infliximab, adalimumab block the action of TNF, a mediator that triggers cell-mediated inflammatory response in the body. These drugs reduce manifestations of rheumatoid arthritis and slow the progression of joint damage by inhibiting the inflammatory response. The medication causes immunosuppression and increased susceptibility for infection and malignancies. Patients should have a baseline TB skin test before initiating therapy and yearly skin tests thereafter. Those with latent TB must be treated with anti-tubercular agents before initiating treatment with these drugs

Contraction stress test

Evaluates fetal well being under stress by identifying uteroplacental insufficiency. Uterine bloodflow is decreased during uterine contractons, which stresses the fetus during labor. Contractions are stimulated using either oxytocin administration or nipple stimulation. A fetal tracing is evaluated until 3 uterine contractions lasting 40-60 seconds are captured within 10 minutes. A negative test has no late or variable decelerations and is associated with good fetal outcomes. A positive test includes late decelerations with >50% contractions. A suspicious or equivocal test includes variable or prolonged decelerations or later decelerations with <50% contractions. A CST may be combined with a non stress test to further evaluate fetal well-being. A negative CST with a reactive NST provides strong reassurance of fetal well being.

Small bowel follow through

Examines the anatomy and function of the small intestine using x-ray images taken in succession. Barium is ingested, and x-ray images are taken every 15-60 minutes to visualize the barium as it passes through the small intestine. This can identify increased motility, decreased motility, fistulas, or obstruction Must fast 8 hours before Usually takes 60-120 minutes, but can take longer with obstruction or decreased motility Stools will be white and chalky for 24-72 hours following. IF brown stools do not return after 72 hours or abdominal pain and fullness are present, contact HCP

Dietary sources of folic acid

Excellent: asparagus, turnips, fortified breakfast cereal, cooked dried beans, liver Good: broccoli, spinach, green peas, fresh-cooked beets, fortified pasta, rice Other: tomato juice, oranges, sunflower seeds, peanut butter, enriched bread

Cushing Syndrome

Excess corticosteroids - either corticosteroid therapy or too much ACTH - too much cortisol Acne, hirsutism, menstrual irregularities, truncal obesity, hypertension, hyperglycemia, moon face, buffalo hump. Hematological changes are possible and include easy bruising, purple striae, and skin atrophy; these result from loss of collagen, proximal muscle weakness and bone loss

Crutches

Excessive and prolonged pressure on the axillae can cause localized damage to the radial nerve at the axilla. This leads to a reversible condition known as crutch paralysis, or palsy, which manifests as muscle weakness and/or sensory symptoms (tingling, numbness) of the arm, wrist, and hand. It is caused by crutches that are too long or by leaning on the top of the crutches when ambulating. Therefore, clients are taught to support body weight on the hands and arms, not the axillae, when ambulating to ensure that there is a 1-2 inch space between the axilla and the crutch pad.

Narcissistic personality disorder

Exhibits a recurrent pattern of grandiosity need for admiration and lack of empathy. May project a picture of superiority, uniqueness, and independence that hides their true sense of emptiness. Individuals with NPD have a fragile and damaged ego resulting from childhood environment of inferiority, poor self-esteem, and severe self-criticism. Narcissistic characteristics form as a way to regulate self-esteem and protect the ego from further injury

Isotonic fluids

Expand only extracellular fluid and are used as fluid replacement for fluid volume deficit. Common examples are normal saline and LR. Delay in cap refill can be indicative of dehydration Clients in labor usually receive 500-1000 mL of isotonic fluids prior to an epidural anesthesia as vasodilation below the epidural site can occur and result in hypotension. Hyperemesis gravidarum is severe vomiting that can result in dehydration with low urinary output and tachycardia

Lactose intolerance

Experience varying degrees of GI symptoms after ingesting milk products, including flatulence, diarrhea, bloating, and cramping. This is due to deficiency of the enzyme lactase, which is required for digestion of lactose. Treatment includes restricting lactose-containing foods in the diet. These clients may also take enzyme replacements to decrease symptoms. Supplementation of calcium and vitamin D is recommended due to insufficient intake of fortified milk. Milk and ice cream contain the highest amounts of lactose and should be restricted depending on the client's individual tolerance. Some dairy products, including aged cheeses and live-culture yogurts contain little to no lactose and can be tolerated by most clients with lactase deficiency

Teletherapy

External beam radiation therapy - clients often experience significant effects to the skin of the treatment area. Teaching essential skin care is focused on preventing infection and promoting healing of the affected skin Protect skin from infection by not rubbing, scratching, or scrubbing. Wear soft, loose-fitting clothes, use soft cotton bed sheets, pat skin dry after bathing, avoid applying bandages or tape to affected area Cleanse skin daily by taking a lukewarm shower - use mild soap without fragrance or deodorant. Do not wash off any radiation ink markings Use only creams and lotions provided by the HCP - avoid OTC creams, oils, ointments or powders Shield skin from the effects of the sun during and after treatment Avoid extremes in skin termpearture - no ice packs or heating pads

Primary open angle glaucoma

Eye condition characterized by an increase in intraocular pressure and gradual loss of peripheral vision (tunnel vision). This is due to obstruction of outflow of aqueous humor and is the most common type. The signs/symptoms of POAG develop slowly and include painless impairment of peripheral vision with normal central vision, difficulty with vision in dim lighting, increased sensitivity to glare, and halos observed around bright lights. POAG can lead to blindness if left untreated. Will need to take beta blockers and carbonic anhydrase inhibitors (decrease production of aqueous humor). May also be corrected with surgery

GCS

Eye opening: 4- Spontaneously 3 - To speech 2 - To pain 1 - None Verbal response: 5 - Oriented 4 - Confused 3 - Inappropriate 2 - Incomprehensible 1 - None Motor response: 6 - Obeys commands 5 - Localizes to pain 4 - Withdraws from pain 3 - Flexion to pain 2 - Extension to pain 1 - None Max score 15

Fasting

Fasting for more than 1 or 2 days cause a number of health problems: Increased stress: when fasting, body goes into starvation mode, metabolism slows down and cortisol production increases Muscle damage: body breaks down muscle and converts amino acid to glucose Fluid loss: glycogen stores in the liver are also broken down as energy source; this releases water resulting in fluid loss Increased hunger: appetite hormones are suppressed during fast, however, when regular eating habits are resumed, appetite will be increased Depletion of essential nutrients Fatigue, headache, dehydration, dizziness, and muscle weakness

Agoraphobia

Fear and anxiety about being in or anticipating certain situations or physical spaces. They are highly concerned about having trouble escaping or getting help in the event of a panic attack or panic symptoms. The primary psychological need in agoraphobia is to avoid panic, and individuals with this condition will engage in various behaviors to lessen anxiety and avoid specific situations. In severe, agoraphobia, the individual may become homebound, not going to public places for fear of experienced panic attack that may cause them to become embarrassed or perform an uncontrollable act. The will fear: outside the home alone in a crowd or standing in line travelling in a bus, train, car, ship, or airplane on a bridge or tunnel open spaces (parking lots, marketplaces) enclosed spaces (theaters, concert halls, stores)

Breast cancer risk factors

Female sex and age >50 First degree relative with hx of breast cancer BRCA1 and BRCA2 genetic mutations Personal hx of endometrial or ovarian cancer Menarche before age 12 or menopause after age 55 Hormone therapy with estrogen/progesterone (increased if taken after menopause) Postmenopausal weight gain and obesity as fat cells store estrogen Hx of smoking and alcohol consumption Dietary fat intake Sedentary lifestyle

Nitrazine paper test

Fern tests used to asses for presence of amniotic fluid leaking. Positive amniotic fluid when ferning pattern is seen under a microscope and pH strip turns blue (basic)

Fetal movement and uterine growth

Fetal movement is felt around 18-20 weeks gestation FHR is detectable around 10-12 weeks Fundal height corresponds roughly with the week of pregnancy. 24 centimeters above the pubic symphysis = 24 weeks Urinary frequency is a common symptom in the first trimester

Signs of transfusion reaction

Fever, chills, nausea, vomiting, pruritus, hypotension, decreased UO, back pain, and dyspnea. Stop transfusion immediately Using new tubing, infuse normal saline to keep vein open Continue to monitor hemodynamic status and notify HCP and blood bank Administer any emergency or prescribed meds to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids Collect a urine specimen to be assessed for hemolytic reaction Document the occurrence and send remaining blood and tubing set back to blood bank

Erythema infectiosum

Fifth disease ("slapped face") is a viral illness caused by human parvovirus and affects mainly school-aged children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces. The child may have general malaise and joint pain that are typically treated with NSAIDs. Affected children typically recover quickly, within 7-10 days. Once they develop symptoms, they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition

Bowel irrigation procedure

Fill irrigation chamber with 500-1000 mL of lukewarm water, flush irrigation tubing, and reclamp; hang the container on a hook or IV pole Instruct client to sit on the toilet, place the irrigation sleeve over the stoma, extend sleeve into toilet, and place the irrigation container approximately 18-24 inches above the stoma Lubricate cone-tipped irrigator, insert con and attached catheter gently into the stoma, and hold in place Slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes. Clamp tubing if cramping occurs, until it subsides Once the desired amount of solution is instilled, the cone is removed and the feces is allowed to drain through the sleeve into the toilet

Orthostatic vital signs

First done supine, then sitting, then standing with 2 min in between each position change. Positive orthostatic VS are present when systolic BP drops by 20 mmHg or diastolic BP drops by at least 10 mmHg Pulse usually rises 20 bpm Symptoms: dizziness, weakness, blurred vision, syncope WIll receive isotonic solutions

Impaled objects

First responders should not manipulate or remove the impaled object. Manipulation or removal may cause further trauma and bleeding; therefore stabilization of the object is the first priority to prevent it from moving during initial client assessment and later during transport to a facility. Exception: first responders may remove the object if it obstructs the airway and prevents effective CPR

Propylthiouracil and methimazole

First-line antithyroid drugs that inhibit thyroid hormone synthesis

Metronidazole

Flagyl. Clients should avoid drinking alcohol for 24 hours. Medication has a metallic taste and may turn the urine deep red-brown

Virchow triad

Flow/stasis Endothelial damage Hypercoagulable state Risk factors for DVT: Trauma (endothelial injury and venous stasis from immobility) Major surgery Prolonged immobilization (stroke, long travel) Pregnancy (induced hypercoagulable state and some venous stasis by pressure in vena cava) Oral contraceptives Underlying malignancy (estrogen is a thrombotic) Smoking (endothelial damage) Old age Obesity and varicose veins (venous stasis) Myeloproliferative disorders (increase blood viscosity)

Levofloxacin

Fluoroquinoline used to treat UTIs - has no known cross-sensitivity with penicillin Fluoroquinolines should be taken 2 hours before consumption of antacids, iron supplements, multivitamins with zinc, or sucralfate. They bind up to 98% of the drug and make it ineffective

Sucralfate

Forms a protective layer in the GI mucosa to treat and prevent stomach/duodenal ulcers Prescribed 1 hour before meals and at bedtime - taken on an empty stomach. Binds with many other medications (digoxin, warfarin, phenytoin) and reduces their bioavailability. Other meds should be given 1-2 hours before Sucralfate works better in a lower pH, therefore antacids or other acid-reducing medications should not be taken 30 minutes before or after taking sucralfate to avoid altered absorption

Hepatic encephalopathy

Frequent complication of liver cirrhosis due to accumulation of ammonia in the blood. Clinical manifestations: sleep disturbances, lethargy, coma, altered mental status, client not oriented. Characteristic finding is asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists. Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts.

Alternative medicine therapies

Garlic application: placing crushed garlic directly on skin is thought to heal infections but can cause dermatitis and burns on the wrists. Cupping: used by many cultures to remove illness from the body. Mouth of a steam-filled cup is placed on the skin, causing circular bruised blemishes. Coining: believed by some cultures to remove illness from the body. A rounded surface (coin or spoon) is firmly stroked on the lubricated skin of the back and can produce weltlike linear lesions.

Functional disorders

General diagnosis for a genuine medical issue that medical science does not yet fully understand. Examples include epilepsy and migraines

Diagnostic testing for TB

If a client has a positive screen (skin test or Quantiferon), they must have an early morning sputum sterile specimen collection on 3 consecutive days to do a culture. This will confirm if it is an active case of TB

Failure to thrive

Generally defined as weight less than 80% of ideal for age and/or depressed weight for length, correcting for gestational age, sex, and special medical conditions. The underlying cause of FTT is inadequate dietary intake; contributing factors include a disturbance in feeding behavior and psychosocial factors. Observing the child feeding or when hungry will provide the nurse the opportunity to identify potential factors contributing to insufficient intake. The nurse can observe the type of food being offered, the quantity of food consumed, how the child is held or positioned while being fed, the amount of time for feeding, the parent's response to the child's cues, the tone of feeding, and the interaction between the child and the parent. Other contributing factors include: Poverty Social or emotional isolation - parents may lack the support system needed to assist them with the problems of child rearing Cognitive disability or mental health disorder Lack of nutritional education Young parental age Unplanned or unwanted pregnancy Single-parent home Chronic life stresses/anxiety in home Disordered feeding techniques: prolonged breast or bottle feeding, unstructured meal times, negative or difficult interactions at meal time, poor parental feeding skills, negative attitudes toward food (fear of obesity) Substance abuse Domestic violence Parents who have negative perception of child

Von Willebrand disease

Genetic bleeding disorder caused by deficiency of von Willebrand factor, which plays an important role in coagulation. Intranasal desmopressin or topical therapies (thrombin) may be prescribed to stop minor bleeding, whereas major bleeding may require replacement of vWF. Clients should wear medical alert bracelets in case of emergency.

Chest tube drainage unit

Gentle continuous bubbling in the suction control chamber indicates that the suction is present and the unit is functioning appropriately. The nurse should document the finding and continue to monitor. An air leak would cause bubbling in the air leak gauge or water seal chamber not in the suction control chamber

Advance directives

Give people the chance to make decisions about their medical treatment ahead of time in case they are unable to personally make their wishes known. 2 most common forms are living wills and durable power of attorney. Clients in coma (GCS <7) or with expressive aphasia would need an advance directive to make treatment decisions because they cannot directly express their wishes. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbal and written expression

Erythropoietin

Given to clients with anemia associated with chronic kidney disease. Therapy is initiated when Hgb is <10 and should be discontinued when >11 to prevent venous theomboembolism and adverse cardiovascular outcomes from blood thickened by RBCs HTN is a major adverse effects of erythropoietin. Therefore, uncontrolled HTN is a contraindication of this medication. Must check BP before administering. E-poietin is administered IV or subq Must have adequate stores of iron for the medication to work, so it is often prescribed with an iron supplement

Mass casualty events

Goal is greatest good for greatest number of people. Immediate: life-threatening injuries with good prognoses after minimal intervention - airway obstruction, open long-bone fractures, second or higher degree burns covering 15-40% BSA Delayed: requiring treatment within hours (stable abdominal wounds, soft-tissue injuries) Minimal: requiring treatment within a few days (minor burns or fractures, small lacerations) Expectant: extensive injuries, poor prognosis regardless of treatment (C1-C2 spinal cord injuries)

Grapefruit and medications

Grapefruit inhibits enzyme CYP3A4. Drugs metabolized by the same pathway would not be metabolized, resulting in higher drug levels and serious side effect. CCB use with grapefruit juice can cause severe hypotension; some statins may result in myopathy

Cardiomyopathy

Group of diseases in which the heart muscle has a reduced ability to pump blood effectively, placing clients at risk for cardiogenic shock. Cardiogenic shock is manifested as reduced CO (hypotension, narrow pulse pressure) which can lead to pulmonary edema (tachypnea, bibasilar crackles, decreased O2 saturation) caused by blood backing up into the pulmonary capillaries. To compensate, catecholamines (epinephrine) and vasopressin are released by the adrenal glands to increase CO. However, this compensatory mechanism eventually fails, causing decreased perfusion and oxygenation of tissues as well as death. The client may need additional support with inotropic agents in these situations

Statins

HMG-CoA reductase inhibitor, prescribed to lower cholesterol and reduce the risk of atherosclerosis and CAD. A serious adverse effect of statins, including atorvastatin and rosuvastatin is myopathy with ongoing generalized muscle aches and weakness. A client who develops muscle aches while on a statin drug should call the HCP who will then obtain a blood sample to assess the creatine kinase level. If myopathy is present, CK will be significantly elevated (>10x normal) and the drug will then be discontinued

Administering tube feedings

HOB elevated 30 degrees and for 30-60 min afterward, thereby decreasing aspiration risk Gastric residuals should be checked every 4 hours with continuous feeding or before each intermittent feeding and med administration. Continuing feedings despite a large volume residual increases the clients risk for emesis and aspiration. You should not start a feeding unless you get a residual >100 mL first. Flush the tube before and after bolus feedings to keep the tube patent and avoid contamination of the stagnant feeding solution. Aspirated volume should be returned to the stomach. Gastric pH should be acidic <5

Paroxysmal SVT

HR can be 150-220/min. With prolonged episodes, the client may experience evidence of reduced CO such as hypotension, palpitations, dyspnea, and angina Treatment includes Vagal maneuvers such as Valsalva, coughing, and carotid massage. Adenosine is the drug of choice for PSVT treatment. Due to its very short half life, adenosine is administered rapidly via IVP over 1-2 seconds followed by a 20 mL saline bolus. An increased dose may be given twice if previous administration is ineffective. Beta blockers, CCBs, and amiodarone can also be considered as alternatives. If Vagal maneuvers and drug therapy are unsuccessfuly, synchronized cardioversion may be used.

OTC medications with HTN

HTN clients should be instructed not to take potentially high-risk OTC medications such as high-sodium antacids, appetite suppressants, and cold and sinus preparations It is appropriate to ask a client with HTN about taking OTC cold medications because they normally have phenylephrine or pseudoephedrine. These sympathomimetic decongestants cause vasoconstriction, which is what relieves nasal congestion. This would raise their BP and can cause hypertensive crisis

Fat embolism syndrome

Has no specific treatment. When long bone is fractured, pressure within the bone marrow releases fat globules into the bloodstream. These combine with platelets and can travel to the brain, lungs, and kidneys leading to small-vessel occlusion and tissue ischemia. Early stabilization of the injury and surgery as soon as possible to repair the long bone fractures is recommended to reduce further complications Signs include altered mental status, respiratory distress, and petechiae across chest, axillae, and soft palate

Asthma and NSAIDs

Have the potential to cause problems for clients with asthma. Ibuprofen and aspirin are common OTC drugs. 10-20% of asthmatics are sensitive to these medications and can experience severe bronchospasm after ingestion. This is prevalent in clients with nasal and polyposis

Pediculosis capitis

Head lice Apply pediculocide and remove nits with comb every 2-3 days for 2 weeks. Carpets, rugs, and upholstered surfaces should be vacuumed frequently. Client's bedding should be washed in hot water and dried on hottest setting. Non-washable items can be sealed in a plastic bag for 2 weeks to kill lice. All brushes, combs, and ornaments should be soaked in boiling water for 10 minutes or lice-killing products for 1 hour

Diastolic murmur

Heard in mitral stenosis and aortic regurgitation

Hearing impairment

Hearing impairment in children may be related to family history, an infection, use of certain meds, or congenital disorder. Toddlers with hearing deficits may appear shy, timid, or withdrawn, often avoiding social interaction. They may seem extremely inattentive when given directions and appear dreamy. Speech is usually monotone, difficult to understand, and loud. Increased use of gestures and facial expressions is also common. Children typically begin to use well-formed syllables by age 7 months such as mama and dada. A referral for a hearing test should be made if there is an absence of well-formed syllables by age 11 months or intelligible speech is not present by 24 months

Pursed-lip breathing

Helps to decrease SOB by preventing airway collapse, promoting CO2 elimination, and reducing air trapping in clients with COPD. Taught to use this technique when experiencing dyspnea as it increases ventilation and decreases work of breathing. Regular practice (5-10 min 4 times daily) enables client to do pursed lip breathing when short of breath, without conscious effort. Inhale for 2 seconds through the nose with mouth closed Exhale for 4 seconds through the mouth with pursed lips Exhale twice as long as inhaling

Atypical presentation of large PEs

Hemodynamic instability (right ventricular dysfunction, pulmonary HTN, systemic hypotension, syncope, LOC, distended neck veins)

Physiological anemia of pregnancy

Hemoglobin can drop to 11. Due to increased oxygen requirements of pregnancy, the RBC count increases 30%. However, anemia can result from an increase in plasma volume that is relatively larger than the increase in RBCs. Lowered maternal hemoglobin is within the expected range

Licorice root

Herbal remedy sometimes used for GI disorders such as stomach ulcers, heartburn, colitis, and chronic gastritis. Clients with heart disease or hypotension should be cautious about using licorice root. When used in combination with a diuretic such as hydrochlotorhiazide, it can increase potassium loss, leading to hypokalemia, which can cause dangerous cardiac dysrhythmias. Thiazides are considered potassium wasting diuretics, so this client is already at risk for hypokalemia. The addition of licorice root could potentiate potassium loss. The nurse should discourage the client from using this herbal remedy

Hemophilia

Hereditary bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention, including: Avoid meds such as ibuprofen and aspirin that have platelet inhibition properties Avoid IM injections- can give vaccines subcutaneously. Hold firm pressure for 5 minutes and apply ice if superficial bleeding is noted to promote vasoconstriction Avoid contact sports and safety hazards and use protective equipment Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be used MedicAlert bracelets should be worn at all times Symptoms include hemarthrosis or spontaneous bleeding into the joints, especially the knee, ankle, or elbow. Desmopressin stimulates the release of factor VIII

Hypertonic feeding

Higher osmolality sometimes causes nausea, vomiting, or diarrhea, especially during the initiation of total enteral nutrition. The GI tract will pull fluid from the surrounding intra and extravascular compartments to dilute the formula, making it similar to body fluid osmolality. This process is similar to dumping syndrome and may cause temporary diarrhea with cramps, nausea, and vomiting. Slowing down the rate of administration will usually alleviate these problems. The feeding can gradually progress to the established goal rate

Stress incontinence

Highest priority for a client newly diagnosed with stress incontinence is preventing skin breakdown and UTIs through bladder training. Teaching the client to empty the bladder every 2hours when awake and every 4 hours at night reduces these risks Pelvic floor exercises which strengthen the sphincter and structural supports of the bladder are an essential part of the teaching plan but are not the priority for this client. It will take approximately 6 weeks for pelvic floor muscle strength to improve Caffeine and alcohol should be eliminated Pessaries relieve minor pelvic organ prolapse and may be used in some clients when initial conservative measures fail. This client should receive initial instruction on the importance of emptying the bladder often.

