Final Exam Level 4

DIC, interventions

-Promote Effective Tissue Perfusion -Monitor Gas Exchange -Manage Pain -Manage Fear

Anorexia and S+S, successful treatments.

-is a potentially deadly eating disorder that compels individuals to lose more weight than is healthy for their age and height. -have an intense phobia of gaining weight, even when they show the symptoms of being dangerously underweight. -engage in dieting and exercising to the point of dangerous malnutrition to avoid gaining weight. -typically begins during the teen years, and it is more commonly diagnosed in females. -These women frequently have goal-oriented families or personalities, and they develop rigid "rules" that they use to control weight. These rituals can be simple, such as cutting food into tiny pieces or elaborate, such as preparing lavish dinners for friends or family without consuming any food themselves. -Criteria for diagnosis of AN include possessing an intense fear of weight gain, refusal to maintain a healthy weight, and perceiving a distorted body image. -In order to maintain low body weight, individuals with anorexia severely limit food consumption and offset consumption with excessive exercise. Other behaviors include self-induced vomiting; refusing to eat in the presence of others; using diuretics, laxatives, and diet pills; and cutting food into small pieces as a way of pretending to eat -The condition has the highest mortality rate of any mental illness, due to the complications of malnutrition and the high rate of suicide in the population Clinical Therapies Antidepressants, Cognitive-behavioral therapy, Group therapy, Family therapy

Treatments for schizophrenia

1. typical antipsychotics (block d2 dopamine receptors, can cause permanent distressing motor side effects) 2. atypical antipsychotics (influence d2 receptors, associated with weight gain, increased risk for heart issues, type 2 diabetes, mortality) 3. psychological intervention (cognitive remediation & cognitive enhancement therapy)use

hypovolemic shock

A condition in which low blood volume, due to massive internal or external bleeding or extensive loss of body water, results in inadequate perfusion. caused by a decrease in intravascular volume of 15% or more. In hypovolemic shock, the venous blood returning to the heart decreases, and ventricular filling drops. As a result, stroke volume, cardiac output, and blood pressure decrease. Hypovolemic shock is the most common type of shock, and it often occurs simultaneously with other types.

Monroe-Kelliw hypothesis

A hypothesis that states if the volume of any of the three intracranial components (the brain, cerebrospinal fluid, and blood) increases, the volume of the others must decrease to maintain normal pressures in the cranial cavity. The normal ICP is 5-15 mmHg (measured intracranially with a pressure transducer while the client is lying with the head elevated 30 degrees) or 60-180 cm H2O (measured with a water manometer while the client is lying in a lateral recumbent position).

Seasonal Affective disorder- S+S treatments

A mood disorder typically characterized by depression during fall and winter and normal mood or hypomania during spring and summer. Some forms of mood disorders are related to the time of year and the amount of available sunlight. In seasonal affective disorder (SAD), the individual typically experiences depression during fall and winter, returning to normal mood in spring and summer, although rarely a version of SAD may be seen in which the individual experiences depression in the spring and summer. For those with fall/winter SAD, the depressive state appears to be directly related to the amount of natural sunlight because symptoms disappear when the person is exposed to more sunlight. Light has an inhibiting effect on the production of melatonin, a hormone that affects mood, sensations of fatigue, and sleepiness. The majority of SAD sufferers are women with a family history of mood disorders. Unlike major depression, in which symptoms for children and adults differ, children and adults with SAD exhibit similar symptoms: fatigue, decreased activity, irritability, sadness, crying, worrying, and decreased concentration. A symptom seen more frequently in SAD compared to the other mood disorders is increased appetite, carbohydrate craving, and weight gain.

Understand career development strategies; for example Preceptor, Coaching, Networking

A preceptor is "an experienced nurse who provides knowledge and emotional support, as well as a clarification of role expectations, on a one-to-one basis." Primary function - Orient the new nurse to the unit, socialization to the role. Coaching is the process, on a personal level, of helping an individual achieve a higher potential. Coaching benefits both the coach and the individual and includes improved communication, motivation, performance, enthusiasm, empowerment, and personal and job satisfaction. Primary function - Improve performance, resolve performance issues. Networking is developing and maintaining relationships with others within and outside of your profession and affiliated organization to improve nursing practice, advance career goals, offer support, share information, and provide advice. Networking involves a conscious and intentional effort to establish and maintain relationship with others that entails a long-term commitment to building relationships for the future. Primary function - Career advancement Networking benefits Share ideas and information. Provide support, guidance, and advice. Foster personal and professional growth. Create personal and professional opportunities. Enhance communication. Increase productivity. Establish health policies. Refine interpersonal skills. Promote change. Foster creativity. Develop sense of belonging. Promote personal life and professional work satisfaction.

ventricular tachycardia

A rapid heart rhythm in which the electrical impulse begins in the ventricle (instead of the atrium), which may result in inadequate blood flow and eventually deteriorate into cardiac arrest.

cardiogenic shock

A state in which not enough oxygen is delivered to the tissues of the body, caused by low output of blood from the heart. It can be a severe complication of a large acute myocardial infarction, as well as other conditions. MI is the most common cause

Clinical Manifestations and Therapies Pancreatitis

Acute pancreatitis -Severe epigastric and abdominal pain -Nausea and vomiting -Abdominal distention and rigidity -Decreased bowel sounds -Tachycardia -Hypotension -Elevated temperature -Cold and clammy skin Therapies -NPO -Intravenous hydration -Analgesics -Antibiotics Chronic pancreatitis -Gastric and left upper abdominal pain radiating to the back -Anorexia -Weight loss -Nausea and vomiting -Constipation -Steatorrhea Therapies -Low-fat diet -Abstain from alcohol -Surgery to relieve obstruction -Pancreatectomy The treatment of acute pancreatitis is largely supportive. Opioid analgesics such as morphine sulfate or hydromorphone (Dilaudid) may be used to control pain. Prophylactic antibiotics are prescribed for clients with severe or necrotizing pancreatitis to prevent infection. Clients with chronic pancreatitis may also require analgesics, but must be closely monitored to prevent drug dependence. Pancreatic enzyme supplements are given to manage abdominal pain and reduce steatorrhea. Clients with chronic pancreatitis may need to remain on pancreatic enzyme supplements for life. H2-blockers such as cimetidine (Tagamet) and ranitidine (Zantac), and proton pump inhibitors such as omeprazole (Prilosec) may be given to neutralize or decrease gastric secretions. If the pancreatitis is the result of a gallstone lodged in the sphincter of Oddi, an endoscopic transduodenal sphincterotomy may be performed to remove the stone. When cholelithiasis is identified as a causative factor, a cholecystectomy is performed once the acute pancreatitis has resolved. Surgical procedures to promote drainage of pancreatic enzymes into the duodenum or resection of all or part of the pancreas may be done to provide pain relief in clients with chronic pancreatitis. Large pancreatic pseudocysts may be drained endoscopically or surgically.

Know S+S of acute pancreatitis

Acute pancreatitis is more common in middle adults. Gallstones and alcoholism account for 80% of the cases of acute pancreatitis in the United States. Acute pancreatitis develops suddenly, typically with an abrupt onset of continuous severe epigastric and abdominal pain. This pain commonly radiates to the back and is relieved somewhat by sitting up and leaning forward. The pain often is initiated by a fatty meal or excessive alcohol intake. Other manifestations include nausea and vomiting; abdominal distention and rigidity; decreased bowel sounds; tachycardia; hypotension; elevated temperature; and cold, clammy skin. Within 25 hours, mild jaundice may appear. Retroperitoneal bleeding may occur 3-6 days after the onset of acute pancreatitis; signs of bleeding include bruising in the flanks (Turner sign) or around the umbilicus (Cullen sign). Systemic complications of acute pancreatitis include intravascular volume depletion with shock, acute tubular necrosis and renal failure, and acute respiratory distress syndrome (ARDS). Hypovolemic shock and acute renal failure usually develop within 24 hours after the onset of acute pancreatitis. Manifestations of ARDS may be seen 3-7 days after its onset, particularly in clients who have experienced severe volume depletion. Localized complications include pancreatic necrosis, abscess, pseudocysts, and pancreatic ascites. Pancreatic necrosis causes an inflammatory mass that may be infected. It may lead to shock and multiple organ failure. Pancreatic pseudocysts, encapsulated collections of fluid, may develop both within the pancreas itself and in the abdominal cavity. They may impinge on other structures, or may rupture, causing generalized peritonitis. Rupture of a pseudocyst or of the pancreatic duct can lead to pancreatic ascites. An infected pancreatic pseudocyst becomes a pancreatic abscess. A pancreatis abscess may also form as areas in damaged and infected pancreatic tissue become encapsulated. Pancreatic ascites is recognized by gradually increasing abdominal girth and persistent elevation of the serum amylase level without abdominal pain.