How to facilitate secretion removal with pneumonia

Hydration - IV fluids, respiratory humidification Huff coughing technique Chest physiotherapy Fowlers position Do not position on side, however if you do, position on the unaffected side because it will increase ventilation to perfusion ratio due to gravity and improves oxygenation.

Thiazide diuretics

Hydrochlorothiazide and chlorthalidone are thiazide diuretics that treat HTN. Common side effects: Hypokalemia (muscle cramps) Hyponatremia (altered mental status and seizures) Hyperuricemia (worsened gout attacks) Hyperglycemia (adjustment of diabetic meds) Photosensitivity

Pyloric stenosis

Hypertrophied pyloric muscle causes postprandial vomiting secondary to obstruction at the gastric outlet. An olive-shaped mass may be palpated in the epigastric area just to the right of the umbilicus. Emesis is nonbilious and leads to progressive dehydration. Infants will be hungry constantly despite regular feedings. A hematocrit of 57% is elevated and indicative of hemoconcentration caused by dehydration/ Elevated blood urea nitrogen is also a sign of dehydration. The patient would have metabolic alkalosis and hypokalemia

Near drownings

Hypothermia is generally seen in near-drowning victims. The first goals of treatment are to warm the client. This is done using warmed IV fluids, blankets, and air. Sustained hypothermia will eventually lead to organ failure, making this an urgent finding but not initially life-threatening. A weak and thread pulse is generally detected in near-drowning victims due to hypothermia. When wheezing is heard on auscultation after a near-drowning, the first observation would be that the client is still moving air and providing oxygen to the body. If the client has aspirated fluid, crackles would be heard. Most clients with this will develop ARDS

What to do if chest tube disconnects from drainage unit

If the chest tube disconnects from the drainage tubing without contamination, wipe the end of the chest tube with an antiseptic and immediately reconnect it. If the chest tube is disconnected with contamination and cannot be immediately reattached, or if the chest drainage unit breaks, cracks, or malfunctions, submerge the distal end of the chest tube 1-2 in below the surface of a 250 mL bottle of sterile water or saline. This creates an immediate water seal and prevents air from entering into the pleural space as the new chest tube drainage system is established. Emergency equipment should be kept at the bedside, including 2 chest tube clamps, a 250 mL bottle of saline, and antiseptic wipes Clamping briefly is allowed when checking for an air leak in the system or when changing the drainage unit

Azathioprine

Immunosuppressant drug that can cause bone marrow depression and increase the risk for infection. It is prescribed to treat autoimmune conditions such as IBS and to prevent organ transplant rejection. Fatigue and nausea can be expected as minor adverse effects or may be associated with the disease. Leukopenia can be a severe adverse effect of the drug and should be reported to the healthcare provider administering the medication.

Proton pump inhibitors

Impair intestinal calcium absorption and therefore are associated with decreased bone density, which increases possibility of fractures of the spine, hip, and wrist. PPIs cause acid suppression that otherwise would have prevented pathogens from more easily colonizing the GI tract. This leads to increased risk for pneumonia and C-diff.

Heart failure in infants

Impaired myocardial contractility: tachycardia, pale cool extremities, weak peripheral pulses, decreased blood pressure, decreased urinary output, activity intolerance during feeding with infants, weakness/fatigue, loss of appetite Pulmonary congestion: dyspnea, tachycardia, orthopnea Systemic venous congestion: hepatomegaly, peripheral edema (periorbital in children), neck vein distension, weight gain, ascites

Pancreatic enzymes

In CF, unusually thick mucus obstructs the pancreatic ducts, preventing pancreatic enzymes from reaching the small intestine. The result in malabsorption of carbs, fats, and proteins, the inability to absorb fat-soluble vitamins (ADEK). GI signs and symptoms include flatulence, abdominal cramping, ongoing diarrhea, and/or steatorrhea. Must administer pancreatic enzymes with or just before every meal or snack. These enzymes are enteric-coated beads designed to dissolve only in alkaline environments similar to the small intestine. They must not be mixed with a substance that would cause them to dissolve prior to reaching the jejunum. Capsule contents may be sprinkles on applesauce, yogurt, or acidic, soft, room temperature foods with pH <4.5. Capsules should be swallowed whole and not crushed or chewed; chewing the capsules may irritate oral mucosa. Excessive intake of pancreatic enzymes can result in fibrosing colonopathy. Capsules should not be taken with milk, as they can cause milk to curdle.

Risks for PTL

Infection: periodontal disease, UTIs. Infection causes release of prostaglandins, which are uterotonic and contribute to cervical softening Previous PTL Previous cervical surgery - cone biopsy Tobacco or illicit drug use Maternal ages <17 or >35 Maternal undernutrition Non-Hispanic black women have highest rate of PTL

Mal de ojo

In Latin American culture, an illness called mal de ojo is believed to be cause when a stranger or someone perceived as powerful compliments a child. The illness or curse is usually manifested by vomiting, fever, and crying. The mal de ojo curse can be broken if the admirer touches the child while speaking to the child or immediately afterward. Mexican American mothers worry when strangers compliment their babies without touching. To protect against this, the child may wear charms or beaded bracelets The parents may consult a traditional healer, or curandero, who may perform rituals meant to cure the child of the curse.

Rectal suppositories in children

In children younger than 3 years, suppositories are inserted with fifth finger of the nurse's gloved hand. Position patient supine with knees and feet raised. Lubricate with water-soluble jelly (petroleum based will reduce absorption). Insert suppository past internal sphincter - angle suppository and guide it along the rectal wall. Hold buttocks together for several minutes, or until the urge to defecate has passed.

Rib fractures

In the absence of significant internal injuries (pneumothorax, pulmonary contusion, spleen laceration), interventions focus on pain management and pulmonary hygiene techniques (coughing, deep breathing, incentive spirometry) Breaths may become shallow as the client experiences pain with inspiration, which can result in a buildup of secretions, atelectasis, and pneumonia. The nurse should ensure adequate pain control prior to encouraging pulmonary hygiene techniques

Chronic heart failure

Inability of the heart to fill and pump blood effectively to meet the body's oxygen demands. As a result, clients can develop dilutional hyponatremia. Should question isotonic solutions as this client is already fluid overloaded. Require a low salt diet and fluid restriction. If taking furosemide, will need potassium replacements

Vaginal discharge at end of pregnancy

Increases at the end of pregnancy and may become mucoid and blood-tinged (pink/brownish) in the days preceding labor. This assessment finding may be a sign of approaching labor in this client at term gestation

Digoxin in children

Increases myocardial contraction in children with heart failure, which increases CO and tissue perfusion. It has a narrow margin of safety in dosage. Digoxin should be held if HR is <90-110 in infants and young children or <70 in older children Administer oral liquid in the side and back of mouth Do not mix the drug with food or liquids as the refusal to take these would result in inaccurate intake of medication If a dose is missed, do not give an extra dose or increase the dose. Stay on the same schedule If more than 2 doses are missed, notify HCP If child vomits, do not give a second dose. Nausea, vomiting, or slow pulse rate could indicate toxicity - notify HCP Give water or brush the client's teeth after administration to remove the sweetened liquid

Huntington Disease

Incurable autosomal dominant hereditary disease that causes progressive nerve degeration, which results in impaired movement, swallowing, speech, and cognitive abilities. Chorea (involuntary tic-like movement) is a hallmark sign. The onset of active disease is usually at age 30-50, and death from neuromuscular and respiratory complications typically occurs within 20 years of diagnosis HD is confirmed with genetic testing. Clients who have a parents with HD and are considering having children should receive genetic counseling

Spiral fracture

Indicate pressure was applied to the leg in opposite directions (torsion), which is an unlikely accidental injury in a non ambulatory child. Should be reported. After reporting, nurse should: Facilitate a complete physical evaluation Document facts and observations objectively, using medical terms when possible. Include history given by parent or caregiver and the time period from injury occurrence to evaluation. Perform a review of child-care practices with the caregiver

Synchronized cardioversion

Indicated with V-tach with a pulse, SVT, and a-fib with rapid ventricular response The synchronizer switch must be turned on when cardioversion is planned. The synchronize circuit in the defibrillator is programmed to deliver a shock on the R wave of the QRS complex on the ECG. This allows the unit to sense the client's rhythm and time the shock to avoid having it occur during the T wave. A shock delivered during the T wave could cause the client to go into a more lethal rhythm (V-tach, v-fib). If this client becomes pulseless, the synchronize function should be turned off and the nurse should proceed with defibrillation. If the client is awake and hemodynamically stable, sedation is indicated.

Asthma action plan

Individualized management plan developed collaboratively between the client and the HCP to facilitate self-management of asthma. It includes information on daily and long term treatment, prescribed medicines, and when to take them according to a zone system, how to manage worsening symptoms or attacks, and when to call the HCP or go to the emergency department Action plan uses traffic signal colors to categorize into zones degrees of asthma symptom severity and airway obstruction. Green zone: asthma is under control and PEF is 80-100% of personal best. When in this zone, there is no worsening of cough, wheezing, or trouble breathing Yellow zone means caution; even on a return to the green zone after use of a rescue medication, further medication or a change in treatment is needed Red zone indicates a medical alert and signals the need for immediate medical treatment if the level does not return to yellow immediately after taking rescue medications

ECT

Induces generalized seizure by passing an electrical current through the scalp. 15-20 second seizures are proven to help symptoms of depression, bipolar, and schizophrenia. NPO status requires 6-8 hours prior to treatment except for sips of water. Anesthesia is used so they will feel no pain during procedure Driving is not permitted during course of ECT treatment Temporary memory loss and confusion in immediate recovery period are expected Patients are not permitted to take their anticonvulsants prior to treatment as they will interrupt the therapeutic effect of ECT

Infant weight

Infant growth is fast paced during the first year of life, with birth weight doubling by age 6 months and tripling by age 12 months. Length increases by 50% in first year. At birth, head circumference is slightly more than chest circumference, but these equalize by 12 months

Diabetic pregnancy

Infants of diabetic mothers are at risk for hypoglycemia and hypocalcemia. The transitional time is especially high risk fro hypoglycemia as the fetus has produced excess insulin. Hypoglycemia for a newborn is considered <40 and is accompanied by jitteriness, irritability, hypotonia, apnea, lethargy, and temperature instability

Proper car seat and sleeping use

Infants should be placed in a federally approved rear-facing safety seat secured in the back seat of the car. The harness should be snug with the retaining clip secured under the level of the armpits. If the newborn is preterm or small, rolled blankets or car seat inserts on both sides and under the crotch level buckles may be used to support trunk and reduce slouching. Infants should be placed at a 45 degree angle to prevent airway obstruction Safe sleep: supine position is recommended for first few months. Infants should sleep in the crib in clothing such as a sleep sack. These lower the risk of suffocation by keeping the infant warm while preventing the head from being covered. Parents should remove loose bedding and other objects from the crib. Clib slats should be no more than 2 1/4 inches apart to prevent infants head from being lodged in them

Pediculosis pubis

Infestation of pubic lice. Most often passed via sexual contact and feed on human blood for nourishment. Clients with public lice have intense itching in the affected area. The nits are attached to hair shafts and appear as yellow-white ovals. Pubic lice may also infest eyelashes, facial hair, and body hair. May be passed through close contact and sharing of linens. All household members are at risk and should be screened. Use lice treatment shampoo or rinse on pybic and body hair to kil lice After treatment, remove nits with a fine-toothed nit comb, fingernails, or tweezers Wash and dry clothes, towels, and bedding with hot water and highest heat dryer setting Sexual partners should also receive pubic lice treatment

Extravasation

Infiltration of a drug into the tissue surrounding the vein. Norepinephrine is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepi should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until CV access is established. Stop infusion immediately and disconnect IV tubing Use a syringe and aspirate the drug from the IV catheter, remove the IV catheter while aspirating Elevate extremity above the level of the heart Notify HCP and obtain a prescription for the antidote phentolamine, a vasodilator injected subq to counteract the effects of some adrenergic agonists

Bell's Palsy

Inflammation of cranial nerve VII that causes motor and sensory alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation, and taught eye/oral care. In Bell's Palsy, the eyelids do not close properly. This may result in eye dryness and risk of corneal abrasions. However, weakness of the lower eyelid may cause excessive tearing due to overflow in some clients. Facial muscle weakness results in poor chewing and food retention. Client teaching should include: Eye care: use glasses during the day; wear a patch or tape the eyelids at night to protect the exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea Oral care: chew on the unaffected side to prevent food trapping; a soft diet is recommended. Maintain good oral hygiene after every meal to prevent problems from accumulated residual food (parotitis, dental caries) Vision, balance, consciousness, and extremity motor function are not impaired in Bell's Palsy

Bacterial meningitis

Inflammation of the meninges of the brain and spinal cord caused by infection. General manifestations in infants and children age <2 include fever, restlessness, and high-pitched cry. One common acute complication of meningitis is hydrocephalus, an increase in ICP resulting from obstruction of CSF flow. Increased ICP can progress to permanent hearing loss, learning disabilities, and brain damage. Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in children. Frequent assessment for developing complications is vital for any client with suspected bacterial meningitis

Acute pericarditis

Inflammation of the pericardium. Inflammation causes pericardial effusion, a buildup of fluid between the pericardial layers. A serious, sometimes fatal, complication of pericarditis is cardiac tamponade, in which large amounts of pericardial fluid cause the heart to be squeezed and unable to contract effectively. Heart tones become muffled, cardiac output and blood pressure drop, pulse increases, and the client develops JVD, pulsus paradoxus, and narrowed pulse pressure. This emergency requires immediate pericardiocentesis. Clinical manifestations include pain upon deep breathing or in the supine position and is relieved by sitting upright and leaning forward. ST-segment elevation is seen in almost all leads (as the entire pericardium is inflamed). This is in contrast to acute MI, in which ST segment elevation is seen in localized leads (depending on which vessel is occluded). Pericardial friction rub is also an expected finding in pericarditis (high-pitched, leathery, scratchy sound).

Gout

Inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk for kidney damage Clients with medical risk factors (obesity, HTN, dyslipidemia, insulin resistance) and other lifestyle factors (poor diet, alcohol consumption, sedentary lifestyle) have increased risk for future gout attacks. Improvements in uric acid control are often seen when weight loss is accompanied by dietary modifications: Increase fluid intake to help eliminate excess uric acid Implement a low-purine diet, particularly avoiding organ meats (liver, kidney, brain) and certain seafood (sardines, shellfish) Following a healthy, low-fat diet, as excess dietary fats impair urinary excretion of urates Low fat dairy products are good sources of protein that are associated with decreased risk of gout

Ankylosing spondylitis

Inflammatory disease affecting the spine that has no known cause or cure. AS is characterized by stiffness and fusion of the axial joints (spine, sacroiliac), leading to restricted spinal mobility. Low back pain and morning stiffness that improve with activity are the classic findings. Involvement of the thoracic spine (costovertebral) and costosternal junctions can limit chest wall expansion, leading to hypoventilation. Promote extension of the spine with proper posture, daily stretching, and swimming or racquet sports Stop smoking and practice breathing exercises to increase chest expansion and reduce lung complications Manage pain with moist heat and NSAIDs Take immunosuppressant and anti-inflammatory medications as prescribed to reduce inflammation and increase mobility Best to rest during flare ups. Clients with AS are encouraged to sleep on their backs on a firm mattress to prevent spinal flexion and the resulting deformity.

Tiotropium

Inhaled anticholinergic drug that inhibits receptors in smooth muscles of the airways. Prescribed daily for long-term management of bronchospasm in clients with COPD. The powdered medication is contained in a capsule that the client places in an inhaler device. The client inhales the powder. Clients should rinse mouth after using tiotropium to remove any medication remaining in the mouth. Should not be used as a rescue medication because it is taken daily with peak effect of approximately 1 week

Allopurinol

Inhibits uric acid production and improves solubility to prevent gout and renal stones. Should be taken with a full glass of water, and it is very important for the nurse to educate about fluid intake with this medication. This will prevent the formation of renal stones and promote diuresis. Client should report for renal, liver, and blood lab counts regularly. Take med with food to decrease GI irritation. Will not help with an acute gout attack - may take NSAIDs or colchicine for acute attacks If a rash occurs, follow up immediately with HCP as this could turn into life-threatening Steven Johnson syndrome and toxic epidermal necrolysis

Incident reports

Injury to a client caused by medical management rather than a client's underlying condition. It may or may not be preventable. 4 types of errors: Diagnostic: delay in diagnosis, failure to employ indicated tests, failure to act on results of monitoring Treatment: error in performance of procedure, treatment, dose, avoidable delay Preventive: failure to provide prophylactic treatment, inadequate follow up/monitoring of treatment Other: failure of communication, equipment failure, system failure

Meniere disease

Inner ear disorder characterized by vertigo, tinnitus, and muffle hearing. Treatment during an attack includes antihistamines (diphenhydramine, meclizine), antiemetics, anticholinergics (scopolamine), and benzodiazepines (diazepam). Vertigo can be severe and is associated with nausea and vomiting. Clients report feeling being pulled off the ground (drop attacks). May be minimized by staying in a quiet, dark room and avoiding sudden head movements. Should reduce stimulation by not watching television and not flickering lights. Client should be on fall precautions and a salt restricted diet to prevent further fluid buildup in the ear

Reducing exposure to household and environmental allergens

Installing high-efficiency air-filters Keeping windows closed and staying indoors Using hypoallergenic pillow and mattress covers to prevent exposure to dustmites Reducing or eliminating carpet and area rugs from home Regularly mopping hardwood floors and damp dusting furniture May not need to get rid of animals if the child is not allergic. However, may need to bathe the dog and have doormats to eliminate the possibility of dog bringing environmental allergens into the house

Sunscreen use

Instruct clients to avoid sun exposure from 10 AM to 4 PM, apply 20-30 min before going outside, use SPF 15 or 30 minimum and reapply when wet and every 2 hours.

Metabolic syndrome

Insulin resistance syndrome - have an increased risk for diabetes and coronary artery disease. The presence of abdominal obesity causes increased production of insulin. This excess insulin leads to insulin resistance, the primary feature of metabolic syndrome. Metabolic syndrome is characterized by the presence of 3 or more of the following criteria: Increased weight circumference >40 in in men and >35 in in women Increased blood pressure Triglyceride level >150 HDL levels <40 in men and <50 in women Fasting glucose levels >100 or drug treatment for elevated blood glucose. HTN >130/85 or hypertension drug treatment. Fasting BG >100 or hyperglycemia drug treatment

ACE inhibitors and ethnicity

Intractable cough is a common side effect of ACE inhibitors and it is thought to be due to an increase in bradykinin that occurs due to ACE being inhibited and inability of it to convert bradykinin to inactive bradykinin Asians, especially of Chinese descent, have a high risk for ACE inhibitor-related cough Persons of African descent are also at high risk for cough and angioedema

Timeline of infant nutrition

Introduction of solid foods generally occurs at 4-6 months. The process usually starts with a form of iron-fortified infant cereal, such as rice or oatmeal. Cereal can be mixed with breast milk, formula, or water. When introducing new foods, it is important to allow 5-7 days between foods to observe for any allergies to a particular food. Allergic responses often worsen with subsequent exposure, so it is a priority to identify food triggers as soon as possible When an infant reaches 6-8 months, pureed fruits and vegetables are introduced to provide needed vitamins. After introducing purees, it is also appropriate to begin offering simple finger foods, such as teething crackers and small pieces of fruit, soft vegetables, of cheese. These foods help children develop motor skills and learn to chew, even before they have teeth. Cow's milk is not introduced until after first year because it lacks crucial vitamins and minerals for appropriate growth and is also more difficult for an infant to digest

Radioactive iodine uptake test

Involves administering low dose of radioactive iodine, in contrast to radioactive iodine treatment for some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue. The thyroid gland is the only tissue that uses iodine, which is a key component of thyroid hormones. A scan is performed at 2, 6, or 24 hours to assess the areas actively absorbing iodine, which can narrow the diagnosis to hyperfunctioning thyroid disorder (Graves disease) Notify HCP if computerized tomography scan or other recent x-ray using iodine contrast has been performed; the iodine may alter the test results. Antithyroid or thyroid hormone medication should be help 5-7 days before undergoing RAIU test as these can alter the results All premenopausal women should take a pregnancy test, as radioactive iodine can affect the development of the fetal thyroid gland Maintain NPO status for 2-4 hours prior to procedure. Eating may resume 1-2 hours after swallowing iodine; a normal diet can be restarted when the test ends. Remove dentures and jewelry/metal around the neck to allow clear visualization during scan Drink plenty of fluids after procedure to clear RAI from system. Notify HCP if allergic to iodine. However, RAIU tests is generally safe even in the presence of iodine allergy due to the diminutive amount of iodine used Will be awake during the procedure but there should be no discomfort Do not breastfeed immediately after procedure

Arteriovenous fistula

Involves an anastomosis between an artery and a vein. Fistula permits the arterial blood flow through the vein, causing the vein to become larger in diameter and the walls to thicken, enabling blood flow at high pressures. After the AVF is palced, it takes 2-4 months to mature to accommodate the repeated venipunctures necessary for hemodialysis access. Major complications are infection, stenosis, thrombosis, and hemorrhage. Clients should: Report numbness or tingling in the extremity Do not allow anyone except dialysis personnel draw blood or take blood pressure measurements on the extremity to prevent thrombosis Avoid wearing restrictive clothing Do not use arm with vascular access to carry heavy objects, but exercises to increase strength include squeezing a soft ball or sponge several times a day Check the function of the site several times a day by feeling for vibration to assess for patency, stenosis, and clotting Do not sleep on the arm with vascular access or use creams or lotions on the site Monitor for signs of infection Keep site clean

Chronic subdural hematoma

Involves bleeding into the subdural space that can occur several weeks to months following a head trauma. Elderly clients and those taking anticoagulants are at increased risk. Manifestations include headache, gait disturbance, memory loss, decreased LOC. Should be investigated immediately as the condition can lead to increased ICP and death.