Alcohol abuse, treatment and nursing Dx.

All CNS depressants, including alcohol, benzodiazepines, and barbiturates, have a potentially dangerous progression of withdrawal. Alcohol and the entire class of CNS depressants share the same withdrawal syndrome. Treatment of severe withdrawal during detoxification is mostly symptomatic through acetaminophen, vitamins, and medications to minimize discomfort. In managing alcohol withdrawal, the goal is to minimize adverse outcomes such as client discomfort, seizures, delirium tremens, and mortality and to avoid the adverse effects of withdrawal medications, such as excess sedation. Close monitoring is essential to ensure protection of the client. Critical care monitoring may be indicated to manage alcohol withdrawal delirium, particularly when very high doses of benzodiazepines are needed or when significant concurrent medical conditions are present. Medications such as benzodiazepines are a first-line therapy, used to minimize the discomfort associated with alcohol withdrawal and to prevent serious adverse effects, particularly seizures. Two contrasting treatment approaches are fixed-schedule dosing and a symptom-triggered approach. The Clinical Institute Withdrawal Assessment for Alcohol—Revised (CIWA-Ar) scale is currently recommended as the best scale to assess the severity of symptoms of acute alcohol withdrawal. Triage nurses can use that scale to determine the need for inpatient hospital admission, such as when the CIWA-Ar score is 10 or more points. However, recent research indicates that the CIWA-Ar scale may underestimate the severity of alcohol withdrawal syndrome in certain ethnic groups, such as Native Americans. Two unique medications used to treat alcoholism are disulfiram (Antabuse) and naltrexone (ReVia, Depade). Disulfiram is a form of aversion therapy that prevents the breakdown of alcohol, causing physical illness (intense vomiting) if taken while drinking alcohol. All forms of alcohol, including over-the-counter cough and cold preparations, must be avoided. Naltrexone can help reduce the craving for alcohol by blocking the pathways to the brain that trigger a feeling of pleasure when alcohol and other narcotics are used. Because naltrexone blocks opiate receptors, clients should avoid taking any narcotics, such as codeine, morphine, or heroin, while on naltrexone. Clients also should discontinue all narcotics 7-10 days before starting on naltrexone. It also is recommended that clients wear a medical alert bracelet stating that they are on naltrexone, in case of emergency medical treatment. Clients taking disulfiram or naltrexone must also participate in psychosocial treatments such as AA meetings, individual counseling, or group therapy because the desire to "take a break" from treatment can overcome the client's motivation to continue taking the medication. AA meetings and therapy provide support and reinforce clients' efforts to continue treatment. Peer connections made through AA can be especially motivating. CAM therapy Electroencephalograph (EEG) biofeedback, also called neurotherapy, has been found to provide some benefit in the treatment of alcoholism. Many people who are addicted to alcohol and other addicts also have found yoga to be helpful in the recovery process. Both neurotherapy and yoga may provide calming effects on the centers of the brain involved in anxiety and impulse control. Yoga involves maintaining control over one's body and using deep breathing techniques and is frequently hailed as an effective stress reliever. Risk for Injury Risk for Violence Ineffective Denial Ineffective Coping Imbalanced Nutrition: Less Than Body Requirements Chronic or Situational Low Self-Esteem Deficient Knowledge Disturbed Sensory Perception Disturbed Thought Processes.

Know ARDS + Treatments

All body systems are at risk of failure caused by poor oxygenation and alterations in perfusion. Conduct CBC, chemistry panel, ABG, blood cultures, sputum cultures, and gastric and stool cultures as indicated by symptoms. Monitor vital signs at least hourly. Continual monitoring may be required. Monitor oxygenation status with ABG and pulse oximetry. Monitor neurological status, including orientation and LOC. Auscultate lung and heart sounds. Provide analgesia, anxiolytics, and sedation medications as ordered. Provide beta-agonist to maintain patent airways as ordered. Maintain head of bed at 30° or higher. Position the individual prone for 30 minutes to an hour as tolerated three or four times a day. This position may facilitate oxygenation of the posterior alveoli and posterior drainage. Suction airways as needed. Monitor hemodynamic status with central venous catheters or pulmonary artery catheter as ordered. Monitor renal function by intake and output as well as blood urea nitrogen and creatinine levels. Place Foley catheter. Administer intravenous fluids as needed, but avoid fluid overload. Monitor glucose levels, and maintain levels within normal limits. Assess peripheral pulses. Education: Maintain a Patent Airway Promote Spontaneous Ventilation Enhance Cardiac Output Monitor for Dysfunctional Ventilatory Weaning Response Relieve Anxiety Prepare for Discharge

Nurses role in patients DNR wishes

An advance directive may provide instructions regarding do-not-resuscitate (DNR) orders, the withholding of emergency measures to sustain life, the termination of life-sustaining measures, or any combination thereof. The ANA recommends that nurses play an active role in initiating discussions about DNR/AND with clients, families, and healthcare team members to prevent confusion about the clients' and family's wishes about end-of-life care. With this responsibility, nurses have the duty to educate clients and their families about procedures and treatments used at the end of life, to inform clients about advance directives and ensure the documentation and implementation of existing advance directives, to encourage clients to think about their preferences for end-of-life treatment, to communicate clients' end-of-life decisions to the healthcare team, and to advocate for clients' decisions about end-of-life care in spite of differing opinions by the healthcare proxy or physician. Regardless of clients' DNR/AND status, nurses have the responsibility to provide palliative care and other medical treatments for all clients.

Liver disease-complications and labs involved

Ascites is the accumulation of plasma-rich fluid in the abdominal cavity. Although portal hypertension is the primary cause of ascites, decreased serum proteins and increased aldosterone also contribute to the fluid accumulation. Hypoalbuminemia (low serum albumin) decreases the colloidal osmotic pressure of plasma. This pressure normally holds fluid in the intravascular compartment, but when the plasma colloidal osmotic pressure decreases, fluid escapes into extravascular compartments. Hyperaldosteronism (an increase in aldosterone) causes sodium and water retention, contributing to ascites and generalized edema. Portal hypertension causes blood to be rerouted to adjoining, lower-pressure vessels. This shunting of blood involves collateral vessels. Affected veins, which become engorged and congested, are located in the esophagus, rectum, and abdomen. Portal hypertension increases the hydrostatic pressure in vessels of the portal system. Increased hydrostatic pressure in the capillaries pushes fluid out, contributing to ascites formation. -Liver function studies. These include studies of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyltransferase. All four may be elevated in clients with cirrhosis, but usually not as severely as in clients with acute hepatitis. Elevations in these enzymes may not correlate well with the extent of liver damage in cirrhosis. -Complete blood count (CBC) with platelets. A low RBC count, hemoglobin, and hematocrit demonstrate anemia related to bone marrow suppression, increased RBC destruction, bleeding, and deficiencies of folic acid and vitamin B12. Platelet counts are low, related to increased destruction by the spleen. Leukopenia (low WBC count) also relates to splenomegaly. -Coagulation studies. A prolonged prothrombin time results from impaired production of coagulation proteins and lack of vitamin K. -Serum electrolytes. Hyponatremia is common, resulting from hemodilution. Hypokalemia, hypophosphatemia, and hypomagnesemia are also frequently seen, related to malnutrition and altered renal excretion of these electrolytes. -Bilirubin. Both direct (conjugated) and indirect (unconjugated) bilirubin usually are elevated in clients with severe cirrhosis. -Serum albumin. Hypoalbuminemia results from impaired liver production. -Serum ammonia. Levels are elevated, because the liver fails to effectively convert ammonia to urea for renal excretion. -Serum glucose and cholesterol. These levels frequently are abnormal in clients with cirrhosis. -Abdominal ultrasound. This test is performed to evaluate liver size, detect ascites, and identify liver nodules. Ultrasound may be used in conjunction with Doppler studies to evaluate blood flow through the liver and spleen -Esophagoscopy. Upper endoscopy may be done to determine the presence of esophageal varices. -Liver biopsy. This test is not always necessary to diagnose cirrhosis, but it may be done to distinguish cirrhosis from other forms of liver disease. Biopsy may be deferred if the client's bleeding time is prolonged (e.g., prothrombin time .3 sec over the control).

Bioterrorism, nursing role

Bioterrorism is the deliberate release of viruses, bacteria, or other microbes as weapons. The CDC has assigned the highest priority to biological agents that can be easily disseminated or transmitted from individual to individual; cause a high mortality rate; have a significant impact on public health; cause public panic; and disrupt society and government. The primary agents identified by the CDC as potential bioterrorist threats are anthrax, botulism, plague, smallpox, tularemia, and viral hemorrhagic fevers and arena viruses.

Know symptoms of acidosis and alkalosis and the differences.

Causes of Resp. Alkalosis -Hyperventilation due to -Extreme anxiety -Elevated body temperature -Overventilation with a mechanical ventilator -Hypoxia Salicylate overdose -Brain stem injury -Fever -Increased basal metabolic rate

Nursing roles and care for spinal cord injuries, Bowel and Bladder training

Clients with a spinal cord injury will require extensive nursing care. Immediate nursing care involves maintaining an airway, assisting with ventilation, and immobilizing the client. Nursing care also includes preventing complications such as urinary or bowel problems, pressure sores, and infection. During the healing process, the nurse will also play a role in the client's rehabilitation and client teaching for home care. Bladder training, which requires that the client postpone voiding, resist or inhibit the sensation of urgency, and void according to a timetable rather than according to the urge to void. The goals are to gradually lengthen the intervals between occasions of urination to correct the client's frequent urination, to stabilize the bladder, and to diminish urgency. This form of training may be used for clients who have bladder instability and urge incontinence. Delayed voiding produces larger voided volumes and longer intervals between instances of voiding. Initially, voiding may be encouraged every 2-3 hours except during sleep, and then every 4-6 hours. A vital component of bladder training is inhibiting the urge-to-void sensation: Every time the client has a premature urge to void, repeat the instruction to practice deep, slow breathing until the urge diminishes or disappears.

Know CDS (Clinical Decision Support System)

Clinical decision support systems are an important addition to electronic health records. They are designed to give healthcare providers tools to supplement decision-making processes during and after client care. These tools can include diagnostic support, documentation templates, clinical guidelines, alerts and reminders, condition-specific order sets, reference information, and focused data reports and summaries. Most of these tools are designed to be integrated with the EHR, while others have been designed as stand alone systems. One study found that more than 90% of electronic clinical decision support systems significantly improved clinical care in randomized controlled trials. These systems give advantages to clients and clinicians by helping prevent errors and adverse events, increasing quality of care and outcomes, and improving efficiency

Know treatment and nursing care for gunshot victims in the ED, priority, protocols

Gunshot wounds may be classified in a variety of ways: by nature (e.g., contact or non-contact wound, entry or exit wound), size, or severity. Clinical priorities for the treatment of a gunshot wound are as following: Maintain airway and assist ventilation as necessary. Control hemorrhage. Prevent hypothermia. Rapid, recurrent assessment of neurological status is also necessary, as is infection control. Bleeding can result in hypovolemia, leading to inadequate perfusion and oxygenation of tissues. Family members of gunshot victims typically are very upset and often very angry. An experienced nurse should work closely with these families while the victim is being treated. Gunshot victims may themselves display dangerous behaviors. If law enforcement has not determined that the victim is free of weapons, such an assessment should be done before treatment is initiated. Violent or angry victims may need to be restrained during treatment for the protection of the trauma team. Law enforcement may assign officers to remain present during treatment. Because the majority of gunshot wounds require an investigation by law enforcement, nurses working in emergency departments and trauma centers should be familiar with their agency's protocols for maintaining evidence required by law enforcement. Often, law enforcement does not want the victim's hands or the area around the victim's wounds cleansed. Clothes and personal items are often wanted as evidence.

Understand VP shunts, why they are needed, nursing interventions and teachings, complications involved.

I know the book does not go over VP Shunts in great detail just mentions them as a treatment option for Hydrocephalus. A Ventriculoperitoneal shunt is a medical device used to relieve IICP. It is basically a catheter starting in the head internally implanted and draining into the peritoneum to relieve the excess CSF. You as the nurse will be in charge of teaching families and patients complications involved. Complications would be the S+S of IICP. Just understand what this device is for.

Spinal cord injuries, nursing interventions treatments and medications

Immediate care will include assistance with ventilation, immobilization, care of wounds, and bladder and bowel control. Interventions during the recovery phase will include assistance with mobility, exercise, and self-care activities and prevention of complications. Rehabilitation interventions will include assistance with ambulation, training for ADLs, and referral to rehabilitation therapy. Most clients will receive high-dose methylprednisone within 8 hours after injury to improve neurological recovery. Methylprednisone appears to decrease inflammation and reduce damage to surrounding nerve cells. Adverse effects are usually minor. Prophylactic anticoagulation therapy (e.g., heparin, Coumadin) may be given to help prevent DVT and pulmonary embolism. Infections, especially pneumonia, should be treated promptly with appropriate antibiotics; pain can be treated with opioids, NSAIDs, and other analgesics as needed. After a SCI, surgery may also be needed to stabilize the spine. Spine stabilization may involve realigning the spine and using instrumentation such as rods and screws to internally immobilize the spine. A bone graft from the client or bone bank is often added to promote fusion of the vertebrae. Surgery can also be performed to set up spinal traction using Gardner-Wells tongs or other traction devices or external fixation with a halo brace. A halo brace is often used for clients with cervical fractures without major cord damage. The client may be in traction or external fixation for several weeks or months.

Nursing interventions in Depression

Improve Self-Esteem While low self-esteem is a chronic problem, the nurse can take a number of actions to reduce negative thinking, thereby promoting improved self-esteem: Provide distraction from self-absorption by involving the client in recreational activities and pleasant pastimes. Simple conversation with a staff member or another client helps interrupt the pattern of negative thoughts. Use care to select activities that are not too complex for the client's current level of functioning. Experiences of success, not more failures, are needed. Increase the complexity of activities as the client progresses. Dispel the notion that clients often have that when they feel better, they will want to engage in activities. Explain that they must begin doing things in order to feel better. Being active promotes a more balanced feeling state. Acknowledge that it takes self-discipline and energy to do something when one doesn't really feel like it. Recognize accomplishment, but do not use flattery or excessive praise. Give positive, matter-of-fact reinforcement, such as "I notice that you combed your hair," rather than overly enthusiastic compliments such as "What a great hairstyle!" Appropriate recognition increases the likelihood that the client will continue the positive behavior, while insincerity can be perceived as ridicule or infantilizing. Be accepting of clients' negative feelings, but set limits on the amount of time spent discussing accounts of past failures. Be alert for opportunities to interrupt negative conversational patterns with more neutral ones. Teach assertiveness techniques, such as the ability to say "no" to protect one's rights while respecting the rights of others. Clients with low self-esteem often allow others to take advantage of them. Defining passive, aggressive, and assertive behavior and giving examples of each also are helpful when teaching assertiveness. Practice these techniques with the client, providing feedback on how it feels to the recipient of assertive communication or an assertive action. Instill Hope It is equally important to help clients identify the aspects of their lives that are not within their control. Being able to accept what cannot be changed is just as essential as developing the ability to bring about positive change. This skill is particularly helpful in reorienting clients from feelings of hopelessness to a more hopeful aspect. Other interventions to help clients combat hopelessness include the following: Help clients identify their personal strengths. It may be useful to write these down. Recognize that it often takes time for clients to realize that they have any strengths. Recognizing strengths helps a client design an activity or engagement plan that the client is more likely to enjoy and find successful. Engage clients in setting goals for themselves. Direct clients to focus on small goals at first. For example, instead of "going to yoga twice a week," the initial goal might be to go to the yoga center and get a list of class times and teachers or sit in on a class. Help clients weigh and choose alternatives. Taking responsibility even for small choices such as when or where to eat helps the client regain self-esteem. Explore problem-solving models with the client, including practicing problem solving. "When you found out the toaster was broken, you threw it against the wall. You said all that did was put a dent in the wall and make a mess for you to clean up. What might you do differently next time that might be more helpful?" Help clients to identify resources such as family, community, or friends who can provide support and encouragement in overcoming problems they identify. Planning for discharge should begin with the first client contact and is particularly important with hopeless, dependent clients. Help these clients and their families and significant others identify resources in the community they can use to build support systems. Support groups, therapy groups, and social groups can help clients separate from caregivers more readily when the time comes to end therapy.