Femoral-popliteal bypass

Involves circumventing a blockage in the femoral artery with a synthetic or autogenous (artery or vein) graft to restore blood flow. The nurse performs neurovascular assessments on the affected extremity (pulses, color, skin temp, cap refill, pain, movement) and compares the findings with the preop baselines. A nonpalpable pedal pulse distal to the graft can indicate compromised blood flow or graft occlusion and should be reported to the HCP immediately

Percutaneous kidney biopsy

Involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases. The kidney is a highly vascular organ, therefore uncontrolled hypertension is a contraindication for a kidney biopsy due to the risk for post-procedural bleeding

Kidney biopsy

Involves obtaining a tissue sample for pathological evaluation to determine the cause of certain kidney diseases (nephritis, transplant rejection). The kidney has extensive vasculature (similar to the liver); therefore, bleeding from the biopsy site is the major complication following a percutaneous kidney biopsy. Before the procedure, the client must give informed consent and discontinue all anticoagulants (warfarin, heparin, ribaroxaban) and antiplatelet agents (aspirin, clopidogrel, NSAIDs) for at least one week. The client should be typed and crossmatched for blood (although need for transfusion is rare). Blood pressure should be well controlled. After procedure, VS should be monitored every 15 min for first hour as tachycardia, tachypnea, and hypotension can indicated blood loss. Nurse should also assess puncture site for bleeding. Client should be positioned on the affected side for 30-60 min to provide pressure and help prevent bleeding. Client is usually placed prone during procedure

PVCs

Irregular rhythm with wide, distorted QRS and large inverted T wave PVCs can be associated with stimulants (caffeine), medications (digoxin), heart diseases, electrolyte imbalances, hypoxia, and emotional stress Usually not harmful in a healthy heart. In the client with MI, PVCs indicate ventricular irritability and increase the risk for the rhythm to deteriorate into a life-threathing dysrhythmia (V-tach, V-fib). Treattment is based on the underlying cause (oxygen for hypoxia, reduction of caffeine intake, electrolyte replacement)

Types of solutions

Isotonic crystalloid (0.9% NaCl, LR): osmolality is 250-375; concentration is same as plasma and extracellular fluid. When fluid is infused into extracellular vascular compartment, it remains there because no concentration gradient is present Hypotonic crystalloid solutions (2.5% dextrose and water, 0.45% NaCl): osmolality is less than that of extracellular fluid. When infused into extracellular vascular compartment, body fluid shift out of intravascular compartments into interstitial tissues and cells Hypertonic solutions: (dextrose 5% and 0.9% NaCl, 5% dextrose and LR) and colloid solutions (dextran, albumin): osmolality is more than that of extracellular fluid. When infused into vascular compartment, body fluids shift from intracellular compartment to extracellular vascular compartment. Albumin would be used with increased fluid in interstitial spaces (cirrhosis and ascites) NOTE: Dextrose 5% starts off as a hypertonic solution, but when the water is metabolized, it becomes hypotonic. It can cause a fluid shift of the fluid into the extravascular compartment, which may cause further hypotension in clients with low blood pressure. Hypotonic solutions are typically used to treat hypernatremia Isotonic solutions are used FIRST for immediate fluid resuscitation in clients with hypovolemic shock

Jaundice in newborns

Jaundice in the first 24 hours is considered pathological and not an expected finding. After 24 hours, it is considered physiological and is normal

Meningitis

Keep HOB at 10-30 degrees Droplet precautions Reduced stimulus Seizure precautions

Radiation exposure

Key aspects are time and distance. The greater the distance, the less dosage received. Acute radiation syndrome has the following phases: prodromal, latent, manifest, and recovery or death. Initally, all victims will appear well, however, the damage is mostly internal, leads to cell destruction, and manifests later one. Victims farthest away from the radiation source are the most salvageable. In this scenario, the principle of disaster nursing is to do the most good for the most people with the available resources. Damage from radiation affects the most radiosensitive cells first; these are the hematopoietic, digestive, central nervous system, and cutaneous cells. The presence of severe symptoms indicates extensive internal damage and the victims are less salvageable in the long-term. Usually affects tissues with rapidly proliferating cells (oral mucosa, GI tract, and bone marrow) first, followed by tissues with slowly proliferating cells (cartilage, bone, kidney). As a result, early manifestations of radiation damage include oral mucosal ulceration, vomiting/diarrhea, and low blood cell counts

Wilms tumor

Kidney tumor that usually occurs in children age <5. Most often involves one kidney and the prognosis is good if the tumor has not metastasized. The abdomen should NOT be palpated, as this can disrupt the encapsulated tumor.

Causes of high pressure ventilator alarm

Kinked ventilator tubing Condensation in circuit tubing Kinked ET tube Obstructions (secretions) in tube Biting ET tube Increased airway resistance (bronchospasm, excessive secretions) Decreased lung compliance (pneumothorax, atelectasis, pulmonary edema, ARDS) Ventilator dyssynchrony (anxiety, pain coughing)

Blood thinner regulation

LWMH (Enoxaparin): monitor CBC for thrombocytopenia but not coagulation studies Heparin: PTT Warfarin: INR Avoid aspirin and NSAIDs with all of these medications

Premature infant findings

Lanugo Smooth, pink skin with visible veins with lack of subcutaneous fat Areolae may be barely visible with no raised breast buds Smooth soles with only faint red marks and a single transverse crease Testes not descended into scrotal sac

Uterine contractions in first stage of labor

Last 45-80 seconds (should not exceed 90 seconds). 2-5 contractions every 10 minutes - should not occur more frequently than every 2 minutes. Contractions should be 25-50 mmHg and should not exceed 80 mmHg. Resting tone should be 10 mmHg and should not exceed 20 mmHg

Stages of labor

Latent: 0-5 cm (stage 1). Client is able to maintain focus and follow directions. Provide education during this period. Active: 6-10 cm - encourage to breathe (stage 1). Apprehension and pain increase and ability to follow instruction decreases. Client is more serious. Stage 2: 10 cm - complete cervical dilation to birth - encourage client to bear down. Patient will feel the need to defecate and may have nausea, vomiting, trembling, or shivering when the baby's head reaches +1 station below the ischial spines Stage 3: birth of baby to expulsion of placenta Stage 4: 1-4 hours after birth, maternal physiological readjustment

Ulcerative colitis

Low-residue, high protein, high calorie diet, along with daily vitamin and mineral supplements, is encouraged to meet the nutritional and metabolic needs of the client with UC. Low-residue diet limits trauma to the inflamed colon and may lessen symptoms. Easily digested food such as enriched breads, rice, pastas, cooked vegetables, canned fruits, and tender meats are included in the diet. Raw fruits and vegetables, whole grains, highly seasoned foods, fried foods, and alcohol are avoided. The well-balanced diet includes 2000-3000 mL/day of fluid to maintain fluid and electrolyte balance and hydration

Barium enema

Lower GI series uses fluoroscopy to visualize the colon outlined by contract to detect polyps, cancers, tumors, and diverticula. This procedure is contraindicated for clients with acute diverticulitis as it may rupture inflamed diverticula and cause subsequent peritonitis Pre-procedure instructions: Take a cathartic (magnesium citrate, polyethylene glycol) to empty stool from the colon. Follow a clear liquid diet the day before the procedure to aid in bowel preparation and prevent dehydration; avoid red and purple liquids Do not eat or drink anything 8 hours before test Expect to be placed in various positions during the procedure. May experience abdominal cramping and urge to defecate Post-procedure: Expect passage of chalky white stool Take a laxative to assist in expelling the barium. Retained barium can lead to fecal impaction Drink plenty of fluids to promote hydration and eat high-fiber diet to prevent constipation

Pregnancy vaccines

MMR and varicella may not be administered during pregnancy, as they can cause severe birth defects. Inactivated vaccines contain a killed version of the virus and pose no risk of causing illness from the vaccine. Some vaccines contain weakened (attenuated) live virus and pose a slight risk of contracting the illness. For this reason, women should not receive live virus vaccines during pregnancy or become pregnant within 4 weeks of receiving such a vaccine. Tdap vaccine is recommended for all pregnant women between the beginning of the 27th and end of the 36th week of gestation as it provides the newborn with passive immunity against pertussis. During flu season, it is safe and recommended for pregnant women to receive the injectable inactivated flu vaccine regardless of trimester

S3 sound

Made when blood from the atrium is pumped into a noncompliant ventricle. S3 is heard after S2 (ventricular gallop). It may present as a normal finding in young adults. However, a new S3 in older adults is a significant finding as it may indicate development of volume overload or heart failure. These conditions require prompt intervention as they may rapidly progress to life-threatening events (respiratory compromise, cardiogenic shock). This client may be receiving excessive IV fluids that are causing volume overload.

Magnesium toxicity

Magnesium sulfate is given to pregnant women with preeclampsia and eclampsia. Normal blood magnesium is 0.75-1.25, but a therapeutic mag level of 4-7 is necessary to prevent seizures in a preeclamptic client. Mg toxicity causes CNS depression because toxic Mg levels (>7) block neuromuscular transmission. Absent or decreased deep tendon reflexes are the earliest sign of Mg toxicity. DTRs are scored on a scale of 0-4+ and should be assessed during Mg infusion; normal findings are 2+. If toxicity is not recognized early, clients can progress to respiratory depression, followed by cardiac arrest. Assessments including VS should be performed every 5-15 minutes during loading dose, followed by 30 to 60 minute intervals until the client stabilizes, then every 2 hours. Treatment for magnesium toxicity is immediate discontinuation of the infusion and administration of calcium gluconate is recommended only in the event of cardiorespiratory compromise. Urine output <30 mL/hr is also a sign of Mg toxicity

Buck's traction

Maintains proper alignment of an injured body part by using weights to apply a continuous pulling force The client should be supine or in Semi-Fowlers (20-30 degrees max). Elevating the head of the bed more would promote sliding Regularly assess the neurovascular status and skin integrity of the limb in traction. Loosen Velcro if boot is too tight. Should reassess in 30 min if a change is made Provide a fracture pan, which is smaller than a bedpan for elimination needs to maximize client movement and provide comfort Weights should be free-hanging at all times and should never be placed onto the bed or touch the floor. A staff member should support the weight while the client is being repositioning to prevent excessive pull on the extremity.

Toilet training

Major developmental achievement for toddler. Need neuromuscular maturity and voluntary control of anal and urethral sphincters. This usually occurs at age 2 1/2 to 3 1/2 years.

Delirium

Major predisposing factors: Advanced age Underlying neurodegenerative disease (stroke, dementia) Polypharmacy Coeexisting medical conditions (infection) Acid-base/ABG imbalances (hypoxemia, hypercarbia, acidosis) Metabolic and electrolyte disturbances Impaired mobility Surgery Untreated pain and inadequate analgesia Least restrictive restraint should be used. One-on-one supervision provided by trained staff member who stays with client at all times can promote safety while reducing or eliminating the use of restraints on a client who is confused and agitated. Frequent reassurance, touch, and verbal orientation (regarding name, location, time, and client's situation) can lessen disruptive behaviors. Placing a large clock and calendar in view could also help

Hemorrhoidectomy

Management: Pain relief: pain is severe. Initially, pain is managed with medications including NSAIDs, acetaminophen, and opioids initially but can cause constipation. Beginning 1-2 days post-op, warm Sitz baths are used as a means to relieve pain. Clients often dead their first BM due to severe pain with defecation. Preventing constipation: encourage a high fiber diet and adequate fluid intake. Administer stool softener or oil-retention enema if constipation persists for 2-3 days The HCP may pack the rectum and add a T-binder to hold the packing in place. Dressing is usually removed 1-2 days postop unless excess soaking is noticed before

Basilar fracture

Manifestations: raccoon eyes Blood surrounded by CSF (serosanguinous ring) Bruising behind ears (Battle sign) CSF from ears If the drainage is clear, dextrose testing can determine if it is CSF. However, if blood was present the testing would make this test unreliable because it also contains glucose. In this case, you can add a couple drops of the blood tinged fluid to a piece of gauze and it will form a ring with the blood in the middle and CSF around the edges. If this is the case, the client's nose should not be packed and no NG or OG tubes inserted for risk of penetrating the skull through the fracture site and into the brain. They can be placed under fluoroscopic guidance if necessary

Venturi mask

Many clients with COPD breathe because their oxygen levels are low rather than because CO2 levels are high. This is commonly referred to as hypoxemic drive. If they receive too high a level of inspired oxygen, this drive can be blunted. It is therefore important for these clients to receive a guaranteed amount of oxygen as an increase in inspired oxygen can decrease their drive to breathe. To promote adequate gas exchange, the nurse should use a high-flow Venturi mask to deliver a specified, guaranteed amount of oxygen. Because this device has a mechanism that controls the mixture of room air, the inspired oxygen concentration remains constant despite changes in respiratory rate, depth, or tidal volume. It is the most appropriate intervention to promote adequate gas exchange

Systemic analgesia in labor

May be administered to the laboring client who is in the active phase of stage 1 labor. Systemic analgesia crosses the blood-brain barrier to provide an analgesic effect. These meds also cross the placental barrier, with a resulting effect on the fetus depending on dose and time of administration prior to delivery. Parameters for safer administration include the following: Stable maternal vital signs Fetus with HR of 110-160 bpm Well-established labor contractions Cervix dilated to at least 4-5 cm in primipara and 4 cm in multipara

Hyperkalemia

May cause fatigue, generalized weakness, or in severe cases muscle paralysis and/or dysrhythmias. Management includes preventing dysrhythmias and correcting potassium levels. IV calcium gluconate is administered for hyperkalemic patients with ECG changes. It does not decrease serum potassium level but temporarily stabilizes the myocardium by raising the threshold for dysrhythmia occurrence. After this happens, other actions may be implemented to decrease potassium level (IV regular insulin with dextrose, Kayexylate, hemodialysis)

Mitral valve prolapse

May have palpitations, dizziness, and lightheadedness. Chest pain can occur. Beta blockers may be prescribed for palpitations. Teaching: adopt healthy eating habits and avoid caffeine that may exacerbate symptoms Check ingredients of OTC medications or diet pills for stimulants such as caffeine or ephedrine Reduce stress and avoid alcohol use Should maintain an exercise program No need for medic alert bracelet as this is usually a benign condition

Ectopic pregnancy

May include lower abdominal and pelvic pain, amenorrhea, possibly followed by vaginal spotting and bleeding; and a palpable adnexal mass on pelvic exam. An ectopic pregnancy may impant in one of many locations outside the uterine cavity, including the fallopian tubes, ovaries, or abdominal cavity. As the ectopic pregnancy outgrows its environment, it may rupture, causing life-threatening maternal hemorrhage. Symptoms indicative of a ruptured ectopic pregnancy include hypotension, tachycardia, dizziness, and referred shoulder pain. Shoulder pain results from irritation of the diaphragm by intraabdominal blood. A ruptured ectopic pregnancy is a surgical emergency and requires immediate intervention.

Minimal variability in FHR

May indicate fetal sleep or CNS depression. The nurse should check the medication administration record for recently administered CNS depressants. However, minimal or absent variability requires further assessment if accompanies by late decelerations, as it may indicate fetal hypoxemia or acidosis.

Sepsis neonatorum

Medical emergency - newborns may not exhibit obvious signs of infection but instead may have elevated temperature or be hypothermic. Subtle changes such as irritability, increased sleepiness, and poor feeding would be considered red flags. Blood, urine, and CSF cultures should be obtained immediately and broad-spectrum antibiotics ordered

Postoperative cognitive dysfunction

Memory impairment, problems with concentration, language comprehension, and social integration. Some clients may cry easily or become teary. The risk for POCD increases with age and in clients with preexisting cognitive deficits, longer operating times, intraoperative complications, and postsurgical infections. Can occur days to weeks after surgery and normally resolve after healing has occurred.

PEG tube

Minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastromy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. Tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to close within hours of tube dislodgement. The nurse should notify the HCP who placed the PEG tube as early dislodgement requires either surgical or endoscopic replacement

Preventing VAP

Minimize duration of intubation, minimize sedation with daily sedation interruptions, semirecumbent position, ET tube with subglottic drainage. ET cuff should be inflated at least >15 mmHg Reducing colonization: antibiotic prophylaxis not recommended. Use antiseptics for oral decontamination, avoid PPI except for patients at heightened ulcer risk because the natural acidity of the stomach helps to reduce colonization. Change circuit only if visibly contaminated

Cancer signs

Mnemonic CAUTION Change in bowel or bladder habits (black stool - colorectal cancer) A sore that does not heal (skin cancer) Unusual bleeding or discharge (cervical or endometrial cancer) Thickening or lump (breast or testicular cancer) Indigestion or difficult swallowing (gastric or esophageal cancer) Obvious change in wart or mole (skin cancer) Nagging cough or hoarseness (lung or larynx cancer) Unintentional weight loss of >10% of usual weight (in non-obese clients) requires evaluation and could indicate underlying cancer. Nausea, anorexia, and dysgeusia (altered taste sensation) are also clinical features of cancer. Breast cancer signs: include a newly retracted nipple or an orange-peel appearance of the breast tissue

Palliative care

Model of treatment that involves managing symptoms, providing psychosocial support, coordinating care, and assisting with decision making to relieve suffering and improve quality of life for clients and families facing serious illnesses. An interdisciplinary palliative assessment team often includes nursing staff, chaplains, social workers, therapists, and nutritionists who work together in a comprehensive treatment plan. This model care has been found to decrease unnecessary medical interventions and reduce depressive symptoms. Families of clients who receive palliative care interventions also experience lower rates of prolonged grief and PTSD Palliative care is not limited to 6 months before death and can begin immediately after diagnosis of a terminal illness The main difference between hospice and palliative care is that clients receiving palliative care can receive concurrent curative treatment. Hospice can only be started after the client decides to forego curative treatment

CABG discharge instructions

Modification of cardiac risk factors including smoking cessation, weight reduction, maintaining a healthy diet, and increasing activity levels through exercise Encourage a daily shower as a bath could introduce microorganisms. Surgical incisions are washed gently with mild soap and water and patted dry Explain that light house work may hbe resumed in 2 weeks but do not lift anything >5 lb until cleared by HCP (about 6 weeks after discharge) Clarify no driving for 4-6 weeks or until HCP approves If client is able to walk 1 block or climb two flights of stairs without symptoms, safe to resume sexual activity Notify the HCP if you have chest pain, SOB not subsiding with rest, fever, or signs of infection at incisions

Lithium

Mood stabilizer commonly prescribed for mania (bipolar disorder) as long-term maintenance therapy. Because lithium has a narrow therapeutic range (0.6-1.2), >1.5 is considered toxic. Serum levels should be monitored regularly (following dose changes) to prevent toxicity. Lithium is excreted through the kidneys. To prevent toxicity, the nurse should hold doses and clarify prescriptions for clients who have conditions/illnesses in which the kidneys try to conserve sodium (hyponatremia, dehydration) as sodium and lithium are absorbed in proximal tubules simultaneously. Should also hold or question when the client has a decreased GFR (severe renal dysfunction) as less of the drug is filtered into urine. Common side effects: drowsiness, weight gain, dry mouth, GI upset Clients taking lithium should take in consistent amounts of fluid and sodium to prevent fluctuations in serum lithium. Clients should report signs (weight changes, dizziness) and precipitating factors (vomiting, diarrhea, increased sweating) of fluid and electrolyte imbalance NSAIDs decrease renal bloodflow and cause sodium retention, so they should not be used with lithium. Also should not take with thiazide diuretics

Uterine hyperstimulation

More than 5 contractions in 10 minutes or a resting tone more than 20 mmHg indicates uterine hyperstimulation from oxytocin. If the FHR tracings are reassuring, the client is placed/maintained in a side-lying position and a bolus of IV fluid is given. If these measures do not reduce uterine activity, the oxytocin dose is reduced. However, if the FHR tracing shows a non-reassuring pattern (late decelerations, fetal bradycardia, tachycardia, and decreased variability), then stop the oxytocin, reposition, apply oxygen, give IV fluid bolus, and consider giving terbutaline subq per unit protocol

Osteopenia

More than normal bone loss for the client's age and sex. Adequate dairy intake of calcium and vitamin D is necessary to promote bone growth, prevent resorption (bone loss), and prevent progression to osteoporosis. Milk and milk products are the best sources of calcium. However, other food sources are available for lactose intolerant individuals. Some fish (sardines, salmon, trout), tofu, some green vegetables (spinach, kale, broccoli), and almonds. Good sources of vitamin D include egg yolks and oily fish (sardines, salmon, tuna)

PCA

Needs a continuous IV solution at Y-site to keep the vein open and flush the PCA medication through the line so that the boluses reach the client.