Therapeutic nursing interventions and teachings with pediatric end of life

Improving Pediatric Palliative and End-of-Life Care Palliative care should be designed to care for the child's physical, cognitive, emotional, and spiritual development. Appropriate care involves families as part of the care team and respects both the child's and the family's wishes. Nurses should provide effective and compassionate care from the time of diagnosis through death and bereavement. Nurses should educate themselves and others about the identification and management of the last phase of the child's condition. Nurses should advocate within their facility for guidelines aimed at providing consistently excellent palliative, end-of-life, and bereavement care for children and their families. Nurses are encouraged to engage in research activities designed to enhance healthcare providers' awareness and understanding of approaches to improving palliative, end-of-life, and bereavement care for children and their families. Principles of Pediatric Palliative Care Pediatric palliative care provides care to children and families experiencing a debilitating chronic or life-threatening illness, condition, or injury. The uniqueness of each child and family is respected, and the care plan is determined by the goals and preferences of the child and family with guidance from the healthcare team. Palliative care ideally begins at the time of diagnosis of a life-threatening or debilitating condition and continues through cure or until death and into the family's bereavement period. Palliative care uses a multidimensional assessment to prevent and alleviate physical, psychological, social, and spiritual distress. Care providers should assist children and their families in understanding changes in the child's condition and the implications of these changes as they relate to future care and treatment. Palliative care indicates a need for an interdisciplinary care team, including but not limited to physicians, nurses, social workers, chaplains, pharmacists, art therapists, child-life therapists, and speech and language pathologists. The primary goal of palliative care is to prevent and relieve suffering, including pain and other symptoms. Effective communication includes sharing developmentally appropriate information, listening actively, assisting with medical decision making, and determining goals and preferences. Palliative care specialists must be knowledgeable about signs and symptoms of imminent death and the associated care and support of children and their families before and after death. Palliative care is appropriate for inclusion in all settings where health care is provided, including hospitals, emergency departments, home care, and schools. Palliative care should be provided equally to all children with any life-limiting condition, regardless of race, ethnicity, or ability to pay. Palliative care services should be committed to providing excellent and high-quality care based on six aims: timely care, client-centered care, beneficial and/or effective care, accessible and equitable care, knowledge- and evidence-based care, and efficient care.

Know about nursing shortages and strategies involved to solve

With a nationwide shortage of nurses, nursing care is becoming a limited health resource. Short staffing is a critical concern because a number of studies link staffing levels to safe client care. Unfortunately, some facilities continue to staff nursing units with fewer registered nurses and more unlicensed caregivers. When this occurs, nurses become concerned that staffing in their institutions is not adequate to ensure client safety, much less to allow them to provide the level of care that they value. California is the only state that has enacted legislation mandating specific nurse-to- client ratios in hospitals and other healthcare settings. This is not the simple solution that it seems: Another ethical dilemma arises when organizations begin to turn away clients in need in order to ensure adequate staffing levels. The multiple factors influencing the current nursing shortage are different from those influencing previous nursing shortages. Although registered nurses make up the largest group of healthcare providers, fewer nurses are entering the workforce, and certain geographic areas are experiencing acute nursing shortages. The supply is inadequate to meet the demand, especially for specialized nurses (e.g., critical care nurses), and this situation is expected to worsen. Addressing the nursing shortage requires collaboration among healthcare systems, policy makers, nursing educators, and professional organizations. Recommendations include, but are not limited to, the following: Develop mechanisms for nursing students to progress to and through educational programs more efficiently and quickly. Recruit young people to nursing early (e.g., in grade school). Improve the nurse's work environment: Provide greater flexibility in work hours, reward experienced nurses who serve as mentors, ensure adequate staffing, and increase salaries. Increase funding for nursing education. Factors contributing to the nursing shortage: -Nursing school enrollment not growing fast enough -aging nurse workforce -shortage of nursing faculty -changed demographics -increased demand for nurses -workplace issues (inadequate staffing, heavy workloads, increased use of overtime, lack of sufficient support staff, inadequate wages, etc.)

Know Nursing interventions in manic phase patients

o Set boundaries and be assertive without confrontation b/c it will only escalate o Pt do not sleep in this state o Nursing interventions to help this patient -Clients in the manic phase of bipolar disorder appear deceptively energetic when they may actually be nearing the point of exhaustion. -Design nursing activities to facilitate regular sleep-wake cycles. -Monitor clients closely for signs of fatigue and make provisions for rest periods. -Promote nighttime sleeping by limiting extended daytime naps. -Sleep may promote the rapid resolution of first episodes of mania. -Prior to bedtime, decrease light and noise and encourage quiet activities and pre-sleep routines such as listening to soothing music. -A warm bath and snack or a backrub may aid relaxation. -Administer medications that do not suppress REM sleep, such as zolpidem tartrate (Ambien), as prescribed. -If clients experience extended nighttime wakefulness, avoid engaging them in long conversations or otherwise stimulating them or giving extra attention at night. -Firmly encourage clients to stay in their darkened room with the expectation that they will fall asleep. -If they will not stay in their room, assign a monotonous, repetitive task such as folding towels or sorting papers to encourage drowsiness. -When clients are able to sleep, avoid waking them for nonessential care or activities. -Allow for sleep cycles of at least 90 minutes.

Know nursing interventions and teachings for patients in crisis

redirect or remove from situation if at risk Nursing care of clients in crisis includes establishing a therapeutic relationship; ensuring client safety from the first moment of contact; mobilizing support through the significant other, family, relatives, friends, church support groups, and healthcare institutions; and collaborating with mental health professionals. Directive suggestion may be helpful, such as gently advising the mother of a critically sick child to go home and sleep while assuring her that she will be called immediately if her child's condition changes. Offering time, attention, and direction is most critical during a crisis. An arrangement for a follow-up care appointment suggests concern for the individual's well-being. The opportunities to offer care in crisis are endless and may involve only a moment of time. Therapeutic Communication Communicating with individuals in crisis requires frequent, brief, simple, and often directive communication. Biologically speaking, the brain of the individual in crisis is in the process of being bombarded with electrochemical reactions. Concentration and the ability to remember and retain information can be impaired. The nurse must continually reassess what the individual has heard or interpreted. In applying the transactional model, it is important to remember primary appraisal. What does the individual believe is happening? How can the nurse add resources and information to the reappraisal process to facilitate adaptive coping? Continual observation of patterns of communication within the family and/or group is essential. Due to the hyperarousal that occurs during the crisis, the nurse must be cognizant of nonverbal communication, tone, inflection, and mannerisms while communicating. Communication may also be a powerful tool in the prevention of the development of a crisis. Anticipatory guidance incorporates recognition of the potential for a crisis and assisting the client with identifying potential methods for averting the crisis. Examples of anticipatory guidance include counseling pregnant women about prenatal nutrition recommendations and facilitating connections between respite care organizations and caregivers of clients with chronic illness. In times of crisis, the nurse may be the one responsible for communicating bad news regarding injury or death of loved ones. Crisis counseling is focused on brief solutions, focused interventions, and supportive care. During the course of a crisis, nurses should consider each individual's physical vulnerability and degree of emotional stability, with special emphasis on determining the client's risk for self-harm or potential for harming others. While prioritizing the safety of the client and others, the nurse should assess the client's perception of and response to the crisis, while also ensuring that the client's basic needs are met. The alarm reaction, anxiety, and fear may prevent the person from resting, sleeping, or eating. Important members of the healthcare team during a crisis may include the hospital chaplain or family minister, a grief counselor, a social worker, a child and family therapist, and a teacher. A crisis intervention is an emergent approach to care that is intended to assist clients with recognizing a crisis situation and identifying and implementing an immediate, short-term solution. For the client, the ultimate goal of crisis intervention is restoration to a level of functioning that is at or above the level of the pre-crisis state. This approach often incorporates the client's family members and loved ones, as well as those individuals who are significant to the client in terms of providing social support. Depending on the circumstances, a crisis intervention also may include professionals from a variety of specialties, such as school guidance counselors, law enforcement or probation officers, rescue workers, and clergy members. Successful completion of a crisis intervention depends on the client's needs; for example, some crisis interventions may culminate in the client's receiving outpatient counseling or guidance, while others may require immediate hospital admission or transfer to a facility that provides treatment for clients with substance abuse disorders. Clients in crisis—in particular, those who are homeless and those who are subject to abuse—may require assistance with meeting one of the most basic needs: finding shelter. Nurses should be aware of community organizations and representatives who can assist clients with finding emergency living arrangements. DO SAY: "These are normal reactions to an abnormal situation." "It is understandable that you feel this way." "It wasn't your fault; you did the best you could." "I am sorry that this happened." "Things will get better, and you will feel better, although they may never be the same again." DON'T SAY: "It could have been worse." "You can always get another pet/car/house [or have another child, get married again, etc.]." "It's best if you just stay busy." "I know just how you feel." "You need to get on with your life." "If I were you, I would . . ."

Nursing accreditation and nursing agencies, ex. ANA, NLN

The ANA is the only full-service professional organization representing the nation's 3.1 million registered nurses (RNs) through its 54 constituent member associations (CMAs). Its mission statement is "Nurses advancing our profession to improve health for all." The ANA fosters high standards of nursing practice, promotes the rights of nurses in the work- place, projects a positive and realistic view of nursing, and lobbies Congress and regulatory agencies on healthcare issues affecting nurses and the public. There is one CMA in each of the 50 states and in Guam, the Virgin Islands, and Washington, DC, as well as the Federal Nurses Association. The National Student Nurses Association (NSNA) is a non- profit organization that mentors nursing students who are preparing for initial licensing as a registered nurse. Students may be enrolled in associate, baccalaureate, diploma, and generic graduate programs. NSNA is dedicated to fostering the professional development of these students by conveying "the standards, ethics, and skills students will need as responsible and accountable leaders and members of the profession." NSNA membership provides students opportunities for workshop participation, networking, scholarships, exposure to well-known nursing leaders, and nursing certification exam mini-reviews. The National League for Nursing (NLN), the first nursing organization in the United States, was founded in 1893 as the American Society of Superintendents of Training Schools for Nurses. Its mission is promoting excellence in nursing education to build a strong and diverse nursing workforce to advance the nation's health. The NLN is committed to delivering improved, enhanced, and expanded services to its members and championing the pursuit of high-quality nursing education in all types of nursing education programs. "The National League for Nursing offers faculty development programs, net-working opportunities, testing and assessment, nursing research grants, and public policy initiatives" The American Association of Colleges of Nursing (AACN) is the national voice for America's baccalaureate and graduate nursing education. AACN's educational, research, federal advocacy, data collection, publication, and special programs work to establish quality standards for nursing education; assist deans and directors to implement those standards; influence the nursing profession to improve health care; and promote public support for professional nursing education, research, and practice in nursing—the nation's largest health- care profession

NOC (Nursing Outcomes Classification)

The Nursing Outcomes Classification (NOC) is designed to assess the outcomes of clients based on the nursing interventions performed

Signs associated with death in a terminally ill patient

The following signs and symptoms indicate that death has occurred: Flat encephalogram No pulse or respiratory activity No response to external stimuli No reflexes No muscle movement

Nursing interventions and therapeutic communication in suicidal patients

The majority of suicidal individuals are also depressed. Nurses help clients by discussing the various symptoms of depression, including feelings of helplessness, worthlessness, and a lack of energy, while reassuring clients that it takes time for feelings associated with depression to dissipate. Similar discussions should be conducted with clients who have other comorbid disorders, especially bipolar disorder and schizophrenia. If any medications have been prescribed for clients with these disorders, nurses will explain how the medication works, its intended purpose, along with any potential side effects. While clients are at increased risk to themselves due to suicidal ideation, nurses will ensure that they do not have access to any sharp objects, or other weapons or modes that could be used for suicidal purposes. Guests will be instructed as to what objects they cannot have while visiting the client, including knives, razor blades, and large quantities of pills. Nurses caring for suicidal clients will often ask them to sign a no-suicide contract, which says that the client will not attempt suicide while in the facility's or hospital's care, but will instead ask for help. If a client is at an extremely high risk for suicide, nurses will ensure that the client is never left alone. A nurse, healthcare professional, or other healthcare worker will be with the client at all times until the risk for suicide decreases. Family will not be asked to perform this task for various reasons, the most par- amount of which is a lack of training in how to handle the situation if the client does attempt suicide. In situations where the nurse is caring for a client whom they suspect might be considering suicide, the nurse will alert the client's general healthcare practitioner as well as a mental health worker. Individuals who display suicidal warning signs will generally not ask for help in obvious ways, but will instead dis- play signs associated with suicide, such as talking about wanting to die, giving away prized possessions, or saying that she will not be around much longer. These warning signs are the client's way of asking for help, and nurses should be able to recognize them and respond effectively.

Understand what it means to be a patient advocate

The nurse may represent the client's needs and wishes to other health professionals, such as relaying the client's wishes for information to the physician. The nurse also assists clients in exercising their rights and helps them speak up for themselves.

First steps in emergency situations

The priority when assessing any client always begins with the ABCs: Airway Breathing Circulation. Only when these priority needs have been met will the nurse go on to conduct a more complete physical survey.

Understand the theory of shared governance

The shared governance model can be used in concert with other models of nursing care delivery. In this organizational model, nursing staff participate with administrative personnel in making, implementing, and evaluating client care policies. The focus of this model is to encourage the participation of nurses in decision making at all levels of the organization. Individuals may participate either at their own request or as part of their job role criteria. More commonly, nurses participate by serving as members of decision-making groups, such as committees and task forces. The decisions made may address employment conditions, cost effectiveness, long-range planning, productivity, and wages and benefits. The underlying principle of shared governance is that employees will be more committed to the organizational goals if they have input into planning and decision making.

QSEN 6 competencies for graduating nurses

The six competencies critical to the nursing role include client-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics.

Understand the process of hemodialysis and differences from peritoneal dialysis

The two most common methods of dialysis are hemodialysis and peritoneal dialysis. In hemodialysis, the client's blood flows through vascular catheters, passes by the dialysis solution in an external machine, and then returns to the client. In peritoneal dialysis, the dialysis solution is instilled into the abdominal cavity through a catheter, allowed to rest there while the fluid and molecules exchange, and then removed through the catheter. Both hemodialysis and peritoneal dialysis must be performed at frequent intervals until the client's kidneys can resume the filtering function. For some clients, the nurse is responsible for monitoring the dialysis procedure. Depending upon the type of dialysis indicated, a specially trained nurse may administer the procedure, as well.