Calcium carbonate

Most available elemental calcium of OTC products and is inexpensive and preffered for osteoporosis. Absorption is impaired when taken in excess of 500 mg and therefore, should be taken in divided doses (<500 mg per dose). These should be taken within an hour of meals as food increases calcium absorption. Constipation is a frequent side effect of calcium carbonate. This med is also used to reduce serum phosphrous in clients with chronic kidney disease. In such cases, calcium should remain in the intestine and bind to phosphorous present in food and then excreted in stool. These clients should take calcium before meals.

Duchenne muscular dystrophy

Most common form of childhoos MD. Lack of protein called dystrophin needed for muscle stabilization. Disease onset is 2-5 years. Muscles of the proximal lower extremities and pelvis are affected first. Calf muscles hypertrophy initially in response to proximal muscle weakness and are later replaced by fat and connective tissue. Gower sign involves use of hands to rise from squat or from a chair to compensate for proximal muscle weakness No effective cure. Children are often wheelchair bound by adolescence and die by age 20-30 from respiratory failure. It is important to remove floor clutter and prevent falls/injury Encouraged to participate in regular gentle exercises and swimming to avoid disuse muscular atrophy and social isolation. Overexertion such as weight lifting is not recommended due to risk of muscle injury

Pinworm

Most common worm infection in the US, easily spread by inhaling or swallowing microscopic pinworm eggs, which can be found on contaminated food, drink, toys, and linens. Once eggs are ingested, they hatch in the intestines. During the night, the female pinworm lays thousands of microscopic eggs in the skinfolds around the anus, resulting in anal itching and troubled sleep. When the infection is treated with anti-parasitic medications.

Preventing wandering in dementia patients

Most important: placing locks above or below eye level on doors that lead outside. Cleints with AD lose their peripheral vision and they cannot see objects unless they are directly in front of them or they purposely move their heads Adding a motion sensor or alarm that goes off when someone tries to exit Placing a large stop sign on door ecits Disgusing door with a curtain or wall hanging Using childproof doorknob covers Placing a black mat or strip by exit. Client may perceive this as impassable black hole due to changes in depth perception

Incident reports

Must be filed by anyone who witnesses an adverse or unexpected event. However, filing the incident report should not be documented in the medical record because it is a method of quality improvement. Physical, verbal, or sexual assault occurring in a health facility Client falls, with or without injury Staff and visitor falls, regardless of acceptance of or refusal of treatment Failure to obtain or intervene upon the results of diagnostic procedures Inadequate or delayed diagnosis and monitoring Delay, omission, or incorrect performance or administration of prescribed therapies and meds Hospital equipment failure

Adult learning

Must keep in mind several principles of adult learning. The learner's: Need to know Readiness to learn Prior experiences Motivation to learn Orientation to learning Self concept Adults learn best when teaching provides information that the client views as being needed immediately. Readiness to learn is increased if the client perceives a need, has the belief that the change has value, or perceives the learning activity as new and stimulating. Sitting with a client and pointing out low sodium foods in his meal will help him be actively involved and provides immediately applicable information.

ABGs

Must measure 30 min after a ventilator change to assess how well they have tolerated it. Factors such as changed in client's activity level or oxygen settings, or suctioning within 20 minutes prior to a blood draw can cause inaccurate results

Immunosuppressive therapy in transplants

Mycophenolate, tacrolimus, corticosteroids. Required after organ transplantation to prevent acute and chronic rejection of the organ. This is a lifelong drug regimen for the transplant client, and it has adverse side effects (nephrotoxicity, hepatotoxicity, infection susceptibility). Prior to surgery, the client needs to fully understand the physical, psychological, and financial commitment required. Endomyocardial biopsies will be performed regularly, in addition to routine blood tests, to check for signs of rejection.

Naproxen

NSAID commonly used for joint pain and inflammation GI toxicity - GI bleeding, GI upset - can be reduced if taken with food Kidney injury HTN and heart failure - can cause fluid retention Bleeding risk - should not take with other anticoagulants or antiplatelets

Nausea in PACU

Nausea is a common complication caused by anesthetic side effects and decreased GI motility. Clients are at high risk for aspiration and possible asphyxiation due to there altered level of consciousness, which is caused by anesthesia. Clients reporting nausea should be placed immediately on their side to prevent aspiration of vomit

Morning sickness

Nausea with or without vomiting that is a common problem during the first trimester of pregnancy. Can happen at any time during the day. It is thought to be due to rising hormone levels (estrogen, progesterone, HCG). Interventions: Eating several small meals a day (high protein, high carbs, low fat) Having a high-protein snack before bedtime and on awakening Consuming foods/drinks with ginger Drinking fluids (clear, cold, carbonated) between meals Consuming foods high in vitamin B6

Neonatal hypothermia

Neonates are unable to generate heat by shivering due to their lack of muscle tissue and immature nervous systems. They produce heat by increasing their metabolic rates through nonshivering thermogenesis. Brown adipose tissue developed during the third trimester, is metabolized for thermogenesis when available. Once BAT is depeleted, nonshiviering thermogenesis is less effective and the neonate may experience cold stress, possibly leading to death. Preterm neonates have fewer stores of BAT and are at higher risk for cold stress. Frequent temperature monitoring is the best method to assess if an infant is cold. In cold stress, metabolism increases to generate heat, causing a greater demand for oxygen and glucose and the release of norepinephrine. If adequate oxygenation is not maintained, hypoxia and academia occur. Hypoglycemia develops when available glucose is depleted, and repletion of glucose is impaired by GI immotility and poor oral intake. Clinical manifestations of cold stress: Neurological - altered mental status (irritability or lethargy) Cardio: bradycardia Resp: tachypnea early, followed by apnea and hypoxia GI: high gastric residuals, emesis, hypoglycemia Musculoskeletal: hypotonia, weak suck and cry

Biological weapons

Nerve agents used as biological weapons (sarin) inhibit acetylcholinesterase, and their effects are excess ACh. This causes miosis, rhinorrhea, copious secretions, shortness of breath, and flaccid paralysis. Treatment is with suction and support ventilation and circulation.

Filgrastim

Neupogen and pegfilgrastim (Neulasta) stimulate neutrophil production and are given prophylactically or if the client has an infection and more neutrophils are needed to fight it. This is mostly given in chemotherapy patients, since they will experience bone marrow suppression with the lowest blood counts usually 7-10 days after therapy initiation

Therapeutic hypothermia

Neurologic injury is the most common cause of mortality in cardiac arrest. Therapeutic hypothermia within 6 hours of arrest and maintaining it for 24 hours has been shown to decrease mortality rates and improve neurologic outcomes. It is indicated for all clients who are comatose or do not follow commands after resuscitation. The client is cooled to 32-34 degrees C for 24 hours and then rewarmed. Cooling is accomplished by cooling blankets, ice placed in the groin, axillae, and sides of neck, and cold IV fluids. The nurse must closely assess the cardiac monitor because bradycardia is common, core body temp, blood pressure (MAP >80), and skin for thermal injury. Keep HOB elevated >30

Transporting a patient with a chest tube

Never clamp the tube at the insertion site during transfer. This could cause buildup of air in the chest cavity due to no means of escape and cause a tension pneumothorax. Wall suction needs to be temporarily disconnected during transport and promptly reconnected at the destination. The chest tube collection should be hung below the level of the chest to promote adequate drainage and keep fluids from re-entering the cavity. All connections should be secured and taped to prevent accidental disconnection or air to enter the system

Febrile seizures

Never leave seizing clients alone to prevent them from causing self-injury. Main objective is to monitor oxygen saturation levels. If these levels begin to drop or cyanosis occurs, prompt intervention is needed, which may be as simple as a head tilt or jaw thrust. Use ibuprofen and acetaminophen to control fever. Aspirin should never be used in children to treat fever as it can cause Reye syndrome (swelling of liver and brain). Most febrile seizures do not require medications to stop convulsions. Not necessary to bag mask if there are no signs of hypoxia or distress. After administration, may apply cool damp compresses to the forehad, increase air circulation in the room, and wear loose or minimal clothing to increase skin exposure to air. Call 911 for a seizure lasting more than 5 minutes.

Preeclampsia

New onset hypertension after 20 weeks gestation plus proteinuria or signs of end organ damage. Proteinuria diagnostic of preeclampsia is defined as >300 mg/24 hour urine collection, protein/creatinine ratio >0.3, or dipstick of >1+ Cerebral symptoms such as headache and visual changes are potential manifestations. There is risk for cerebral edema, hemorrhage, and stroke. Important to prevent progression of preeclampsia to eclampsia (tonic clonic seizures). Edema is normal in pregnant women, but is also a common manifestation of preeclampsia. They will not experience anemia as a result of preeclampsia

Calcium channel blockers

Nifedipine, amlodipine, felodipine, nicardipine cause vasodilation and clients may have lower leg edema Used to treat hypertension and chronic stable angina. They promote relaxation of vascular smooth muscles leading to decreased systemic vascular resistance and arterial blood pressure Adverse effects: dizziness, flushing, headache, peripheral edema, and constipation. The reduced blood pressure may initially cause orthostatic hypotension. Leg elevation and compression can help to reduce the edema. Constipation should be prevented with daily exercise and increased intake of fluids and fiber

Kosher rules

No pork, shellfish, or fish without scales. Must separate meat and poultry from dairy. When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product is consumed.

Propanolol

Non-selective beta blocker that inhibits beta 1 and beta 2 receptors. Bronchoconstriction may occur due to the effect on the beta 2 receptors.

Bilious vs nonbilious vomiting

Nonbilious vomiting is seen in conditions where the pathology is proximal to the pylorus (hypertrophic pyloric stenosis). Bilious (green) vomiting is seen in conditions where the pathology is distal to the duodenum as the common bile duct drains at the duodenum

Methotrexate

Nonbiologic disease-modifying antirheumatic drug prescribed to treat RA. Adverse effects associated with this medication include bone marrow suppression, hepatotoxicity, and GI irritation (nausea, vomiting, diarrhea). Stomatitis (inflammation of mouth, oral ulcers) is a common side effect associated with methotrexate and can be prevented with folic acid supplementation. This drug is teratogenic and should not be taken during pregnancy. Should not be takne for at least 3 months before becoming pregnant Bone marrow suppression can lead to anemia, leukopenia, and thrombocytopenia. Anemia manifests as fatigue, dyspnea on exertion, and pallor. Leukopenia increases the risk for infection. Thrombocytopenia presents as petechiae, purpura, or bleeding. Petechiae are small, purplish hemorrhagic skin spots that occur when the platelet count is <150,000. Bone marrow suppression is managed with a dose reduction or discontinuation of the medication

CHD risk factors

Noncoronary atherosclerotic disease (carotid, peripheral artery, abdominal aortic aneurysm) Diabetes mellitus Chronic kidney disease Age (especially >50 in men and menopause in women) Male gender Family history of CHD in first-degree relative age <50 (men) or age <60 (women) Hypertension Dyslipidemia Cigarette smoking Obesity

Extracorporeal shockwave lithotripsy

Noninvasive procedure used to break up kidney stones. It is typically done on an outpatient basis, although the client will require local or general anesthesia. The shock waves break up the stones into a fine sand that can then be excreted in the urine. Ureteral stents are often placed after the procedure to help with the passage of the sand and prevent buildup within the ureter. The stents are removed within 1-2 weeks. Client should be encouraged to drink large amounts of fluid to facilitate washing out of the stone fragments and sand created by the shock waves. Infection is a serious complications after the procedure as the breakup of stones can release organisms and cause sepsis. Pain can be severe and require analgesics. Hematuria is common, and the urine should go from bright red to pink-tinged over several hours. Bruising on the back or abdomen after the procedure is normal. Ambulation is encouraged to promote removal of stone fragments

Magnetic resonance cholangiopancreatography

Noninvasive test used to visualize the biliary, hepatic, and pancreatic ducts via MRI. MRCP uses oral or IV gadolinium (noniodone contrast) and is a safer, less invasive alternative to endoscopic retrograde cholangiopancreatography to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. Nurse must assess for contraindications before the procedure, including the presence of certain metal and/or electrical implants (aneurysm clip, pacemaker, cochlear implant) or any previous allergy to gadolinium. Pregnancy is also a contraindication to MRCP as gadolinium crosses the placenta and may adversely affect the fetus. Delayed/irregular menses may be a normal variation in some clients; however, delayed menses may indicate pregnancy and should be reported for further investigation prior to MRCP. Clients should be NPO for 4 hours prior to allow better visualization of the anatomical features. Smoking is not a contraindication

Differential diagnosis of antepartum bleeding

Normal labor: intermittent pain with contractions, small amount of blood-tinged mucus Placental abruption: sudden-onset dark red vaginal bleeding, abdominal pain, hypertonic/tender uterus, tachysystole. Can result in decreases placental perfusion and fetal death Placenta previa: painless vaginal bleeding, ultrasound with placenta covering cervical os Uterine rupture: sudden onset vaginal bleeding, constant abdominal pain, cessation of uterine contractions, loss of fetal station, fetal deterioration

Spinal immobilization

Not a benign procedure. An acronym to help determine the need for spinal immobilization is NSAIDs: N: neurological exam. Focal deficits include numbness and decreased strength S: significant traumatic mechanism of injury A: alertness. The client may be disoriented or have an altered level of consciousness I: intoxication. The client could have impaired decision-making ability or lack awareness of pain D: distracting injury. Another significant injury could distract the client from spinal pain S: spinal examination. Point tenderness over the spine or neck pain on movement may be present

Neuropathic pain

Numbness and tingling in both lower extremities are classic examples of neuropathic pain. The common causes of bilateral peripheral neuropathy include: Diabetic neuropathy - most common; distribution is usually sock and glove pattern Autoimmune: Guillan-Barre Toxic neuropathy: alcohol use

Postmortem care

Nurse should provide opportunities for family participation and accommodate religious and cultural rituals when possible Maintain standard or isolation precautions in place at the time of death Gently close the patients eyes Straighten ans wash the body and change linens. Handle the body carefully as tissue damage and bruising occur easily after circulation has ceased Leave dentures in place or replace if removed to maintain the shape of the face - it is difficult to replace dentures after rigor mortis sets in A towel folded under the jaw will help keep the jaw closed Place a pad under the perineum to absorb any stool or urine leaking from the relaxed sphincters Place a pillow under the head to prevent blood from pooling and discoloring the face Remove equipment and soiled linens from room Give client's belongings to family member or send with body

Topical capsaicin cream

OTC analgesic that effectively relieves minor pain (osteoarthritis, neuralgia). Instruct patient to wait at least 30 min after putting cream on before washing them to ensure adequate absorption. Client should avoid contact with mucous membranes or skin that is not intact as capsaicin is a component in hot peppers that can cause burning. When applying cream to areas besides the hands, client should wear gloves or wash hands immediately after. Local irritation (burning, stinging, redness) is common and usually subsides within the first week of regular use. Often used concurrently with acetaminophen or other NSAIDs (naproxen, celecoxib) to effectively treat osteoarthritis pain. Capsaicin should be used regularly (3-4 times daily) for long periods (weeks to months) to achieve desired effect

Volkmann contracture

Occurs as a result of compartment syndrome associated with distal humerus fractures. Swelling of the AC tissue causes pressure within the muscle compartment, restricting arterial bloodflow. The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers. A Volkmann contracture is a medical emergency that can cause permanent damage to the extremity if left untreated. Any restrictive dressing should be removed immediately, and the HCP must be notified for possible surgical intervention

CO poisoning

Occurs due to smoke inhalation, defective heating systems, and motors operating in poorly ventilated areas. Can occur with water heaters fueled by natural gas or oil, coal or wood stoves, fireplaces, and engine exhaust. Pulse ox is falsely normal because they detect saturated hemoglobin only and cannot differentiate between CO and oxygen. Symptoms are nonspecific: headache, dizziness, fatigue, nausea, dyspnea. Serum carboxyhemoglobin test is needed to confirm the diagnosis. Normal values are <5% in nonsmokers and slightly higher (<10%) in smokers. Treatment is high flow 100% oxygen and intubation/hyperbaric oxygen therapy if severe

Necrotizing enterocolitis

Occurs predominantly in preterm infants secondary to GI and immunologic immaturity. On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine. As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the bowel wall. Measuring the client's abdominal girth daily is important nursing intervention to note any worsening intestinal gas-associated swelling. Clients are made NPO and receive NG suction to decompress the stomach and intestine. Parenteral hydration and nutrition and IV antibiotics are given. They should be placed supine and undiapered and may not be stable enough for kangaroo care. Rectal temps should be avoided due to risk of perforation of the gangrenous, friable colon.

Coup-contrecoup

Occurs when body in motion stops suddenly (eg, head hits car windshield), causing contusions (bruising) of the brain tissue as the brain moves back and forth within the skull. First, the soft tissue strikes the hard skull in the same direction as the momentum (coup) and as the body bounces back, the brain strikes the opposing side of the skull (contrecoup). Frontal lobe will suffer the primary impact (coup) and they will likely have changes in executive function, memory, speech generation (Broca area), and voluntary movement. The contrecoup most likely injured the occipital lobe, where vision is processed.

Sickle cell crisis

Occurs when client's sickle shaped cells block blood flow through the vessels. These clients tend to have a small spleen due to repeated small splenic infarctions (autosplectomy). Splenic sequestration crisis occurs when a large number of "sickled" cells get trapped in the spleen, causing splenomegaly. This is a life-threatening emergency as it can lead to severe hypovolemic (hypotensive) shock. The classic assessment finding is a rapidly enlarging spleen Can also cause stroke, which is another life-threatening thing

Heatstroke

Occurs when excessive environmental heat exposure and/or overexertion cause hyperthermia and depletion of fluid and electrolytes (sweating, increased respirations), specifically sodium. Eventually, hypothalamic thermoregulation fails and sweat production stops, causing a rapid elevation of core temperature Symptoms include: Temperature >104 Hot, dry skin Hemodynamic instability (tachycardia, hypotension) Altered mental status/neurological symptoms (confusion, lethargy, coma) Risk for permanent neurological injury or death from heatstroke is related directly to the degree and duration of hyperthermia. Treatment involves stabilization of ABCs and rapid cooling interventions (cool water immersion, cool IV infusion). Antipyretics are ineffective as hyperthermia is unrelated to the inflammatory process (infection)

Brain lobes

Parietal lobe: integrates somatic and sensory input Frontal lobe: controls higher-order processing, such as executive function. Production of speech and personality. Injury often results in behavioral changes Temporal lobe: integrates visual and auditory input and past experiences. Injury may result in inability to understand verbal or written language Occipital lobe: registers visual images. Injury could result in a deficit with vision

Rhabdomyolysis

Occurs when muscle fibers are released into the blood, usually after an intense muscle injury from exercise, heat stroke, vasoconstriction (cocaine), or physical trauma. Acute renal failure can occur when elevated myoglobin (protein found in muscle tissue) levels overwhelm the kidney's filtration ability. The nurse's priority is to prevent kidney damage using rapid IV fluid resuscitation to flush the damaging myoglobin pigment from the body. Common signs of rhabdo are blood urine, oliguria, and fatigue. Severely elevated creatine kinase levels typically >15,000 are observed with severe muscle damage and can be a precursor to kidney injury. Forced saline diuresis with IV fluids (to prevent blockage of the renal tubules with myoglobin) is necessary to prevent kidney damage Causes hyperkalemia, which can potentially cause dangerous arrhythmias. ECG and cardiac monitoring are needed. However, if you administer IV fluids, potassium levels can decrease rapidly. In addition, clients with rhabdo have extensive third spacing of fluids into injured muscles. Therefore, aggressive fluid resuscitation is a high priority.

Intussusception

Occurs when part of intestine telescopes into another adjacent part and causes blockage. Tissue death as well as perforation of the bowel may result. If peforation occurs, the client could develop peritonitis which can lead to sepsis and organ failure. Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness. This condition can be fatal if not treated early. Dehydration is very common in clients in intussusception. They will have currant jelly-like stool and a sausage shaped mass. Treatment is an air or barium enema to unfold the intestine

Aortic dissection

Occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle (media) layers. Clients with ascending aortic dissections typically have chest pain, which can radiate to the back. Descending aortic dissection is more likely associated with back pain and abdominal pain. It is frequently abrupt in onset and described as "worst ever", "tearing", or "ripping" pain. Hypertension is a contributing factor. Extending dissection from uncontrolled hypertension can cause cardiac tamponade or arterial rupture, which is rapidly fatal. Emergency treatment includes surgery and/or lowering the blood pressure

Back labor

Occurs when the fetal occiput rotates and faces the mother's posterior or sacrum Can apply counterpressure to the client's sacrum during contractions to help alleviate back pain associated with OP fetal positioning

Placenta abruption

Occurs when the placenta prematurely detaches from the uterine wall. This can interrupt fetal oxygen supply and cause maternal hemorrhage. Symptoms: frequent contractions, abdominal pain, dark red vaginal bleeding, uterine tenderness, and elevated uterine resting tone. Priorities involve assessment of maternal vital signs, palpation of the abdomen/uterus, and continuous FHR monitoring. If there is fetal distress, the team will prepare for emergency c section Vaginal examination is not performed in the presence of active bleeding until the possibility of placenta previa is ruled out

Physiological anorexia in toddlers

Occurs when very high metabolic demands of infancy slow down to keep pace with moderate growth of toddler hood. During this phase, toddlers are increasingly picky about their food choices and schedules. Although to the parents it may appear that the child is not consuming enough calories, intake over several days actually meets nutritional and energy needs. Strategies for dealing with toddler during physiologic anorexia and pickiness: Set and enforce a schedule fr meals and snacks Offer the child 2 or 3 choices Do not force the child to eat Keep portions small Expose the child repeatedly to new foods on several separate occasions Avoid TV and games during meals or snacks

Metabolic alkalosis

Occurs with loss of acidic gastric contents from prolonged gastric suctioning. Metabolic imblances affect bicarbonate levels. The clients pH would be high and bicarbonate would be high. The lungs will attempt to compensate by hypoventilating to attempt to retain CO2 and make the blood more acidic.