S+S of acute renal failure

Maintain hourly intake and output records. Accurate intake and output records help to guide therapy, especially fluid restrictions. Weigh the client daily or more frequently as ordered. Use standard technique (same scale, clothing, or coverings) to ensure accuracy. Rapid weight changes are an accurate indicator of fluid volume status, particularly in the client with oliguria. Assess vital signs at least every 4 hours. Hypertension, tachycardia, and tachypnea may indicate excess fluid volume. Assess breath and heart sounds, neck veins for distention, and back and extremities for edema; report abnormal findings. If not contraindicated, place client in semi-Fowler position to enhance cardiac and respiratory function. Report abnormal serum electrolyte values and manifestations of electrolyte imbalance. The client with ARF is at particular risk for the following electrolyte imbalances: Hyperkalemia caused by impaired potassium excretion. Manifestations include irritability, nausea, diarrhea, abdominal cramping, cardiac dysrhythmias, and electrocardiographic changes. Hyponatremia caused by water retention. Manifestations include nausea, vomiting, and headache, with possible central nervous system manifestations of lethargy, confusion, seizures, and coma. If the serum sodium concentration rises and the client's weight falls, insufficient fluids are being administered. If the serum sodium level falls and the client's weight increases, excessive fluids are being administered. Hyperphosphatemia caused by decreased phosphate excretion. Manifestations include hyperreflexia, paresthesias, and possible tetany (tonic muscle spasms). ARF impairs electrolyte and water excretion, causing multiple electrolyte imbalances. Turn the client frequently, and provide good skin care. Edema decreases tissue perfusion and increases the risk of skin breakdown, especially in the older or debilitated client. Restrict fluids as ordered. Provide frequent mouth care, and encourage use of hard candies to decrease thirst. If ice chips are allowed, include the water content (approximately half the total volume) as intake. Fluids are restricted to minimize fluid retention and complications of fluid volume excess. Administer medications with meals. Giving oral medications with meals minimizes ingestion of excess fluids. Address nutrition imbalances provide client teaching (avoid nephrotoxic drugs up to one year after ARF, s/s of complications of ARF such as FVE or D, HF, and electrolyte imabalances

Sepsis-treatments and nursing interventions

Manifestations of sepsis include fever or hypothermia, tachycardia, tachypnea, peripheral vasodilation, septic shock, and mental status changes. Hemodynamic monitoring shows an increase in cardiac output. Lab results show an abnormal CBC (leukocytosis or leukopenia) and alteration in clotting factors (thrombocytosis or thrombopenia), and elevated liver enzyme, C-reactive protein, and creatinine levels are likely. Hypophosphatemia and positive blood culture are anticipated.

Mass casualty nursing

Mass casualties call for the implementation of reverse triage, in which the most severely injured or ill victims who require the greatest resources are treated last to allow the greatest number of victims to receive medical attention.

Typical traits of a mentor

Mentors are "competent, experienced professionals who develop a relationship with a novice for the purpose of providing advice, support, information, and feedback in order to encourage development of the individual." Primary function - career development Guides personal and professional growth Role model Long period of time Supports and nurtures growth Volunteer participation Self-selecting One-to-one interaction Teacher

Know tumor lysis, causes and treatments

Metabolic emergencies result from the lysis (dissolving or decomposing) of tumor cells, a process called tumor lysis syndrome (TLS). In TLS, cellular lysis leads to the release of intracellular contents into the circulation, causing hyperkalemia, hyperuricemia, and hyperphosphatemia. Consequences of this syndrome may include cardiac arrhythmias, renal failure, and death. Although usually associated with rapid cell lysis due to chemotherapy, TLS may also occur spontaneously, without any apparent cause. TLS is most often seen in cancers with high growth rates, acute leukemias, and lymphomas Maintain adequate hydration, and administer prescribed medications, such as allopurinol and diuretics, as ordered. Hydration is vital to maintain renal function and promote elimination of tumor lysis by-products. Allopurinol reduces the risk of uric acid crystallization in the kidneys and other tissues

Signs of end of life in terminally ill patients

Nausea Dyspnea Hypotension Anorexia, nausea, and dehydration Altered levels of consciousness Pain Psychosocial needs (say final good-byes, make final arrangements, cultural or religious practices)

Benners 5 levels of nursing competence

Novice -beginners without nursing experience -do actions by following rules -limited ability to act independent of being told what to, when to, and how to do nursing actions Advanced beginner -typically new graduates -have limited nursing experience -beginning to recognize significant cues from internal cognitive processing Competent -after 2-3 years experience -intentional planning of care -still not able to see bigger picture form significant cues Proficient -can see the whole picture -formulates own rules for actions by analyzing significant cues Expert -many years experienced -intuitive practitioner -highly developed cognitive abilities The different levels of competence reflect four progressive changes in thinking processes: 1. Moving from not having nursing experiences to relate to, to having concrete clinical experiences to relate to new situations requiring critical thinking 2. Progressing from following steps in a specific sequential order to being able to customize and adapt actions using nursing experience and intuition 3. Moving from taking in many significant cues and trying to make sense of all of them to identifying significant cues and clustering them to form patterns 4. Progressing from being a bystander watching to being an actively involved participant.

Nursing interventions for Head injury and goals associated with head injury

Nurses can help clients prevent head injury by providing anticipatory guidance related to safe practices, especially wearing protective equipment such as helmets when engaging in sports or activities with a high risk for concussion.

Pulmonary Embolism, S+S, Treatments and diagnostics

Dyspnea and shortness of breath Chest pain Anxiety and apprehension Cough Tachycardia and tachypnea Crackles (rales) Low-grade fever Diaphoresis Hemoptysis Syncope Cyanosis An S3 and/or S4 gallop Diagnositics -Plasma D-dimer -Chest CT w/ contrast -Lung scans -Pulmonary angiography -Chest X-ray -electrocardiography -ABGs -ETCO2 -coag studies Anticoagulant therapy is the standard treatment for preventing pulmonary emboli. In the client with DVT or a pulmonary embolus, anticoagulants are administered to prevent further clotting and embolization. When anticoagulant therapy fails to prevent recurrent emboli or is contraindicated, an umbrella-like filter may be inserted into the inferior vena cava to trap large emboli while allowing continued blood flow. The filter usually is inserted percutaneously, via either the femoral or jugular vein. Intervention: The primary and most emergent focus of nursing care for the client with pulmonary embolism is to promote oxygenation and gas exchange. Other considerations include pain management and reduction of the anxiety that often results from hypoxia. Client Teaching Pulmonary Embolism: Use of prescribed anticoagulant, including drug interactions, scheduled laboratory testing, and manifestations of bleeding to report to the primary care provider Using a soft toothbrush and electric razor to reduce the risk of bleeding Avoiding aspirin (unless prescribed) and other over-the-counter medications unless approved by the physician Importance of wearing a medic alert tag for anticoagulant use Health promotion measures to reduce the risk of recurrent pulmonary embolism Symptoms of recurrent pulmonary embolism, such as sudden chest pain, shortness of breath, and possibly bloody sputum.

Differences between early sepsis and late phase sepsis

Early (Warm) Septic Shock Blood pressure: normal to hypotension Pulse: increased, thready Respirations: rapid and deep Skin: warm, flushed Mental status: alert, oriented, anxious Urine output: normal Other: increased body temperature; chills; weakness; nausea, vomiting, diarrhea; decreased CVP Septic shock has an early phase and a late phase. In early septic shock (sometimes called the warm phase), vasodilation results in hypotension due to intense vasodilation and fluid shifts due to increased capillary permeability, weakness, and warm, flushed skin. Septicemia often causes high fever and chills. Late (Cold) Septic Shock Blood pressure: hypotension Pulse: tachycardia, arrhythmias Respirations: rapid, shallow, dyspneic Skin: cool, pale, edematous Mental status: lethargic to comatose Urine output: oliguria to anuria Other: normal to decreased body temperature; decreased CVP In late septic shock (sometimes called the cold phase), hypovolemia and activity of the compensatory mechanisms result in typical shock manifestations, including cold, moist skin; oliguria; and changes in mental status. Death may result from respiratory failure, cardiac failure, and/or renal failure.