Nasal polyps

Often have sensitivity to NSAIDs including aspirin. Also, NSAIDs should not be used with asthma

Phenylketonuria

One of a few genetic inborn errors of metabolism. Individuals with PKU lack the enzyme (phenylalanine hydroxylase) required for converting amino acid phenylalanine into the amino acid tyrosine. As unconverted phenylalanine accumulates, irreversible neurologic damage can occur A low phenylalanine diet is essential for treatment of PKU. Phenylalanine cannot be entirely eliminated from the diet as it is an essential amino acid and necessary for normal development. The diet must meet nutritional needs while maintaining phenylalanine levels within a safe range (2-6 mg/dL in clients age <12). There is no known age at which the diet can be discontinued safely, and lifetime dietary restrictions are recommended for optimal health. Management: Monitoring serum levels of phenylalanine Including synthetic proteins and special formulas (Lofenalac, Phenyl-Free) in the diet Eliminating high phenylalanine foods (meats, eggs, milk) from diet Encouraging consumption of natural foods low in phenylalanine (most fruits and vegetables) Restriction of dietary tyrosine is not necessary. Tyrosine levels in clients with PKU can be normal or slightly decreased

Pneumococcal vaccine

One-time pneumococcal vaccines are ineffective for preventing community acquired pneumonia. The current guidelines for pneumococcal vaccination state that all adults age >65 should receive 2 pneumococcal vaccines >1 year apart. IN addition, revaccination is recommended after 5 years for clients who are immunocompromised, those with splenectomy, and those who are >65 years old if the first dose was given before this age

Cataracts

Opacity of the lens that ma occur at birth or more commonly in older adults. The signs include painless, gradual loss of visual acuity with blurry vision, scattered light on the lens producing glare or halos, which are worse at night, and decreased color perception

Mannitol

Osmotic diuretic used to treat cerebral edema (increased ICP) and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure (similar to excess glucose) that draws free water from the extravascular space into the intravascular space, creating a volume expansion. The fluid, along with the drug is excreted through the kidneys, thereby reducing cerebral edema and ICP. However, if a higher dose of mannitol is given or it accumulates (as in kidney disease), fluid overload that may cause life-threatening pulmonary edema results. An early sensitive indicator is crackles in the lungs. To prevent these complications, clients require frequent monitoring of serum osmolality, I/O, serum electrolytes, and kidney function. An increased UO would be expected in these clients

Scleroderma

Overproduction of collagen that causes tightening and hardening of the skin and connective tissue. This is a progressive disease without a cure, and treatment is aimed at managing complications. Renal crisis is a life-threatening complication that causes malignant hypertension due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis is needed to prevent acute organ failure. Even with treatment, this can be fatal. Raynaud phenomenon can develop secondary to scleroderma and is characterized by vasospasm-induced color changes in the fingers, toes, ears, and nose. Requires immersion in warm water, but is not life threatening Pulmonary fibrosis is a progressive complication of scleroderma that is defined as scarring of the lung tissue, which then causes reduced function, dry cough, and dyspnea. Heartburn and dysphagia are common symptoms associated with scleroderma. This is due to the disease process of internal scarring, and it is not life-threatening

PA catheter waveforms

PA wedge pressures are measured periodically to assess left ventricular function or left ventricular end diastolic pressure (ventricular preload). The balloon should be inflated for only 10-15 seconds and then allowed to deflate passively. A balloon that is inflated for a long period may cause PA rupture or damage. Locking the balloon port of the PA catheter will prevent the balloon from being accidentally inflated. If the balloon is inflated, it will show an irregular small waveform around 10 mmHg. The priority in this situation is to deflate and lock the balloon. Other interventions may include repositioning the patient or asking them to cough, as this may correct the position of the catheter tip.

Risks for PPH

PPH in prior pregnancy Multiple gestation Polyhydramnios Macrosomic infant Labor lasting >24 hours Meds: mag sulfate, lots of oxytocin, inhaled anesthesia Early PPH often due to boggy uterus Later PPH often due to placenta remnants in uterus

Ventricular trigeminy

PVCs occur every third heart beat. Myocardial injury predisposes the client to ectopy, which increases the clients risk for lethal dysrhythmias. PVCs are caused and/or exacerbated by hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and exercise. This client's morning lab results show hypokalemia, and therefore, the underlying cause of the ectopy. Priority is correcting this and administering potassium replacement.

Procedure positions

Paracentesis: requires client to be upright (semi- to high Fowlers) so that fluid accumulates in lower abdomen where the trocar will be inserted to drain it Lumbar puncture: clients are placed in side-lying fetal position or hunched in seated position to separate the vertebrae. Afterwards, clients remain supine in bed for 4-12 hours to minimize risk of post-puncture headache from loss of CSF Enema: sims position - left side lying with right hip and knee flexed Liver biopsy: after this procedure, place clients in right side lying position for >3 hours afterward to promote direct internal pressure of the liver against itself, which minimizes bleeding Cardiac catheterization: via femoral artery. patients must lay flat or in low Fowlers with the affected extremity straight for about 4-6 hours to avoid pressure at insertion site Suspected air embolus: place in Trendelenburg and the client positioned on the left side so the air will rise into the right atrium Chest tube placement: client arm raised above the head on the affected side. HOB raised 30-60 to prevent risk of injury to diaphragm

Toxoplasmosis

Parasitic infection that can be acquired from exposure to cat feces or ingestion of undercooked meat or soil-contaminated fruits/vegetables. Pregnant clients who contract toxoplasmosis can transfer the infection to fetus and potentially cause serious fetal harm (stillbirth, malformations, blindness, mental disability). pregnant clients should be advised to take precautions when gardening and thoroughly wash all produce to decrease exposure risk

Obstructive sleep apnea

Partial or complete airway obstruction during sleep that occurs from relaxation of the pharyngeal muscles. The result I repeated episodes of apnea >10 seconds and hypopnea <50% normal ventilation, which causes hypoxemia and hypercapnia. Common symptoms include frequent periods of sleep disturbance, snoring, morning headache, daytime sleepiness, difficulty concentrating, forgetfulness, mood changes, and depression.' Interventions: CPAP devices at night to keep pharynx and tongue from collapsing Limiting alcohol intake because it can cause relaxation of oral airway Weight loss and exercise can reduce snoring Avoiding sedating medications

Transfusing RBCs

Patient should void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the lab to analyze for hemolyzed RBCs. It is a life-threatening reaction where the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibility. Early signs of hemolytic reaction include red urine, fever, and hypotension. Late signs include disemminated intravascular coagulation and hypovolemic shock. Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion has started

Bismuth subsalicylate

Pepto Bismol. It has aspirin in it so do not give to children for risk of developing Reye syndrome. Reye syndrome can develop in children with a recent viral illness like the flu and can cause acute encephalopathy and hepatic dysfunction. Children with viral infection should not be given aspirin or products containing salicylates.

Wound cultures

Perform hand hygiene and apply clean gloves. Remove the old dressing. Remove and discard gloves Perform hand hygiene, and apply sterile gloves. Assess the wound bed. Cleanse the wound bed and surrounding skin with normal saline to remove drainage and debris. Remove and discard gloves Perform hand hygiene, and apply clean gloves. Gently swab the wound bed with a sterile swab, from the wound center toward the outer margin. Avoid contact with skin at the wound edge as it can contaminate the specimen with skin flora. Place the swab in a sterile specimen container; avoid touching the swab to the outside of the container Apply prescribed topical medication (bacitracin) after obtaining wound cultures to prevent interference with microorganism identification. Apply new dressing Remove and discard gloves and perform hand hygiene. Label the specimen, and document the procedure

Gastric lavage

Performed through an orogastric tube to remove ingested toxins and irrigate the stomach. It is rarely performed because it is associated with a high risk of complications (aspiration, esophageal or gastric perforation, dysrhythmias. Only indicated if overdose is potentially lethal and if GL can be initiated within one hour of the overdose. Intubation and suction supplies should always be available at the bedside during GL in case the client develops aspiration and respiratory distress. Performed through a large bore OG tube. Clients should be placed on their side or with the head elevated to minimize aspiration risk. Stomach should be decompressed first, but lavage should be initiated as soon as possible afterwards

Torsades de pointes

Polymorphic ventricular tachycardia characterized by QRS complexes that range size and shape in a characteristic twisting pattern. Torsades is usually due to a prolonged QT interval, which is the result of electrolyte imbalances, especially hypomagnesemia or some medications. The first line of treatment is IV magnesium. Treatment may also include defibrillation and discontinuation of any QT-prolonging medications

Wound irrigation

Performed to wash out debris and bacteria to ensure appropriate wound healing. This is important for wounds obtained in an outdoor environment because there is an increased risk for infection. Administer analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect. Don a gown and mask with face shield and sterile gloves Fill a 30 to 60 mL syringe with the prescribed irrigation solution Attach an 18 or 19 gauge needle to the syringe and hold 1 in above the area Use continuous pressure to flush the wound, repeating until drainage is clear Dry the surrounding wound area to prevent skin breakdown and irritation Should be cleaned from least to most contaminated area to prevent recontamination. Immunization history should be reviewed to determine tetanus vaccination status

Paranoid personality disorder

Pervasive distrust and suspicion of others; they believe that people's motives are malicious and assume that others are out to exploit, harm, or deceive them. These thoughts permeate every aspect of their lives and interfere with their relationships. Indviduals with PPD are usually difficult to get along with as they may express their suspicion and hostility by arguing, complaining, making sarcastic comments, or being stubborn. They have a strong need to be self-sufficient and maintain a high degree of control over their environment.

Milrinone

Phosphodiesterase-3 inhibitor given via IV infusion to increase contractility and promote vasodilation. Milrinone is an inotropic agent that is often prescribed to clients with heart failure unresponsible to other pharamacological therapies. The medication is usually infused over 48-72 hours in a hospital setting, however home infusion has become more common as a palliative measure of end-stage heart failure. Milrinone infusion requires central venous access as the medication is a vesicant and can cause extravasation if infused through a peripheral IV. Should monitor weight, for hypotension, and central line site for signs of infection.

Aspiration

Place in High Fowlers Perform oropharyngeal suctioning Administer 100% oxygen by nonrebreather mask Assess lung sounds Notify HCP

Hyperosmolar hyperglycemia

Plasma glucose >600 Arterial pH >7.30 Serum HCO3 >18 Minimal ketones Will still have osmotic diuresis In DKA: Plasma glucose >250 Arterial pH <7.30 Serum HCO3 <18

Signs of pregnancy

Positive (diagnostic signs): fetal heartbeat heard by Doppler, US visualization of fetus, fetal movement palpated or observed by the HCP Presumptive (subjective): breast tenderness, nausea, amenorrhea, urinary frequency, quickening, excessive fatigue Objective (probable): uterine and cervical changes, Braxton Hicks contractions, ballottement, fetal outline palpation, uterine and funic soufflé, chloasma, linea negra, areola darkening, striae gravidarum, positive pregnancy tests

Tonsillectomy

Post op bleeding is an important complication. Manifests as frequents swallowing and or cough from the trickling blood. Clients may also develop restlessness. Avoid coughing, clearing the throat, or blowing the nose Limit physical activity Milk products should be avoided as they can coat the throat and prompt clearing Oral mouth rinses, gargling, and vigorous tooth brushing should be avoided to prevent irritation

Perinatal mood disorders

Postpartum blues: considered normal. Occur 2-3 days postpartum and resolves within 2 weeks. Emotional lability, mild sadness, irritability, insomnia. Treated with supportive care, client and fam education, ongoing assessment, assessment for worsening symptoms Postpartum depression: 8-15%. Occurs 4-6 weeks postpartum; up to 12 months postpartum; gradual improvement over 1st 6 months postpartum. Extreme sadness, irritability, emotional outbursts, severe mood swings, postpartum anxiety. Treatment is supportive care and pharm intervention or therapy Postpartum psychosis: 0.1-0.2%. 2 weeks postpartum; severity and duration varies. Hallucinations, delusions, impulsivity, hyperactivity, confusion, delirium, associated with bipolar disorder. Treatment is emergent psychiatric hospitalization, pharm intervention

Clonidine patch

Potent antihypertensive agent available as a patch. Should be replaced every 7 days and can be left in place during bathing. Apply the patch to dry hairless area on the upper outer arm or chest once every 7 days Do not shave the area before applying the patch. Skin should be free of cuts, scrapes, calluses or scars. Wash hands with soap and water before and after application Wash the area with soap and water, then rinse and wipe dry Remove the patch from the package and do not touch the sticky side Rotate sites of patch application with each new patch. Remove the old patch one when applying a new one When removing, fold in half with sticky sides together. Discard the patch out of reach of children and pets. Notify HCP if experiencing dizziness or slow pulse rate.

Bumetanide

Potent loop diuretic used to treat edema associated with heart failure and liver and renal disease. The diuretic inhibits reabsorption of sodium and water and promote renal excretion of water and potassium. Nurse should question this in a client with heart failure that has hypokalemia and is already at risk for cardiac dysrhythmias.

Methadone

Potent narcotic with a longer half-life than its duration due to its lipophilic properties. The risk for overdose exists as clients can inadvertently take too many tablets for additional pain relief even though fat cells will continue to release high amounts of the drug into circulation Early signs of toxicity include nausea/vomiting and lethargy. Can also result in life-threatening respiratory depression Occasional PVCs are a common, insignificant finding in most adults. The client should have cardiac monitoring in the setting of methadone use/overdose as there is risk of QT interval prolongation, which can lead to cardiac arrhythmias.

Parathyroidectomy

Potential complication is hypocalcemia because parathyroids regulate calcium in the blood. When one or more is removed, it may take some time for others that have been dormant during hyperparathyroidism (which causes an increase in serum calcium) to begin regulating serum calcium. Trousseau's (BP) and Chvostek's (tapping the face at the angle of the jaw) signs may indicate hypocalcemia before signs and symptoms such as tetany occur.

Refeeding syndrome

Potentially fatal complication of nutritional rehab in chronically malnourished clients (anorexia, alcoholism). The client's lack of oral intake results in the pancreas making less insulin. After the client receives food with IV fluids and glucose, insulin secretion is increased, leading to phosphorous, magnesium, and potassium shifting intracellularly. Phosphorous is the primary deficient electrolyte that is required for energy (ATP). Hyperphosphatemia causes muscle weakness and respiratory failure. Deficiencies and potassium and mag potentiate cardiac arrhythmias.

Reportable to state board

Practicing outside of the scope Falsification of records - lying on documentation Stealing narcotics Abandonment Criminal acts

ADHD

Predominantly inattentive type, have trouble holding attention on tasks or play activities, experience difficulty organizing tasks and activities, and are easily distracted/side-tracked. They cannot give close attention to detail and dislike and/or avoid tasks that require mental effort over a long period. Also may interfere with social skills and may result in rejection and critical judgement by others leading to: Poor self esteem, increased risk for depression and anxiety, increased risk for substance abuse, academic or work failure, trouble interaction with peers and adults Key nursing intervention is to provide a calm, structured, organized, and consistent environment. A written chart or list of daily activities will help remind the child of what to expect and what will happen at any given time. A structured environment helps these children organize their thoughts and activities. Verbal explanations should be provided in a clear, concise manner that allows the child to ask questions. Keep in mind that verbal communication may not be the most effective approach Children do NOT outgrow ADHD and it usually continues into adulthood. However, they can learn to cope and manage symptoms.

PE in postpartum

Pregnancy is a hypercoagulable state that provides protection from hemorrhage after birth, but also augments risk of thrombus formation. Women who give birth by C section are at particularly increased risk for DVT. Additional risk factors for DVT include obesity, smoking, and genetic predisposition. DVT may progress to PE, often characterized by anxiety/restlessness, pleuritic chest pain/tightness, SOB, tachycardia, hypoxemia, and hemoptysis. Assess respiratory status, administer oxygen, and notify HCP.

MMR and pregnancy

Pregnant women are tested for rubella immunity. If they are not immune, a vaccination will be administered following birth of the fetus. Pregnancy should be avoided for at least 1-3 months after the immunization is given Congenital defects of rubella in a fetus include congenital cataracts, deafness, heart defects, and cerebral palsy.

Associative play

Preschoolers (age 3 to 6) enjoy associative play, in which they engage in similar activities or play with the same or similar items, but the play is unorganized without specific goals or rules. They often borrow items from each other without directing each other's play. Preschoolers also enjoy play involving motor activities and imaginative pretend play

Fentanyl patch

Prescribed for clients suffering from moderate to severe chronic pain. The patch provides continuous analgesia for up to 72 hours. However, the drug is absorbed slowly thorough the skin and can take up to 17 hours to reach its full analgesic effect. It is not recommended for treating postoperative, temporary, or intermittent pain as it does not provide immediate analgesia when applied Need to be disposed of securely by folding the patch in half and flushing it down the toilet or discarding in a sharps container. Heat should not be placed over a patch as this accelerates absorption. Do not cut patches in half as this damages the medication delivery system and delivers an imprecise dose. Should be applied to an area of flat, intact skin (upper back, chest) to prevent accidental removal. Does not need to be applied directly to the painful area as it becomes systemic

Nitroglycerine patch

Prevent angina in clients with coronary artery disease. Usually applied once a day and worn for 12-14 hours and then removed. Continuous use of patches without removal can result in tolerance. No more than one patch at a time should be worn. The patch should be applied to the upper body or upper arm . Clean, dry hairless skin that is not irritated, scarred, burned, broken, or calloused should be used. A different location should be chosen each day to prevent skin irritation. Phosphodiesterase inhibitors used in erectile dysfunction (tadalafil, sildenafil, vardenafil) are contraindicated with the use of nitrates. Both have similar mechanisms and cause vascular smooth muscle dilation. Combined used can cause severe hypotension. Patches may be worn in the shower. Headache are common with use of nitrates - the client may need to take an analgesic

Z-track technique

Prevents tracking (leakage) of the medication into the subq tissues and is universally recommended for administration of IM meds. Displacing the skin while injecting the medication and then releasing the skin back to its normal position after removing the needle creates a zigzag track. Pull the skin laterally away from injection site Hold skin taut with nondominant hand and insert needle at 90 degrees Inject med slowly while maintaining traction Wait 10 seconds after injection to withdraw the needle while maintaining traction on the skin Release the hold on the skin - allows tissues layers to slide back to normal position Apply gentle pressure but do not massage

ACE inhibitors

Prils Given post MI to prevent ventricular remodeling (hypetrophy) and the progression of heart failure. Can cause hyperkalemia so must check potassium levels before administering. Should also check blood pressure before administering. Can also be used for diabetic neuropathy Can also cause symptomatic hypotension, intractable cough, angioedema (allergic reaction involving edema of face and airways), and temporary increase in serum creatinine For clients unable to tolerate ACE inhibitors, angiotensin II receptor blockers (ARBs) such as valsartan and losartan are recommended. ACE inhibitors are TERATOGENIC

RAI treatment

Primary treatment for nonpregnant adults with hyperthyroid disorders such as Grave's Disease. The use of RAI is contraindicated in pregnancy can could cause harm to the fetus. Pregnancy results should therefore be confirmed using a valid pregnancy test in all clients who still have menstrual cycles rather than using a subjective form of assessment such as asking when the last menstrual period was. Causes dryness and irritation in the mouth. Teach client to take sips of water frequently or use a salt and soda gargle solution 3-4 times daily to relieve symptoms RAI damages or destroys the thyroid tissue, thereby limiting thyroid secretion and can result in hypothyroidism. Clients need to take thyroid supplementation for life. RAI has a delayed response and may take up to 3 months to have a maximum effect. For this reason, other meds should be maintained to lower thyroid hormone synthesis and treat symptoms of hyperthyroidism until RAI begins to have max effect Should be taught the following precautions for up to a week: Avoid close proximity to pregnant women or children Do not breastfeed as RAI may be excreted through breast milk and could harm the infant Do not share utensils with others or use bare hands to handle food that is to be served to others Isolate personal laundry (bed linens, towels, daily clothes) and wash it separately Use a separate toilet from the rest of the family and flush 2-3 times after each use Wash hands frequently and thoroughly, especially after restroom use Drink plenty of fluids Sleep in a separate bed from others and do not sit near others in an enclosed area for a prolonged period of time (train or plane)

Endoscopic retrograde cholangiopancreatography

Procedure in which an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Using fluoroscopy with contrast media, the ducts can be visualized and treatments including removal of obstructions, dilation of strictures, and biopsies can be performed. Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threatening complication after an ECRP. Signs and symptoms include acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid rise in pancreatic enzymes (amylase, lipase)

Percutaneous nephrolithotripsy

Procedure that breaks and removes kidney stones and can lead to severe pain. Involves the insertion of a needle and sheath through the skin into the pelvis of the kidney. A nephroscope is inserted through the sheath to break and remove kidney stones too large to remove with other methods. Post procedure, a temporary percutaneous nephrostomy tube may be placed to prevent obstruction by stone fragments and to promote healing of injured tissue; maintaining tube patency is critical. If a client is experiencing flank pain and has no drainage from the nephrostomy tube, this may indicate obstruction to urine flow that can lead to kidney injury (pressure atrophy). Gentle irrigation of the nephrostomy tube with a small volume of sterile normal saline using aseptic technique is the appropriate intervention. IF tube patency cannot be established after irrigation, the healthcare provider is notified.

Cystoscopy

Procedure that uses a fiber-optic scope inserted into the urethra into the bladder with the client in lithotomy position. Complications include urinary retention, hemorrhage, and infection. Notify HCP immediately if you have bright red blood when urinating, blood clots, inability to urinate, fever >100.4, chills, or abdominal pain unrelieved by analgesia. May require abx therapy or insertion of urinary catheter to irrigate the baldder, remove clots, or drain the bladder. Pink tinged urine, frequency and dysuria are expected for up to 48 hours following the procedure. Take a mild analgesic (acetaminophen) and warm tub/sitz bath (except with recurrent UTIs) for pain relief

Peritoneal dialysis

Process that uses the abdominal lining as a semipermeable membrane to dialyze a client whose kidneys are not functioning properly. A catheter is placed in the peritoneal cavity for infusing dialysate. Dialysate is infused into the cavity and then the tubing is clamped to allow the fluid to dwell for a specified period. After the specified dwell time, the catheter is unclamped and the fluid (effluent) drains out via gravity. Waste products and electrolytes cross the membrane into the dialysate during the dwell time with the aid of osmotic agents. Peritonitis is a major concern with PD. There is also a risk for infection at the catheter exit site. Using sterile technique when spiking and attaching bags of dialysate fluid to the client's catheter is a priority to prevent contamination and decrease incidence of infection. Any signs of developing complications (cloudy effluent, low-grade fever, redness or tenderness of the exit site) should be reported to the HCP. Insufficient outflow results most often from constipation when distended intestines block the catheter's holes. If outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer appropriate prescribed medications (stool softeners). The nurse should also check the tubing for kinks and reposition the client to side-lying position or assist with ambulation. The drainage bag should be maintained below the abdomen to promote gravity flow. The nurse should assess for fibrin clots and milk the tubing to dislodge or administer fibrinolytics as prescribed. If these measures are ineffective, an x-ray may be needed to check the catheter location

Phases of a seizure

Prodromal: period with warning signs that precede the seizure (before the aural phase) Aural: period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or recognize a prodromal or aural phase Ictal phase: period of active seizure activity Postictal phase: may experience confusion and headache. Confusion can help differentiate between seizure and syncope. In syncope, there should be no prolonged post-event confusion

Macular degeneration

Progressive incurable disease of the eye in which central portion of the retina, the macula, begins to deteriorate with age causing blurred or wavy disturbances in the central field of vision Dry macular degeneration occurs when the microvasculature supplying the macula is blocked, causing ischemia Wet macular degeneration is abnormal blood vessels forming that eventually destroy the macula. Further progression can be slowed r stopped using surgery or antineoplastic agents

Parkinsons Disease

Progressive neurological disorder characterized by bradykinesia (loss of autonomic movements) and tremors. Clients with PD have an imbalance between dopamine and acetylcholine in which dopamine is not produced in high enough quantities to inhibit ACh.

Multiple sclerosis

Progressive, de-myelinating disease of the CNS that interrupts nerve impulses, causing a variety of symptoms. Symptoms may vary, but muscle weakness, spasticity, incoordination, loss of balance, and fatigue are usually present, causing impaired mobility and risk for fall and injury. Walking with feet apart increases support base, improving steadiness and gait. Assistive devices, such as a cane or walker, are usually required as demyelination of the nerve fibers progresses. ROM, strengthening, and stretching exercises help limit spasticity and contractures in clients with MS. Rather than increasing duration of exercise, clients should balance exercise with rest. Clients should also exercise when the weather is cool and stay hydrated; dehydration and extreme temperatures can cause symptom exacerbation

Priapism

Prolonged painful erection >2 hours caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications (sildenafil, trazadone) or a preexisting medical condition (sickle cell disease, cocaine use). The nurse should return this call first as the condition is a medical emergency that can result in permanent erectile dysfunction

Inguinal hernia

Protrusion of intraperitoneal contents through a weakened area in the abdominal wall (groin, scrotum). Clients may experience dull pain exacerbated by exercise or straining and a palpable bulge on assessment. A hernia is reducible if the organs can be returned to the peritoneal cavity by applying pressure to the bulge, and incarcerated, if they cannot. If intestinal strangulation occurs, the client requires emergency treatment to prevent bowel ischemia or perforation. Strangulation symptoms include severe pain, nausea, and vomiting. Direct inguinal hernia: Intestine pushes through the peritoneum through the superficial inguinal ring Indirect inguinal hernia: intestine pushes through the peritoneum through the deep inguinal ring into the spermatic cord Manifestations of a mechanical bowel obstruction (pain, distension, nausea, vomiting) are caused by compressed loops of bowel incarcerated by the hernia. Subsequent bowel ischemia and strangulation can lead to infection and death. Immediate evaluation and urgent surgical intervention are critical To prevent hernia reoccurrence after surgical repair, the client is taught to avoid activities that increase abdominal pressure (coughing, heavy lifting) for 6-8 weeks. If sneezing or coughing are unavoidable, the client should splint incisions and keep the mouth open when sneezing Scrotal support garments and ice packs will help decrease postop pain and scrotal swelling. Scrotum should be elevated with a pillow.

Renal arteriogram

Radiologic test performed to visualize renal blood vessels to detect abnormalities (renal artery stenosis or aneurysm). A contrast medium is injected into the femoral artery; therefore, the client should be taught to increase fluid intake after the procedure to flush the dye from the body. Increased output is an expected finding

Newborn lung assessment

Rales in the lungs are normal immediately after birth due to fluid in the lungs. They will clear as the neonate transitions to extrauterine life. However, wheezes, stridor, or persistence of crackles after the first few hours of birth are abnormal

Tumor lysis syndrome

Rapid release of intracellular components into the bloodstream. Massive cell lysis releases intracellular ions (potassium and phosphorous) and nucleic acids into the bloodstream. Catabolism of the nucleic acids produces uric acid, resulting in severe hyperuricemia. Released phos binds to calcium, lowering serum calcium levels. Both calcium phosphate and uric acid are deposited in the kidneys, causing renal injury

Neuroleptic malignant syndrome

Rare but life-threatening condition often seen with "typical" antipsychotic drugs. Characterized by fever, muscle rigidity, altered mental status, and autonomic dysfunction (sweating, hypertension, tachycardia) Treatment in an ICU may be required. Most important intervention is to immediately discontinue the antispcyhotic medication and notify the HCP for further assessment

Dialysis disequilibrium syndrome

Rare but potentially life-threatening complication that can occur in clients during the initial stages of hemodialysis. It can be prevented by slowing the rate of dialysis. During HD, solutes (urea) are removed more quickly from the blood than from the brain cells and CSF, creating a concentration gradient that can lead to excess fluid in the brain cells and increased ICP. Characterstic neurologic manifestations include nausea, vomiting, headache, restlessness, change in mentation, and seizure activity Contact HCP immediately if suspected. If severe, DDS can progress to coma and death. If DDS is identified during treatment, the rate of dialysis should be slowed or stopped. Treatment focuses on interventions to decrease cerebral edema and manage symptoms

Retinal detachment

Separation of the retina from the underling epithelium that allows fluid to collect in the space. The signs/symptoms include sudden onset of light flashes, floaters, cloudy vision, or curtain appearing in the vision. If detachment becomes complete, blindness occurs

Malignant hyperthermia

Rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia as well as succinylcholine (paralytic used in conjunction with anesthesia for intubation) in susceptible clients. The triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. It can occur in the OR or in the PACU. As the condition progresses, the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardiac dysrhythmias, and myoglobinuria. Most characteristic signs are hypercapnia, tachypnea, tachycardia, generalized muscle rigidity (jaw, trunk, extremities), and hyperthermia. Hyperthermia is a later sign and can confirm suspicious of MH. The nurse monitors temperature as it can rise 1 degree every 5 minutes and can exceed 105. Treatment: IV dantrolene reverses the process by slowing metabolism, cooling blanket, fluid resuscitation, treating hyperkalemia A client just returning from anesthesia would be expected to have hypothermia, pinpoint pupils, and be difficult to arouse. Hyperthermia is also common due to blood products and trauma from surgery, but stiffness/rigidity in the presence of elevated temperature is more concerning

Epistaxis

Rarely serious and is usually due to mucosal irritation from dryness, local injury, a foreign body, or rhinitis. Most bleeding arises from the highly vascular network on the anterior nasal septum. Epistaxis generally resolves spontaneously or with simple home management The initial step in treatment is to tilt the client's head forward and apply direct, continuous pressure to the nose for 5-10 minutesl. Pressure should be applies to the soft, compressible tissue below the nasal bone. Holding pressure on the nasal bridge does not provide effective relief. Holding a cold cloth or ice pack to the bridge of the nose may also help induce vasoconstriction. Keeping the child quiet and calm may help provide the adequate time and pressure necessary for clotting. Epistaxis can often be prevented by avoiding local trauma and maintaining hydration of the mucosa with saline nasal spray or a humidifier

Different brain lobes

Rate and depth of respirations regulated by medulla oblongata Frontal lobe: Broca aphasia Temporal lobe: Wernicke aphasia Parietal lobe: inability to feel being touched

Dabigatran

Reduces the risk of clot formation and stroke in clients with chronic atrial fib. Implement bleeding precautions. Should be kept in original container or blister pack until time of use to avoid moisture contamination. Take with food or water and do not crush.

Good sleep habits

Reducing stimuli in the bedroom (reading and television) Avoid naps later in day Keep bedroom cool, dark, and quiet Avoid caffeine, nicotine, and alcohol within 6 hours of sleep Avoid exercise or strenuous activity within 6 hours of bed Avoid going to bed hungry Practice relaxation techniques if stress is causing insomnia

Types of delusions

Reference: clients believe that secret messages are being sent to them in songs, newspapers, etc. Grandeur: "need to get to Washington for meeting with the president" Control: "don't drink the tap water - that's how the government controls us" Nihilistic: "it doesn't matter if I take my medicine - I'm already dead." Somatic: "the doctor said it's fine, but I really have lung cancer" Paranoid/persecutory: "I am being poisoned" Somatic: false ideas about bodily functioning Interventions: do not challenge the belief. Reinforce reality by talking about and encouraging client to participate in real events. The nurse should not delve into or have long conversations about the delusional belief system

Fecal incontinence in children

Refers to repeated passage of stool in inappropriate places by children age >4. In more than 80% of cases, it is due to functional constipation (retentive type); in about 20% of cases, it may be caused by psychosocial triggers (nonretentive type) Management of fecal incontinence/constipation primarily includes 3 components: disimpaction followed by prolonged laxative therapy, dietary changes (increased fiber and fluid intake), and behavior modification. Behavioral strategies are used to promote and restore regular toileting habits and to gain the child's cooperation and participation in the treatment program. Regularly schedule toilet sitting times 5-10 minutes after meals for 10-15 minutes Provide a quiet activity for the child during toilet sitting, which will help pass the time and make the experience more enjoyable Initiate the reward system to boost the child's participation; the reward would be given for effort, not for success of evacuation in the toilet (children with retentive encopresis have dysfunctional anal sphincters and little control over bowel movements; giving reward for something the child has no control over would not be effective) Keep a diary or log of toilet sitting times, stooling, meds, and episodes of soiling to evaluate the success of the treatment

Snack for toddlers

Safety: small hard sticky and/or slippery foods pose a choking risk (hot dogs, grapes, nuts, raw carrots, popcorn, hard candy, raisins) Nutritient density: snack should be of high nutritional value and not empty calories Food-borne illness: children are at higher risk for food-borne illness if given raw unpasteurized foods like juice, partially cooked eggs, raw fish, or raw bean sprouts Healthy snacks for toddlers: whole-wheat crackers, banana slices, yogurt, cooked vegetables, mini pizzas, and cottage cheese with cut-up fruit

ARDS

Refractory hypoxemia is the hallmark signs of ARDS, a progressive form of acute respiratory failure that has a high mortality rate. It can develop following pulmonary insult (aspiration, pneumonia, toxic inhalation) or nonpulmonary insult (sepsis, multiple blood transfusions, trauma) to the lung The insult triggers a massive inflammatory response that causes the lung tissue to release inflammatory mediators (leukotrienes, proteases) that cause damage to the alveolar-capillary membrane. As a result of the damage, the A-C membrane becomes more permeable, and intravascular fluid then leaks into the alveolar space, resulting in a noncardiogenic pulmonary edema Lungs become stiff and noncompliant, which makes ventilation and oxygenation less than optimal and results in increased work of breathing, tachypnea and alkalosis, atelectasis, and refractory hypoxemia. Profound hypoxemia despite high concentration of oxygen is a key sign of ARDS.

Meckel's diverticulum

Remnant of the umbilical cord that should have disintegrated at 8 weeks in utero but became an out pouch in the small intestine. Characterized by rectal bleeding

Ophthalmic medication

Remove secretions from eyelid by wiping from inner to outer canthus Place client in sitting position with head tilted back toward the affected eye Rest hand on client's forehead Pull lower lid down gently with thumb or forefinger against bony orbit Instruct client to look up and instill drops into conjunctival sac Close eyelid and move the eye around then apply pressure to lacrimal duct for 30-60 seconds if medication has systemic effect (beta blocker for glaucoma) Remove excess med from each eye Wait 5 min before instilling a different med in the same eye

Kidney disease and HTN

Renal damage often results in elevated blood pressure, so clients with chronic kidney disease are at risk for uncontrolled HTN and hypertensive emergencies. Hypertensive encephalopathy is a type of hypertensive crisis characterized by nausea, vomiting, and headache. Treatment is urgent (within 1 hour) to prevent damage to the heart, kidney, and brain. The client should check blood pressure at home if possible, and then proceed to the ED for further assessment and treatment (titration of antihypertensive medication)

RACE

Rescue and evacuate clients to safety Alarm (activate) Confine fire by closing doors Extinguish fire Then encourage visitors not to use the elevator

Cushing syndrome

Result of prolonged exposure to excess corticosteroids. Can also be from adrenal hyperfunction (tumor) Skin manifestations such as easy bruising, purple striae, and skin atrophy, which are a result of collagen loss Fat redistribution resulting in truncal obesity and moon like face; thin extremities. Fat pads are seen on the back and supraclavicular areas In women, androgens are produced in the adrenal gland. Androgen excess from adrenal gland stimulation can result in acne, hirsutism, and menstrual irregularities *Aldosterone excess* can result in hypernatremia, hypokalemia, and hypertension (due to fluid overload) Hyperglycemia will occur as a result of excess corticosteroids Untreated clients can develop proximal muscle weakness and bone loss (steroids catabolic to muscle and bone)

Heat exhaustion

Result of prolonged exposure to excessive heat. Manifests with elevated body temperature, intravascular volume depletion, and electrolyte imbalance. Manifestations include dizziness, weakness, fatigue, sweating, flushing, nausea, tachycardia, and muscle cramping If heat exhaustion is suspected, the client should be moved to cooler temperatures and provided a cool sports drink, another electrolyte-containing beverage, or water. Priority is to lower body termpature to prevent heat stroke, a potentially fatal condition associated with mental status changes and additional organ damage (kidney injury, rhabdomyolysis)

Fibromyalgia

Results from abnormal CNS pain transmission and processing. Characterized by chronic, bilateral musculoskeletal axial pain (above and below the waist), multiple tender points, fatigue, and sleep/cognitive disturbances. Drugs to treat chronic pain are duloxetine, pregabalin, and amitriptyline (tricyclic antidepressant)

Primary angle closure glaucoma

Results from blocking the outflow of aqueous humor into the trabecular meshwork; causes include lens or pupil dilation from medications or sympathetic stimulation

Supine hypotensive syndrome

Results from compression of the maternal inferior cava by the large gravid uterus in mid to late pregnancy when the client is in the supine position. The venous return is reduced, causing maternal hypotension from reduced CO. The client can also report feeling dizzy and faint. The first step is to rectify the cause by turning the client laterally (to the right since the aorta is on the right and has higher pressure)

Compartment syndrome

Results from swelling and increased pressure within a confined space (a compartment). It is most common with lower extremity injuries but can also occur in the arm. Pressure from bleeding/edema can exceed capillary perfusion pressure and lead to decreased perfusion and tissue ischemia below the site of increased pressure. Early manifestations include increasing pain unrelieved by opioids or elevation, pain with passive motion, pallor, and paresthesia due to nerve compression and ischemia. If the pressure is not relieved within 4-6 hours of onset (surgical fasciotomy, cast removal), irreversible nerve damage and muscle injury can occur Must keep extremity at the level of the heart, not elevated. Elevation may decrease perfusion to the area 6 P's of compartment syndrome: Pain: increasing despite elevation, analegsics, and ice Pressure: affected extremity or digits are firm and tense; skin is tight and appear shiny Paresthesia: tingling, numbness, or burning sensation Pallor: skin appears pale, cap refill is >3 seconds Pulslessness: pulse distal to injury is impalpable Paralysis: loss of function or inability to move extremity or digits. muscle weakness appears before paralysis

Naloxone

Reversal agent for opioids. The effects can start to wane at 20-40 minutes after administration, and its duration of action is approximately 90 minutes. Opioid duration may last longer than naloxone duration, so it is important to monitor respiratory status after as they may fall back into the excessive sedation and/or respiratory depression

Osteomalacia

Reversible bone disorder caused by vitamin D deficiency and is characterized by weak, soft, and painful bones that can easily fracture or become deformed. In vitamin D deficiency, calcium and phosphorous cannot be absorbed from the GI tract and are unavailable for calcification of bone tissue. Vitamin D deficiency is also associated with risk fo falls, especially in elderly clients, due to muscle weakness. Implement safety measures such as canes or walkers to prevent falls or injury Encourage light to moderate activity, which can help promote bone strength and heart Increase dietary intake of calcium (leafy green veggies, dairy), phosphorous (milk, organ meats, nuts, fish, poultry, whole grains), and vitamin D (milk, cereal, egg yolks, saltwater fish, liver); exposure to sunlight is also recommended OTC or prescription supplemental vitamin D

Atypical antipsychotics

Risperidone, quetiapine, olanzapine Used in treatment of schizophrenia, bipolar disorder, and other mental health disorders. The nurse should teach clients and caregivers about potential side effects of antipsychotic medications. Key teaching points include: Extrapyramidal symptoms including akathisia (restlessness, fidgeting) and Parkinsonism (tremors, shuffling gait). These are important to watch for, as EPS is easily mistaken for agitation or negative schizophrenic symptoms Fever or muscle rigidity may indicate neuroleptic malignant syndrome, a potentially fatal condition requiring emergent intervention Clients may experience anticholinergic effects (dry mouth, constipation) Clients should change positions slowly to prevent orthostatic hypotension Sedating effects (drowsiness, hypersomnia) are common Tardive dyskinesia is a complication and involves involuntary movements after chronic use (lip smacking)

STI reporting

STIs must be reported to public health and partners may need to be contacted to receive treatment, even if the client claims right to confidentiality

Diverticular disease

Sac-like protrusions in the large intestine. Diverticulosis is characterized by the presence of these protrusions; the client is asymptomatic. Diverticulitis occurs whne diverticula become infected and inflamed. Complications include abscess, fistula formation, intestinal obstruction, peritonitis, and sepsis. Diverticular bleeding occurs when a blood vessel next to one of these pouches bursts and this may cause blood in the stool. Etiology has been linked to chronic constipation, a major cause of excess intracolonic pressure. Measures to prevent constipation include a diet high in fiber, daily intake of at least 8 glasses of water, and exercise. A fiber supplement may be advised. Increased consumption of red meat and other high-fat foods can increase risk

Laparoscopic cholecystectomy

Safest and most commonly used procedure for gallbladder removal. A laparoscope and grasping forceps are inserted through small punctures made in the abdomen. The procedure is associated with decreased post op pain, better cosmetic results, shorter hospital stays, and fewer days for recovery versus the open technique. In the immediate post-op period, place client in Sim's position to facilitate movement of CO2 utilized during surgery to fill the abdominal cavity. CO2 can irritate the phrenic nerve and diaphragm, potentially causing breathing difficulty. Post op teaching: Diet: low fat is recommended postoperatively - regular diet can be resumed after a few weeks although weight loss may be recommended Activity and work: resume normal activity slowly as tolerated. Most people can return to work within a week Incision care and hygiene: dressings can be removed the day after surgery, and showering is permitted at this time. Do not bathe. Signs of infection should be reported immediately

Peripheral IV sites

Should be selected in the hand or forearm to reduce the risk of catheter associated bloodstream infections. Sites on upper extremities located at flexion sites (wrist, bend of arm) and the lower extremities should be avoided

Herbal supplements

Saw palmetto: BPH - increased bleeding risk Hawthorn extract: HF St John's Wort: depression - may cause hypertensive crisis or serotonin syndrome if used with other antidepressants. Caution with other anticoagulants Black cohosh: postmenopause symptoms (hot flashes) - may cause liver dysfunction Kava: anxiety or insomnia. Can cause severe liver damage Garlic: used to improve cholesterol and lower BP. May increase bleeding risk. Glucosamine: used to improve joint function. Hypoglycemia may occur when taken with antidiabetic drugs Licorice: anxiety or insomnia. Can cause HTN or hypokalemia Echinacea: cold and flu - may cause anaphylaxis Ephedra: cold and flu, weight loss. Can cause HTN, MI, stroke, seizure Ginseng: improved mental performance. Increases bleeding risk Ginkgo biloba: memory enhancement. Increased bleeding risk Hawthorn extract: used to control HTN and heart failure

Flail chest

Scenario where multiple ribs sustain multiple fractures and become independent of the chest wall, floating on top of the lung and pleura. The fractured segment moves paradoxically in relationship to the intact chest wall, pushing outward with expiration and inward with inspiration. In addition to being extremely painful, impaired respiration can occur and rib fragments may puncture the pleura or vessels, causing hemothorax and/or pneumothorax at any time. Supplemental oxygen is often necessary and a chest tube may be necessary

Tamoxifen

Selective estrogen receptor modulators have differential action in different tissues (mixed agonist/antagonist). In the breast, they block estrogen (antagonist) and are therefore helpful in inhibiting growth of estrogen-receptive breast cancer cells. However, tamoxifen has estrogen-stimulating (agonist) activity in the uterus, resulting in excessive endometrial proliferation (endometrial hyperplasia). This hyperplasia can eventually lead to cancer. Irregular or excessive menstrual bleeding in premenopausal women or any bleeding in postmenopausal women can be a sign of endometrial cancer. Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (stroke, pulmonary embolism, DVT) Clients with breast cancer take tamoxifen for several (5-10 years) to prevent recurrence. Therefore, monitoring for life-threatening side effects is very important. Because tamoxifen blocks estrogen receptors, it can cause symptoms of menopause. Vaginal dryness, hot flashes, and decreased libido are common and would be discussed after addressing more concerning symptoms

Histrionic personality disorder

Self-dramatizing, exaggerated or shallow emotional expression Attention-seeking, needs to be the center of attention Overly friendly and seductive, attempts to keep others engaged Demands immediate gratification and has little tolerance for frustration The signs and symptoms are maladaptive and have a negative impact on the client's social, interpersonal, and occupational life

Sepsis vs septic shock

Septic shock is defined as having sepsis-induced hypotension despite adequate fluid resuscitation. Hypotension and inadequate tissue perfusion (elevated serum lactate) despite fluid resuscitation and decreased CVP (decreased circulating volume) and pulmonary artery wedge pressure (decreased preload) indicate the presence of septic shock in the client. Sepsis is a systemic inflammatory response (increased HR >90, RR >20, temp >100.4, leukocytosis >12,000, and decreased SBP) to a documented or suspected infection and is present in the this client. SIRS: generalized inflammatory response to an infectious or noninfectious insult to the body. It is often difficult to distinguish from early sepsis. When SIRS is suspected, a source for sepsis should be sought MODS: failure of 2 or more body organs (AKI, ARDS). Septic shock can progress to MODS.