Burn patients, nutritional status, pain management, wound care.

Expected findings: Hypovolemic Shock (Burn Shock) Cardiac Rhythm Alterations Peripheral Vascular Compromise Loss of water secondary to evaporation Infection secondary to loss of skin integrity, which allows pathogens to enter the body Difficulty maintaining body temperature due to heat loss from open wounds Urine output decreases, and serum creatinine and blood urea nitrogen increase. Fluid resuscitation is the administration of IV fluids to restore the circulating blood volume during the acute period of increasing capillary permeability, thus counteracting the effects of burn shock. Fluid replacement is necessary for all burn wounds that involve 20% or more of the TBSA. During fluid resuscitation, crystalloid fluids are administered through two large-bore (14- to 16-gauge) catheters, preferably inserted through unburned skin. Because it most closely approximates the body's extracellular fluid composition, warmed lactated Ringer solution is the IV fluid most widely used during the first 24 hours after burn injury. -Parkland formula and ABLS Consensus formula. These formulas specify the volume of fluid to be infused over the first 24 hours from the time of the burn injury, with 50% of the fluid to be infused during the first 8 hours, followed by the remaining 50% during the next 16 hours (25% per 8 hours)

End of life Nursing Dx

Fear Death Anxiety Grieving related to impending death

Understand treatments and nursing care for IICP, Increasing Intracranial Pressure

Maintain airway patency. Monitor neurological status; assessment areas include LOC, behavior, motor/sensory functions, pupillary size and reaction to light, and vital signs. Monitor IICP monitor orventilator. Decrease stimuli. Raise pads and bed rails; seizures may occur. Elevate the head of bed 30 degrees unless otherwise indicated. Monitor arterial blood gases. Position client as prescribed. Prevent complications associated with immobility. Monitor fluid and electrolytes. Monitor bladder distention and bowel constipation. Provide emotional support as needed. Administer medications as ordered. Clients with IICP may undergo various intracranial surgical techniques to treat the underlying cause. In addition, infarcted or necrotic tissue may be resected to reduce brain mass. A drainage catheter or shunt may be inserted laterally via a burr hole into a ventricle to drain excess CSF and reduce hydrocephalus. The removal of even a small amount of CSF may dramatically reduce IICP and restore cerebral perfusion pressure. Diuretics, particularly osmotic diuretics, are commonly used to reduce ICP and are the mainstays of pharmacologic treatment. Loop diuretics such as furosemide (Lasix), the drug of choice, and ethacrynic acid (Edecrin) may be prescribed for some clients with IICP. Antipyretics, such as acetaminophen, are used alone or in combination with a hypothermia blanket to treat hyperthermia. (Hyperthermia increases the cerebral metabolic rate and exacerbates an existing increase in ICP.) Anticonvulsants are often required to manage seizure activity associated with brain injury and IICP. Antihypertensives, in particular beta-blockers, may be used if the mean arterial pressure (MAP) is high. Vasopressors may be used if the MAP is low. Gastrointestinal prophylaxis with intravenous histamine H2 antagonists or proton pump inhibitors are often used because clients with IICP are at increased risk for developing stress gastritis and ulcers. Intravenous fluids are usually necessary to maintain the client's fluid and electrolyte balance and vascular volume. If the client's blood pressure is unstable, vasoactive medications may be administered to maintain the MAP in a range that supports cerebral perfusion while minimizing increases in ICP. When enteral feeding is not possible, total parenteral nutrition may be administered. Nonpharmacologic therapies for clients may include ICP monitoring and mechanical ventilation. Continuous assessment is necessary to determine and respond to changes in the client's condition. The criteria for ICP monitoring depends on the client's condition, but in general, clients who are comatose and have a Glasgow Coma Scale score of 8 or lower should be monitored. Assess for and report manifestations of IICP every 15 minutes to 1 hour and as necessary.

Signs of substance abuse in a fellow nurse and what to do if you suspect.

In the 1970s, research on impaired nursing practice began to appear, and in 1982, the American Nurses Association (ANA) passed a resolution entitled "Action on Alcohol and Drug Misuse and Psychological Dysfunctions Among Nurses." The hope was to shift the focus from punishment to rehabilitation. In 2002, the ANA adopted an updated resolution entitled "The Profession's Response to the Problems of Addictions and Psychiatric Disorders in Nursing," calling attention again to impaired nursing practice, stressing the need for peer assistance programs. The ANA currently joins with the International Nurses Society on Addictions to promote a treatment-over-discipline approach. Healthcare providers are as susceptible as anyone else to developing substance abuse. By the very nature of their roles, dentists, pharmacists, physicians, and nurses are in frequent contact with drugs and are at high risk for substance abuse problems. As a rule, nurses experience many pressures in the workplace and have easy access to drugs. Thomas and Siela (2011) estimated that 10%-15% of all nurses may be impaired or in recovery from alcohol or drug addiction. They also reported that the two best predictors of successful recovery from addiction are the length of treatment and the willingness of the nurse. Nurses who remained in treatment for at least a year are twice as likely to be drug-free. Substance abuse and dependence can lead to impaired professional practice; therefore, nurses must act responsibly when coworkers display signs of substance abuse. The American Nurses Association Code of Ethics for Nurses provides a framework for client safety. Four suggestions for implementing its philosophy are: Do not ignore poor performance. Do not lighten or change the nurses' client assignment. Do not accept excuses. Do not allow yourself to be manipulated or fear confronting a nurse if client safety is in jeopardy. If nurses are showing signs of a substance abuse problem, to help them, their colleagues can find information about impaired nurse programs through state boards of nursing. When nurses have an addiction, shame and guilt are magnified. They are not expected to have their own problems, certainly not an addiction that could lead them to take drugs from clients or be less than 100% in control when they are at work. Nurses now have access to peer assistance and statewide programs to seek treatment and to maintain or reinstate their licenses.

Treatments for Borderline Personality and depression

Individuals with personality disorders often are prescribed medications to control their symptoms. Obsessive-compulsive, aggressive, and self-destructive behaviors may be held in check with the use of selective serotonin reuptake inhibitors (SSRIs), such as Prozac. Symptoms associated with avoidant and borderline disorders may be minimized with antidepressants, just as acute psychosis may be ameliorated with antipsychotic drugs. Medications, however, should be used to complement a comprehensive treatment plan that includes therapy (ideally long-term) that incorporates various approaches

Understand Intradisciplinary Assessment

Intradisciplinary assessment occurs within a group of individuals who have similar positions within a healthcare system, such as a group of nurses or a group of surgeons. An intradisciplinary assessment is important for identifying areas of improvement at each level of care. Intradisciplinary assessment includes peer reviews, audits, and outcomes management.

Understand nurse's role in delegation

Know that as a RN you are accountable for all of your patients care even what is delegated to others

Understand Lean Six Sigma

Lean Six Sigma combines the strategies of Six Sigma, described above, with the Lean system. The objective of the Lean system is to eliminate waste to maximize value. Waste is defined as anything that does not bring value to the customer. Therefore, Lean Six Sigma is a methodology used to reduce waste and provide consistency in the quality of care. It primarily uses the DMAIC system similar to Six Sigma.