Huff coughing

Series of mini coughs that is more effective in mobilizing secretions with COPD. Less airway collapse, less energy, less oxygen consumption, and greater secretion removal. 1. Position upright 2. Inhale through the nose using abdominal breathing and prolong the exhalation through pursed lips for 3 breaths - deflates excess air from lungs 3. Hold breath for 2-3 seconds following an inhalation, keeping the throat open - opens glottis structures and prevents high pressure cough 4. Deeply inhale and while leaning forward, force the breath out gently using the abdominal muscles while making a "ha" sound; repeat 2 more times - keeps airways open while moving secretions up an dout of lungs 5. Inhale deeply using abdominal breathing and give one forced huff cough - the last, increased force "ha" usually results in mucus being expectorated from larger airways

Status epilepticus

Serious and life-threatening emergency in which a client has been seizing for 5 minutes or longer. Could result in brain damage and death. Grunting and a dazed appearance are 2 common signs. A client with hydrocephalus (abnormal collection of CSF in the head) and VP shunt is at a higher risk for seizures. Stopping seizure activity is the first nursing priority as long as there is an adequate airway and the client is breathing. IV benzos (diazepam, lorazepam) are used acutely to control seizures. However, rectal diazepam is often prescribed when the IV form is unavailable or problematic. Parents often get prescriptions for rectal diazepam and are advised to administer a dose before bringing a child to the ED.

Thyroid storm

Serious and potentially life-threatening emergency for clients with Grave's disease. This condition occurs when the thyroid gland releases large amounts of thyroid hormone in response to stress (trauma, surgery, infection). Characteristic features include tachycardia, hypertension, cardiac arrhythmias (a-fib), and fever up to 104-106 F. Other findings include severe nausea, vomiting, anxiety, altered mentation, and seizures.

Hyperosmolar hyperglycemic state

Serious complication associated with type II diabetes. Clients are able to produce enough insulin to prevent DKA, but not enough to prevent extreme hyperglycemia and osmotic diuresis, and extracellular fluid deficit. Blood glucose rises slowly and symptoms may not be recognized until hyperglycemia is extreme, often >600. This eventually causes neurological manifestations such as blurry vision, lethargy, obtundation, and progression to coma. Because the insulin is still present, symptoms associated with ketones and acidosis, such as Kussmaul respirations and abdominal pain are typically absent

HIT

Serious complication that often develops rapidly, requiring prompt recognition and treatment. HIT can result in arterial or venous thrombosis, although the exact association is unknown. A decrease in platelet count by >50% or below 150,000 is suggestive of HIT, which requires heparin discontinuation

Trazodone

Serotonin modulator used for major depressive disorders. Also blocks alpha and histamine receptors. Blockade of alpha receptors causes orthostatic hypotension. Blockade of H1 receptors leads to sedation, so it is effective in treating insomnia with depression. Cannot take with benzos, sedating antihistamines, and alcohol. Priapism is a serious side effect of trazodone

Vancomycin

Serum vancomycin trough levels should be monitored to assess for therapeutic range (10-20 mg/L). Vancomycin is nephrotoxic and ototoxic. Trough serum vancomycin concentrations are the most accurate and practical for monitoring efficacy. Trough should be obtained just prior (15-30 min) to administration of the next dose. Should be administered over a minimum of 60 minutes. Too rapid administration can cause red man syndrome, considered a toxic effect rather than an allergic reaction. Monitor BP during infusion because hypotension is a possible adverse effect Monitor for anaphylaxis Monitor IV site every 30 minutes. May cause thrombophlebitis or tissue necrosis if extravasation occurs. CVC is preferred, but PIV can be used for short-term therapy

Hyperemesis gravidarum

Severe, persistent nausea and vomiting during pregnancy. Excessive loss of gastric contents leads to fluid and electrolyte imbalances (hypokalemia, hyponatremia), metabolic alkalosis, nutritional deficiencies, ketonuria, and weight loss Expect signs and symptoms of dehydration (dry mucous membranes, poor skin turgor, decreased urine output, tachycardia, hypotension). Urine is concentrated with dehydration, indicated by increased specific gravity. Ketonuria indicates that the body is breaking down fat to use for energy due to the client's starvation state

Technique for metered dose inhalers

Shake canister well for 3-5 seconds Tilt head back slightly and exhale slowly for 3-5 seconds Hold canister mouthpiece about 1 1/2 inches in front of open mouth; as an alternative, place the mouthpiece in the mouth with lips sealed around it. Holding it in front of open mouth prevents impaction of the particles into the tongue and sides of mouth Compress canister while inhaling slowly for about 3-5 seconds Hold breath for 10 seconds if possible before exhaling Wait at least 1-2 minutes before taking a second puff of a bronchodilator

Infant formula

Should closely follow the manufacturer's recommendations for preparation, particularly if the product requires dilution. Keep bottles, nipples, caps, and other parts as clean as possible, either by boiling or washing in dishwasher Wash the tops of formula cans prior to opening to prevent contamination Prepared formula or opened cans of ready-to-feed or concentrated formua should be kept in the refridgerator and discarded after 48 hours if unused Prepared bottles can be warmed by placing in a pan of hot water for several minutes Test temperature on the inner wrist before giving to infant. Should be lukewarm, but never hot Never microwave formula Any formula left in bottle after a feeding should be discarded immediately because the infant's saliva has mixed with it and this will encourage bacterial growth

Scabies

Skin infestation caused by Sarcoptes scabei mite. Spreads easily via person to person contact. Pregnant female mite burrows into outer layer of skin to lay eggs and feces, leaving a superficial burrow track. Intense itching, especially at night, occurs due to the body's inflammatory process. The lengthy 30-60 day incubation period (timeframe between infestation and appearance of symptoms) makes it necessary to treat all persons who have had contact with the infested child during that time. Those age >2 months can receive one-time treatment with scabicde (permethrin), which is applied to all body areas below the head. It is important to inform the parents and child that itching will continue for several weeks after treatment. Scabies mites do not survive away from human skin for more than 2-3 days. Therefore, disinfecting the client's clothes, linens, and stuffed animals involved placing these in a plastic bag for a minimum of 3 days or machine washing them in hot water and drying them on hottest cycle. Fumigation is not needed

Weight gain in toddlers

Slows during toddler years with an average yearly weight gain of 4-6 pounds. By age 30 months, current weight should be approximately 4 times greater than birth weight. Chest circumference exceeds abdominal circumference after age 2, resulting in a taller and more slender appearance. Head circumference increases by 1 inch during the second year and then slows to a growth rate of 0.5 inches per year until age 5

Home care for burns

Soak area briefly in cool water Remove any clothing and jewelry around the burn to avoid constriction as edema develops. Only HCPs may remove clothing that is stuck to a burned area Cover with a clean, dry cloth to prevent contamination, further trauma, and hypothermia NO ice, ointments, or creams should be applied to the area

Halo external fixation device

Stabilizes cervical or high thoracic fracture when there is insignificant damage to the ligaments or spinal cord. Sensory and muscle function should be monitored to determine any new deficits, and pin sites should be regularly assessed for loose pins or infection Clean pin sites with sterile solution (chlorhexidine, water) Keep vest liner clean and dry ( changing weekly or when soiled, using a cool blow dryer to dry) Placing foam inserts under pressure points to avoid pressure injury Placing a small pillow under the client's head when supine to reduce pressure on the device Keeping the correct-sized wrench available at all times in case of emergency Avoid grabbing the device frame when moving a client Only HCP can tighten the screws

Valsalva maneuver

Straining during defecation - holding breath while bearing down on the perineum to pass stool. Straining to have a bowel movement is to be avoided in clients recently diagnosed with increased ICP, stroke, or head injury as straining increases intra-abdominal and intra-thoracic pressure, which raises ICP. The Vagus nerve is stimulated when bearing down; this temporarily slows the heart and decreases cardiac output, leading to potential cardiac complications in clients with heart disease. Straining increases intra-abdominal and intrathoracic pressure and should be avoided in clients diagnosed with portal hypertension due to cirrhosis for risk of variceal bleeding The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery Contraindicated in stroke, increased ICP, head injury, heart disease, glaucoma, eye surgery, abdominal surgery, and liver cirrhosis

Major depressive disorder

Subtype of depressive disorder, classified by specific symptoms that interfere with the ability to perform activities of daily living, work, sleep, and enjoy activities that are usually pleasurable to the client. 5 or more of the following symptoms must be present almost everyday for at least two weeks, and 1 of the symptoms must be depressed mood and loss of interest or pleasure Sleep (increased or decreased) Interest deficit Guilt Energy deficit Concentration deficit Appetite Psychomotor retardation or agitation Suicidality

CPR in pregnant women

Sudden causes of cardiac arrest in women: embolism, eclampsia, Mg overdoses, uterine rupture Heart is displaced to the left because growing uterus pushes upward on the diaphragm. Hands should be placed on the sternum slightly higher than usual for chest compressions. Uterus should be manually displaced to the client's left to reduce pressure on the vena cava and aorta. Nurse can also place a rolled blanket or wedge under the right hip to displace the uterus If return of spontaneous circulation does not occur within 4 minutes, emergency C section is usually initiated. Delivery should be within 5 minutes of initiating CPR

Trigeminal neuralgia

Sudden, sharp pain along the distribution of the trigeminal nerve. The symptoms are usually unilateral and primarily in the maxillary and mandibular branches. Clients may experience chronic pain with periods of less severe pain or cluster attacks of pain between long periods without pain. Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Pain is severe, intense, burning, or electric shock-like. Primary intervention is consistent pain control with carbamazepine. Behavioral interventions: Oral care - use small soft-bristled tooth brush and warm mouthwash Use lukewarm water and avoid beverages that are too hot or too cold Room should be kept at an even and moderate temperature Avoid rubbing or facial massage. Use cotton pads to wash face if necessary Have a soft diet with high calorie content and avoid foods that are difficult to chew Do not massage face

Sulfasalazine

Sulfonamide and non-biologic disease-modifying antirheumatic drug used to treat chronic RA and IBS. It inhibits prostaglandin production Most sulfa medications share common side effects: Crystalluria causing kidney injury - important to stay well-hydrated Photosensitivtiy and risk for sunburn Folic acid deficiency Rarely life-threatening agranulocytosis - should be monitored for CBC at the start of therapy and report symptoms immediately Stevens-Johnson syndrome Urine and skin can turn an orange-yellow color

Trimethoprim-sulfamethoxazole

Sulfonamide antibiotic, commonly referred to as a sulfa drug. These antibiotics are prescribed to treat bacterial infections. Contraindications include hypersensitivity to sulfa drugs, and pregnancy or breastfeeding. Glyburide is a sulfonylurea and has the potential to cause a sulfa cross-sensitivity reaction. Commonly used diuretics (thiazides, furosemide) are also sulfa derivatives and can cause cross-sensitivity reaction. Although this reaction is uncommon, an alternate antibiotic, is possible, can be prescribed by the HCP. Crystalluria is a potential adverse effect of sulfa medications. Clients should drink 2-3 L of water daily to prevent crytalluria.

Glyburide

Sulfonylurea that stimulates insulin release via the pancreas and carries a risk for prolonged hypoglycemia, especially in the elderly population due to potential delayed elimination. If a child who does not have diabetes accidentally takes these, it can cause life-threatening hypoglycemia and they would be a priority

Ruptured cerebral aneurysm

Surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless they rupture; they are often called silent killers as they may go undetected for many years before rupturing without warning signs. The distinctive description of a cerebral aneurysm rupture is the abrupt onset of the worst headache of my life that is different from previous headaches (including migraines). Immediate evaluation for a possible ruptured aneurysm is critical for a client experiencing a severe headache with changed in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance for survival

Vasectomy

Surgical procedure performed for permanent male sterilization. Vasa deferentia (ducts that carry sperm from the testicles to the urethra) are cut and sealed, preventing sperm from entering the ejaculate. The vasa deferentia are severed in the scrotum at the site before the seminal vesicles and prostate. As a result, the procedure should not affect the ability to ejaculate, amount and consistency of ejaculatory fluid, or other physiological mechanisms (hormone production, erection, orgasm). Following a vasectomy, sperm will continue to be produced but are absorbed by the body Following the procedure, it can take several months for the remaining sperm to be ejaculated or absorbed. Alternative birth control should be used until the healthcare provider confirms that semen samples taken at a follow up appointment are free of sperm; otherwise, pregnancy can occur

Ileal conduit

Surgical technique that uses an excised piece of the client's ileum to create an incontinent uirinary diversion. A client's ureters are connected to the ileal conduit, which is used to create an abdominal stoma that allows the passage of urine. A healthy stoma should be pink to brick-red and moist, indicating vascularity and viability. If the stoma is dusky or blue, the nurse should suspect impaired perfusion and contact the HCP immediately. This is considered a medical emergency

Hyperthyroidism

Sustained hyperfunctioning of the thyroid gland due to excessive secretion of thyroid hormones. This increases metabolic rate. Teaching and learning objectives to satisfy hunger and prevent weight loss and tissue wasting include: High calorie diet Consumption of approximately six meals a day packed with protein, carbs, and vitamins and minerals Avoidance of high fiber foods due to constant hyperstimulation of GI tract. HIgh fiber foods may increase GI symptoms. However, high-fiber diets are recommended the client with hyperthyroidism has constipation. Avoidance of stimulating substances (caffeine) Avoidance of spicy foods - can increase GI stimulation

Dopamine

Sympathomimetic inotropic med that improves hemodynamic status in clients with shock and heart failure. Increases myocardial contractility, increasing heart rate, and elevating blood pressure by causing vasoconstriction. Improves renal perfusion as well. Lowest effective dose of dopamine should be used with dopamine administration because it can cause tachycardia, dysrhythmias, and myocardial ischemia

Tramadol

Synthetic opioid analgesic used to treat moderate to severe postop pain. It is appropriate to prescribe at discharge as it has fewer respiratory depression complications

Misoprostol

Synthetic prostaglandin that protects against gastric ulcers by reducing the stomach acid and promoting mucus production and cell regeneration. It is often prescribed to prevent gastric ulcers in clients receiving NSAIDs. Antacids, especially those that contain magnesium, can increase the adverse effects of misoprostol (diarrhea, dehydration). If clients require therapy with antacids, they should choose one that does not contain magnesium (calcium carbonate) and contact the HCP if adverse events occur. Take with food to help decrease GI side effects Misoprostol is also used with labor induction and is classified as a pregnancy category X drug. Women of childbearing age must be educated on using reliable birth control and the possible sensation of uterine cramping when taking misprostol. Clients who suspect they are pregnant must stop taking the medication and contact HCP immediately Client can continue taking NSAIDs because it is designed to reduce side effects of NSAIDs

Adalimumab

TNF inhibitor, biologic disease-modifying antirheumatic drug classified as a monoclonal antibody. Its major adverse effects are similar to those of other TNF inhibitor drugs (etanercept, infliximab) and include immunosuppression and infection (current, reactivated). An elevated WBC count in this client can indicate underlying infection and should be reported immediately

CVL care

TPN should always be administered through a CVL Occlusive dressing should be changed every 7 days Distal port is the largest lumen, and should be used for CVP monitoring. Distal lumen is closest to the heart (reversed in regards to the client) Heparin flushes to maintain patency: 2-3 mL with 10 or 100 units/mL

Nitroglycerin

Tablets are heat and light sensitive: they should be kept in a dark bottle and capped tightly. Opened bottle should be discarded after 6 months You may take up to 3 pills in a 15-minute period - 1 pill every 5 minutes. EMS should be called if pain does not improve or worsens 5 minutes after the first tablet has been taken. Avoid fatal drug reactions: concurrent use of erectile dysfunction drugs or alpha blockers (terazosin, tamsulosin) is contraindicated due to fatal hypotension Headache and flushing may occur - does not warrant medication discontinuation Waking up at night with chest pain can signify that angina is occurring at rest and is no longer stable angina - this should be reported to the HCP NTG will cause a slight tingling sensation under the tongue if it is sufficiently potent. The mouth must be moist in order for it to dissolve. If using spray, direct it under the tongue and do not inhale it. Client should lie down before taking the pill as it may cause orthostatic hypotension. Headache and flushing are common side effects

Arteriovenous malformation

Tangle of veins and arteries that is believed to form during embryonic development. The tangled vessels do not have a capillary bed, causing them to become weak and dilated. AVMs are usually found in the brain and can cause seizures, headaches, and neurologic deficits. BP control is crucial. Clients with AVMs are at high risk for having an intracranial bleed and because the veins are weak and can easily rupture. Any neurologic changes such as headache, nausea, and vomiting should be evaluated immediately as these are usually the first signs of intracranial hemmorhage

TPN

Target range for glucose: 140-180. Hypoglycemia <70 can e due to slowing the rate of infusion. Although it occurs less frequently in clients receiving TPN than hyperglycemia >180 does, hypoglycemia can lead to life-threatening complications (seizures, nervous system dysfunction) Hyperglycemia may occur as well, and would manifest as polydipsia, polyuria, headaches, or blurred vision. Hyperglycemia should be corrected quickly because it can lead to seizures, coma, or death

Normal liver finding

The normal finding is a soft, distinct liver edge that is even with the bottom of the right rib cage or right costal margin. An abnormal finding would be a boggy liver edge below the rib cage (hepatomegaly)

Esophageal atresia/tracheoesophageal fistula

The upper esophagus ends in a blind pouch and the lower esophagus connects to the primary bronchus or the trachea through a small fistula. EA/TEF can usually be corrected surgically. Clinical manifestations include frothy saliva, choking, coughing, and drooling. Clients may also develop apnea and cyanosis when feeding. Aspiration is the greatest risk for clients with EA/TEF. Priority nursing interventions for infants with suspected EA/TEF include maintaining NPO status, positioning the client supine, elevating the HOB 30 degrees, and keeping the suction equipment by the bed to clear secretions from the mouth. If surgery must be staged or delayed, the priority is to maintain a clear airway and prevent aspiration. Gastrostomy tube may be placed to release air and drainage of gastric contents to prevent aspiration; however, feedings or irrigations through the tube are contraindicated until after surgical correction of TEF

INR

Therapeutic INR range is 1.5-2 times the normal control value (2-3). An INR of 3-3.5 is preferred to patient with mechanical heart valve. An INR of 5.0 or higher places the client at risk for bleeding and requires a dosage adjustment or administration of vitamin K as an antidote Warfarin inhibits vitamin-K-dependent synthesis of active clotting factors

Feeding clients with dysphagia

Thickened liquids Modification of food consistency (pureed, mechanically altered, soft) Having the client sit upright at a 90 degree angle Placing food on the stronger side of the mouth to aid in bolus formation Tilting the neck slightly to assist with laryngeal elevation and closure of the epiglottis Do not use straws - harder to control Thinner consistencies are also harder to control and increase risk for aspiration A client with hemianopsia from a CVA may have trouble seeing the entire plate. Having the client turn the head during a meal will help the client see everything on the plate