Treatments for bipolar disorder

Lithium and other mood stabilizers

Know the process of caring for MVA patients from the ED to home care

Nursing interventions and associated complications involved with MVA Maintain Airway Patency and Ventilation Assess for Disability and Expose Obscured Areas Promote Fluid Volume Balance Prevent Infection Promote Mobility Offer Spiritual Comfort Measures Promote Psychosocial Well-Being Facilitate Community-Based Care Mild head injury to brain, bruising, bleeding, and/or swelling Tearing or injury to the posterior cruciate ligament of the knee, whiplash, spinal cord injury either incomplete or complete For the client who has sustained injury in a motor vehicle crash, primary consideration should be given to the airway: Assess if the airway is patent, maintainable, or nonmaintainable. Assess for manifestations of airway obstruction: stridor, tachypnea, bradypnea, cough, cyanosis, dyspnea, decreased or absent breath sounds, changes in oxygen levels, and changes in level of consciousness. Assessing the airway and initiating interventions are the first steps in managing the client with multiple injuries. A cervical collar (or C-collar), which stabilizes and maintains neutral alignment of the cervical spine, should be applied to clients with potential or suspected cervical spine injury. Longboard spinal immobilization, which provides support and immobilization of the entire spine below the level of the neck, should be instituted for clients with a potential or suspected spinal cord injury. Cervical and longboard spinal immobilization should be discontinued only by physician's order after determining that the client has not sustained a spinal injury. Although not always needed, this determination may require evaluation of the client's spine using CT scan.

KSA competencies

PATIENT-CENTERED CARE For example, KSAs relevant to working with clients experiencing pain and suffering would include: Knowledge: Exhibit comprehension of pain and suffering as well as physiological modes of pain and comfort. Skills: Evaluate levels of client pain and suffering as well as client emotional and physical comfort; assess client and family's expectations of pain relief. Attitudes: Acknowledge the nurse's position as a source of pain relief and treatment; acknowledge that client expectations can affect outcomes. QUALITY IMPROVEMENT Examples of KSAs relevant to quality improvement might include: Knowledge: Acknowledge that healthcare professionals affect client results. Skills: Examine root causes of sentinel events. Attitudes: Recognize the value of contributions to care out- comes. EVIDENCE-BASED PRACTICE Examples of KSAs Relevant to evidence-based practice would include: Knowledge: Display familiarity with scientific methods and processes. Skills: Take part in quantitation and research activities; develop client care based on client values and beliefs, professional expertise, and research evidence. Attitudes: Recognize the pros and cons of scientific research in practice; recognize the necessity for research to be ethical and responsible. TEAMWORK AND COLLABORATION Examples of KSAs relevant to teamwork and collaboration are: Knowledge: Detail the roles of team members. Skills: Fulfill your role as a team member; ask for help in appropriate situations. Attitudes: Respect the views and skills of all team members; recognize the client and family as essential team members. SAFETY Examples of KSAs relevant to safety include: Knowledge: Detail common safety factors as well as unsafe practices. Skills: Show how successful protocol implementation can increase safety. Attitudes: Recognize the benefits of standardization toward safety; recognize the limits of personal performance. INFORMATICS Examples of KSAs relevant to informatics would be: Knowledge: Detail the benefits of information technology skills. Skills: Use information technology systems to provide safer care. Attitudes: Recognize the need for continuous information technology education during a healthcare career.

Understand the PICOT formulation (population, Issue, Comparison, Outcomes, Timeframe)

Population (of clients) Issue of interest Comparison of interventions Outcomes Time frame Examples P - A specific age, gender, health problem, or medication taken by all group members I - A treatment, medication, therapy, test, or new routine of care C - 1. Comparing two ways of doing something to find the best way. 2. Identifying the effect of taking medication A by comparing one group receiving medication A with a group receiving a placebo. O - 1. The desired effect is to minimize or eliminate a specific symptom. 2. An improved outcome is to reduce the time needed to accomplish a task. T - 1. A brief time could be the first 12 hours after taking a medication. 2. An extended time could be 6 months following a treatment regimen.

Understand neutropenia in ALL, CML. Nursing interventions and treatments, medications

Prevent and manage adverse medication effects Prevent Infection Protect from injury related to bleeding Protect mucous membrane integrity Promote balanced nutrition Promote healthy grief response Bone marrow suppression results in anemia and thrombocytopenia (decreased platelets) with resultant coagulation disturbance. Idiopathic bleeding, which is bleeding due to unknown causes, may be a sign of thrombocytopenia. Thrombocytopenia may also lead to bruising easily or bruising that is not related to injury. The manifestations of AML result from neutropenia and thrombocytopenia.The manifestations of thrombocytopenia include petechiae (red or purple spot that looks like a spider caused by a broken capillary), purpura (small areas of subcutaneous bleeding), ecchymoses (bruising), epistaxis (nosebleeds), hematomas, hematuria, and gastrointestinal bleeding. Neutropenia is present when the absolute neutrophil count (ANC) is less than 500 cells/mm3 or if between 500 and 1,000 cells/mm3 when chemotherapy is being given and falling levels are anticipated. The manifestations of AML result from neutropenia and thrombocytopenia. Decreased neutrophils lead to recurrent severe infections, such as pneumonia, septicemia, abscesses, and mucous membrane ulceration. Herpes simplex virus and Candida (yeast) are more common in clients with neutropenia

Strategies for workplace conflict

Preventing Address issues as they arise. Avoid destructive criticism, including harsh words, threats, and generalized condemnation of behaviors or performance. Treat others with respect, which will decrease defensiveness. Avoid arguments. Sometimes people do need to vent, and as long as it is done appropriately and in a private place, it may be helpful in decreasing tension. Listen to each other. Consider the other individual's point of view, including cultural beliefs and values. For individuals who are in leadership roles, strategies to promote conflict prevention include the following Allocate resources fairly, including fair distribution of workload balance and intensity when assigning client care. Clearly define role expectations for all team members. Encourage staff to provide feedback and identify potential concerns without the threat of punitive action. Acknowledge team members' accomplishments and achievements, as well as significant life events. When conflict occurs, each individual involved has a personal perspective of the issue and conflict. To respond effectively to conflict, the nurse should apply the following guidelines: Demonstrate honesty, trustworthiness, and respect. State the issue objectively and provide a factual basis for the concern. Avoid emotion-based discussions. Be open to hearing all individuals' viewpoints and avoid passing judgment. Allow all individuals involved to express their concerns without interruption. Apply active listening techniques. Focus on identifying solutions as opposed to exacerbating the problem. Throughout the process of conflict resolution, recognize that the delivery of safe, effective client care is the central concern.

Heparin uses and labs involved, antidote

Prophylactic anticoagulation therapy (e.g., heparin, Coumadin) may be given to help prevent DVT and pulmonary embolism. Heparin interferes with the clotting cascade by inhibiting the effects of thrombin and preventing the conversion of fibrinogen to fibrin. This prevents the formation of a stable fibrin clot. At therapeutic levels, heparin prolongs the thrombin time, clotting time, and activated partial thromboplastin time (aPTT). When given intravenously, its effect is immediate. Given subcutaneously, its onset of action is within 1 hr. Heparin has a short biological half-life and should be given frequently or via continuous infusion. Heparin-induced thrombocytopenia (HIT) is a potential complication of therapy with unfractionated heparin. The APTT range that corresponds to the heparin therapeutic range (0.2 - 0.4 U/mL by protamine titration) is the established heparin therapeutic range (56 - 84 seconds in this example). Keep protamine sulfate, a heparin antagonist, available to treat excessive bleeding. Monitor laboratory results, including the INR (prothrombin time), aPTT, hemoglobin, and hematocrit as indicated. Report values outside the normal or desired range. Coagulation studies are used to monitor the effect of anticoagulant medications. Values within the desired range prevent further clot development while carrying a low risk for bleeding and hemorrhage. A fall in the hemoglobin and hematocrit may indicate undetected bleeding.

Decreased cardiac output, S+S

Simply defined, decreased cardiac output is the inability of the heart to meet the bodily demands. The normal cardiac output is about 4 to 8 L per minute and it can be calculated as: Cardiac Output = Stroke Volume x Pulse Rate Decreased cardiac output adversely affects the cardiac rate, rhythm, preload, afterload and contractibility, all of which can have serious complications and side effects. The signs and symptoms of decreased cardiac output include the abnormal presence of S3 and S4 heart sounds, hypotension, bradycardia, tachycardia, weak and diminished peripheral pulses, hypoxia, cardiac dysrhythmias, palpitations, decreased central venous pressure, decreased pulmonary artery pressure, dyspnea, fatigue, oliguria and possible anuria, decreased organ and tissue perfusion, and adventitious breath sounds like crackles, and orthopnea.