Evisceration

Total separation of wound layers with protrusion of internal viscera through the incision. Medical emergency that can lead to localized ischemia, peritonitis, and shock. Emergency surgical repair is necessary. Clients at risk for poor wound healing (obesity, diabetes) are at increased risk for evisceration. Remain calm and stay with client. Have someone notify HCP immediately and bring sterile supplies. Tell client not to cough or strain Place client in low Fowler's position (no more than 20 degrees) with knees slightly flexed to relieve pressure on the incision and have the client maintain absolute bed rest to prevent tissue injury Assess vital signs (and repeat every 15 minutes) to detect possible signs and symptoms of shock (hypotension, tachycardia, tachypnea) Cover the viscera with sterile dressings saturated in NS solution to prevent bacterial invasion and keep exposed viscera from drying out Document interventions taken and the appearance of the wound and eviscerated organ (color, drainage). If the blood supply is interrupted, the protruding organs can become ischemic (dusky) and necrotic (black)

Tuberculosis

Transmitted through the airborne route. TB is usually pulmonary but can also be extrapulmonary (meninges, genitourinary, bone and joints, GI) TB commonly presents with constitutional symptoms including: Low-grade fever Night sweats Anorexia and weight loss Fatigue Additional symptoms depends on the location of the infection. TB typically includes: Cough Purulent or blood-tinged sputum Shortness of breath Dyspnea and hemoptysis are typically seen in the late stages. The classic manifestations can be absent in the immunocompromised clients and the elderly. Jaundice can be present in disseminated TB with liver involvement. Can also be a side effect of drugs used to treat pulmonary TB (isoniazid) Back pain indicates spinal TB

Acute diarrhea in children

Treatment focuses on maintaining adequate fluid and electrolyte balance. The first-line treatment is oral rehydration therapy, using rehydration solutions to increase reabsorption of water and sodium. Even if diarrhea is accompanied by vomiting, ORS should still be offered in small amounts at frequent intervals. Continuing the child's normal diet is encouraged as it shortens the duration and severity of the diarrhea. The BRAT (bananas, rice, applesauce, and toast) diet is not recommended as it does not provide sufficient protein or energy. Do not use anti-diarrheal meds. Parents should be taught to monitor their child for signs of dehydration by checking the amount of fluid intake, number of wet diapers, presence of sunken eyes, and condition of mucous membranes. Protect perineal skin during bouts of diarrhea by using skin barrier creams (petrolatum or zinc oxide)

Lactulose

Treatment for hepatic encephalopathy. Not digested or abdorbed until it reaches the large intestine where it is metabolized, producing an acidic environment and hyperosmotic effect. In this acidic environment, ammonia is converted to ammonium and excreted rapidly. Lactulose can be given orally with water, juice, or milk or it can be administered via enema. For faster results, administer on an empty stomach. Desired therapeutic effect is production of 2-3 soft bowel movements each day. Dose will be titrated until this is achieved. Electrolytes will need to be closely monitored as it can cause dehydration, hypernatremia, and hypokalemia

Adenosine

Treats tachycardia rhythms such as paroxysmal SVT Half life is <5 seconds, so adenosine should be administered rapidly as a 6 mg bolus IV over 1-2 seconds followed by a 20 mL saline flush. Repeat boluses of 12 mg may be given twice if the rapid rhythm persists. Injection site should be as close to the heart as possible (AC area). The client's ECG should be monitored continuously. A brief period of asystole is due to adenosine slowing impulse conduction through the AV node. The client should be monitored for flushing, dizziness, chest pain, or palpitations during or after administration

Amitriptyline

Tricyclic antidepressant often used for nerve pain and insomnia Side effects: *orthostatic hypotension*, dry mouth, constipation, difficulty urinating, drowsiness, blurred vision, photosensitivity Lethal if taken in overdose and can cause serious cardiac arrhythmias

Allergy immunotherapy injections

Trigger an increase in the body's production of specific immunoglobulins to reduce the client's allergy symptoms when exposed to specific allergens. Small doses of the allergen are injected subcutaneously on a client-specific schedule. Rarely, allergy shots may induce an immediate and potentially fatal anaphylactic reaction. The client must remain at the facility for 30 min after the injection. Allergy shots are typically given every week with a dose increase at every injection until the target maintenance dose is reached, which is then given every few weeks for 3-5 years. It is normal to have a little bit of redness and itching at the shot site

Parallel play

Typical behavior of a toddler and involves activities focused on improving motor skills, imitative efforts, and the use of multiple senses. Toddlers play alongside rather than with other children. Having a variety of different balls for a group of children allows each child to be present with others and participate as they desire. Other examples of parallel play activities include pushing and pulling large toys; smearing paint; playing with dolls or toys cars; and digging in a sandbox

Umbilical cord prolapse

Umbilical cord slips below the presenting fetal part and may cause cord compression and impaired fetal oxygenation. Emergency C section is usually required unless vaginal birth is imminent. Postiioning the client on her hands and knees or Trendelenberg is used to relieve pressure on the compressed cord. Nurse may also use a sterile gloved hand to help lift the presenting part off the cord. Hand should remain there until the HCP arrives. Other actions include oxygen and IV fluids

Acromegaly

Uncommon condition caused by an overproduction of GH. It is usually due to pituitary adenoma, and onset in adult clients generally occurs at age 40-45. In an adult, increased GH results in overgrowth of soft tissues of the face, hands, feet, and organs. Additional heart sounds (S3,S4) require further assessment for cardiac conditions (heart failure). Clinical features: Local tumor effect: pituitary enlargement, visual field disturbances, headache Musculoskeletal/skin: gigantism, malooccluded jaw, arthralgias/arthritis, hyperhidrosis (excessive sweating), skin tags Cardiovascular: HTN, heart failure Enlarged organs: tongue, thyroid, salivary glands, liver, spleen, kidney, prostate Endocrine: galactorrhea (excessive production of milk), decreased libido, diabetes mellitus

Fondaparinux

Unfractionated heparin - an anticoagulant used for DVT and PE prophyaxis after hip/knee replacement or abdominal surgery. However, this med should not be given until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place. Associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand, could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and paralysis.

Retinoblastoma

Unilateral or bilateral retinal tumor, most common childhood intraocular malignancy. Typically diagnosed under age 2 and first recognized with a white glow of the pupil (leukocoria). Light reflecting off pupil will be white instead of the usual red reflex. Strabismus is the second most common sign. Visual impairment is a late sign. Treatment depends on severity and may include radiation therapy or enucleation (removal of eye) and fitting for prosthesis. Siblings should undergo regular ocular screening

Nursing standards of practice

Universal criteria that are used when determining if appropriate professional care has been delivered. Definition of minimum acceptable level of care reflects what a reasonable, prudent, and careful nurse would do in specific circumstances. Sources used to define standard of care include statements from professional organizations, agency policies and procedures, textbooks, current literature, expert consensus, Nurse Practice Act, and statues from regulatory organizations

Perpetrators of child abuse

Unrealistic expectations of the child's performance, behavior, and/or accomplishments; overly critical of child Confusion between punishment and discipline; having a stern, authoritative approach to discipline Having to cope with ongoing stress or crises like poverty, violence, illness, lack of support, and isolation Hx of substance abuse or current substance abuse Punitive treatment and/or abuse as child Lack of parenting skills, inexperience, minimal knowledge about child care and development, and young parental age Resentment or rejection of child Low tolerance for frustration and or poor impulse control Attempts to conceal the child's injury or being evasive about an injury; shows little concern about the child's injury Both men and women abuse at approximately the same rate Often appear calm and in control

Pediatric CPR algorithm

Unresponsive - call for help and assess for breathing and pulse simultaneously. If they are breathing normally and have a pulse, monitor until help arrives. If they have a pulse but abnormal breathing, perform rescue breathing (1 breath/3-5 seconds; 12-30 breaths/min). If pulse <60 with poor perfusion, begin compressions. After two minutes of CPR attain AED and assess for a shockable rhythm *In infants and children, a heart rate <60/min and signs of poor perfusion is considered pulseless* If the nurse saw the victim collapse, they would get the AED before starting CPR

Repositioning and transferring clients

Unstable clients and spinal cord stabilization require the presence of a nurse for repositioning or moving. The client who is 8 hours post-op for hip replacements requires assessment prior to repositioning as the client is at risk for hip dislocation. To reduce the risk of staff injury, safe transfers and repositioning are achieved using the following guidelines: Use a gait/transfer belt to transfer partially weight-bearing client to a chair (1 person) Use 2 or more caregivers to reposition clients who are uncooperative or unable to assist Use a full-body sling lift to move/transfer nonparticipating clients Use 2-3 caregivers to move cooperative clients weighing less than 200 pounds Use 3 or more caregivers to move cooperative clients weighing more than 200 lbs

Phenazopyridine hydrochloride

Urinary analgesic prescribed to relieve the pain and burning associating with a UTI. Urine will turn bright red-orange while on this medication and other body fluids may be discolored as well. Should wear eyeglasses during the use of this medication and use sanitary napkins to avoid staining. Provides symptomatic relief, but no antibiotic action, so the client still needs to take full course of antibiotics

Phototherapy

Use of fluorescent lights to treat hyperbilirubinemia or jaundice in newborns. Light is absorbed by the newborn's skin and converts bilirubin into a water-soluble form, allowing it to be excreted in the stool and urine Newborn should be fully exposed, except for a diaper, when placed under the phototherapy lights. Lotions and ointments should not be applied as they can absorb the heat and cause burns. Maintaining skin integrity is important as bilirubin products in stool can cause loose stool with frequency and produce skin excoriation and breakdown. Infant should only be removed for feeding and adequate hydration from milk will prevent dehydration. Temperature should be monitored closely and the incubator should be placed on low-heat setting. Eyes need to be covered with eye shields to prevent retinal damage

Belladonna-opium suppositories

Used for bladder spasms, an expected complication of the TURP procedure

Pavlik harness

Used for developmental dysplasia of the hip joint that may be present at birth or develop during the first few years of life. Nonsurgical treatment methods, such as a harness or cast, are most successful when initiated during the first 6 months of life. After this time, surgery is frequently required. Can also prevent development of DDH by swaddling the infant with the hips bent up (flexion) and out (abduction). Do not use narrow infant carriers or car seats that force the legs to straighten A Pavlik harness maintains the infants hips in a slightly flexed and abducted position, allowing for proper hip development. Typically worn for about 3-5 months or until the hip joint is stable. The straps are adjusted periodically by the HCP to account for groth Teaching: Regularly assess skin for redness or breakdown under the straps Dress the child in a shirt and knee socks under the harness to protect skin Avoid lotions and powders to prevent irritation and excess moisture Lightly massage the skin under the straps every day to promote circulation Only apply 1 diaper at a time as wearing more diapers increases risk fo incorrect hip placement Apply diapers under the straps Should be worn all the time - may be removed for a short bath once a day, but should be left on for diaper changes

Cochicine

Used for gout. Decreases inflammation and pain associated with deposition of uric acid crystals in the joints

Rifampin

Used for treatment of TB. Causes hepatotoxicity. Changes color of body fluids - urine and sweat due to its body-wide distribution. Tears can turn red, making contact lenses appear discolored. Clients should wear eyeglasses instead. Women should use nonhormonal birth control methods while taking this drug as it can decrease effectiveness of oral contraceptives. Should not take hepatotoxic drugs (acetaminophen, alcohol)

Infant CPR

Used in children age <1 To check pulse, palpate brachial artery by placing 2-3 fingers halfway between shoulder and elbow on medial aspect of arm. Pulse should be assessed for 5-10 seconds to determine its presence before CPR is initiated For neonatal resuscitation: neonate should be placed on back with neck slightly extended in the "sniffing position". A blanket or towel roll can be placed under the shoulders

Niacin

Used in large doses for lipid-lowering properties. In large doses, it may produce cutaneous vessel vasodilation. The resulting warm sensation within the first 2hours after oral ingestion is uncomfortable but harmless. It may last for several hours

Quick-acting carbohydrates

Used in treatment for suspected hypoglycemia. 4-6 oz Regular soda, 8-10 Lifesavers candies, 1 tbs honey or syrup, 4 tbsp jelly, 4-6 oz orange juice, 8 oz low fat milk, or commercial dextrose products. Treatment is repeated in 15 minutes if there is no improvement. If treatment is unconscious or symptoms worsen, treatment could be subq or IM injection of glucagon or 25-50 mL 50% glucose

Memantine

Used to ease symptoms of moderate to severe AD, thereby improving the quality of life for clients and caregivers. Memantine is an N-methyl-D-aspartate antagonist that works by binding to NMDA receptors, blocking the brain's NMDA glutamate pathways, and protecting brain cells from overexposure to glutamate (excess levels contribute to cell death) Results in improvement in: Cognition - memory, thinking, language Daily functioning - dressing, bathing, grooming, eating Behavioral problems - agitation, depression, hallucinations

Oxytocin

Used to induce labor. Contractions can become too strong after oxytocin is used and lead to reduced placental bloodflow. Reduced blood flow can result in non-reassuring FHR patterns such as late decelerations, fetal bradycardia, tachycardia, or minimal variability. These non-reassuring FHR patterns may necessitate emergency C-section, which would not have been required if the labor had not been induced. After birth, the nurse should observe for postpartum hemorrhage, especially if the client received oxytocin for a long period. The uterine muscles become fatigues and may not contract effectively to compress vessels at the placental site. Oxytocin is a hormone that triggers the milk ejection/let-down reflex, but exogenous oxytocin has no known effects on milk production Greater uterine activity form oxytocin increases the risk of placental abruption and uterine rupture. Placenta previa is abnormal implantation and is unrelated to oxytocin infusion

Levothyroxine

Used to replace thyroid hormone. They have to take it for the rest of their lives. Excess hormone will cause heart palpitations, tachycardia, weight loss, and insomnia. Safe to take during pregnancy. Best to take first thing in the morning on an empty stomach separately from other medications. Antacids, soy, dietary fiber, calcium, and iron can impair the absorption of levothyroxine. Dosing is adjusted based on blood tests for TSH or other thyroid levels.

Balloon tamponade tube

Used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution in the event of airway obstruction, the nurse can cut the tube for rapid balloon deflation and tube removal

Roux-en-Y gastric bypass

Uses small proximal portion of the stomach to create a gastric pouch that is anastomosed to the Roux limb of the small intestine, bypassing most of the stomach and a portion of the duodenum. Dumping syndrome is a potential complication. The presence of a large quantity of hyperosmolar intestinal contents causes fluids to shift out of the vascular system into the intestines, leading to symptoms such as nausea, vomiting, diarrhea, weakness, and hypotension. To prevent dumping syndrome, clients should eat multiple small meals, eat low-carb diet, and separate their consumption of fluid and food (at least 30 minutes) Iron-deficiency anemia is a common side effect after an RYGB as iron is absorbed in the duodenum and proximal jejunum. Taking supplements of iron and calcium can help with this problem but does not prevent dumping syndrome Client will need parenteral or intranasal cobalamin replacement because the smaller gastric pouch decreases the amount of intrinsic factor made by the parietal cells in the stomach, causing cobalamin deficiency

V-fib vs V-tach

V-fib: no pulse - more serious V-tach: may have a pulse

Pessary

Vaginal device that provides support for the bladder. Clients can remain sexually active while wearing a pessary. They are fitted for the proper type and size by an HCP in the office. Surgery is not required for pessary placement, clients who are able can insert and remove the pessary themelves. If a pessary or other treatment is ineffective, reconstructive surgery may be indicated. Clients should remove weekly for cleaning and may remove prior to sexual intercourse although it is not necessary. When the client cannot remove it on their own, removal by an HCP at 2 or 3-month intervals is recommended. Increased vaginal discharge is a common side effect. However, if it is odorous, it may indicate infection

Depression in adolescents

Vague somatic symptoms include headache and stomachache. Irritable or cranky mood as well as sad or dejected mood. Hypersomnolence or insomnia; napping during daily activities Low self esteem; withdrawal from previously enjoyable activities Outburst of angry, aggressive, or delinquient behavior (vandalism, absenteeism), inappropriate sexual behavior, weight gain or loss, increased food intake or lack of interest in eating

VEAL CHOP

Variable decelerations: Cord compression Early decelerations: head compression Accelerations: OK (no intervention needed) Late decelerations: Placental insufficiency (stop oxytocin, administer oxygen, move mother to left lateral side, and initiate IV bolus, notify HCP

Live vaccines

Varicella-zoster MMR Rotavirus Yellow fever Children who are immune compromised (corticosteroid, chemo, AIDS) should NOT receive live vaccines Children CAN receive vaccines if they have penicillin allergy, mild illness, mild site reactions, recent infection or exposure, or current course of antibiotics

Normal pregnancy weight gain

Vary by pregnancy BMI. 1.1-4.4 lb weight gain in the first trimester and approximately 1 lb per week thereafter is normal and expected for women with a healthy BMI (total of 25-35 lb) For underweight (BMI <18.5): total of 38-40 lb For overweight (BMI 25-29.9): 15-25 total. 1.1-4.4 in first trimester and then approximately 0.6 lb/week For obese (BMI >30): 11-20 total. 1.1-4.4 in first trimester and then approximately 0.5 lb/wk

Raynaud phenomenon

Vasospastic disorder resulting in an episodic vascular response related to cold temperatures or emotional stress. It most commonly affects women age 15-40. Vasospasms induce a characteristic color change in the appendages (fingers, toes, ears, nose). When vasoconstriction occurs, the affected appendage initially turns white from decreased perfusion, followed by a bluish-purple appearance due to cyanosis. Clients usually report numbness and coldness during this stage. When blood flow is subsequently restored, the affected area becomes reddened and clients experience throbbing or aching pain, swelling, and tingling. Acute vasospasms are treated by immersing hands in warm water. Teaching: Wear gloves when handling cold objects Dress in warm layers, particularly in cold weather Avoid extremes in temperature and abrupt changes in temperature Avoid vasoconstricting drugs (cocaine, amphetamines, ergotamine, pseudoephedrine) Avoid excessive caffeine intake Refrain from using tobacco products Implement stress management techniques (yoga, tai chi) Clients may be prescribed calcium channel blockers to relax arteriole smooth muscle and prevent recurrent episodes

Ebola

Viral hemorrhagic fever - extremely contagious disease with a high mortality rate. Clients require standard, contact, droplet, and airborne precautions. Client is placed in a single-client airborne isolation room with the door closed. Visitors are prohibited unless absolutely necessary for the client's well-being. For disease surveillance, a log is maintained of everyone entering or exiting the room, and all logged individuals monitored for symptoms. Procedures and use of sharps/needles are limited whenever possible

Middle east respiratory syndrome

Viral respiratory illness caused by coronavirus. Symptoms are fever, cough, SOB, and may cause death. Not fully understood how virus is spread, but it is spread through respiratory secretions. CDC recommends standard, contact, and airborne precautions with eye protection

Cyclophosphamide

Well-known complication is hemorrhagic cystitis. Clients are instructed to drink plenty of fluids. May need IV fluids. Rarely life threatening

Pertussis

Whooping cough. Very contagious disease that causes swelling of the airway. Droplet precautions Characteristic by a violent spasmodic cough lasting >2 weeks. Coughing is so severe that the person is forced to inhale afterward, resulting in a distinctive, high-pitched whooping sound. Episodes may continue until a thick mucous plus is expectorated and is sometimes followed by vomiting. Treatment consists of antibiotics and supportive measures. Humidified oxygen and adequate fluids will help loosen the thick mucus. Suction is needed for infants. Respiratory status should be monitored for obstruction. The client should be positioned on the left side to prevent aspiration is vomiting occurs. Vaccination against whooping cough is available, but some individuals will develop the disease in a milder form. Cough suppressants are not effective for pertussis, and the child needs to cough up any mucus plugs that may develop to keep the airway clear

Infants with increase ICP

Will be very irritable and have fever and high pitched cry. Other signs of increased ICP include changes in pupillary reaction, sunset eyes, dilated scalp veins, poor feeding, vomiting, and bulging fontanels. Increased ICP may be due to bacterial meningitis

Neonatal abstinence syndrome

Withdrawal from placental opiates due to maternal drug use. Typically occurs within 24-48 hours of birth Clinical manifestations: irritability, hypertonia, jittery, seizures (rare), diarrhea, vomiting, feeding intolerance, sweating, sneezing, pupillary dilation, stuffy nose, frequent sneezing and yawning, tachycardia, tachypnea, abnormal sleep pattern, vomiting Treatment: opioid therapy (morphine, methadone) Hypersensitivity can make feeding difficult; the newborn should be placed in a side-lying position while swaddled to minimize stimulation and promote nutritive sucking. Between feedings, a pacifier may be used to soothe the infant and help establish an organized sucking pattern. Infant should be tightly swaddled to prevent excessive movement and skin excoriation; Hand mittens and barrier skin protection to the knees, elbows, and heels may be used. Should be placed in a quiet, dim-lit section of the nursery and the nurse should cluster care to minimize stimulation.

First dental visit

Within 6 months of first tooth eruption or by their first birthday. Purpose is to assess risk for dental disease, provide dental care and treatment for dental caries, provide anticipatory guidance about dental hygiene, fluoride, dietary habits, and non-nutritive sucking, and establishing care with a licensed dentist and scheduling future visits

Phenytoin

used for seizure disorders Can cause gingival hyperplasia. Causes folic acid deficiency, so diet should be high in folic acid. Excess caffeine, sleep deprivation, and stress are seizure triggers. This medication should not be stopped abruptly. Reduces the effectiveness of oral contraceptives Therapeutic range is 10-30 mcg/mL Signs of toxicity: ataxia (unsteady gait), nystagmus, slurred speech, decreased mentation. Bradyarrhythmias and hypotension seen with IV phenytoin Calcium (antacids, calcium supplements) and/or enteral tube feedings can inhibit absorption of phenytoin, so should pause feeding for 1-2 hours before administering. Effects the liver, not kidneys - LFTs recommended during therapy